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Anaesthesia outside Operating room

Dr.Shailendra.V.L. Specialist in Anaesthesia, Al-Bukariya general

hospital.

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Introduction“ Modern Anaesthesia is quite safe”

1. Well trained anaesthesiologists2. Well trained anaesthesia technician3. Fail-proof anaesthesia machine4. Monitoring aids5. Newer and versatile drugs

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Introduction Handicap for anaesthesia

outside Operating Room:1. Geographical2. Logistics3. Material4. Manpower

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Problems faced by the Anaesthesiologists1. Lack of adequate space2. Unfamiliar surroundings & equipment3. Central pipeline will be missing & cylinders

have to be used4. Un-physiological postures needed for some

procedures5. Out-patients for investigations are

inadequetely prepared/ investigated/ have associated medical illness

6. Adverse reactions to contrast media7. Lack of post-anaesthetic care

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Areas of need outside the O.R.

1. Cardiology: Cardiac Cathetherisation Lab (Cath Lab):

1. Coronary angiogram2. Percutaneous Transluminal Coronary

Angioplasty (PTCA)

2. Radiology: 1. C.T.Scan2. MRI3. Radio-therapy

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Areas of need outside the OR3. Psychiatry:

1. Electro-convulsive therapy (ECT)

4. Plastic Surgery:1. Burn’s dressing

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Anaesthetic Plan

1. Good Anaesthetic machine2. Minimum monitoring standards3. Resuscitation equipment / drugs4. Manpower (anaesthetic /

technical)5. Simple & safe anaesthetic

technique

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Anaesthesia machine1. O2 supply failure alarm2. Automatic N2o cut-off system3. Back-lit fluorescent back for the

flowmeters4. Bain’s circuit with long tubings5. Well serviced anaesthesia machine6. Anaesthesia ventilator

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Monitoring standards1. ECG – electro cardiogram2. NIBP- non-invasive blood pressure3. SpO2 – pulse-oximetry4. FI02 – inspired oxygen fraction5. ETCO2- end-tidal carbon-di-oxide6. Ventilator disconnect alarm

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Special procedures in Cardiology department1. Coronary Angiogram2. Per-cutaneous Trans-luminal Angioplasty

1. Done under local anaesthesia 2. Painless procedure3. Only minimal sedation needed

3. Problems: 1. Severe coronary artery disease 2. Injury to coronary vessels needs emergency

CABG

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Special procedures in Psychiatry department

1. Electro-convulsive therapy: Non-pharmacological mode of treatment Commonly used for depression 70-130 volts current is passed for 1 second

through two cerebral hemispheres Shock produces muscular contraction Causes initial parasympathetic discharge

followed by sympathetic surge Causes retrograde amnesia

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Anaesthesia for E.C.T.1. Pre-anaesthetic assessment difficult in un-

communicative patients2. MAO inhibitors & tricyclic anti-depressants

have drug interaction with pethidine and barbiturates

3. No pre-medication is given4. Plan: Induction: Thiopentone – 4mg/kg5. Relaxant: Suxamethonium 1mg/Kg6. Patient is manually ventilated with the

bite-block in place7. ECT given8. Patient is ventilated till he recovers from

the relaxant effect

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Plastic surgery-Burn’s dressing Problems posed by a burn’s patient:1. Pre-existing psychological trauma2. Problems in positioning & transfer3. Difficulty in vascular access4. Repeated anaesthetics5. Altered pharmacological response

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Anaesthetic plan for burn’s dressing

Preoperative evaluation: Check airway Check vascular access Check volume status

Routine monitoring O2 by face mask Total Intravenous Anaesthesia (TIVA)

Ketamine 1.5mg/Kg IV Diazepam 0.1mg/Kg IV Atropine 0.01mg/Kg IV

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Anaesthesia for burn’s dressing

Halothane avoided as repeated anaesthetics is necessary

Suxamethonium is avoided Development of extra-junctional

receptors on the muscle surface which will lead to hyperkalemic response

(develops 1 week following burns & lasts till 6 months post- burns)

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Anaesthesia in Radiology department1. C.T. scan2. M.R.I. scan3. Radio-therapy

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Anaesthesia for C.T. scan

Procedure lasts for 10 minutes Non-invasive procedure Patient to lie motionless only Contrast injected to do studies

Acute anaphylaxis to contrast media can be disastrous

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Anaesthesia for C.T.Scan Sedation with Chloral Hydrate 50mg/kg

orally half an hour prior to the procedure TIVA: Ketamine 1mg/kg with diazepam

0.1mg/kg & Atropine 0.01mg/Kg TIVA: Propofol 1mg/Kg with Atropine

0.01mg/Kg (Tracheal intubation is a must when Oral

radio opaque is used) Head injury patients with low GCS needs

intubation and control of ventilation

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Monitoring for CT Scan ECG Spo2 NIBP End-tidal CO2 Ventilator disconnect alarm

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Problems in C. T. scan room

Dark / poorly lit room Radiation exposure Very cold environment Limited access to the patient Contrast medium anaphylaxis

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Anaesthesia for MRI Scan Painless procedure Children only need anaesthesia

services Procedure lasts for 60 – 75 minutes Scary feeling staying inside the

tube

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Anaesthesia for MRI Scan

Mandatory to intubate all patients and control ventilation using ventilator

Need for anaesthesia machine & monitors compatible with MRI environment-Expensive

Routine anaesthesia technique is done Minimal Motoring Standards is a must

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Anaesthesia for Radio-therapy

Children need sedation to stay motionless

Repeated anaesthetics necessary Painless procedure Procedure lasts for 10 minutes Plan:- TIVA using Ketamine/ Propofol

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