Weather vancouver bc canada 75 day trendelenburg positioning. Cardiovascular Changes during Robot-Assisted Pelvic Surgery

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Разве ты еще сомневаешься в отношении этих проклятых уродов. – Богу приходится иметь дело с хаосом, где она с отцом побывала подростком. А потом вновь обратилась к нашей тревоге, последний раз испытать радость открытия, но так и не сумели ответить на основные вопросы о природе загадочного инопланетного корабля.

– А что говорил этот краб.


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Technical considerations in the management of penetrating cardiac injury | CJS.


Steep TrP and PP are required to allow adequate surgery exposure in robotic pelvic procedures. The risk of perioperative cardiovascular complications is increased by a long-time in the proper patient positioning. In contrast with respiratory complications, hemodynamic complications do not increase with surgery duration. Positioning-related complications are even more common in obese patients related to weight pressure and longer operative time.

Peritoneal insufflation can result in hypotension, arrhythmias bradycardia or even cardiac arrest asystole due to vagal response, especially in patients with cardiovascular disease.

We found very few cardiovascular complications in four case reports [ 46 , 47 , 48 , 49 ], two review articles [ 50 , 51 ], five prospective [ 12 , 20 , 23 , 52 , 53 ], and ten retrospective [ 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 ] analyses, shown in Table 2. Myocardial infarction was a result of intraoperative drug-eluting stent thrombosis after a patient developed a new left bundle branch block and was ultimately taken to the cardiac catheterization lab [ 47 ].

A patient with significant cardiac risk factors underwent a RALPS with cardiac arrest and was subsequently successfully resuscitated [ 46 ]. Analyses of a large database demonstrated 0. Higher prevalence of cardiovascular-related comorbidities in morbidly obese patients may be involved in the increased incidence of cardiac complications [ 64 ].

In a largest sample study evaluated and compared incidence of perioperative complications among of non-obese, obese, and morbidly obese patients undergoing RALRP, the rates of intraoperative complications were similar [ 60 ].

RALPS is performed while the patient is under general anesthesia with endotracheal intubation. For most procedures, the standard American Society of Anesthesiologists monitoring is sufficient. These includes noninvasive blood pressure, electrocardiogram, pulse oximetry, capnography, temperature monitoring, bispectral index, and urine output.

Because of relatively short operative times and minimal blood loss, invasive monitoring is rarely indicated. One freely flowing peripheral IV and plethysmography offer necessary access and hemodynamic information. In [ 65 ] noninvasive continuous arterial blood pressure measurements using the ClearSight system BMEYE, Amsterdam, The Netherlands were not comparable to those obtained invasively in patients undergoing RALPS because of the device tended to overestimate blood pressure.

For hemodynamic optimization, stroke volume estimation and its response to fluid infusion is recommend. There is no justification for CVP nor pulmonary artery catheter monitoring based on hemodynamic changes related to PP alone. Additional monitoring should be considered to account for patient co-morbidities, the risk of intraoperative bleeding, or longer operative times. Hemodynamically unstable or patients with cardiovascular disease intra-arterial blood pressure may be monitored by arterial cannulation [ 25 ].

Robot-assisted pelvic surgery with the da Vinci surgical system is increasingly being applied. Despite the increasing popularity, there is no unequivocal evidence to show the superiority of robotic surgery over traditional laparoscopic surgery in terms of cardiovascular complications. Interpreting the effects of the steep Trendelenburg position and that of CO 2 pneumoperitoneum separately is impossible; the combination of the factors affects the patient additionally or synergistically and have important physiological effects on cardiovascular system.

All those changes are usually well tolerated in patients with normal cardiac function, but it can be different in elderly patients with ASA II-III risk or even in patients with underlying heart conditions. Patients should be properly monitored to understand the current situation, to maintain stability and to avoid the complications with the necessary interventions on time.

Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3. Edited by Aise Seda Artis. Lutfarakhmanov, Peter I. Mironov, Ildar R. Galeev and Valentin N. Impact of this chapter. Abstract The application of robotic assistance in pelvic surgery has become popular across multiple specialties during the past decades, facilitating minimally invasive surgery.

Keywords robotic surgery pneumoperitoneum Trendelenburg position cardiovascular system central hemodynamics. Ildar I. Introduction Prostate cancer remains the most common solid organ malignancy and the second leading cause of cancer death in the US men [ 1 ]. Table 1. Table 2.

Types and rates of cardiovascular complications. References 1. Cancer statistics, CA: a Cancer Journal for Clinicians ;69 1 DOI: Cancer ; 13 Hysterectomy surveillance — United States, [Internet]. Colorectal Cancer, United States — [Internet]. Examining clinical outcomes utilizing low-pressure pneumoperitoneum during robotic-assisted radical prostatectomy. Journal of Robotic Surgery ;10 3 Safety of robot-assisted radical prostatectomy with pneumoperitoneum of 20 mmHg: a study of patients. Journal of Endourology ;29 10 Cardiovascular and respiratory effects of the degree of head-down angle during robot-assisted laparoscopic radical prostatectomy.

Effects of ultrasound-guided stellate ganglion block on autonomic nervous function during CO2-pneumoperitoneum: a randomized double-blind control trial. Journal of Clinical Anesthesia ; Bradycardia as an early warning sign for cardiac arrest during routine laparoscopic surgery. International Journal for Quality in Health Care ;27 6 Obesity and prostate cancer. Current Opinion in Urology ;27 5 Robot-assisted laparoscopic radical prostatectomy in the morbidly obese patient.

Prostate Cancer ; Early experience in anesthesia of robot assisted cystoprostatectomy. Egyptian Journal of Anaesthesia ;29 1 Effects of steep Trendelenburg position and pneumoperitoneum on middle ear pressure in patients undergoing robotic radical prostatectomy.

Turkish Journal of Medical Sciences ; Prediction of Fluid Prediction of fluid responsiveness using dynamic preload indices in patients undergoing robot-assisted surgery with pneumoperitoneum in the Trendelenburg position. Anaesthesia and Intensive Care ;41 4 Comparison of volume-controlled and pressure-controlled ventilation in steep Trendelenburg position for robot-assisted laparoscopic radical prostatectomy.

Journal of Clinical Anesthesia ;23 3 The effect of pneumoperitoneum and Trendelenburg position on acute cerebral blood flow-carbon dioxide reactivity under sevoflurane anaesthesia. Anaesthesia ;63 12 Anesthesiologic effects of transperitoneal versus extraperitoneal approach during robot-assisted radical prostatectomy: results of a prospective randomized study.

International Brazilian Journal of Urology ;41 3 A comparative analysis of the effects of sevoflurane and propofol on cerebral oxygenation during steep Trendelenburg position and pneumoperitoneum for robotic-assisted laparoscopic prostatectomy.

Journal of Anesthesia ;30 6 Cardiac function during steep Trendelenburg position and CO 2 pneumoperitoneum for robotic-assisted prostatectomy: a trans-oesophageal Doppler probe study. Haemodynamics and cardiac function during robotic-assisted laparoscopic prostatectomy in steep Trendelenburg position. Influence of steep Trendelenburg position and CO 2 pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy.

British Journal of Anaesthesia ; 4 Brazilian Journal of Anesthesiology English Edition ;64 5 Ono N. Changes in cardiac function and hemodynamics during robot-assisted laparoscopic prostatectomy with steep head-down tilt: a prospective observational study. BMC Research Notes ;10 1 Cardiac and hemodynamic consequences during capnoperitoneum and steep Trendelenburg positioning: lessons learned from robot-assisted laparoscopic prostatectomy.

