Background: Airway management of the critically ill patient is challenging. An audit of airway management in the UK reported higher incidence of significant airway complications (death and hypoxic brain damage) in the Intensive Care Unit (ICU) compared to regular anesthetic practice in the operating theatre.1 Virtual bronchoscopy (VB) can be valuable in airway management in the ICU. Methods: Virtual reality (VR) emerged in the clinical field 20 years ago2,3 utilizing graphics, high-end information technology, advanced sensors, and human-computer interfaces to create an immersive and interactive artificial environment. Conversion of standard radiological Computer Tomography (CT) images as computer-generated simulation of airway anatomy is referred to as VB or virtual endoscopy (VE).2,3 VB allows the display of high-resolution airway images down to 6/7th bronchial subdivisions and simulates findings of traditional fiberoptic bronchoscopy (FOB)3 (Figures 1 and 2).The indications of VB in ICU include evaluation and management of tracheobronchial stenosis, airway trauma, inhalation injury, foreign body aspiration, tracheostomy tracheoesophageal fistula (TOF) (3), and bronchopleural fistula (BPF)2. Results: VB has several advantages including non-invasiveness, non interruption of mechanical ventilation or potential loss of airway, and no need for specific patient preparation. In addition, there is no exposure to contrast and it can be accomplished within a minute. VB allows airway evaluation of intra- and extra-luminal airway structure from all angles in isolation from its surroundings. Being operator-independent is a major advantage of VB.4 FOB has significant limitations and potential complications. These include limited access via severe stenosis, inability to evaluate caliber and morphology of post-stenotic airway, limited information about airway surrounding structures in addition to risk of hypoxia, hypercarbia, and de-recruitment. Notably there is absence of bronchial colour or texture information, no endobronchial gesture such as bacterial sampling is possible, there are many false negatives and false positives, and the reproducibility of the measurements is still mediocre. Adequate sedation is needed during FOB with associated hazards. Moreover, risks of airway trauma, bleeding, pneumothorax, infection, and increased airway pressure with FOB have been observed.2–4 In tracheobronchial stenosis, VB showed sensitivity of 63–100% and specificity of 61–99%, allows examination of the post-stenotic section of tracheobronchial tree and provides information about extra-luminal pathology.3 VB is safe and well-tolerated by critically ill patients and does not pose a risk of contamination or infection of critically ill immunocompromised patients.3 3D reconstruction and VB can be performed either by the radiologist, anesthetist or surgeon on an appropriate workstation utilizing widely available software to generate an internal simulated view of the airway or the pathology. This can be utilized to formulate an airway manage...
It is assumed that lower endotracheal tube (ETT) cuff pressure is associated with a lower incidence of postoperative sore throat. However, this is not confirmed in many studies. The relation between ETT size and cuff pressure and the incidence of postoperative sore throat were studied in three different facilities. Methods: Three facilities at Hamad Medical Corporation, Qatar, Tertiary care hospital/ two secondary care hospitals (2ry (1) and 2ry (2)) were addressed in this study. ETT cuff pressure and size were measured by blinded observer after induction of general anesthesia and patients' intubation before the surgery. The sore throat was recorded after full recovery of the patients and before discharge from PACU by a blinded observer. Statistical analysis was performed using Chi-square for comparing between two categorical variables, Pearson Correlation for parametric variables were used to correlate tube size to cuff pressure. Spearman's for non-parametric variables was used to correlate throat pain to changes in cuff pressure and tube size (Sig. is p<0.05). Results: The sore throat was not significantly correlated to either tube size or cuff pressure in the three facilities. Only at 2ry (1), the tube size was significantly correlated to cuff pressure, probably more standardized work. Conclusion: A large number of trainees at tertiary care hospitals may explain the increased incidence of postoperative sore throat and not ETT size and/or cuff pressure.
Background and Aims:Human plasma protein fraction 5% (PPF5%) is an albumin-based colloid used to expand the plasma volume during volume deficiency. The current basic medical experimental study assessed in vitro coagulation of PPF5% solution and its effects on blood coagulation and chemistry.Methods:The study involved 20 volunteers, and each volunteer donated 20–50 ml of fresh blood. Three dilutions of blood with PPF5% dilutions were prepared (30, 50, and 70%). The fibrinogen dose required to correct coagulation in the 50% diluted samples was assessed (two doses used). The thromboelastogram (TEG) measured the haemostatic parameters (fibrinogen level, initiation of coagulation [R time], kinetics [K], acceleration of coagulation [α angle], maximum amplitude [MA] and coagulation index [CI]), and the ABL gas analyser measured the blood chemistry changes.Results:All dilutions showed significant TEG and blood chemistry changes when compared to controls. The two doses of fibrinogen corrected the clot formation speed with no significant difference in speed between the two doses. Acidosis measured by the strong ion gap (SID) and pH were significant for all dilutions when compared with the baseline. The 30% dilution remained within the lower normal acceptable value while 50% dilution was beyond the critical normal values.Conclusion:In vitro PPF5% to replace blood loss up to 50% dilution did not have significant coagulation and blood chemistry effects while coagulopathy should be expected in extreme dilutions (70%). Fibrinogen in a dose equivalent to 4 gm/70 kg adult improved clot strength at 50% dilution.
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