Acute Pancreatitis with Intra Abdominal Hypertension- An Airway Issue.

Acute Pancreatitis with acute intra abdominal pressure buildup is an important ICU Airway management issue from time to time. The report below brings this to our attention and while this is primarily a combined Medical / Surgical issue there are many reasons to  rethink the problem.
The recent update of general guidelines are found in the report of the working group IAP/APA Acute Pancreatitis Guidelines.

NB: These Guidelines have been reviewed in 2015

Jiten et.al. reviewed literature and have called for an update of approaches to the problem.

Complications known to occur have been listed and of course include Acute  Respiratory Failure which is approached as indicated with support by ventilation.

The issue of surgical intervention is controversial but the surgery , if done, probably should be carried out when organ failure is beginning to emerge and perhaps less than 6 hours into failure of medical therapeutic options. 

The surgery may be best carried out via a midline incision using mesh and also , importantly , the negative pressure drainage techniques now common. (1.)  This can reduce intra abdominal pressures below the 20 mm Hg level and will permit reduced compliance ventilation. This then will reduce fluid infusions necessary to maintain cardiovascular and renal support.

Conclusion:

In short the Alert from Jiten Jaipura and his team is timely and serves to refocus our attention on the criteria of the Working Group.

1. Plaudis H. et. al. Abdominal Negative Pressure Therapy: a New Method In Countering Abdominal Compartment And Peritonitis- A Prospective Study and Critical Review Of  Literature. Ann. Intensive Care2 Suppl 1 S23, 2012 PMID 23281649

Anesthesia Change Management- Nasal Tse Pap -an example of change resistance psychology

Nasal Tse PAP- The most flexible and effective Nasal Route?

The Airway management world and anesthesia in particular now recognizes the advantages of nasal routes to oxygenation in management of challenging airway management. Change is now happening in spite of the culture of resistance. 

        There are now several strategies and techniques available including:

1. The time honored "NASAL CANNULA" strategy which has been ubiquitous but not used often historically during challenging airway encounters.-this is now being changed as the simplicity and effective use as an adjunct to pre oxygenation becomes recognized.

2. Naso Pharyngeal Cannulae have been recognized as useful to enrich oxygen distal to the nose in the pharynx. The work of Richard Levitan and Scott Weinberg repeatedly pressed the advantages of this strategy.

3. The successful development and commercialization of the " THRIVE " device has added a new strategy that is being shown to be effective by creation of "high flow nasal oxygen" induced CPAP with flow rates up to 70 L/min in adults.

4.  The conception and development of NASAL TSE PAP is , I believe , an example of systematic failure to seriously study and adopt a demonstrated and recognized optimal technology. Dr. James Tse , professor of Rutgers University department of Anesthesiology , has been demonstrating the effectiveness of nasal CPAP ( I call this NASAL TSE PAP in his honour) for perhaps 10 years. Recognition of the pivotal change possible with this teaching has been best recognized by an award from the Anesthesia Patient Safety Foundation a few years ago and by repeated awards at the PGA and ASA.

     The unique value of NASAL TSE PAP is that it is far more effective that ORO-NASAL mask in many situations because of the unique splinting of the airway during ventilation. Also the transition to positive pressure ventilation is at a Medical Student Level of difficulty. The reasons for neglecting this great contribution, that works seamlessly with Video Laryngoscopy in synchronous application, is based I believe on lack of scientific discipline.

    Change management in Anesthesiology is like a popularity contest which reminds me of the adoption of the Hula Hoop in popular culture.