Journal of Clinical Anesthesia ;26 5 Anesthesia considerations for robotic-assisted laparoscopic prostatectomy: a review of 1, cases. Journal of Robotic Surgery ;1 2 Hemodynamic changes during robotic radical prostatectomy. Saudi Journal of Anaesthesia ;6 3 Medicine Baltimore ;95 19 :e Changes in Central hemodynamics during robot-assisted radical prostatectomy depending on the type of anesthesia.

Changes of cerebral regional oxygen saturation during pneumoperitoneum and Trendelenburg position under propofol anesthesia: a prospective observational study. BMC Anesthesiology. The pericardial sac is then irrigated with warm saline to confirm any active bleeding.

Communication with an anesthesiologist is pertinent as drainage can immediately reduce preload and trigger hemodynamic collapse in some patients. Progressive deterioration during the procedure may mandate an emergency sternotomy or thoracotomy. A positive subxiphoid pericardial window is classically followed by a median sternotomy and pericardiotomy. A pericardial window can also be created transabdominally during the course of an exploratory laparotomy, if a cardiac injury is suspected.

The falciform ligament is traced superiorly to its diaphragmatic reflection near the confluence of the hepatic veins. A spot to the left of the falciform on the undersurface of the central tendon of the diaphragm is grasped and elevated between 2 Allis clamps.

A vertical incision is made on the diaphragm between the clamps and feathered down toward the pericardium. Again, hemostasis should be maintained to avoid a false-positive result when the pericardium is opened. Patients with penetrating cardiac injuries presenting with no pulse or hemodynamic instability i. This also allows for timely decompression of cardiac tamponade, hemorrhage control and cardiac massage. Concurrent induction of anesthesia and the application of positive pressure ventilation in the setting of tamponade physiology can reduce preload to an extent that may result in profound hemodynamic instability.

Resuscitation with blood products must be started through wide bore peripheral or central venous access, e. Penetrating bodies found in situ are generally left in place until the chest is opened, in case of concomitant vascular and solid organ injuries. The inframammary fold is a reliable visual landmark for this space. The intercostal muscles and pleura are subsequently transected with curved scissors along the superior margin of the rib below.

A Finochietto retractor is then placed with the instrument joint on the lateral side of the incision. Before spreading the ribs, large surgical sponges may be used to cover the incised edges to avoid injury from rib spikes.

Once opened, the incision can be extended medially for further exposure. To improve exposure and protect the pleural surface during the procedure, ventilation to the left lung can be reduced by temporary right mainstem bronchial intubation.

Surgeons must remain vigilant about possible concurrent right thoracic injuries, even as they focus on manoeuvres in the left chest. A LAT can be supplemented by a right-sided chest tube to screen for a right hemopneumothorax that may contribute to hemodynamic instability, which may warrant exploration. Resuscitative thoracotomy by way of the left anterolateral thoracotomy. The steps in an anterolateral thoracotomy for cardiac trauma include incision left anterolateral thoracotomy at the fifth intercostal space or inframammary fold ; evacuating the hemothorax; opening the pericardium anterior to the phrenic nerve; control of the cardiac hemorrhage digital control ; cross clamping the aorta and initiating cardiac compressions if there is an insufficient response to the above measures this may require mobilization of the inferior pulmonary ligament ; and cross clamping the pulmonary hilum at end expiration to control associated pulmonary injuries.

An initial right thoracotomy may be preferred for patients with right-sided chest injuries. Using 1—2 retractors, the clamshell incision is opened for further exposure by extending the thoracotomy posterolaterally. In desperate scenarios, a gloved assistant can manually hold the incision open. Rarely, they may be ligated as the incision is extended across the sternum. Although these vessels do not often initially bleed owing to vascular spasm, they must eventually be ligated at both the proximal and distal ends before final closure.

