Anaesthesia for JMOs

Dr Ben Piper

ICU and Anaesthetic Registrar

Gas Monkey

What we will cover today

1. Acute Pain on the wards-• Some “go-to” moves.

2. Special circumstances-• Problems after Spinal and Epidural anaesthesia

If we have time…

1. My patient needs surgery- • What does the anesthetist want to know?

Pain

• What is pain?– An unpleasant sensory and emotional experience

associated with actual or perceived tissue damage.

• Types of Pain- “the good, the bad and the ugly”– Somatic- good– Visceral- bad– Neuropathic– Psychogenic (careful now)

Ugly

Multi Modal Analgesia

Case Study

• 46yo 140kg lady 12hrs post ORIF of patella• 10/10 pain in anterior knee• Screaming, sweaty, tachycardic

– Currently on Paracetamol 1g QID, Endone 5-10mg Q4H,

• What sort of pain is this? • Why now?• What can you do? What do you do?

Options…. What would you do?

1. Endone: give double stat dose (20mg)

2. NSAIDs STAT and chart regular dose

3. Oxycontin 20mg BD

4. IM Morphine 0.1mg/kg

5. IV Morphine 0.05mg/kg

6. Say: “What did you expect, this is surgery- harden up princess”.

7. Page the Anaesthetic Registrar

Lean body mass!!!!!

Pain is like fire……

Get it before it gets you……

Case Study cont…

• Your plan:– Damage control- “put out the fire”

• IV morphine 5mg STAT• IV morphine 2mg increments every 10min• Patient will need supplemental Oxygen• Regular obs- Q15min for 1hr post IV morphine

– Planning ahead• Chart regular ibuprofen 400mg TDS• Increase Endone frequency to 10mg Q3H• If not controlled call APS for help

Case Study cont…

• Your excellent plan worked…1hr later

– Pain is now 1/10– RR 7– Sat 92% on 3L

• What is going on? What will/can you do?

Case Study cont…

• O/E: pupils 2mm R=L, drowsy.– You increase Oxygen to 100% NRBM

– Sats now 94%

• What is the problem?• How long does morphine “last”

• You decide on Naloxone– What about the pain?

– How much?

– How often?

Morphine and Naloxone• Morphine

– IV Peak 10-20min Duration 1-2hrs– IM Peak 30min Duration 2-3hrs

• Naloxone– IV Dose 100mcg at a time wait 1min- repeat.– (slow and steady, you can always give more!!)– Duration 30-60min HENCE need to remain monitored and

may need repeat dosing (it wears off before morphine!)– What are you aiming for?

– Here is an ampoule- draw it up as you would use it!

Much longer than most think!

Endone peak 30min duration 1-2 hrs

Fixed

• After two doses of 100mcg the patient is less drowsy, RR 14, sat 98%

• You keep her on Oxygen with 15min Obs for the next hour, 30min the hour after that.

• Pain is settling and she gets a good nights sleep! She thinks you are a hero!

Take home message

• All doctors need to have a plan for the patient with severe pain!

• All patients on IV/IM opiates need Oxygen!• Get to know your core drugs- discuss a plan

with a senior and try it in daylight hours! – (alone at night is not the time!)

• Know how to get: 1. Help when you are unsure

2. Yourself and the patient out of trouble!– Have a few “go to moves”

Special Circumstances

“Stuff that fancy pants Anaesthetic doctors do but don’t tell anyone about” – Anonymous JMO

Case study: “No sympathy”

• 64yo man returned to ward post TURP– Bkg: HTN, smoker, BPH

• Nurse calls for clinical review:– Obs: BP 90/40 HR 60– O/E: pain free, talking to you

• What do you do?

Choose your own adventure

1. Bolus IVF 500mL

2. Don’t worry his HR is not elevated (60)

3. Withhold tonight's perindopril dose

4. Panic

Case study: “No sympathy”

• You bolus 500mL and with hold his perindopril

• 15min later:– BP75/40, HR 52, nauseated– What do you do? What is going on?

– Why is this man not maintaining his BP?

