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Delirium
Published in Henry J. Woodford, Essential Geriatrics, 2022
So, benzodiazepines have a limited role in delirium management when it is provoked by drug or alcohol withdrawal or associated with seizures. Antipsychotic drugs may be better for treating psychosis and aggression in highly selected people, whereas benzodiazepines may be preferable if sedation is the main aim. Sedation could be required to enable essential medical therapies, such as intubation (under the specialist care of an anaesthetist).5 However, such scenarios are not common among hospitalised frail older people. Given the fluctuating nature of delirium, it is better to postpone less urgent interventions.
Patient Transfer
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
The commonest reason for transfer is for neurosurgical intervention, as these services are now organized on a regional (tertiary) basis. In this cohort, careful medical management can significantly reduce secondary brain injury. There are clear guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and brain trauma foundation on the best way to manage brain-injured patients requiring critical care.12, 20 Tight control of ventilation and oxygenation is vital; hypoxia should be avoided as should hypercarbia. Equally prolonged periods hyperoxia should be avoided and PaCO2 should be kept between 4.5 and 5.0 kPaPaO2 > or equal to 13 kPa Blood gases are unlikely to be available during transfer. There is often a significant and unpredictable difference between arterial CO2 (PaCO2) and end tidal CO2 (ETCO2). Once established on the transfer ventilator and circuit, a blood gas confirming the difference between PaCO2 and ETCO2 is essential prior to departure. In order to achieve satisfactory ventilation, intubation may be required. The indications for intubation for brain-injured patients are in Box 32.2.
Weaning from Mechanical Ventilation
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
Recent efforts have focused on processes for caring for the patient after extubation to prevent reintubation. The use of non-invasive ventilation as a rescue modality in patients with respiratory failure following extubation fails to prevent reintubation and is associated with increased mortality [6]. However, extubation directly to non-invasive ventilation before any failure has occurred has been studied, and for patients with chronic obstructive lung diseases demonstrated a decrease in the rates of post-extubation respiratory failure and 90-day mortality [7]. More recently, extubation directly to a high-flow nasal cannula for patients with a high risk of post-extubation respiratory failure was found to be effective in preventing respiratory failure and in reducing the rate of reintubation [8].
Myasthenic crisis as an initial presentation of myasthenia gravis in an 81-year-old following endoscopic myotomy for Zenker’s diverticulum
Published in Baylor University Medical Center Proceedings, 2023
Daniel Tran, Lucas Fair, Bryana Baginski, Bola Aladegbami, Steven Leeds, Marc Ward
In patients presenting in myasthenic crisis, airway support is paramount for optimal outcomes. Patients with appropriate mentation and secretion management may be candidates for noninvasive positive pressure ventilation or bilevel positive airway pressure. Intubation can be performed if necessary, and decisions regarding this are similar to those for other critically ill patients. Once a patient with myasthenic crisis is stabilized, further evaluation can be performed to evaluate for triggers. Infectious evaluation may include a chest radiograph, complete blood count, urinalysis, and blood cultures. As metabolic abnormalities can result in crisis, electrolyte levels and thyroid function tests should be checked. Pregnancy can precipitate crisis, and beta-human chorionic gonadotropin levels should be obtained in females of childbearing age. Creatinine kinase levels can be measured to evaluate for other myopathies. Electrocardiography is useful in evaluating a cardiac dysrhythmia or a toxicologic etiology. Arterial or venous blood gases may not be useful for diagnosing crisis, but can help with ventilator management. Plasma exchange and intravenous immunoglobulin are the primary treatments for myasthenic crisis.12 If the trigger is identified, the underlying cause should be treated concurrently.
Effect of COVID-19 on the incidence of postintubation laryngeal lesions
Published in Baylor University Medical Center Proceedings, 2023
Madison Buras, Nicole DeSisto, Randall Holdgraf
Recent research has shown a high prevalence of glottic injury with prolonged intubation, ranging from mild soft tissue injury to more severe glottic stenosis and vocal fold hypomobility.1,2 With the increased duration and number of intubations during the COVID-19 pandemic, our otolaryngology division noticed an increased incidence of laryngeal injuries on fiber-optic endoscopic evaluation of swallowing (FEES) exams. Various laryngeal injuries, including vocal fold immobility, ulcerations, granulomas, and stenosis, can result from intubation. Laryngeal injuries can hinder swallowing, vocal, and, most importantly, respiratory function. Determining whether this increase is, in fact, more common in COVID-19 patients and identifying possible risk factors may reveal ways to decrease potential morbidity.
The critical period for development of secondary restenosis following post-intubation tracheal stenosis surgery
Published in Acta Oto-Laryngologica, 2022
Yilmaz Ozkul, Murat Songu, Asuman Feda Bayrak, Akif İşlek
Sixty-one patients were included in the study. Twenty-eight (45.9%) of the patients were female and 33 (54.1%) were male. The mean age of the patients was 46.9 ± 8.5 (range, 18 to 66) years. The causes of intubation which resulted as PITS were multiple trauma (n = 21, 34.5%), respiratory distress (n = 11, 18.1%), myocardial infarction and cardiac arrest (n = 10, 16.4%), cerebrovascular disease (n = 7, 11.4%), septic shock (n = 6, 9.8%), substance overdose (n = 3, 4.9%), and undefined (n = 3, 4.9%). The duration of intubation was 12.4 ± 3.6 days (range, 1 h to 25 days). Restenosis developed in 11 (18.0%) patients. The mean follow-up period of the study population was 266.3 ± 82.6 days. Restenosis was diagnosed after a mean of 39.3 ± 38.5 (range, 22 to 155) days. A summary of the findings is given in Table 1.