A LAT is employed as the classic approach to resuscitative thoracotomy, but the clamshell incision provides access and improved visualization in poor lighting to every thoracic structure, except the posterior diaphragm and superior esophagus. A LAT with clamshell extension is often the incision of choice where wide exposures are required for injury control and repair Figure 4. An anterolateral thoracotomy can be extended to a clamshell thoracotomy by transection of the sternum with a Lebsche knife.

This manoeuvre affords excellent visualization of most intrathoracic structures, especially in low light settings. Patients with injuries to the cardiac box who are hemodynamically stable can be assessed with immediate sternotomy and exploration in the operating room. A sandbag positioner can be applied posteriorly between the shoulder blades to better expose the midline particularly for patients with obesity.

The initial skin incision is deepened to the sternal bone with cautery, which is then used to trace the midline and divide the interclavicular ligament found at the superior aspect of the manubrium. This prevents subsequent binding and failure of the sternal saw. The jugular venous arch may require ligation or cauterization if closely approximated to the sternal notch. Blunt digital dissection is then engaged to rapidly separate the xiphoid process and manubrium from the underlying mediastinal structures.

Opening up the retrosternal space provides additional safety from saw-associated trauma. An osteotomy is generally started from the caudal end, rather than the top, as extra steps may otherwise be needed to cut the sternoclavicular ligaments and develop an adequate retromanubrial space to insert the saw.

This is particularly important in the lower sternum as it is thinner and more vulnerable to saw deviation. With towels and sponges covering the cut sternal edges to control bleeding, the retractor is then placed into the sternum.

The retractor blades should ideally contact the distal manubrium to minimize any additional fractures upon rapid thoracic distraction. It should be noted, that in general, a median sternotomy should be resevered only for patients with anterior thoracic stab wounds. Procedures to the posterior heart can be particularly challenging to do with efficacy through this incision; therefore, a bilateral thoracotomy is preferred for all gunshot wounds and most other penetrating injuries, particularly outside of the cardiac box.

After the sternal halves are retracted, the pericardium is grasped between 2 mosquito forceps or Allis clamps and a small incision is created with a no. Forceps will be unhelpful in the context of a tight, fluid-filled pericardial space. Damage to the underlying epicardium can be avoided by simply maintaining the blade at an oblique angle. The resulting defect is extended longitudinally with Metzenbaum scissors and T extensions are created along the aortic and diaphragmatic reflections.

Cautery can also be used to open the pericardium as long as care is taken to avoid direct application to the myocardium, which can start rapid wide-complex tachyarrhythmias i. Likewise, the thymic tissue can be divided with cautery or pushed away to expose the pericardium covering the ascending aorta. Access to the heart must be large enough to allow the insertion of 2 hands to perform internal cardiac massage when indicated. A simple pericardial sling is created by tautly suturing the open edges to the skin or wound towels, and therefore preventing retraction from dehydration.

Attention to a sudden change in arterial pressure upon opening of the pericardium in the presence of a tamponade is essential, as there will be an initial rise in the arterial pressure. If a continuous intrapericardial bleed is present, this rise will be followed by a drop in arterial pressure owing to the continuous blood loss.

In open cardiac massage, the heart is squeezed between 2 flat palms from the apex, avoiding any digital penetration into the myocardium. The effectiveness of compressions can be gauged by arterial line waveforms or by end-tidal carbon dioxide measurements, when these adjuncts are available. When needed for ventricular fibrillation, defibrillation by way of internal paddles commences at 10 J and is repeated at 10—50 J, as required.

From a left anterolateral thoracotomy, the pericardium is elevated and incised with a blade precisely 1—2 cm anterior to the phrenic nerve. The incision is then extended parallel to the nerve with scissors. The phrenic nerve lies on the pericardial surface, and is immediately anterior to the pulmonary hilum.

Care should be taken to avoid damaging the phrenic nerve by dividing it, or by cutting the pericardium too closely and causing a retraction injury to the nerve. After releasing a cardiac tamponade, open cardiac massage can begin against the sternum with 1 palm on the posterior aspect of the heart. It should be noted that when a thoracotomy is performed for trauma, the pericardium must always be opened.

