perioperative care anaesthesia

8/12/2019 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


Monitoring

Induction Maintenance (specific/general)


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


IV anaesthetic induction agents

Inhalational anaesthetic agents

+ ..other general groups = ?


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Anaesthetic Agents/Drugs


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


Monitoring

Induction Maintenance (specific/general) per-op


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


Monitoring

Induction Maintenance (specific/general issues)





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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


Monitoring






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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


Monitoring






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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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perioperative care anaesthesia

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