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GLOBAL
RECONSTRUCTIVE
SURGERY
GLOBAL
RECONSTRUCTIVE
SURGERY
James Chang, MD
Chief of Plastic & Reconstructive Surgery
Johnson & Johnson Distinguished Professor of Surgery
Stanford University Medical Center
Stanford, CA, USA
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or
contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence, or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
ISBN: 978-0-323-52377-6
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
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CONTENTS
As you will read in the forewords written by three visionaries in the field, there is currently a tremendous
need for Global Reconstructive Surgery. The goal of this textbook is to teach perioperative principles and
surgical techniques for optimal reconstruction throughout the body—from head to toe. The outstanding
contributors—surgeons, anesthesiologists, nurses, and therapists—all have first-hand medical experience
in working in austere environments, with basic equipment and limited supplies. We hope this textbook can
be used across the developing world to help deliver and teach reconstructive surgery to the overwhelming
number of patients in need.
vii
F O R E WO R D
viii
FOREWORD ix
Psychic Income is a distinctive feature in reconstructive plastic surgery: In the 1960s, plastic surgery was still evolving. For the first time ever,
It is the rich feeling associated with helping another in a dramatic, it was believed that plastic surgery could rehabilitate and reintegrate
successful, and sustainable fashion. In addition, reconstructive surgery those who were outcasts because of deformities and disabilities. One
is known and respected in its use of fine surgical technique, and we are man, Dr. Donald Laub of Stanford University, pioneered the idea that
known for skill and knowledge for problem solving for other specialties. reconstructive plastic surgery could renew lives and restore hope. With
It was mandated by Hippocrates, founder of medicine: “Perfect your that vision, Interplast (now ReSurge International) was born in 1969.
own skill and knowledge for the benefit of the other person.” It was the first organization of its kind.
Once focused only on multiplication of our efforts, we now think Thousands of volunteers traveled overseas to help children. By 1979,
globally. In other words, the expansion of reconstructive surgery has 4000 surgeries had been provided. Medical volunteers transformed lives
been in a linear growth track, but with global thinking it has become by dedicating their time to ReSurge, providing surgeries and training
logarithmic. Reconstructive surgery has become internationalized. From local doctors so that they could perform the surgeries on their own.
the medically high-resourced countries, it now includes medium- to As the developing world changed with the Internet and better infra-
low-resourced countries. structure, ReSurge forged a bold new course. In 1999 we established
This development is the result of reconstructive surgery becoming the first permanent Surgical Outreach Program, where local surgeons
worldwide. Its multiplication has resulted in a bona fide component provide year-round care. By building surgical capacity and supporting
of surgery and medicine, and the word global has become part of our local surgeons, the program now enables twice as many patients to
everyday thinking and vocabulary. Additionally, these programs also receive care annually.
provide substantial benefit both to the doers and the recipients. The Now more than 80% of our surgeries are performed by developing
multiplication is the result of six factors: world surgeons with ReSurge oversight, training, and support; it is our
(1) Residents’ popularity and requests. most efficient and cost-effective way to provide life-changing surgery.
(2) The many international projects of medical schools and independent ReSurge also continually improves the quality of health care through
foundations. education programs. We have provided more than 100,000 surgeries
(3) The medium-resource countries that have developed expertise and and look forward to pioneering the way for generations to come.
resources and now help other midlevel places. For example, we are exploring our success in identifying, cultivating,
(4) The more than 58 organizations are now doing Foreign Medical and supporting humanitarian surgical leaders, seeking to understand the
Programs (FMPs). elements of our success and to replicate that elsewhere. And we are looking
(5) The happiness and satisfaction of participants in the service and at ways to scale up our training practices to have a greater effect.
teaching trips. Training the next generation of reconstructive surgeons and allied
(6) The national plastic surgery societies who have begun to engage professionals has moved to the center of ReSurge’s work in Africa, Latin
many of the FMPs, embracing them into organized plastic surgery, America, and Asia. By partnering with respected academic faculty and
showing that the movement is becoming more mainstream. practitioners, ReSurge has developed curricula in reconstructive surgery,
This new textbook, Global Reconstructive Surgery, a monumental anesthesia, nursing, and occupational therapy. These faculty and prac-
work, is the essential fund of knowledge that will serve practicing recon- titioners, or Visiting Educators, teach current techniques in each of the
structive surgeons around the world. Each chapter was authored by a specialties. ReSurge follows up on those trainings by reviewing and
distinguished, experienced, dedicated expert and humanitarian. Because providing feedback on subsequent surgeries performed by the trainees.
of this work, the future is clear and has good compass bearing. We are By engaging this next generation, ReSurge hopes to expand the number
now pointed straight up to the benefit of our patients, ourselves, and of Surgical Outreach Partners who provide reconstructive surgery
humanity. worldwide.
