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B. Volkar, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.

Deputy Director, Perelman School of Medicine at the University of Pennsylvania

Contraindications There is a long list of absolute and relative contraindications which can be found in any Anesthesia text. The latter two causes are usually relative while the genetic defect can produce a complete lack of pseudocholinesterase activity in homozygous individuals. The use of succinylcholine in a patient with pseudocholinestersase deficiency leads to prolonged paralysis. Internal Internal Medicine specialists use neostigmine (or its relative, pyridostigmine) for the treatment of myasthenia gravis. Mechanism of Action Anticholinesterases inhibit the breakdown of acetylcholine (Ach) in the synaptic cleft by inhibiting the cholinesterase enzyme. It must be given with an anticholinergic (atropine or more commonly glycopyrrolate) in order to minimize these effects. Neostigmine does not antagonize succinylcholine and may prolong phase 1 block of succinylcholine. Clinical uses in anesthesia include the treatment of bradycardia; as a antisialagogue for awake intubation; or (most commonly) for counteracting the muscarinic effects of the anticholinesterases used for the reversal of neuromuscular blockade. Clinical use in anesthesia includes the treatment of bryadycardia and asystole; as a antisialagogue for awake intubation; or for counteracting the muscarinic effects of the anticholinesterases used for the reversal of neuromuscular blockade. Onset Immediate Duration 1-2 hours Elimination Hepatic, renal Effects Most effects result from the anticholinergic action of atropine. Has additive anticholinergic effects with antihistamines, phenothiazines, tricyclic antidepressants, mono-amine oxidase inhibitors and benzodiazepines. Contraindications Contraindicated in patients with narrow-angle glaucoma, gastrointestinal or genitourinary obstruction. Etomidate Image courtesy of the Wood Library-Museum of Anesthesiology, Park Ridge, Illinois. Can also be used for maintenance of anesthesia or for sedation, in each case by continuous infusion. Occasionally excitement, tonic-clonic movements or opisthotonus is seen on induction with propofol. Propofol must be used with caution in patients with poor left ventricular function or critical coronary artery insufficiency or in those who are seriously ill or debilitated. Must be used with caution in patients with poor left ventricular function or critical coronary artery insufficiency or in those who are seriously ill or debilitated. Can be used as an induction agent (usually in hemodynamically-compromised patients) or for sedation during painful procedures. Duration Approximately 10-15 minutes after single induction dose, with full orientation occurring after 15-30 minutes. However, ketamine does possess direct myocardial depressant effects which may lead to worsened hypotension in patients in a prolonged shock state. Undesirable psychological reactions are common on emergence: vivid, unpleasant dreams, excitement, confusion, fear. They tend to occur in the first hour of emergence and abate within one to several hours. Etomidate suppresses corticosteroid synthesis in the adrenal cortex and can lead to primary adrenal suppression. Nitrous oxide Image courtesy of the Wood Library-Museum of Anesthesiology, Park Ridge, Illinois. Has the potential to increase intracranial pressure which can be mitigated with hyperventilation. Rapid elimination requires initiation of post-operative analgesia prior to emergence. If given for prolonged periods, wake-up will be slower as adipose stores have been saturated and are slow to offload. Sevoflurane is sweet-smelling and not as irritating to the respiratory tract as desflurane. Potential nephrotoxicity due to Compound A which is produced through contact with soda lime.

