Perioperative Care Anaesthesia
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Transcript of Perioperative Care Anaesthesia
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Perioperative Care
Anaesthetic Core Tutorial (5/5)
4thYear Med Students Group
Dr P Mullen
Consultant in Anaesthesia
07 May 2014
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Perioperative Care
Patient journey: Laparotomy
Components of the anaesthetic
Some problem solving
(Role of HDU/ITU in perioperative care)
(Anaesthesia as a career)
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The patient, a boy of about 14, was placed on the lap of an
able assistant, but on the first incision the boy screamed
and struggled with so much violence .
Restrained by many broad shouldered gentlemen A
regular confusion now ensued; the operator supplicated for
light, air and room; his privileged brethren thronged but the
more intensely around him
.the patient was shifted to a table but still remained
invisible; his continued screams however, and the repeated
remonstrance's of Mr Carmichael insisting for elbow room ,
assured us that the operation was still going on
(Richmond Hospital, Dublin 1825)
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USA 1846: W Morton (Ether)
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The Anaesthetic
Pre-op Assessment
Pre-op preparation
Safety briefings, pre-op checks
Monitoring
Induction
Maintenance (specific/general)
Reversal (of neuromuscular paralysis)
Awakening, Recovery unit discharge Post-op care/issues (ward)
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Pre-operative Preparation:(how do these relate to this patient?)
(Pre-operative assessment)
Information & informed consent process
Resuscitation
Existing medical problems/medications
Fasting period (6h food, 2 h clear fluids)
Pre-medication
Psychological support
Transport to/from theatre, Escort policy etc.
Other (VTE prophylaxis)
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Pre-medication agents
Anxiolysis
Antiemetic
Analgesia
Anti-salivation Antacid
Anti-coagulation (VTE prophylaxis)
(Patients usual medication)
Exceptions ?Our patient was on aspirin, so ?
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If she was also on Clopidogrel,
then how relevant/how to manage?
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Which of these VTE risk factors is your patient +ve for? (Old list)
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Safety briefing
&Pre-operative checks:
PatientEquipment
Team
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WHAT IS THE MOST IMPORTANTMONITOR?
(same answer for ward, A/E,Theatre, ICU, )
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THE CONTINUED PRESENCE OF A
TRAINED & VIGILENT person
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CONCEPTS
Latin: monere - to warn
Uses: trends, prediction, action
Classification, types, uses, calibration,
Continuous/intermittent
Invasive/non-invasive
Situational awareness
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Oxyhemoglobin
Saturation Curve
mmHg
Pulse rate (~ HR)
Arterial pulsation*
in finger (~ BP)
Indirect paO2
Pulse Oximetry
*plethysmograph
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Monitors: minimal standard
SpO2
NIBP
ECG
(insp/exp gas concentrations)
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Monitoring: INTERFACES
MonitorsPatient (cold hands & SpO2)
Anaesthetist - Patient
AnaesthetistMonitors
Anaesthetistsurgeon/staff
(and vice-versa!)
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Arterial Cannulation
Indications Multiple arterial blood samples
Continuous blood pressure
Sites (Allens test, collateral circulation in hand)
Complications
Hematoma/blood loss (RIP)
Thrombosis/distal ischemia Arterial injuryfalse aneurysm formation
Infection
Whi h f th i di ti i ti t + f ?
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Indications for invasive BP
Unsuitability of non-invasive techniques
Failure of non-invasive techniques
Cardiovascular instability
Potential cardiovascular instability
Which of these indications is our patient +ve for?
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The Anaesthetic
Pre-op Assessment
Pre-op preparation
Safety briefings, pre-op checks
Monitoring
Induction Maintenance (specific/general)
Reversal (of neuromuscular paralysis)
Awakening, Recovery unit discharge Post-op care/issues (ward)
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Cricoid Pressure
Cricoidcomplete ring of cartilage
4Kg force to obstruct oesophagus
Prevents passive regurgitation of stomach
contents, in patients with a full stomach
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Full stomach
Recently eaten
Epistaxis
Hemetemesis
Intestinal obstruction
Ileus/peritonitis
GORD
Pharyngeal pouch etc.
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Anaesthetic Agents
IV induction drugsPropofolThiopentone(Etomidate)
(Ketamine)
Inhalational anaesthetic drugsNitrous Oxide
Isoflurane, Sevoflurane, (Desflurane)
What is the lay personsterm for N2O?
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Induction (Anaesthetic Room)
Monitoring: minimal standardadvanced monitoring
IV access Partial/Full pre-oxygenation
Pharmacological loss of consciousness
ABC support
Anaesthetic depth established by gases
Transfer to theatre/op table
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Anaesthetic Agents/Drugs
Pre-medication agents
IV anaesthetic induction agents
Inhalational anaesthetic agents
+ ..other general groups = ?