Dr. Donald Rudolf Laub This textbook is a key contribution to the training of surgical pro-
Founder – Interplast fessionals in the global workforce. We are pleased to support the leader-
ship of our Dr. James Chang, our Consulting Medical Officer, the editor,
and driving vision of this resource.
Jeff Whisenant
CEO, ReSurge International
LIST OF CONTRIBUTORS
x
LIST OF CONTRIBUTORS xi
I offer special thanks to Angela Sotelo, Kathleen Roeder Chang, and Julia Roeder Chang for their copyediting
and proofreading assistance, and to my talented editors at Elsevier, Trinity Hutton, Belinda Kuhn, and Joanna
Souch. Their guidance and encouragement have been essential.
xiv
D E D I C AT I O N
This textbook is dedicated to the staff, board, and volunteers of the non-profit organization, ReSurge Inter-
national. Their collective goal for 50 years has been to deliver and teach reconstructive surgery to those in
need, regardless of religion, politics, or social standing. Their generosity of time, money, expertise, and spirit
is inspirational to me.
xv
VIDEO CONTENTS
1.2 Operating Room Requirements and Setup 3.4 Primary Cleft Palate Repair
Video 1 Operating Room Requirements and Setup Video 1 Furlow Palatoplasty in Veau II Cleft
xvi
1.1
Pre-Operative Screening
Katherine D. Gallagher
1
2 SECTION 1 Perioperative Management
• Vital signs (normal values for age are found in Table 1.1.1):
PATIENT SCREENING: LABORATORY EVALUATION
• Weight: For accurate calculation of fluids and medication doses
and as part of the evaluation of nutritional status. Infants and • Hemoglobin: Visual assessment of pallor for anemia lacks
small children must be undressed to avoid overestimating weight. sensitivity.
• Pulse, respirations, and pulse oximetry: As screening for unrec- • Platelet count is needed only if petechiae suggest thrombocytopenia.
ognized cardiac or pulmonary issues. • White count is rarely useful.
• Blood pressure: Required for ages 3 years and above to rule out • Pregnancy test in females between puberty and age 55: This needs
hypertension. to be requested and done discreetly and in private. Patients are
• Temperature: As a screen for acute illness. Temperature >100.4°F assured that it is standard testing for ALL female patients, regardless
or >38°C is considered a fever. of history.
• General appearance: • Additional considerations:
• Note and categorize any syndromic features. • HIV testing in areas of high prevalence
• Assess general developmental level. • Malaria screen, sickle cell screen in areas of high prevalence
• Assess tone: Hypotonia increases the risk of functional airway • Chest x-ray and electrocardiogram (ECG) in patients 65 years
obstruction and of post-operative atelectasis. Additionally, some and older
types of hypotonia (mitochondrial defects) are at risk for malig- • There is no evidence that other “routine” tests such as urinalysis or
nant hyperthermia. electrolytes are useful. Clotting studies do not reliably predict intra-
• Assess nutritional status. Mid-upper-arm circumference is the operative or post-operative bleeding in the absence of “red flags” in
standard measure. Wasting of the buttocks (gluteals) is an easily the individual and family history.
noted sign suggestive of malnutrition.
• Airway: PATIENT SCREENING: SPECIFIC CONCERNS
• Assess mouth opening and adequacy of the airway (Mallampati
score). Age
• Look carefully for micrognathia/Pierre Robin sequence because Infants (age 1 month to 1 year) are at increased risk for adverse events
intubation and maintenance of the airway can be very difficult. (estimated 4 times that of older children), and neonates are at particu-
• Evaluate neck extension for intubation (and while checking the larly great risk (up to 40 times that of older children). The absolute
neck, in adults, also look for jugular venous distention). lowest age limit for surgery is 10 weeks, and infants under 1 year should
• Check for loose teeth because they are a potential aspiration risk. be considered only if the surgery is time sensitive (cleft lip repair).
• Lungs: Additionally, prematurity (gestational age under 37 weeks) independently
• Note tachypnea with or without retractions (“quiet tachypnea” increases anesthetic risk up to 60 weeks post-conception; in premature
may point to cardiac issues). infants who had bronchopulmonary dysplasia, the risk is present through-
• Listen for wheezes, cough, rales, or lower airway rhonchi indicat- out life. Older adults (age 65 years and above) are also at increased risk,
ing active pulmonary involvement. largely due to atherosclerosis and lung damage from smoking and
• Note frequency and quality of any cough during the interview environmental exposure.