The intensity must therefore be increased until the patient has a pins and needles sensation (tingling) that is not considered painful. For neuromuscular electrostimulation programmes which do not cause tetanic muscle contractions (frequencies < 10Hz), the energies must be increased gradually until muscle twitching is produced that can be clearly seen or felt. To start the programme, you will need to increase the energy levels in the channels you are going to use. The different energies reached during the contraction phase are shown by a series of black bar graphs. Press it twice to increase the levels in the first 3 channels, and 3 times to increase the levels in the first 2 channels. If you start a programme with the 2+2 function the following screen will be displayed. The session will resume at 80% of the energy levels that were being used prior to the interruption. If the error message persists when the unit is switched on again have the unit insprected by an authorised service technician before using it again. The corresponding data is transferred automatically from the sensor to the stimulator! It performs a key function in that it measures certain physiological characteristics of the muscle to be stimulated and transfers this data to the stimulator, which, in turn, analyses the data and adapts its parameters accordingly. This tailoring of each programme to the changing condition of the muscle clearly enhances both patient comfort and therapeutic efficacy. By purchasing more cables with Mi-sensors it is possible to take advantage of the Mi-technology on the 4 channels. By purchasing one or more cables with Mi-sensors it is possible to take advantage of the Mi-technology. It allows the stimulator to adjust the width (duration) of the pulse to the measured chronaxy value. Using a width (duration) of the pulse corresponding to the chronaxy of the stimulated muscle allows the use of the minimum power to obtain the same muscle response. During this time, a horizontal bar will move up and down the figure on the left of the screen. It is essential that the patient remains completely still and relaxed while these measurements are being taken. Note that certain people might feel an unpleasant tingling sensation during the test. Once the test is complete, a symbol will appear on the screen indicating that the programme can be started. A testing phase takes place systematically after each increase in stimulation intensity. In order to allow its smooth progress it is essential to remain perfectly still during this time. According to the test results recorded by the device, the level of stimulation intensities may be slightly decreased automatically. Contraction by electrostimulation is perfectly controlled by voluntary triggering of muscle contraction. Underperforming muscles may, in some cases, impede the onset of electrically induced contraction. At the end of the first contraction an active rest phase begins, characterised by muscular twitches. The voluntary triggering of a new contraction is only possible after a minimum rest period, which varies depending on the programme. As soon as the voluntary triggering of a contraction is possible, the device emits a beep to inform the user.

The "4/2/1 rule" to calculate maintenance requirements applies equally well to the pediatric patient. The blood volume of a child is greater, relative to their weight, compared to the adult (Table 20). This becomes important when calculating estimated blood loss as a percentage of the estimated blood volume as is done to guide to transfusion therapy. Because of its glucose and sodium concentrations, 2/3 D5W-1/3 N/S is appropriate for maintenance fluid administration in adults and children. In the operating room, we routinely administer N/S or R/L for maintenance because it is the crystalloid of choice for replacing blood volume and third space losses, which make up the bulk of the fluid needs in the intra-operative period. In infants and young children, however, it is less appropriate to use N/S or R/L for maintenance especially during prolonged cases. For 96 example, it is common practice to allow clear fluids from 2-4-hours pre-operatively in children under 12 years of age. Infants may be allowed breast milk up to 4 hours pre-operatively and formula up to 6 hours preoperatively, breast milk being more readily digestible than formula. By 6 months to a year of age, infants become sufficiently aware of their surroundings to feel anxiety in the immediate pre-operative period. They are generally less inhibited about expressing their anxiety than their adult counterparts. There are many different approaches to minimizing this anxiety which must be individualized according to the needs of the patient, her parents and the anesthesiologist. Pediatric patients may be pre-medicated with benzodiazepines, opioids or anticholinergics. Unfortunately the administration of a premedication (even orally) can be distressing for these patients. In many centers a parent is allowed in the operating room for induction to avoid separation anxiety for the child. This requires additional personnel to prepare and stay with the parent throughout. Studies have failed to show a clear benefit to the child with this technique although the parents, for the most part, seem to prefer it. Anesthesia Care in Remote Locations As diverse and ever-evolving as operating room practice is, anesthesiologists also have many opportunities to expand their practice outside of this realm. Anesthesiologists may provide conventional anesthetic services in locations remote from the operating room, such as radiology, burn center, endoscopy unit, lithotripsy unit, electrophysiology lab, or cardiac investigation unit. The anesthesiologist is often requested to monitor and sedate patients in order to render interventional procedures safer and more palatable to the patient. General anesthesia outside the operating room poses unique problems for the anesthesiologist and certain risks for the patient. Nonetheless, with adequate preparation and appropriate care, general anesthesia can be carried out almost anywhere. As an expert in airway management, vascular access and fluid resuscitation, the anesthesiologist is a key member of the trauma team. The team resuscitates the patient, establishes the extent of injury and carries out appropriate investigations. Often, these victims arrive in the operating room urgently, where resuscitation is vigorously continued before and during the anesthetic. Many anesthesiologists spend a proportion of their clinical time working in the intensive care setting. Many anesthesiologists pursue specialty training in critical care after their residency training. These interventions are intensive and brief; they require constant and ongoing assessment to ensure safety and effectiveness. Acute pain management requires a special set of skills that contributes greatly to patient recovery and satisfaction.

