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Perioperative Care

Anaesthetic Core Tutorial (5/5)


4
th
Year Med Students Group
Dr P Mullen
Consultant in Anaesthesia
07 May 2014

Perioperative Care
Patient journey: Laparotomy
Components of the anaesthetic
Some problem solving

(Role of HDU/ITU in perioperative care)
(Anaesthesia as a career)

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)

USA 1846: W Morton (Ether)

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)

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)

Pre-medication agents
Anxiolysis
Antiemetic
Analgesia
Anti-salivation
Antacid
Anti-coagulation (VTE prophylaxis)
(Patients usual medication)
Exceptions ?
Our patient was on aspirin, so ?

If she was also on Clopidogrel,
then how relevant/how to manage?


Which of these VTE risk factors is your patient +ve for? (Old list)

Safety briefing
&
Pre-operative checks:

Patient
Equipment
Team


WHAT IS THE MOST IMPORTANT
MONITOR?

(same answer for ward, A/E,
Theatre, ICU, )

THE CONTINUED PRESENCE OF A
TRAINED & VIGILENT person

CONCEPTS
Latin: monere - to warn
Uses: trends, prediction, action

Classification, types, uses, calibration,
Continuous/intermittent
Invasive/non-invasive

Situational awareness


Oxyhemoglobin
Saturation Curve
mmHg
Pulse rate (~ HR)
Arterial pulsation*
in finger (~ BP)
Indirect p
a
O
2
Pulse Oximetry
*plethysmograph

Monitors: minimal standard
SpO2
NIBP
ECG
(insp/exp gas concentrations)

Monitoring: INTERFACES
Monitors Patient (cold hands & SpO2)

Anaesthetist - Patient

Anaesthetist Monitors

Anaesthetist surgeon/staff

(and vice-versa!)

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

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?

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)

Cricoid Pressure
Cricoid complete ring of cartilage

4Kg force to obstruct oesophagus

Prevents passive regurgitation of stomach
contents, in patients with a full stomach

Full stomach
Recently eaten
Epistaxis
Hemetemesis
Intestinal obstruction
Ileus/peritonitis
GORD
Pharyngeal pouch
etc.


Anaesthetic Agents
IV induction drugs
Propofol
Thiopentone
(Etomidate)
(Ketamine)

Inhalational anaesthetic drugs
Nitrous Oxide
Isoflurane, Sevoflurane, (Desflurane)
What is the lay persons
term for N2O?

Induction (Anaesthetic Room)

Monitoring: minimal standard
advanced monitoring
IV access
Partial/Full pre-oxygenation
Pharmacological loss of consciousness
ABC support
Anaesthetic depth established by gases
Transfer to theatre/op table

Anaesthetic Agents/Drugs
Pre-medication agents
IV anaesthetic induction agents
Inhalational anaesthetic agents

+ ..other general groups = ?

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

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)


Depth: stages of Anaesthesia
I awake to loss of verbal response
II excitement/increased reflexes (light)
III surgical anaesthesia (stage 3 level 3)
IV overdose & death

IV vs inhalational induction
This is where our
patient needs to get to



6 things you can do with your
hands to achieve a patent airway?

OPA & NPA
OPA
- not tolerated well if
semi-conscious
- laryngospasm
- dental damage

NPA
- well tolerated
- epistaxis

LMA
Easy to insert
Easy to dislodge
Spont resps preferred
Well tolerated
Not airtight seal
Regurgitation a
problem

POCETT/PNCETT
Trans-laryngeal
Airtight seal
Definitive airway
Poorly tolerated if
semi-conscious
GA to insert
Or
Awake Fibreoptic
Intubation (AFOI)

Regional anaesthesia
Regional analgesia
Major LA neuraxial blocks
Spinal (sub-arachnoid) anaesthesia: LSCS, lower limb ops
Epidural analgesia: ops below sternum (major abdo surgery)

Major LA nerve plexus blocks
Interscalene brachial plexus block (shoulder & upper limb ops)
Lumbar plexus block: e.g. for THR

Individual LA nerve blocks
Femoral & Sciatic nerve for TKR
Fascia iliaca blocks for #NOF


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

Determinants of Cardiac Output
Cardiac
Output
heart rate
preload
afterload
contractility
CVS Support intra-op

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)




Other intra-op issues
Blood loss
Thermoregulation
Prolonged immobility (nerve injury)
Surgical factors
mechanical DVT prophylaxis
Special monitoring situations
TURP syndrome
Intra-op wake up test (neuro)

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 well
being)
Neonatal anaesthesia


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)

Recovery & Awakening
Issues
Position
Return of (protective) airway reflexes
Adequate breathing & muscle power
Extubation hypertension & straining
Disorientation & distress (children)
Pain score (0 1 2 3 scale)
PONV
Stable or unstable
Discharge (from Recovery Unit) criteria

Post-op Care: 1
st
24 hrs
Anaesthesia Issues
PONV
Analgesia & fluids & when can eat
Sore throat
Diffuse muscle pains
Machinery & alcohol
Occult complications
Special requirements

Post-op Care: 1
st
24 hrs
Surgical issues
HDU or ward care
Fluids & when can eat
Drains plan
Suture removal plan
Mobilisation
Wound haematoma
Occult complications (e.g. DVT prophylaxis)
Special requirements (e.g. bladder irrigation)

Role of Critical Care
Perioperatively:
=
Resp/CVS support/monitoring
Other organ support/monitoring

Survival from critical illness

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)

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


Extra theatre Anaes sessions
SAMP in Critical Care
SAMP in Anaesthesia
F2 in Critical Care (ITU)
F2 in Critical Care (HDU)

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

?
patrickmullen@nhs.net