and examination. A significant cough can be provoked by using
a tongue blade to produce a gag reflex. Weight
• Heart: Weight is a function of age and nutrition, both of which are independent
• Note rate, rhythm, and abnormal murmurs. Many children have risk factors. The absolute minimum weight for elective surgery is 10
an exaggerated “sinus arrhythmia” (variation in heart rate with pounds (4.6 kg). Certain surgeries are best performed after a patient
respiration), and up to one-third will have a short systolic flow reaches a size that allows a clear operative field and sufficient tissue for
murmur at the left sternal border. Any other abnormalities or repair.
any murmurs that the examiner cannot confidently identify as
benign warrant further investigation before surgery. Malnutrition
• Abdomen: A malnourished child presents an increased anesthesia risk, but is par-
• Palpation of the abdomen can identify organomegaly or masses ticularly at risk for poor wound healing and post-operative infections
requiring further investigation. due to suppressed immune function. Additionally, malnutrition may
• Skin and nails: be a marker of chronic illness, malabsorption, or feeding difficulties.
• Abnormalities may suggest nutritional issues. Clubbing of fingers Malnourishment may be evaluated using the World Health Organiza-
is a sign of underlying chronic illness, usually pulmonary. Pete- tion (WHO) weight for height charts (Table 1.1.2). A child is considered
chiae and excess bruising suggest platelet or clotting problems, malnourished if it is below 2 standard deviations (SD) and severely
respectively. malnourished if below 3 SD from the mean. A malnourished child is
4 SECTION 1 Perioperative Management
not a candidate for elective surgery and requires nutritional not be scheduled for surgery and should not be considered for surgery
rehabilitation. in the following 2 weeks. A child should NOT be given antibiotics or
“cold medications” and scheduled soon after because neither alters the
Syndromes and Developmental Delay course of the illness or changes the airway hyperreactivity.
A genetic syndrome does not automatically preclude surgery; however, A more difficult situation is the afebrile child with a history of
caution and additional workup are advised. Certain syndromes may cough only, or with clear rhinorrhea and a negative chest examination.
have associated cardiac defects, airway anomalies and, particularly, Changes in weather and travel may trigger an irritant cough. Children
hypotonia, all of which independently increase anesthesia risks. A child with cleft palates often have chronic irritant rhinorrhea and cough,
with Down’s syndrome, in addition to hypotonia and a challenging and judgment must be made on examination, general appearance,
airway, may have atlanto-occipital instability. Children with Holt-Oram and parental report of baseline symptoms.5 Parental assessment has
syndrome, sometimes seen for hand surgery, may have arrhythmias or been shown to be quite accurate in determining illness. If the parent
pulmonary hypertension. Discussion of all syndromes and their impli- feels that the child is acting ill, this must be taken seriously. Any child
cations is beyond the scope of this chapter. An excellent reference is with a family member who is experiencing a significant illness should
Smith’s Recognizable Patterns of Human Malformation, now available in be evaluated with care. Up to half of the children who have respi-
a digital version.3 ratory syncytial virus (RSV) or influenza may be asymptomatic on
Developmental delay also does not automatically preclude surgery; examination, yet are at increased risk for intra- and post-operative
however, the presence of delay should alert the examiner to look for complications.
underlying syndromes. Additionally, the level of function should be
considered when planning repairs. Cleft palate repair/revision to improve Chronic Medical Conditions
speech is not reasonable in a child who will remain non-verbal. These need to be evaluated on a case-by-case basis. Asthma, for example,
increases anesthesia risk even if it is well controlled. The risk can be
Anemia minimized with pre-operative bronchodilators. Many anesthesiologists
This presents a twofold risk. There is a greater risk of tissue hypoxia are comfortable handling a patient who is currently asymptomatic from
during periods of compromised airway or relative hypotension, and mild asthma. Controlled type 2 diabetes and controlled hypertension
there is a smaller margin of tolerance for blood loss during a procedure. do not preclude elective surgery. Some conditions, on the other hand,
A minimum hemoglobin of 10 g/dL is generally recommended. At high require specialized monitoring and expertise, which may not be avail-
altitude (>8000 feet), the minimum should be higher (11–12 g/dL), able. Examples would be sickle cell disease and insulin-dependent dia-
although exact values have not been defined. betes. An exhaustive list of chronic conditions and their requirements
and risks are beyond the scope of this chapter. If there is any question
Acute Respiratory Illness about the effect of a chronic condition, surgery should be deferred.
This is one of the more difficult situations to assess.4 It is of particular Patient safety is paramount.6
concern in children, because they are subject to frequent respiratory
illnesses, and their smaller airways render them more susceptible to
PATIENT SCREENING: DAY OF SURGERY
obstruction. An acute respiratory illness is known to increase airway
irritability and the risk of laryngospasm or bronchospasm during anes- All patients should be reevaluated on the day of their surgery to ensure
thesia. The airway remains hyperreactive for at least 2 weeks after an that the child is fasting and free of acute illness and that all screening
illness. A child with a recent onset of runny nose, cough, and particularly steps have been completed. A stamp, or a separate form attached to the
fever, and any child with wheezing, rales, or lower airway rhonchi should front of the patient’s chart, should be filled out to document the process.