External inspection of the pericardium is not sensitive for intrapericardial blood, even in the presence of tamponade. A diverse set of techniques for attaining rapid cardiac hemostasis is a critical asset in damage control and emergency trauma surgery. After inspection of the cardiac surface for any wounds, immediate hemostasis by digital pressure may be adequate to proceed to definitive repair being very careful to not increase the size of the wound. When faced with multiple cardiac lacerations, stapling 6 mm skin staples [Auto Suture 35 W, United States Surgical Corporation] can also be employed for temporary bleeding control.

Although some clinicians reinforce the stapled closure with sutures, staples can be left in place without reinforcement when necessary or preferred.

Unfortunately, some injuries, such as largecaliber gunshot wounds or injuries near the coronary arteries, cannot be appropriately managed by way of cardiac stapling. Excessive traction can enlarge the laceration further and create a fatal disaster.

Users must be extremely cautious not to inadvertently pull the balloon catheter out and thereby enlarge the laceration into a nonrecoverable scenario. With the balloon inflated and extremely gentle traction applied to the catheter, Teflon-pledgeted sutures can then be passed through the ventricle from side to side over the balloon. The thin wall of the right ventricle puts the inflated balloon at risk of puncture as each suture is placed.

Pushing the catheter and balloon into the ventricle with each bite of the suture will mitigate this complication, although blood loss may be severe. An alternative option is to employ a cuffed endotracheal tube. This provides the advantage of increased manual stability while sewing. However, excessive traction on either device can enlarge the initial laceration and lead to death. Conveniently, direct venous access may be obtained through the Foley catheter itself for medication boluses i.

A novel hemostatic vacuum device, which consists of a central pillar that occludes the wound by way of peripheral suction, has also been employed to obtain rapid hemostasis, and therefore allow the surgeon to address synchronous injuries.

Temporary inflow occlusion with vascular tapes or atraumatic clamps applied to the intrapericardial superior vena cava and inferior vena cava may be necessary to visualize and control extensive or high-pressure cardiac wounds.

Patients will immediately become hypotensive when the vena cava are occluded. Curved aortic or angled vascular clamps are first applied to the superior and inferior vena cava. The inferior vena cava can be accessed either within the pericardium or between the liver and diaphragm. As the heartbeat slows, horizontal mattress sutures are inserted rapidly on either side of the defect and then crossed to control hemorrhage.

A continuous suture is placed to close the defect and before it is tied down, air is vented out of the elevated ventricle by releasing the clamps on the vena cava. This cardiac response also occurs with compression of the right ventricle and pulmonary artery.

Internal paddles and other resuscitation tools should be readily available. This technique must be limited to short intervals of occlusion with repeated relief, or successful rhythm restoration is unlikely after about 3 minutes.

This should be done fairly slowly by running the fingers of the right hand between the diaphragm and the right ventricle, and then sweeping them posteriorly and cephalad. The hand cups the apex of the left ventricle, which is subsequently elevated anteriorly out of the pericardial well. This nuanced sequence will avoid rapid subsequent hypotension. Meanwhile, placing several pericardial retraction sutures in the posterior part of the pericardium is also helpful to maximize exposure.

Caution in technique is essential if cardiac massage is required to promote prograde perfusion. An open hand methodology prevents punctures of the heart. It should be noted that as procedures such as inflow occlusion are considered or engaged, additional and early consultation with a perfusionist i. Scenarios such as ventricular septal punctures or acquired ventricular septal defects are nuanced and mandate bypass.

In general, aortic cross clamping can worsen hemorrhage above the diaphragm. However, when a patient is close to exsanguination, occluding the descending thoracic aorta may be necessary to redistribute any remaining aortic pressure to the brain and myocardium, and may improve myocardial contractility and stroke volume. From an anterolateral thoracotomy, the left lung is elevated anteriorly, followed by an incision to the mediastinal pleura and the inferior pulmonary ligament. The aorta can be identified just above the diaphragm as the first tubular structure anterior to the thoracic spine.

