lefort !

A nice rundown of Anesthetic considerations available at Continuing Education in Anesthesia, Critical Care and Pain (2014): http://ceaccp.oxfordjournals.org/content/early/2013/06/28/bjaceaccp.mkt027.full

A few of the key points:

  • Nasal intubation preferred, and smooth extubation is essential
  • Watch out for local anesthestic toxicity, and they use lots of epinephrine
  • PONV is critical to avoid – use copious anti-emetics and go for TIVA
  • Remifentanil helps smoothen anesthetic and smoothens extubation
  • P/O ICU is historical, blood loss is minimal
  • Severe malocclusion can be intubation difficult
  • Surgeons prefer induced hypotension to minimize bleeding, remi helps this
  • Know post-op if patient will have wired jaw (clippers at bedside in pacu)
Quite the jaw thrust
Quite the jaw thrust (from Elsevier, via article cited)
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Magnesium: a versatile drug for anesthesiologists

From: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726845/

MOA: multiple including blockade of nmda and Calcium channels 

Magnesium has multiple advantages including:

  • Reduced opioid reqs post op
  • Reduced Mac with tiva
  • Tiva reduced remi use -> reduced hyperanalgesia post op
  • Intrathecal MG prolongs labor analgesia, especially motor block and iv Mg prolongs muscle blockade when spinal wearing out 
  • Potentiates Nondepolarizing blockade,  can improve incubating conditions while reducing hemodynamic response to intubation 
  • Reduced post op shivering >70%

However caution:

  • Reduced inh Mac questionable 
  • Blunts release of NE / epi watch out in critically ill patients 
  • Cardiovascular depression possible when given as bolus 

Dosing: 

loading dose of 30-50 mcg/kg followed by a maintenance dose of 6-20 mcg/kg/h (continuous infusion) until the end of surgery; alternatively 4mg bolus

Midazolam for PONV

From Wick, Elizabeth, and Christopher L. Wu. “The Effect of Intravenous Midazolam on Postoperative Nausea and Vomiting: A Meta-Analysis.” (2015).

The gist: Midaz at any point reduces PONV by up to 40%!

BACKGROUND: Research has shown that high-risk surgical patients benefit from a multimodal therapeutic approach to prevent postoperative nausea and vomiting (PONV). Our group sought to investigate the effect of administering IV midazolam on PONV.
METHODS: This meta-analysis included 12 randomized controlled trials (n = 841) of adults undergoing a variety of surgical procedures that investigated the effect of both preoperative and intraoperative IV midazolam on PONV in patients undergoing general anesthesia.
RESULTS: Administration of IV midazolam was associated with significantly reduced PONV (risk ratio [RR] = 0.55; 95% confidence interval [CI], 0.43–0.70), nausea (RR = 0.62; 95% CI, 0.40–0.94), vomiting (RR = 0.61; 95% CI, 0.45–0.82), and rescue antiemetic administration (RR = 0.49; 95% CI, 0.37–0.65) within 24 hours. Individual subgroup analyses of trials excluding the use of thiopental for induction, trials of either female sex or high-risk surgery, trials involving nitrous oxide maintenance, and trials using midazolam in combination with known antiemetics all yielded similar reductions in PONV end points within 24 hours of surgery.
CONCLUSIONS: Administration of preoperative or intraoperative IV midazolam is associated with a significant decrease in overall PONV, nausea, vomiting, and rescue antiemetic use. Providers may consider the administration of IV midazolam as part of a multimodal approach in preventing PONV.