CHAPTER 1.1 Pre-Operative Screening 5
BOX 1.1.3
This is complementary to the surgical “time out” and is of equal impor- KEY REFERENCES
tance. A sample form is included in this chapter (Box 1.1.3).
1. The Pediatrician’s Role in the Evaluation and Preparation of Pediatric
Patients Undergoing Anesthesia. Policy Statement from the American
CONCLUSION Academy of Pediatrics. Pediatrics. 2014;134(5):634–641.
2. Hilditch WG, Ashbury AJ, Jack E, McGrane S. Validation of a
Each patient, each family, and each site is unique. The earlier “require-
pre-anesthetic screening questionnaire. Anaesthesia. 2003;58:874–877.
ments” are meant as guidelines; they are issues to be considered when 3. Jones KL, Jones MC, Del Campo M. Smith’s Recognizable Patterns of
planning surgery in any environment, but they are especially important Human Malformation. Philadelphia, PA: Elsevier/Saunders; 2013.
in resource-limited settings. The simple fact that we CAN perform 4. Houck P. Anesthesia for the child with a recent upper respiratory infection.
surgery does not necessarily mean that we SHOULD. Careful screening http://www.uptodate.com/contents/anesthesia-for-the-child-with-a-recent-
of both the site and the individual patients will allow teams to serve upper-respiratory-infection; Up To Date. Accessed October, 2016.
patients with maximum benefit and minimum risk and to remain true 5. Kulkarni K, Patil M, Shirke A, Jadhav S. Perioperative respiratory
to the medical dictum, primum non nocere. complications in cleft lip and palate repairs. Indian J Anaesth.
2013;57(6):562–568.
6. World Health Organization. Pocket Book of Hospital Care for Children:
KEY PRINCIPLES Guidelines for the Management of Common Childhood Illnesses. 2nd ed.
Geneva: WHO; 2013.
• In a resource-limited setting, pre-operative screening is particularly important,
because there may not be equipment and expertise available to handle
unanticipated complications. Resources at the site will dictate the type and
extent of surgery that can reasonably be offered.
• Patient screening is most effective as a team effort, with collaboration
between the surgeon, the anesthesiologist, and the medical provider.
• A careful medical history including family history is the most useful tool
for assessing anesthesia and operative risk. The medical examination then
concentrates on overall health, the airway, and the cardiopulmonary system.
Minimal laboratory workup is required if the history and examination are
normal.
• Acute respiratory illness increases the risk of peri-operative adverse events
and precludes elective surgery. Many chronic medical conditions require
specialized equipment and monitoring and also preclude elective surgery
in a resource-limited setting.
• With respect to children, the common minimum requirements for surgery
are 10 weeks of age, 10 pounds of weight (4.6 kg), 10 g/dL hemoglobin,
and no acute illness.
1.2
Operating Room Requirements and Setup
Frances L. Snyder, Fran Fisher
6
CHAPTER 1.2 Operating Room Requirements and Setup 7
FIG. 1.2.1 Hard Pelican cases and cardboard boxes containing equip- FIG. 1.2.3 Local staff ready to assist with instrument sterilization.
ment and supplies, labeled and ready for transport.
FIG. 1.2.4 If team supplies run out, locally supplied sterile cloth gowns
and drapes are utilized.
FIG. 1.2.7 Positioning aids such as donuts and shoulder rolls are made
and covered with plastic for ease of reuse.
• Donuts for head support and shoulder rolls are usually not obtain-
able. These will have to be made with available materials (e.g.,
packing material, bed linen). For ease of cleaning and reuse, once
a positioning aid is fashioned, cover it in plastic (e.g., ziplock
bag, clean trash bag) (Fig. 1.2.7). Both pediatric and adult-sized
donuts and shoulder rolls will be required.
• A hand table will be necessary if upper-extremity procedures are
planned. If no hand table is available, one can be made by secur-
ing two arm boards together. A layer of cardboard can be taped
over the top of the arm boards and padded to provide a level
working surface. Cover with plastic for ease of cleaning and reuse.
5. Sitting stools and stepstools
• Surgeons will need sitting stools during hand procedures.
• Stepstools are useful in assisting ambulatory patients in getting
up onto the OR bed.