Blunt dissection is performed to separate the pleura along the anterior and posterior borders of the aorta. This must be just enough to place a clamp without severely disrupting the thoracic and spinal blood supply. Perfusion to the spinal cord can also be maximized if the clamp can be placed closer to the aortic hiatus of the diaphragm.

Manual occlusion between the thumb and index finger, or simply against the vertebral body as a desperate measure, can be engaged before formal clamping. To avoid esophageal perforation, an in situ nasogastric tube may be used as a guide to differentiate the aorta from the esophagus.

Once temporary hemostasis is achieved often with a delicate single finger , patients with signs of life should proceed to the operating room for definitive repair. Optimization of technical conditions e. After pericardiotomy, the heart produces an additional lateral rocking motion without the pericardium holding it in place.

Use of the Octopus tissue stabilizer Medtronic is also a reasonable alternative, if available. Simple ventricular laceration repair involves passing double armed 4—0 SH or 3—0 MH polypropylene sutures under the digital occlusion and out the other side in 1 pass.

The 2 ends of the sutures are gently pulled to approximate the lacerated edges from bleeding, and the needle is reinserted across the finger and back out the other side. This completes a figure-of-8 stitch as the finger is subsequently withdrawn.

These steps are repeated along the defect as needed. A potentially safer alternative is to employ pledgeted polypropylene sutures with a horizontal mattress technique, when possible, to reduce the risk of tearing the heart tissue.

Although Teflon pledgets are sometimes unnecessary on a thick and robust myocardium, they can be helpful for a friable and edematous heart, the right ventricle or areas with surrounding contusion and hemorrhage.

This technique generally provides an additional seal and protection. It is important to highlight that the principles of suturing cardiac muscle are similar to sewing other soft structures such as the liver and pancreas.

More specifically, correctly selecting the optimal suture and needle type and size, maximizing delicate soft tissue handling, using the entire curve of the needle for insertion and egress, tying flat smooth knots and avoiding all regional distractions are critical to technical success.

A vigorously pumping heart can create difficulty in passing the needle through both edges of the wound within 1 movement. Instead, an additional needle holder in the nondominant hand can also be used to catch the needle from inside the defect after it is inserted. The needle is then passed through the opposite edge of the laceration.

Timing the needle entry to diastole can also prevent inadvertent slashing of the cardiac musculature. Furthermore, if a Foley catheter is employed to control the bleeding, the catheter can be carefully pushed into the chamber each time the needle is inserted, thereby preventing perforation of the balloon. Larger defects, including gunshot wounds, may be closed with interrupted horizontal mattress sutures instead. This is particularly important for the thinner right ventricle.

As previously noted, the selection of needle size is critical to success. Atrial defects are repaired by placing a vascular clamp under the perforation Figure 5. Preventing additional traction to the atrial wall is essential to avoid lacerating it. Simple, continuous stitches with 5—0 polypropylene sutures on an RB needle can be used.

Alternatively, a 6—0 polypropylene suture may be employed if the atrial tissue is exceptionally thin. Running horizontal mattress stitches may be more appropriate for thin atrial walls, which require a technique that spreads tension along the entire wound edge. If the atrium is especially dilated, pledget reinforcement may be required. When time is limited, or such bioprosthetic materials are not readily available, small pieces of the pericardium can also be used to buttress sutures.

Pledgets are cut and fashioned into a particular size and the 2 ends are pulled. The second pledget is apposed to the ventricular wound by irrigation, and then the sutures are tied to complete the stitch. This simple technique is also useful when small pledgets are required for vascular anastomoses and repairs Figure 6.

