Awake endotracheal intubation and prone patient self-positioning: anesthetic and positioning considerations during percutaneous nephrolithotomy in obese patients.

BACKGROUND AND PURPOSE: Obesity is associated with adverse outcomes with certain urologic procedures and may make patient positioning more difficult. We describe our technique of awake intubation and prone patient self-positioning before percutaneous nephrolithotomy (PCNL), and review the literature regarding prone positioning in obese patients and the impact of obesity on PCNL. METHODS: Patient preparation begins with detailed preoperative counseling regarding the procedure. Premedication with a sedative and antisialagogue is followed by airway topicalization to suppress gag reflex and pain. Fiberoptic bronchoscope intubation is then carried out. The patient then positions himself/herself comfortably before induction of general anesthesia. RESULTS: We have successfully performed awake intubation and patient prone self-positioning followed by PCNL, most recently in a 58-year-old (body mass index 51.3 kg/m(2)) man with a history of gastric bypass, diabetes mellitus, and hypertension, without added morbidity. Adverse effect on patient cardiopulmonary dynamics can be minimized in the prone position. CONCLUSIONS: The technique of awake intubation with prone patient self-positioning can be helpful for positioning morbidly obese patients before PCNL and has been safe and effective in properly selected patients. Efficacy of PCNL should not be impacted by obesity or prone positioning and morbidity minimized provided that surgical and anesthesia teams understand and safeguard against potential complications.

Medical complications drive length of stay after brain hemorrhage: a cohort study.

INTRODUCTION: Longer length of stay (LOS) is associated with higher complications and costs in ICU patients, while hospital protocols may decrease complications and LOS. We hypothesized that medical complications would increase LOS after spontaneous subarachnoid (SAH) and intracerebral (ICH) hemorrhage after accounting for severity of neurologic injury in a cohort of consecutively admitted patients. METHODS: We prospectively recorded admission characteristics, hospital complications, and LOS for 122 patients with SAH and 56 patients with ICH from February 2006 through March 2008. A multidisciplinary Neuro-ICU team included a dedicated pharmacist and intensivist on daily rounds. Hospital protocols set glucose control with intravenous insulin, ventilator bundles, pharmacist involvement, and hand hygiene. Associations were explored with univariate statistics (t-tests, ANOVA, or non-parametric statistics as appropriate) and linear regression (repeated after log transformation of ICU and hospital LOS). RESULTS: Factors associated with longer LOS after SAH and ICH were similar. In both SAH and ICH the strongest drivers of LOS were infection, fever, and acute lung injury. For SAH, vasospasm and Glasgow Coma Scale were also significant in some models, while in patients with ICH the volume of the initial bleed was significant in some models. CONCLUSION: LOS after spontaneous brain hemorrhage is driven by medical complications even after the adoption of dedicated intensive care medical staff, pharmacist involvement, and evidence-based protocols for ICU care. Further alterations in care will be necessary to eliminate "preventable" complications and minimize LOS after brain hemorrhage.

Assessment and management of patients with pulmonary disease.

OBJECTIVE: Often, the critically ill are not optimized in terms of their chronic diseases and are with little physiologic reserves. DATA SOURCES: This article contains a review of the pathophysiology of the major preexisting and chronic pulmonary disease encountered in the critically ill, such as asthma, emphysematous disease, and chronic bronchitis. It also includes a summary of other significant disease processes such as acute respiratory disease syndrome, cigarette smoking, and pulmonary alveolar proteinosis and the implications of obesity and obstructive sleep apnea. When confronted with critical illness, the morbidity is magnified. Close observation of patients for evidence that the underlying disease may complicate their pulmonary status, and vice versa, creates an environment where the whole patient can heal and recover from illness. CONCLUSION: The aim of the intensive care unit team should be recognition of the patient at risk, use of necessary therapies (i.e., bronchodilators) as early as feasible, and treatment titrated to realistic endpoints as the acute illness progresses and subsequently resolves.