FIG. 1.2.6 An example of the circulator’s work space, including all
supplies required for daily cases. Equipment
Equipment essential for surgery may be sent with the team. Check
room outlets for safety and compatibility with this equipment. Save all
• Be prepared for power outages by having alternate light sources original packing materials to repack equipment for return transport at
ready (e.g., flashlights, headlamps, or mobile phone flashlights). end of the trip. If local facility equipment is to be used by the team,
3. Tables check each item and determine that it functions properly and safely.
• Obtain tables as appropriate for anticipated procedures. A flat 1. Electrosurgery unit (ESU)
surface is required for a sterile procedural back table. A small • All perioperative nurses have experience with and understand
cart with functioning wheels is ideal. Mayo stands are not always the safe use of electrosurgical equipment and accessories. On
readily available. surgical trips an ESU is used for most surgeries, and its proper
• A larger table can be used as the OR nurse’s work space (Fig. operation is essential to prevent patient injury. If using a facility-
1.2.6). The supplies used on every case can be placed here for provided ESU, thoroughly familiarize yourself with how it operates
quick access (e.g., non-sterile examination gloves, prep solutions, before the first case. A large assortment of patient grounding
local medications, dressing supplies, positioning aids, tape). pads (i.e., dispersive electrodes) can be encountered, and you
4. Positioning equipment may be unfamiliar with the options that are available. Disposable
• Arm boards may be variations of standard arm boards or simple grounding pads come in a variety of sizes and are designed for
pieces of wood that are pushed under the OR mattress to secure single use. Reusable grounding pads/plates (e.g., Megadyne pads,
in place. If no arm boards are available, patients’ arms can be metal plates with conductive gel) are convenient and reduce waste
tucked at their sides and secured when applying the safety straps. (Fig. 1.2.8). Every type of dispersive electrode has risks and
CHAPTER 1.2 Operating Room Requirements and Setup 9
FIG. 1.2.8 Metal electrosurgery unit (ESU) grounding plate with conduc-
tive jelly.
Instrument Sets
Instrument sets appropriate for expected types of procedures are usually
sent on each trip (Fig. 1.2.10). At least two basic sets are required. Three
sets are desirable if the cases will be in quick succession (e.g., multiple
cleft lip procedures). These sets will be alternated between cases. While
one is in use, another can be cleaned and sterilized. At the end of each
day of surgery, an appropriate set will need to be sterile and available
in the event of a nighttime emergency. If necessary, this set can be
flash-sterilized and left in the team’s autoclave with the door closed.
All other sets should be wrapped, labeled, and sent to the hospital’s
central processing for sterilization. All instrument sets will then be
sterile and available for the next day’s surgeries. Count these packs
when dropping them off and picking them up again the next morning.
Ensuring sterilization of wrapped instruments may be a challenge.
Most sites use steam sterilization indicator tape, known as autoclave
FIG. 1.2.9 An example of a compact, portable autoclave that may be
tape. This tape’s color change provides visual assurance that the package
sent on team trips.
has been exposed to the steam sterilization process. However, autoclave
tape does not prove that steam has actually penetrated the package and
benefits for patients. To ensure patient safety, you must fully that the internal contents are sterile. To confirm the sterility of wrapped
understand the proper use of the specific type of grounding instruments, place an internal indicator, such as a chemical indicator
option available to you. Pay particular attention to weight limits strip, within each package that is to be sterilized. These internal indica-
and the manufacturer’s instructions and safety suggestions. tor strips are usually not available on-site and will have to be brought
2. Suction with the team.
• A functioning suction machine is critical. Often there is a single Instrument packs sent out for local sterilization are sometimes
suction that is shared between the surgeon and the anesthesia returned in a wet or damp condition (Fig. 1.2.11). These sets cannot
provider. The machine is best placed near the head of the OR be considered sterile. It is necessary and educational to engage in a dis-
bed for ease of joint access. Every day, before proceeding with cussion with the local team emphasizing the importance of the drying
surgery, test the machine to ensure that there is adequate suction. component of the sterilization process. With collaboration a solution
3. Autoclave can be agreed upon that will benefit the patients. For example, when a
• An autoclave may be sent with the team (Fig. 1.2.9). The autoclave wrapped instrument set has finished the sterilization cycle, allow it to sit
should be located near the OR, preferably in an adjoining room. in the hot autoclave, door ajar, to dry for half an hour before removing.
This close proximity provides easy access and ensures that An alternative solution is to process the team’s sets late in the day and
unwrapped sterile instruments aren’t carried long distances down leave them in the autoclave until they are picked up in the morning.
busy hallways. Instrument sets sent on trips usually include just the bare minimum
• It is imperative to read the accompanying operating instructions to perform successful surgery. Any lost or broken instruments may
before use. If operation of the autoclave requires distilled or compromise the following procedures. Check surgical drapes carefully
10 SECTION 1 Perioperative Management
FIG. 1.2.11 A wrapped instrument that was sent out for sterilization
and returned in a wet condition. This instrument cannot be considered
sterile.
