Patients will occasionally report a transient paresthesia during spinal 2297 needle insertion order mentax 15 mg with mastercard fungus gnats australia. These paresthesias may be from needle to nerve root contact within the subarachnoid space or they may emanate from the dura buy 15 mg mentax with mastercard fungus gnats kill larvae. Should a44 transient paresthesia occur buy genuine mentax on-line fungus gnats soil drench, stop advancing the spinal needle, and withdraw the stylet. If the spinal needle contacts bone (A), withdraw it into the shaft of the introducer needle (B). After withdrawing the spinal needle, pivot the introducer (C) and reinsert the spinal needle (D). If using a hyperbaric solution, you will see birefringence (Schlieren lines), which indicates the mixing of solutions of differing baricities. Drug emerges directly from the tip of cutting point needles, so needle bevel orientation has no effect on the subsequent level of subarachnoid block. Pencil-point needles have side holes, which produce directional flow of injected drug. Side-hole orientation, especially caudal versus cephalad, influences the distribution of both hyperbaric and isobaric local 2298 anesthetics. Continuous Subarachnoid Spinal Anesthesia After identifying the subarachnoid space with a large-gauge needle, insert an appropriate sized catheter 2 to 3 cm into the subarachnoid space. The catheter will advance more easily and be more likely to lie cephalad to the insertion site if the bevel or orifice of the needle is directed toward the patient’s head. Caudally directed catheters may cause pooling and maldistribution of local anesthetic, which has been associated with permanent neurologic injury (see Complications). Epidural Anesthesia The epidural space can be identified with either the hanging drop or loss of resistance technique. With the hanging drop technique, place a drop of saline at the hub of the epidural needle. As the needle enters the epidural space, the drop of liquid will be pulled into the needle. Most anesthesiologists use a loss of resistance technique to identify the epidural space. When the tip of the epidural needle lies within the ligamentum flavum, there is resistance to injection. Common variations of the loss of resistance technique use air or saline in the loss of resistance syringe and intermittent or continuous pressure to advance the epidural needle. Air versus Saline Anesthesia providers often have a preference for air or saline in the loss of resistance syringe. In addition, using air makes it easier to recognize an accidental or intentional dural puncture or an intrathecal catheter. However, intracranial air, injected after an accidental dural puncture, will produce an instant headache. In47 addition, large amounts of epidural air, especially in smaller patients, may interfere with the distribution of local anesthetic. Clinical outcomes are similar when anesthesiologists use the technique48 of their choice. Grasping the wings with your index fingers and thumb, place your long fingers alongside the shaft at the site of insertion. Your thumb and index fingers advance the needle while the middle fingers control the needle’s forward movement. Intermittent versus Continuous The epidural needle can be advanced intermittently or continuously. In the United States, the intermittent, or “stop go,” technique is probably more common. The intraspinous ligament will present little resistance, whereas the ligamentum flavum will feel firm and gritty. In between each advance, firmly tap the plunger of the loss of resistance syringe. If using saline in the syringe, include a bubble of air that can be compressed with each tap. For the Bromage technique, make a fist with your nondominant51 hand and place your carpal–metacarpal joints on the patient’s back. Meanwhile, use your dominant hand to apply continuous pressure to the plunger of the loss of resistance syringe, which can contain either air or saline. Grasp the barrel of the loss of resistance syringe with your dominant hand so the metacarpal head of your index finger is positioned on the end of the plunger (Fig. Slowly advance the needle by balancing the driving pressure from your dominant hand with resistance from your bracing hand. Use the metacarpal head of the dominant index finger to exert pressure on the end of the plunger; you will perceive the loss of resistance immediately upon entering the epidural space. Here, the driving pressure is applied directly to the plunger of a saline-filled loss of resistance syringe (Fig. When the tip of the needle enters the52 epidural space, the plunger collapses and the needle stops advancing. As with the choice between air and saline, any technique done well is better than the best technique done poorly. Injecting through the needle will provide slightly faster onset but risks complications if drug is accidentally injected intrathecally or intravenously. Inserting a catheter into the epidural space encourages more careful injection of the initial dose of medication and allows the provision of epidural anesthesia or analgesia for as long as needed. Catheters can have a single orifice at the tip or multiple orifices along the distal end. Multiorifice catheters allow wider distribution of injected medication and, in laboring women, are associated with more extensive block and better analgesia. Nylon and polyamide catheters can be flimsy and kink at the hub of the epidural needle. Many come with “threading assist devices” that seat in the hub of the epidural needle and ease catheter insertion. Although the53 orientation of the epidural needle bevel will determine the initial direction of the epidural catheter, it does not reliably aim the catheter in a cephalad or caudad direction. If you meet resistance while inserting the catheter, do not withdraw and try to reinsert. Some epidural needles have a sharp inner bevel that can shear the tip of a catheter. Instead, remove both needle and catheter together and reidentify the epidural space. The dominant (right) hand advances the needle by grasping the hub while applying pressure to the plunger with the metacarpal head of the index finger.