Sensor ResponseMemory scratcher

Case study: “Overly sympathetic”

• You check his sensation: • “He is numb to the nipples”

• “High Block”: – This is a medical emergency– Stop any intrathecal medications– Call a MET– Give IVF, elevate legs, ACLS

• Treatment: Hopefully the cavalry will arrive!• IVF- Starling may help a bit!• Vasopressor + chronotropy: Alpha and beta agonist!

– Don’t do this unless you know what you are doing!!– Get advise from someone who knows!– This is a registrar “go to move”

Case Study: “Morphology”

• 56yo man, 4hrs post TKR– PMHx: OA, OSA– Nurses ask for review b/c RR 6 sat 98%

• Initial thoughts?

• What do you need to know?

Case Study: “Morphology”

• On Exam:– Drowsy but can answer questions, Pupils

3mm reactive.– Pain free– No opiates have been given post operatively.– Block height to umbilicus starting to wear off.

Case Study: “Morphology”

• RR now 5• Sat 92%- bugger.• 100% NRBM/MET call

• The anaesthetic registrar gives naloxne in 100mcg increments- plan basically the same as before!

• Why??

Case Study: “Morphology”

• As it turns our morphine and Fentanyl in commonly used in spinal anaesthetics. – Here are some charts: these are the areas to look at on the

anaesthetic chart for this info.

• Was it the Morphine or the Fentanyl? Why the delay?? Any ideas?

Take home message

• Neuro-Axial blockade can cause major disruption in cardiovascular/Resp function- it can be delayed and present on the ward.– It must be recognised!!

• Management of Post Op patients needs an understanding of basic physiological principles that many of us forget after med school!

• Read the Anaesthetic sheet! Its full of goodies!• If in doubt ask!! We don’t bite!!

Quick: other pearls for the ward..• Beta Blockers: It is quiet rare that you need to withhold

these (bradycardia, heart block) – generally don’t do it, even if NBM!!

• Oxycontin: Do not withhold chronic opiates pre-operatively even if NBM!

Special patients:• The classic “possible opiate seeker”, give the patient the

benefit of the doubt initially- seek higher level input thereafter. Tramadol can be handy here- less “buz” but good analgesic.

• Palliative care: seek higher advise early!! They are lovely people to deal with!

• Any questions???

My MET call mantra- “ABC and…”• Have a basic plan for the nurses:• Identify the nurse looking after the patient, “Jane”:

• This: – Gives the impression that you are not panicking, – gives others confidence in you and themselves, – and gets things done

“Jane, can you please:1. Increase the oxygen to 100%”

“Jane, can you please get someone else to:1. Check a BSL2. Do an ECG3. Get me the notes

So that you can tell me about what has happened”.“Thankyou Jane-”

Thanks

“Have fun at work:– do Anaesthetics and/or

Intensive Care”

My patient needs Surgery…

My patient needs Surgery…

• What does the anaesthetic team need to know?

(A part from the basic PMHx and current problem)

• We want to know what degree of stress/trauma a person can withstand?– The surgeons are about to unleash their fury on them.

Key Question:• What is their physiological reserve?

A basic approach (there are many)

• Airway & Anaesthetic History:

• Breathing: Respiratory function/reserve

• Circualtion: Cardiovascular function/reserve

• Drugs: what, why and when?

• Eating: When, what

Airway & Anaesthetic History:

• Airway:– Can their mouth open?– Can their neck move?– Can you see their oropharynx? MP score– Are they obese?

• Have they had previous anaesthetics?– Were there any problems?

Breathing: Respiratory function/reserve

• Respiratory– Smoker?– SOB: when, why– WOB due to either

• Restriction from parenchyma (fibrosis/APO)• Obstruction to flow (asthma/COPD)

– Spirometry -if available-• FEV1• FVC

– Concurrent infection

Circualtion: Cardiovascular function/reserve

Cardiovascular: (more than just “patient has history of IHD”!! We all say it, but it means nothing!!)

– Exercise tolerance- the best test• Walking distance/stairs/what actually stops them

– Cardiac Failure: what type, symptomatic?– Angina: when, why, new?– Valve disease: Murmur, symptomatic?– Stents of surgery: what, when

Drugs: what, when and why?

• Special attention to:– Cardiac meds– Antiplatelets– Anticoagulants

– This will effect the type of anaesthesia that can be utilized.

• E.g. Spinal vs General