List the contents of each box on colorful, highly visible labels. Place
these labels on or above each box. This enables all team members to
easily locate items. The storage area needs to be secured at night.
If the team will be procuring supplies upon arrival, the first few
days will be challenging. The type and quantity of supplies needed will
be based on the surgeries scheduled. Planning ahead for future needs
is essential. The team will be relying heavily on the local supply chain,
and requested items may take time to obtain. Some items, such as gauze,
may be received in bulk and need to be sterilized before use (Fig. 1.2.13).
Other items may not be available, or the team may not be accustomed
to the local equivalent. The challenge is to obtain adequate supplies to
provide the best patient care possible. As team members learn the options
and limitations of the local system of procurement and sterilization,
the following days evolve into an easier rhythm.
One of the most significant challenges for the perioperative nurse
on a surgical trip begins with the first surgery and continues until the
final procedure. This involves a thorough familiarity with the limitations
and possibilities of the instrumentation, equipment, and supplies. Most
FIG. 1.2.12 Extra supplies are stored in the packing boxes. Highly large/complicated surgeries will be scheduled early in the trip to allow
visible labels identify the box contents. time for appropriate post-operative care. Toward the end of the trip,
there may a sizable number of shorter surgeries. Dressing changes may
also be performed in the OR. If possible, look at the tentative cases
at the end of each case to avoid discarding small items. Carefully clean scheduled for the entire trip. Based on this plan, identify instrument,
the instruments to avoid any damage. Post a list of the contents of each equipment, and supply needs. Understand that this is only a preliminary
set in the decontamination area. As a set is reassembled, inventory the plan and that cases will be canceled and surgeries will be added. This
instruments and compare to the list. This ensures that the set is complete requires clear communication and collaboration with team members.
and that no instruments have been inadvertently lost. The order of planned surgeries may need to be adjusted to prevent
instrument or equipment conflicts. This ensures that there are no delays
Supplies (Video 1.2.1) and that surgical time is maximized. It is recommended that brief team
Supplies are usually sent with the team. When unpacking the supplies, meetings are convened at the end of each surgical day. These issues can
save all wrappers for reuse as bed sheets, sheet protectors, donuts, shoul- be brought up and handled before they become full-blown problems.
der or chest rolls, etc. Supplies to be used for daily surgeries will be Both careful planning and conservation of supplies are critical from
brought into the OR. Surplus items will be stored in the packing boxes day one.
(Fig. 1.2.12). Group items together in a box according to their use (i.e., • Do not open any sterile supplies unless you are certain that they
all draping items in one box and all dressings together in another box). will be used.
CHAPTER 1.2 Operating Room Requirements and Setup 11
• Remember that other team members have access to and will use the team members will be setting up their specialties. A clinic to evaluate
general supplies. patients for surgery may be concurrently under way. The perioperative
• Check the inventory daily. Cross-check frequently with scheduled nurse will need to collaborate with and provide assistance to other team
cases and communicate with team members regarding any limita- members as required.
tions or shortages. • The clinic may need supplies or extra assistance with patient intake
(e.g., vital signs, weights, pregnancy tests).
• Often the local oxygen delivery system involves large portable cyl-
EMERGENCY PREPAREDNESS inders. These freestanding O2 tanks create a potentially hazardous
All emergency equipment, medication, and supplies should be assigned situation because they can easily fall over. The anesthesia providers
specific, permanent locations. Every member of the team must know may need assistance in safely securing these cylinders (i.e., put the
these locations to provide appropriate care in the event of an emergency tanks into a corner of the room and push heavy objects against
(Fig. 1.2.14). them) (Fig. 1.2.15).
1. Before the first surgery all team members, including the local staff, • Orient yourself to the final anesthesia and PACU setups so you can
should gather to review the location and function of emergency assist as required during the trip.
supplies, medications, and equipment (e.g., automated external To provide safe patient care and to keep cases moving forward, the
defibrillator [AED], fire extinguishers). Plans for safe emergency perioperative nurse must be flexible. Be cognizant of where your skills
egress from the surgical suite should be discussed. may be needed.
2. Names of emergency supplies and medications may be unfamiliar. • Assist with anesthesia induction.
The team must agree on terminology. • Set up the sterile back table or scrub in to assist in the event that
3. Practice using the equipment and supplies because they may differ the local scrub tech process breaks down.
from what you are accustomed to. • Provide backup support to the PACU RN recovering patients.