Resuscitation was successful order mentax amex anti yeast remedies, the dexmedetomidine infusion was discontinued cheap mentax 15 mg overnight delivery fungal rash, and surgery was completed uneventfully purchase mentax on line amex fungus gnats bunnings. Several factors may have contributed to the asystolic arrest, including a centrally mediated increase in parasympathetic activity resulting from dexmedetomidine in a patient who was also being treated with pyridostigmine, which also increases vagal tone. Thus, pyridostigmine may have interacted with dexmedetomidine in an additive or synergistic manner. Such drugs include antiarrhythmics (quinidine, procainamide, calcium-channel blockers), diuretics (by causing hypokalemia), nitrogen mustards, quinine, and aminoglycoside antibiotics. Extubation of the trachea should be performed when the patients are responsive and able to generate negative inspiratory pressures of greater than −20 cm H O. Cases of mild respiratory depression may be treatable with parenteral 2646 anticholinesterase; more severe cases may require reintubation of the trachea and mechanical ventilation of the lungs. In the immediate postoperative period, postthymectomy patients often show a marked improvement in their condition and a decreased need for anticholinesterase therapy. Postoperative Respiratory Failure Myasthenic patients are at increased risk for development of postoperative respiratory failure. A study of patients undergoing transsternal thymectomy suggested that the need for postoperative mechanical ventilation correlated best with preoperative maximum static expiratory pressure. It was concluded that expiratory weakness, by reducing cough efficacy and ability to clear secretions, was the main predictive determinant. Adequate clearance of secretions is essential in these patients and may occasionally necessitate bronchoscopy. In general, the postoperative morbidity in terms of respiratory failure is lower after transcervical rather than transsternal thymectomy. If the anticipated duration of the surgical procedure is 1 to 2 hours, preoperative oral anticholinesterase therapy may be of value because the peak effect of the drug coincides with the conclusion of the surgical procedure and attempts at tracheal extubation. The analgesic effect of morphine and other opioid analgesics has been reported to be increased by anticholinesterases, which has led to the recommendation that the dose of opioid analgesics be reduced by one-third in patients receiving anticholinesterase therapy. Combined epidural–general anesthesia has been reported to provide excellent intraoperative and postoperative conditions for both surgeon and patient. The defect in this condition is prejunctional, is associated with diminished release of acetylcholine from nerve terminals, and improved by agents such as 4- aminopyridine,228 guanidine, and germine that increase repetitive firing. Affected patients are particularly sensitive to the effects of all muscle relaxants, which should be used with great caution or avoided entirely. Adequate postoperative pain control is necessary to ensure a good respiratory 2648 effort. The administration of sufficient opioid to treat pain adequately may cause sedation and respiratory depression. There are other intravenous medications that can be used for pain management in addition to opioids. A meta-analysis indicated a reduction of interleukin 6,237 and a subsequent prospective study did not corroborate that finding. The intercostal blocks can be performed internally or externally before or after surgery using a standard technique. However, the easiest method during thoracic surgery is to have the surgeon perform the blocks under direct vision from inside the thorax while the chest is open. This provides 6 to 24 hours of moderate pain relief, but patients still complain of diaphragmatic and shoulder discomfort caused by the chest tubes. Larger volumes of local anesthetics should not be used in the intercostal space because of the high absorption rate and attendant systemic toxicity that can be produced, as well as the possibility of pushing the drug centrally and producing a paravertebral sympathetic or epidural block with central sympatholysis and severe hypotension. The intraoperative placement of catheters in intercostal grooves allows for a continuous postoperative intercostal nerve block. Placement of a catheter in the paravertebral space allows for 2649 blockade of multiple levels of intercostal nerves. This technique has been reported to provide good analgesia, and with fewer side effects than epidural analgesia. Epidural morphine produces profound analgesia lasting from 16 to 24 hours after thoracotomy and does not cause a sympathetic block or sensory or motor loss. These are significant advantages over systemic opioids or infiltration of local anesthetics. Epidural