Other factors that can affect healing times are tobacco and alcohol use, steroid use, and general nutritional health. A comprehensive checklist of known complicating diagnoses can easily be filled out by your patient prior to initial evaluation. Make sure to allow room for "other" on your list so that patients can go into detail and/or give you approximate surgical dates. Comorbidities Osteoarthritis Osteoarthritis occurs when the cartilage that cushions the ends of bones in synovial joints gradually deteriorates and becomes rough. As the cartilage starts to deteriorate, movement/activity causes increased friction on the two ends of the bones, which irritates the cartilage even more, causing the "wear and tear" to the joint surfaces. Eventually, if the cartilage wears down completely, the patient has bone rubbing against bone, which is typically (but not always) painful. While patients do have a higher risk of developing secondary arthritis, particularly patients with intraarticular fractures, this question should be deferred to the physician so as to not cause any confusion or conflicting information. Not all cases of arthritis are symptomatic, so I believe it is not within our scope of practice ethically to determine whether or not a patient is at risk for developing painful arthritis. Passively stretching patients with rheumatoid arthritis should be done with extreme care, as this could exacerbate alignment dysfunction and cause more pain and disability for patients. Rheumatoid arthritis is not commonly symptomatic in the elbows, but should be considered and reviewed with the patient and physician. Osteoporosis Osteoporosis and osteopenia are common degenerative changes noted in the elderly population, where the body has a reduced capacity to rebuild or remodel bone. In other words, the body perceives otherwise normal stimuli as painful, and responds with severe pain. Patients begin having difficulty sleeping, making them more irritable and less tolerant of pain. Patients can also begin having increased anxiety, forgetfulness, and loss of concentration. Patients may have increased difficulty remembering their home programs and even clinic exercises because they become consumed with pain. They report that they feel "out of control" in many area of their lives as the symptoms persist. If these symptoms present themselves, contact the physician to discuss your findings. Patients do not respond well to any passive treatment such as manual soft tissue mobilizations, joint mobilizations, or passive range of motion. Even when the patient does not complain of pain during these activities, they will oftentimes have a rebound and exacerbation of symptoms following a manual treatment. Allow your patient to work at her own pace and her own comfort level, which will most likely change from treatment to treatment. Although your patient may not get "full range of motion" or seem to be making significant gains, the premise behind this type of treatment is that you are reducing the central sensitization that has occurred in the brain. Patients need to be reminded to respect their body, and that they have total control over their rehabilitation. I usually put together a clipboard of suggested activities including desensitization, stress loading, fine motor, gross motor, open-chain and closed-chain activities, and even online apps and games to play. My patients are told to do the activities in any order they please at whatever pace they please and to report back how they are feeling. Lymphedema Patients with a history of lymphedema will need extra care and attention toward their edema management, as swelling is the complication that most commonly affects functional outcomes in 54 patients with elbow trauma. Make sure to educate your patients who feel that they have their lymphedema under control that an onset of new injury can exacerbate their symptoms. Lymphedema management takes diligence and consistency and should not be overlooked in this population. Other pertinent questions, considerations, and clarifications after trauma to the elbow: How long was the patient immobilized?