Anaesthetic Consideratio

ns in preparations for the OR/OT

Joachim Unger, MD

Germany

-Can only concentrate on one patient-Acts as supportive psychotherapist for surgeons

Hates chaos

Characteristics of an

anesthesiologist

no conflict of interests

AirwayManagement-Respiratory Insuffency:

RR <6 / >29-GCS <9

-Hypoxia: Sat < 90%

-Hemodynamic Instability: BP <90

Choise of Induction

Hypnotics

Maintaining

SedationPrevention of

Awareness

No Pain

No Brain

Zeile 1 Zeile 2 Zeile 3 Zeile 40

2

4

6

8

10

12

Spalte 1Spalte 2Spalte 3

Effects of Muscle Relaxants

HyperkalemiaOxygen consuming

Long-term duration

Laryngoscopy #1

Laryngoscopy #2(+/- Bougie)

Laryngoscopy #3(Attending)

Laryngeal Mask Surgical Airway

ConfirmationCapnography

RSI

Video-Laryngoscopy superior

to direct Laryngoscopy?

Normoventilationlow tidal volumeadequate PEEP

Damage Control

Resuscitation

Acidosis Hypocalcemia Hypothermia

Permissive Hypotentio

n

Establish venous

access

No fluid administration

in normotention

Second line: Intraosseal

access

Arterial line Glue it

Messure PressureAnalyse Astrup

Lactate-free

Crystalloids

Starch is outRestrictiv

euse

Calcium and Tranexamic Acid

Avoid Hypocalcemia < 0,9

TXA: Early Administration 1g/10 min followed by 1g/8h

.

Transfusion Hematocrit 25-30

Ratio

RBC:FFP

1:1

Centralline

For massive Transfusion

Catecholamines can run initially peripherically

Temperature control

Warmedinfusion

Warmed blankets

Strategiesfor

rising ICPHyperventilation Mannitol

Hypertone NaCl 7,5%Normoxie

NormocapnieNormotonie

CCP > 50

Keep itSafe and Simple

(KISS)

References IStephens CT et al. The Success of Emergency Endotracheal Intubation in Trauma Patients: A 10-Year Experience at a Major Adult Trauma Referral Center. (Anesth Analg 2009;109:866–72)

Yeatts DJ et al. Effect of video laryngoscopy on trauma patient survival. J Trauma Acute Care Surg. 2013 Aug;75(2):212-9

Taha SK et al. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction. Anaesthesia. 2010 Apr;65(4):358-61

Wagner CE et al. Etomidate Use and Postoperative Outcomes among Cardiac Surgery Patients. Anesthesiology 2014; 579-89

Wang X et al. Ketamine does not increase intracranial pressure compared with opioids. J Anesth 2014

Futier E et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. NEJM 2013

Errando CL et al. Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients. British Journal of Anaesthesia 101 (2): 178–85 (2008)

Turner J et al. (2000) A randomised controlled trial of prehospital intravenous fluid replacement therapy in serious trauma. Health Technol Assess 4:1-57

Kozek-Langenecker S (2007) Monitoring hemostasis in emergency medicine. Yearb Intensive Care Emerg Med 848-859

References IIShakur H et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) Lancet 2010; 376:23-32

Simonova G1 et al. Cyanoacrylate tissue adhesives - effective securement technique for intravascular catheters: in vitro testing of safety and feasibility. Anaesth Intensive Care. 2012 May;40(3):460-6.

Wilkinson JN et al. Tissue adhesive as an alternative to sutures for securing central venous catheters. Anaesthesia. 2007 Sep;62(9):969-70.

Kwan I et al. (2003) Timing and volume of fluid administration for patients with bleeding. Cochrane Database Syst Rev

Bickell Wh et al. (1994) Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. NEJM 331:1105-1109

Annane D1 et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA. 2013 Nov 6;310(17):1809-17.

John A. Myburgh et al. Hydroxyethyl Starch or Saline for Fluid Resuscitation in Intensive Care. NEJM 2012; 367:1901-1911Richard PD. Damage Control Anesthesia. International TraumaCare (ITACCS) Fall 2005

Perner A. Et al. Hydroxyethyl Starch 130/0.42 versus Ringer's Acetate in Severe Sepsis. NEJM 2012; 367:124-134

Brunkhorst FM et al. Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis (VISEP) NEJM 2008;358:125-39