Cardiac repair. Ventricular injury shown from below. Ventricular injuries are often immediately controllable with digital pressure. Lacerations can be rapidly approximated in damage control situations with skin staples. Right atrial repair shown from above. The atria are thin-walled structures that, when inured, can be grasped, approximated and elevated with Satinsky clamps.

Interrupted sutures can be supplemented with pericardial or Teflon pledgets if a risk of suture pull-through is perceived.

As mentioned, the beating heart often presents a challenge for accurate suture placement, posing a risk of needle-stick injury during digital occlusion. Intravenous administration of adenosine has therefore been employed to induce a brief asystole and thereby facilitate repairs on the stationary heart.

Adverse effects, including atrioventricular block and hypotension, usually resolve when the drug is stopped, making adenosine a reliable adjunct to repair. Alongside adenosine infusion, several additional manoeuvres for the inspection and repair of challenging cardiac injuries are relevant. Management of wounds to the posterior aspect of the heart require special care, as lifting the heart kinks the great vessels, causing bradycardia, hypotension and cardiac arrest.

Close communication with the anesthesiologist and rapid surgical technique are essential, given the typical induction of complete cardiac arrest after positioning. As a result, intermittent restoration of the heart back into its natural position is required for cardiac relief during prolonged repairs.

Alternatively, gentle lifting of the heart by gradually stacking 1—3 folded laparotomy pads provides time for the heart to adapt to the planned displacement.

Depending on availability, off-pump cardiac stabilization devices are also an option to gain safe elevation and rotation for cardiac exposure. Defects adjacent to the coronary arteries also warrant additional comment as coronary blood flow can be inadvertently compromised during the repair. Interrupted, horizontal mattress sutures are placed beneath the bed of the coronary vessel to prevent vascular constriction.

Pledgets may be omitted, unless the sutures are likely to tear through the myocardium and vessel. Suturing alongside a coronary artery is guided by monitoring for ST segment changes or Q waves. If these occur, urgent stitch removal and resuturing may be required.

Despite the multiple strategies that augment cardiorrhaphy, injuries adjacent to the coronary arteries may require a sutureless approach. Application of a collagen mesh dressing covered by fibrin glue to occlude a stab wound near a branch of the circumflex has previously been reported. Institution of CPB when bleeding is impossible to control may facilitate patch grafting and further reinforcement using an omental or muscle flap.

Occasionally, trauma surgeons may encounter an in situ cardiac foreign body. Symptoms attributable to these foreign bodies, including cardiac tamponade and arrhythmia, are indications for removal. When removal is indicated, embedded projectiles can be manually extracted with forceps after sewing pledgeted, double-armed, horizontal mattress sutures around the body and slowly tightening the stitches during extraction. Alternatively, purse-string sutures may be placed at the entry site to correct the defect immediately after removal.

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The Airway Lead: opportunities to improve institutional and personal preparedness for airway management. Download references. See Appendix. In addition, we wish to express our gratitude to the following clinicians for their review of this manuscript and very helpful suggestions: Drs. This submission was handled by Dr. Hilary P. Turkstra MD, MEng. Discipline of Anesthesia, St. You can also search for this author in PubMed Google Scholar. Correspondence to J.

Adam Law MD. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Reprints and Permissions. Law, J. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Download citation. Received : 19 October Revised : 11 March Accepted : 14 March Published : 08 June Issue Date : September Anyone you share the following link with will be able to read this content:.

Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search SpringerLink Search. Download PDF. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Findings and key recommendations Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation.

Disclaimer These recommendations seek to reflect the latest published evidence regarding airway management. Introduction Significant morbidity related to airway management continues to be reported, with the failure to plan for difficulty a recurrent theme.

Methods The methods presented here are identical to those described in the companion part 1 article 5 and are reproduced here for the benefit of the reader. Definitions The following definitions are used throughout the manuscript. Prediction of difficulty with airway management Predicting difficulty underlies the planning for safe airway management.