opioids are most effective at alleviating pain when administered at the thoracic level. Epidural morphine has been shown to decrease pain and improve respiratory function in postthoracotomy patients. On the basis of a meta-analysis of 100 studies in the National Library of Medicine’s PubMed database from 1966 to 2002, Block et al. There may be a reduction in both morbidity and mortality with epidural or spinal analgesia. Subarachnoid (intrathecal) morphine, in a dose of 10 to 12 μg/kg, has been successfully used after thoracic surgery. When morphine is given intrathecally before the induction of anesthesia, a decrease in the dose of anesthetic drugs required may occur. All patients who have received subarachnoid or epidural opioids must be closely observed for potential side effects, including delayed respiratory depression, urine retention, pruritus, nausea, and vomiting. Despite over 30 years of usage, it is still not clear what dosage is optimal for this type of surgery. The administration of analgesic agents before surgery is termed preemptive analgesia and may prevent these neuroplastic changes, thereby decreasing postoperative pain. The injection of local anesthetic between the pleural layers can block multiple intercostal nerves and/or pain fibers traveling with the thoracic sympathetic chain. The chest tubes should not be suctioned for approximately 15 minutes after injection of local anesthetic to avoid loss of the anesthetic into the drainage. The surgeon can also place in the wound a soaker catheter, through which local anesthetics can be administered postoperatively. Although ketamine reduces pain acutely, it does not have a long-term effect, either intravenously or by the epidural route. Although celecoxib has been shown to improve acute postoperative pain following 2651 thoracic surgery as an adjunct to epidural analgesia (Senard), there is no data on an impact on post thoracotomy pain syndrome. Once developed, post- thoracotomy chronic pain is difficult to treat, as it is a form of neuropathic pain. The pain that occurs may be related to trauma to intercostal nerves by insertion of the surgical trocars or by compression during the surgery. In addition, an incision will be required to extract a lobe in the case of a lobectomy, which may exacerbate pain further. If the preoperative lung function is poor, such that the patient may have difficulty breathing adequately postoperatively or may not tolerate systemic opioids, it also may be more prudent to place an epidural for that situation also. In contrast with an epidural, the paravertebral block is unilateral, and does not cause a sympathectomy. The administration of local anesthetic via the chest tubes is another approach which can successfully treat postoperative pain.
Direct surgical access is achieved through with the two layers allowing for separation during blunt incision through the maxillary vestibular mucosa above the dissection buy cheap mentax online antifungal ysp. Te areolar cleavage plane overlies the lower mucogingival junction (Figure 8-1 mentax 15mg fast delivery antifungal pills over the counter, B) order mentax 15mg on line fungus gnats azamax. Te buccal and posterior directions, which permits the spread of pathol- space frequently communicates posteriorly with the mastica- ogy both to and from the buccal space. Surgical access to this space may be space and suspicion of malignancy, may require a preauricular achieved intraorally in the case of simple infections, but may or submandibular approach. Infection in this space may temporal line and passes inferiorly to the zygomatic arch. However, primary infection in this is rare extremely dense and frm fbrous connective tissue. Com- and is generally blood-borne or retrograde through the municating facial-zygomaticotemporal nerve branches pierc- parotid duct. Te fascia that forms the borders of the masseteric space is a well-defned fbrous tissue that surrounds the muscles of mastication and contains the internal maxillary artery and Suprahyoid Fascial Spaces the inferior alveolar nerve. It is bounded anteriorly by the mandible, posteriorly by the parotid gland, medially by the Sublingual Space lateral pharyngeal space, and superiorly by the temporal space. Te sublingual space is bounded between the mylohyoid Most masseteric space infections are of odontogenic origin muscle and the geniohyoid and genioglossus muscles. Te Periapical molar infections may perforate the lingual man- submasseteric space is bounded laterally by the masseter dible cortex above the mylohyoid line and spread to this muscle, medially by the mandible ramus, and posteriorly by space. Infections are mostly of odontogenic origin approach, but when other spaces are involved extraoral (usually a mandibular third molar) and are often misdiag- access may be utilized, usually through a submandibular nosed as a parotid abscesses or parotitis. Te submental space is bounded anteriorly by the symphysis of the mandible, laterally by the anterior bellies of digastric Pterygomandibular Space muscles, superiorly by the mylohyoid muscle, and inferiorly Te pterygomandibular space is bounded by the mandible by the superfcial fascia of the platysma muscle. No vital laterally and medially and inferiorly by the medial ptery- structures traverse the submental space. Te posterior border is formed by the parotid involved in odontogenic infections from the anterior man- gland as it curves medially around the posterior mandibular dibular teeth, as benign or malignant lesions