4. Familiarize yourself with the local oxygen delivery system. Locate • Wash/decontaminate instruments and anesthesia equipment.
the central source and the process for quickly obtaining a backup • Assist with dressing changes.
supply. • Facilitate turnovers between cases and terminal room cleaning at
5. A formal call team must be in place at the end of each day’s surgery. day’s end.
This team must have the keys to access the OR and supply room to
quickly retrieve sterile instruments and surgical supplies. As previ-
EDUCATIONAL COMPONENT
ously stated, members of the call team must know the location of
emergency medications and understand the operation of all critical On surgical trips, education is a key piece of the perioperative RN’s
supplies and equipment. work. Use every opportunity to educate and support the profes-
sional development of local nursing colleagues. Equally important,
be open to learning what they have to teach you. Be aware that you
OTHER CONSIDERATIONS are also a role model. Always maintain the highest standards of
Setup day in the host facility is a long and busy one. Many activities practice. Be willing to interact as peers and collaborate with local
are happening simultaneously. While the OR is being organized, other staff. The example you give by your attitude, professionalism, and
CONCLUSION
Participating in an international surgical trip may be challenging, but
it is also deeply fulfilling both personally and professionally. You will
very quickly become an enthusiastic “veteran.” Sharing your experiences
and knowledge with other nurses will help encourage and motivate
them to enter this very specialized track of perioperative nursing. Patients
all over the world deserve the safe surgical care that our professional
practice offers.
KEY PRINCIPLES
• Maintain rigorous perioperative standards of practice within the structure
of what you find on-site.
• To ensure that all essential pre-operative patient assessment parameters
have been met, create and consistently use a pre-operative assessment
checklist.
• Perform a “time out” or “surgical pause” before each surgical procedure.
Follow recommended processes to verify correct patient, surgery, site, and
side.
• For cleft palate surgery, adhere to safety protocols. FIG. 1.2.16 Pediatric patient in PACU post cleft palate surgery. Note
the tongue stitch taped to the cheek and “no-no’s” on the arms to
• Count and account for the throat pack on every palate procedure.
prevent disruption of the fresh surgical repair.
• Ensure a suture is secured to the throat pack and that the suture is
visibly hanging out of the patient’s mouth.
• Before the patient is transferred to PACU, verify with the anesthesiologist
and surgeon that the throat pack has been removed.
• A tongue stitch is required for each palate patient. It is to be securely taped
to the patient’s cheek before transferring to PACU.
• Ensure that “no-no’s” (padded cylindrical restraints to limit elbow bending)
are placed on the arms of all pediatric patients before transferring to the
PACU. This prevents disruption of a fresh surgical site or premature removal
FURTHER READING
of an IV (Fig. 1.2.16). AORN. Guidelines for perioperative practice 2016. 1st ed. Denver: AORN;
• Be mindful of and take preventative measures against perioperative 2016.
hypothermia. Rothrock JC. Alexander’s Care of the Patient in Surgery. 15th ed. St. Louis,
• Minimize exposed bare skin. MO: Elsevier; 2015.
• Use passive insulation on all patients (e.g., blankets, plastic bags, mayo Osborn K, Wraa C, Watson A, Holleran R. Medical-Surgical Nursing:
stand covers, space blankets). Preparation for Practice. 2nd ed. Upper Saddle River, NJ: Pearson
Publishing; 2014.
1.3
General Anesthesia
Deborah A. Rusy
13
14 SECTION 1 Perioperative Management
electricity, water, and oxygen supplies, which are often intermittently for significant hypothermia, which may be seen during procedures
unavailable at most sites, or permanently unavailable at some of the requiring large body portions to be exposed, or where blood loss with
rural LMIC sites. In hospitals in developed countries, the primary gas repletion may be necessary. Temperature monitoring may also be needed
source for the anesthesia machine is a pipeline supply source delivered for patients having procedures in warmer climates where operating
through wall outlets at a pressure of 50 to 55 psig. In most LMIC rooms have no air conditioning systems, because these patients are at
hospitals, the oxygen source is typically supplied in tanks. When oxygen risk for hyperthermia.
is available from a wall outlet, it is likely that the line is connected to A continuous source of electricity is needed to power most anesthesia
large oxygen tanks outside the hospital and not the typical liquid oxygen equipment including monitors and ventilators. Anesthesia providers
reservoirs used in developed countries. Oxygen tank size and color code in LMICs must be prepared for frequent power outages. If possible, a
also vary according to location. US standards require oxygen tanks to backup generator should be available. The anesthesiologist, surgeon,
be green, whereas the World Health Organization (WHO) specifies that and nurses should have backup plans for how to monitor the patient’s
they be white. The most common tank cylinders available are type E, vital signs and how to provide light, suction, and hemostasis during
G, or H. The E cylinders contain 625 L of oxygen, corresponding to a power failure. Equipment brought by teams should have a backup
pressure of 2200 psi. The G and H cylinders are much larger and can rechargeable battery source. Because the electric power source current
hold 5300 L and 6900 L of oxygen, respectively, when completely full.11 may differ from that in the United States, current converters, plug adapt-
When oxygen supply to an anesthesia machine is by tank, one should ers, and grounding devices may be needed.