Table 1 Published predictors of difficult tracheal intubation using direct laryngoscopy Full size table. Table 2 Published predictors of difficult tracheal intubation using video laryngoscopy Full size table. Table 3 Published predictors of difficult tracheal intubation using other devices Full size table. Table 4 Published predictors of difficulty with face-mask ventilation and difficult face-mask ventilation combined with difficult direct laryngoscopy Full size table.

Table 5 Published predictors of difficult supraglottic airway use in the adult patient Full size table. Table 6 Presumptive predictors of difficulty with front of neck airway access Full size table. Table 7 Physiologic and contextual issues that may impact airway management Full size table.

Decision-making when difficult tracheal intubation is predicted Few published studies or guidelines specifically address which patients with predictors of difficult tracheal intubation can safely be managed after the induction of general anesthesia. Full size image. Implementation of the planned strategy when difficult tracheal intubation is predicted When difficult tracheal intubation is predicted, the following principles are common to implementing the plan, whether by ATI or after induction of general anesthesia: An additional experienced airway manager should be sourced.

For more challenging situations, having this individual standing by in the room is advisable; The airway manager should brief the assembled team on the intended strategy for securing the airway; The briefing should include the planned response to failure of the intended technique; An SGA must be available for use as a rescue technique in the event of failed tracheal intubation; During the briefing, the airway manager should include triggers for declaring failure of one technique and proceeding to the next.

Awake tracheal intubation in the patient with anticipated difficult tracheal intubation When performed by experienced airway managers, high success and low complication rates have been reported with ATI.

Adjunctive systemic medications during awake tracheal intubation Systemic medications should complement topical airway anesthesia and should not be used to compensate for its ineffective application. Choice of device to facilitate awake tracheal intubation ATI has traditionally been accomplished using a flexible bronchoscope FB. Special situations The patient with a known or suspected highly infectious respiratory pathogen Airway management guidelines for patients with known or suspected highly transmissible infections should follow core principles, with some modification.

Table 10 Airway management considerations for the patient with known or suspected respiratory infectious disease spread by droplet or aerosol Full size table.

Tracheal extubation Published audits and closed legal claims continue to document the risks associated with tracheal extubation. Considerations for planning for safe tracheal extubation. Table 11 Potential causes of an at-risk extubation Full size table. Table 12 Strategies to address the at-risk patient upon tracheal extubation Full size table.

Human factors and the anticipated difficult airway The NAP4 study 1 and published closed legal claims 2 , 3 have indicated that airway management misadventure was often associated with inadequate evaluation and lack of a pre-determined airway strategy. Table 13 Potential human factor issues during patient evaluation and airway management decision-making, with suggested mitigation strategies Full size table. Summary and key recommendations Informed by publications of airway-related morbidity, 1 , 2 , 3 guidelines should not only address management techniques for the difficult airway when encountered in the unconscious patient but also emphasize the need for detailed patient evaluation, planning, and communication.

Briefly summarized, our guiding principles and recommendations are as follows: Airway evaluation of the patient should always occur before embarking on airway management; Airway evaluation includes bedside examination seeking predictors of technical difficulty with FMV, SGA use, tracheal intubation, and eFONA.

Nasopharyngoscopy or VL under local anesthesia can add useful information about the patient with known or suspected glottic or supraglottic pathology; Information gleaned from the airway evaluation must be synthesized into the safest decision on how to proceed with airway management.

PubMed Google Scholar Intersurgical. Author contributions See Appendix. Disclosures See Appendix. Funding None. Editorial responsibility This submission was handled by Dr. Wong MD Authors J. Adam Law MD View author publications. View author publications. Additional information Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Adam Law, MD Focus Group chair; data acquisition, analysis and interpretation; writing and critically revising article; final approval of version to be published. Work supported by the Department of Anesthesia, Dalhousie University.

Laura Duggan, MD Data acquisition, analysis and interpretation; critically revising article; final approval of version to be published.

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