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Anaesthetic Agents/Drugs
Pre-medication agents
IV anaesthetic induction agents
Inhalational anaesthetic agents
Analgesics
Local anaesthetic agents
Muscle relaxants
Agents to reverse muscle relaxants
Others
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Balanced anaesthesia
Combining anaesthetic drugs lowers
dosage requirements
(The correct dose of any drug is enough)
(The dose reflects that every drug to
some extent is a poison)
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Depth: stages of Anaesthesia
Iawake to loss of verbal response
IIexcitement/increased reflexes (light)
IIIsurgical anaesthesia (stage 3 level 3)
IVoverdose & death
IV vs inhalational induction
This is where our
patient needs to get t
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6 things you can do with your
hands to achieve a patent airway?
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OPA & NPA
OPA
- not tolerated well if
semi-conscious
- laryngospasm
- dental damage
NPA
- well tolerated- epistaxis
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LMA
Easy to insert
Easy to dislodge
Spont resps preferred
Well tolerated Not airtight seal
Regurgitation a
problem
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POCETT/PNCETT
Trans-laryngeal
Airtight seal
Definitive airway
Poorly tolerated ifsemi-conscious
GA to insert
OrAwake FibreopticIntubation (AFOI)
Regional anaesthesia
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Regional anaesthesia
Regional analgesia
Major LA neuraxial blocksSpinal (sub-arachnoid) anaesthesia: LSCS, lower limb ops
Epidural analgesia: ops below sternum(major abdo surgery)
Major LA nerve plexus blocksInterscalene brachial plexus block(shoulder & upper limb ops)
Lumbar plexus block: e.g. for THR
Individual LA nerve blocksFemoral & Sciatic nerve for TKR
Fascia iliaca blocks for #NOF
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The Anaesthetic
Pre-op Assessment
Pre-op preparation
Safety briefings, pre-op checks
Monitoring
Induction Maintenance (specific/general) per-op
Reversal (of neuromuscular paralysis)
Awakening, Recovery unit discharge
Post-op care/issues (ward)
Continued
resuscitation
CVS Support intra-op
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Determinants of Cardiac Output
Cardiac
Output
heart ratepreload
afterload contractility
CVS Support intra op
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The Anaesthetic
Pre-op Assessment
Pre-op preparation
Safety briefings, pre-op checks
Monitoring
Induction Maintenance (specific/general issues)
Reversal (of neuromuscular paralysis)
Awakening, Recovery unit discharge
Post-op care/issues (ward)
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Other intra-op issues
Blood loss
Thermoregulation
Prolonged immobility (nerve injury)
Surgical factorsmechanical DVT prophylaxis
Special monitoring situationsTURP syndrome
Intra-op wake up test (neuro)
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Monitoring: Special situations/patients
Major cavity surgery
Sitting Neurosurgery
Carotid Endarterectomy
Spinal surgery Thyroid surgery
TURP
Diabetes Mellitus
Previous awareness
CABG & bypass pump
Pregnancy (fetus wellbeing)
Neonatal anaesthesia
Th A th ti
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The Anaesthetic
Pre-op Assessment
Pre-op preparation
Safety briefings, pre-op checks
Monitoring
Induction Maintenance (specific/general)
Reversal (of neuromuscular paralysis)
Awakening, Recovery unit discharge
Post-op care/issues (ward)
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Recovery & Awakening
IssuesPositionReturn of (protective) airway reflexesAdequate breathing & muscle power
Extubation hypertension & strainingDisorientation & distress (children)
Pain score (0 1 2 3 scale)PONV
Stable or unstableDischarge (from Recovery Unit) criteria
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Post-op Care: 1st24 hrs
Anaesthesia Issues
PONV
Analgesia & fluids & when can eat
Sore throatDiffuse muscle pains
Machinery & alcohol
Occult complications
Special requirements
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Post-op Care: 1st24 hrs
Surgical issues
HDU or ward care
Fluids & when can eat
Drains planSuture removal plan
Mobilisation
Wound haematoma
Occult complications (e.g. DVT prophylaxis)
Special requirements (e.g. bladder irrigation)
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Role of Critical Care
Perioperatively:
=
Resp/CVS support/monitoring
Other organ support/monitoring
Survival from critical illness
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Summary: The Anaesthetic
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Summary: The Anaesthetic
Pre-op Assessment
Pre-op preparation
Safety briefings, pre-op checks
Monitoring
Induction Maintenance (specific/general)
Reversal (of neuromuscular paralysis)
Awakening, Recovery unit discharge
Post-op care/issues (ward)
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Perioperative Care
Components of the anaesthetic
Monitoring
Other intra-op issues
Some post-op issues
Role of HDU/ITU in perioperative care
Anaesthesia as a career
www.aagbi.org
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g g
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Extra theatre Anaes sessions
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SAMP in Critical Care
SAMP in Anaesthesia
F2 in Critical Care (ITUF2 in Critical Care (HDU
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Anaesthesia: main prof. bodies
Royal College of Anaesthesia (RCA)www.rcoa.ac.uk
Association of Anaesthetists of Great Britain &Ireland (AAGBI)www.aagbi.org
Intensive Care Society (ICS UK)www.ics.ac.uk
Training, Education, Guidelines & Standards
http://www.rcoa.ac.uk/http://www.aagbi.org/http://www.ics.ac.uk/http://www.ics.ac.uk/http://www.aagbi.org/http://www.rcoa.ac.uk/ -
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