in this area ramus and anteriorly by the pterygomandibular raphe, the are rare. Te inferior alveolar and lingual nerves, other struc- access through an extraoral incision below the chin. When tures in this space, are of particular importance in the infection has spread to this space, it represents one of the administration of local anesthesia, including the inferior components (along with bilateral submandibular and sublin- alveolar vessels, the sphenomandibular ligament, and the gual space involvement) of Ludwig’s angina. Te submandibular space extends from the hyoid bone to the Te buccopharyngeal gap is a potentially dangerous con- mucosa of the foor of the mouth and is bound anteriorly and nection between the submandibular and lateral pharyngeal laterally by the mandible and inferiorly by the superfcial layer spaces that is created by the styloglossus muscle as it passes of the deep cervical fascia. Te mylohyoid muscle separates between the middle and superior constrictors, which may it superiorly from the sublingual space, which communicates allow infection to spread directly to the lateral pharyngeal with it freely around the posterior border of the mylohyoid. Surgical access for drainage may be either intraoral or Te mylohyoid muscle also plays a key role in determining extraoral. When infection has spread to the bilateral subman- the direction of the spread of dental infections. It attaches dibular spaces, it represents one of the components (along to the mandible at an angle, leaving the apices of the second with submental and bilateral sublingual space involvement) and third molars below the mylohyoid line and the apex of of Ludwig’s angina. Periapical molar infections may almost always through multiple extraoral incisions. Te lateral pharyngeal space can riorly by the attachments of the infrahyoid muscles and their be divided into anterior (prestyloid) and posterior (retrosty- fascia to the thyroids cartilage and to the hyoid bone, and loid) compartments by the styloid process. Te anterior com- continues into the anterior portion of the superior mediasti- partment contains only fat, lymph nodes, and muscle, whereas num bounded inferiorly by the sternum and scalene fascia. Rotation of the neck away from the side and thyroid gland between the levels of the inferior thyroid of swelling causes severe pain from tension on the ipsilateral artery and the oblique line of the thyroid cartilage. As this space communicates may allow infection to spread into the superior mediastinum, with the other fascia spaces, spread of infection may also arise as these spaces communicate. Posterior space involvement may have more ominous Fascial Spaces of the Neck signs. Lemierre syndrome may result from pharyngitis or tonsillitis with bacterial spread to the lateral pharyngeal space Te fascial spaces of the neck all lie between the deep cervical that may involve internal jugular vein thrombosis with septic fascia surrounding the pharynx anteriorly and the spine pos- emboli and metastatic infections that most frequently involve teriorly. Te other fascial spaces of the neck bophlebitis and carotid artery erosion or thrombosis. Te intraoral approach cervical fascia, and connects posteriorly to the danger space. Tey may be complicated by the development Peritonsillar Space of supraglottic edema with airway obstruction, aspiration Te peritonsillar space is a potential space of loose areolar pneumonia due to rupture of the abscess, and acute medias- tissue that surrounds the tonsil and is bounded laterally by tinitis that may lead to empyema or pericardial efusions. Most abscesses occur in younger Proximity to the danger space may allow infection to spread patients who present with fever, sore throat, and dysphagia. Surgical drainage of choice for treatment, but treatment may include serial should be performed in the operating room via a transoral aspiration or surgical drainage with tonsillectomy. Peritonsil- approach with the head down to prevent rupture during lar abscess is a complication of acute tonsillitis that is rarely intubation and septic aspiration. Lemierre syndrome may result from Danger Space tonsillitis with bacterial spread to the lateral pharyngeal space that may involve internal jugular vein thrombosis with septic Te danger space is bounded superiorly by the skull base, 14 emboli. Danger space Carotid Sheath Space infections may track from the anteriorly located retropharyn- geal space between the buccopharyngeal fascia and alar fascia Te carotid sheath space is composed of the conjoining of and pass inferiorly to the mediastinum and the pericardium, three cervical fascias—the investing layer deep to the sterno- and they may result in conditions such as purulent cleidomastoid muscle, the pretracheal layers, and the prever- 19 pericarditis. It lies posterior to the para- pharyngeal space, lateral to the retropharyngeal space, antero- Prevertebral Space lateral to the prevertebral spaces, and medial to the parotid Te prevertebral space is bounded by the anterior part of the space and styloid process. It deep cervical lymph nodes, carotid sinus nerve, and sympa- extends from the base of the skull into the mediastinum and thetic fbers. Infections that usually arise from thrombosis of ends at the level of the fourth thoracic vertebra. Te prever- the internal jugular vein or from infection deep cervical tebral space contains the prevertebral muscles (longus colli lymph nodes that lie within the sheath tend to be localized and longus capitis), vertebral artery, vertebral vein, scalene within the cervical region between the hyoid and root of the muscles, phrenic nerve, and the proximal portion of the neck, as the sheath closely adheres to the major vessels in this 20 brachial plexus. Trombosis of the jugular vein from a deep infection radiograph, the normal dimensions of the prevertebral space of the neck is probably not due to direct infection of the in an adult are 4 mm at the C3 level, with a greater than carotid sheath but rather to the fact that infectious material 7 mm value indicating an abnormality such as pathology or follows tributaries of the internal jugular vein to reach infection. Louis, 2006, Mosby, infection: imaging manifestation and pathways rare, but life threatening: a case report with pp 25-83. Early in week 4, parts of of the head and neck—develop from three germ layers: the the most dorsal germ layer, the ectoderm, transform into the ectoderm, mesoderm, and endoderm. Te thickened epithelial cells, which form the during gastrulation, a diferentiation process occurring at the neural plate, are located at and adjacent to the embryo’s cra- beginning of week 3. Te neuronal plate invaginates along this axis, refer to the gestational age of the embryo. Te free edges of the remaining surface ecto- organogenesis is completed, and during the remaining time derm fuse over the neural tube and thereby build a continu- of pregnancy (the fetal period) the organs continue to grow ous layer, which later will diferentiate into epidermis. Te cranial portion of the 2 neural tube, the future brain, closes completely on day 25.
This will be decided over time by practitioners’ actions discount 15 mg mentax overnight delivery fungus gnats cider vinegar, debates in the literature discount mentax 15 mg amex antifungal cream yeast, mandates from malpractice insurers cheap mentax 15 mg without a prescription zinsser anti fungal paint, and, of course, court decisions. This is clearly not true, yet there is a valid concern that these will someday be held up as defining the standard of care. Accordingly, prudent attention within the bounds of reason to the principles outlined in guidelines and parameters will put the practitioner in at least a reasonably defensible position, whereas radical deviation from them should be based only on obvious exigencies of the situation at that moment or clear, defensible alternative beliefs (with documentation). The most recent type of document has been the “practice advisory,” which can seem functionally similar to a guideline, but appears to have the implication of more consensus compromise than previous documents driven more by meta-analysis of the relevant literature. Even though the desired implication is that practitioners must observe (or at least strongly consider) them, they do not have the same implications in defining the standard of care as the other documents. It may well not be a valid legal defense to justify action or the lack of action because of a company or facility protocol. As difficult as it may be to reconcile with the payer, the practitioner still is subject to the classic definitions of standard of care. The other types of standards associated with medical care are those of the Joint Commission, which is the best-known medical care quality regulatory agency. As noted, these standards were for many years concerned largely with structure (e. Joint Commission standards also focus on credentialing and privileges, verification that anesthesia services are of uniform quality throughout an institution, the qualifications of the director of the service, continuing education, and basic guidelines for anesthesia care (need for preoperative and postoperative evaluations, documentation, and so forth). Full Joint Commission accreditation of a health-care facility is usually for 3 years, although the process is considered “continuous. If there are enough problems, accreditation can be conditional for 1 year, with a complete reinspection at that time. Being ready for a Joint Commission inspection (which is unannounced and can come at any time) starts with verification that an essential group/department structure is in place. The process of “constant preparation” ultimately involves a great deal of work, but because the standards usually do promote high-quality care, the majority of this work is highly constructive and of benefit to the institution and its medical staff. These functions have migrated in recent years largely to the government insurers Medicare and Medicaid and have become fixated essentially 147 exclusively on cost issues. This will continue to occur until anesthesia providers educate their constituent surgeon community as to what types of associated medical conditions may disqualify a proposed patient from the outpatient (ambulatory) surgical schedule. If adequate notice is given by the surgeon, the patient can be seen far enough in advance by an anesthesiologist to allow appropriate planning. Because neither alternative is particularly attractive, especially from administrative and reimbursement perspectives, there may be a strong temptation to “let it slide” and try to deal with the patient as an outpatient even though this may be questionable. In almost all cases, it is likely that there would be no adverse result (the “get away with it” phenomenon). Both because of the workings of probability and because of the inevitable tendency to let sicker and sicker patients slip by as lax practitioners repeatedly “get away with it” and are lulled into a false sense of security, sooner or later there will be an unfortunate outcome or some preventable major morbidity or even mortality. Potential liability in this regard is the other side of the standard of care issue. Particularly concerning is the question of postoperative admission of ambulatory patients who have been unstable. Policy and Procedure One important organizational point that is sometimes overlooked in anesthesia practice is the need for a complete policy and procedure manual. Such a compilation of documents is necessary for all practices, from the largest departments covering multiple hospitals to a single-room outpatient facility with one anesthesia provider. Such a manual can be extraordinarily valuable as, for example, when it provides crucial information during an emergency. The organizational35 elements that should be present include a chart of organization and responsibilities that is not just a call schedule but a clear explanation of who is responsible for what functions of the department and when, with attendant details such as expectations for the practitioner’s presence within the institution at designated hours, telephone availability, pager availability, the maximum permissible distance from the institution when on call, and so forth. Experience suggests it is especially important for there to be an absolutely clear specification of the availability of qualified anesthesiology personnel for emergency cesarean section, particularly in practice arrangements in which there are several people on call covering multiple locations. Sadly, these issues often are only considered after a disaster has occurred that involved miscommunication and the mistaken belief by one or more people that someone else would take care of an acute problem. The procedural component of the policy and procedure manual should give both handy practice tips and specific outlines of proposed courses of action for particular circumstances; it also should store little used but valuable information. Policy on ambulatory surgical patients—for example, screening, use of regional anesthesia, discharge home criteria 5. Guidelines for the support of cadaveric organ donors and its termination (plus organ donation after cardiac death if applicable) 11. Guidelines on environmental safety, including pollution with trace gases and electrical equipment inspection, maintenance, and hazard prevention 12. Procedure for change of personnel during an anesthetic and documentation (particularly if a printed hand-off protocol is used) 13. Procedure for epidural and spinal narcotic administration and 150 subsequent patient monitoring (e. Procedure for initial treatment of cardiac or respiratory arrest (updated Advanced Cardiac Life Support guidelines) 16. Policy for handling patient’s refusal of blood or blood products, including the mechanism to obtain a court order to transfuse 17. Organized response to major anesthesia accident will help limit damage: Update of “Adverse Event Protocol” provides valuable plan. Each member of a group or department should review the manual at least annually and sign off in a log indicating familiarity with current policies and procedures. Meetings and Case Discussion There must be regularly scheduled departmental or group meetings. Although didactic lectures and continuing education meetings are valuable and necessary, there must also be regular opportunities for open clinical discussion about interesting cases and problem cases. Whether these meetings are called case conferences, morbidity and mortality conferences, or deaths and complications conferences, the entire department or group should gather for an interchange of ideas. An open review of departmental statistics should be done, including all complications, even those that may appear trivial. Unusual patterns of small events may point toward a larger or systematic problem, especially if they are more frequently associated with one individual practitioner. A problem case presented at the departmental meeting might be an overt accident, a near accident (critical incident), or an untoward outcome of unknown origin. Honest but constructive discussion, even of an anesthesia 151 professional’s technical deficiencies or lack of knowledge, should take place in the spirit of constructive peer review. There may be situations in which inviting the surgeon or the internist involved in a specific case would be advantageous. The opportunity for each type of provider to hear the perspective of another discipline not only is inherently educational but also can promote communication and cooperation in future potential problem cases. Records of these meetings must be kept for accreditation purposes, but the enshrining of overly detailed minutes (potentially subject to discovery by a plaintiff’s attorney at a later date) may inhibit true educational and corrective interchanges about untoward events. In the circumstance of discussion of a case that seems likely to provoke litigation, it is appropriate to be certain that the meeting is classified as official “peer review” and possibly even invite the hospital attorney or legal counsel from the relevant malpractice insurance carrier (to guarantee the privacy of the discussion and minutes). Support Staff There is a fundamental need for support staff in every anesthesia practice. Even independent practitioners rely in some measure on facilities, equipment, and services provided by the organization maintaining the anesthetizing location.