always have a backup tank on-site and immediately available. Due to Volunteer surgical teams may consider transporting portable anes-
the cost and limited availability of the oxygen supply, whenever possible, thesia machines; however this requires knowledge of how to set up and
the fresh gas flow used to deliver an anesthetic should be minimal troubleshoot them. Machines that are brought must have gas connection
(1–2 L/min), and providers should turn off flows when not in use. hoses with connected fittings that have the capacity to attach to the
In some rural hospitals, there is no available source of oxygen, and oxygen gas cylinder valve outlets and pressure regulators at the host
providers are dependent on oxygen concentrators.6 These machines sites, and the machines will also need appropriate tubing that enables
run atmospheric air through zeolite, which absorbs nitrogen, to produce waste gases to be disposed into the atmosphere. Figs. 1.3.5A and 1.3.5B
an admixture that is 95% oxygen concentration. depict a portable anesthesia machine utilized by ReSurge International.
Other gases such as nitrous oxide are often not available. However, This system contains a stand that holds oxygen tubing with connectors
when they are being used, one must be vigilant to frequently check the from tank pressure regulators to a flow meter; to temperature-
oxygen supply source and to continuously monitor patient oxygen compensated, concentration-calibrated, dial-controlled sevoflurane and
saturation, because delivery of a hypoxic gas mixture can easily occur isoflurane vaporizers; and to a portable baralyme circle system (“King
if the oxygen source is empty. This is especially true if safety devices System”) (Figs. 1.3.5A and 1.3.5B).
such as proportioning systems and the measurement of inspired oxygen
concentration are not present. ANESTHETIC DISPOSABLE SUPPLIES AND
Waste gases emitted from the anesthesia machine can be detrimental
to operating room personnel when inhaled. In developed countries,
MEDICATIONS IN LMICS
these gases are scavenged to a central vacuum system or to a passive Most anesthetic supplies that are considered “single-use disposables”
duct system that safely transports the waste gases into the atmosphere. in the United States are cleaned and reused in LMICs. Sterilization
Often in LMIC operating rooms, these gases are not scavenged, and practices are varied, and often inadequate, with increased risk of iat-
they are released directly into the operating room. They can easily be rogenic infections. Pediatric-size endotracheal tubes (ETTs) are extremely
scavenged from anesthesia machines by running corrugated tubing from limited and often unavailable. Available supplies are recycled numerous
the exhaust valve of the breathing system to an outside window or a times, which puts them at risk for weakening, kinking, and balloon
suction device. cuff rupture.10 Pediatric anesthesia circuits, masks, oral airways, laryngeal
The WHO recommends that the minimum standard of care for mask airways (LMAs), and intravenous catheters are a rare commodity.
patient monitoring while receiving anesthesia consists of pulse oximetry, When reusing supplies, careful cleaning and disinfecting processes
heart rate monitoring, non-invasive blood pressure recording, and should be followed. Laryngoscopes, ETTs, suction catheters, oral airways,
temperature monitoring. It also suggests monitoring the capability for LMAs, masks, and other equipment exposed to mucous membranes
inspired and exhaled concentrations of oxygen and applicable anesthetic and bodily fluids should first be thoroughly washed with soap and
agents and also monitoring the availability of additional equipment water to remove particulate organic matter. After initial cleaning, it is
such as bag valve masks, laryngoscopes, oral airways, precordial stetho- then advisable to soak the equipment in a high-level chemical disin-
scopes, and cricothyrotomy kits.16 fectant or use a sterilization process. Examples of high-level disinfectants
The patient monitors encountered in LMICs are often suboptimal, include glutaraldehyde 2% to 3.5% (Cidex®), ortho-pthalaldehyde
with missing or broken parts and cables, or none at all. In most facili- (Cidex-OPA®), sodium hypochlorite 1000 to 2500 ppm (bleach), hydro-
ties, there are no volatile anesthetic or EtCO2 gas analyzers, and the gen peroxide 6%, iodine at a concentration of 450 ppm, and 70% to
ability to monitor ECG and pulse oximetry is also sporadic. Often, 90% ethyl and isopropyl alcohol. These disinfectants are bactericidal,
anesthesia providers must rely on obtaining blood pressure via blood tuberculocidal, fungicidal, and virucidal with 10- to 40-min exposure.14
pressure cuff and sphygmomanometer and auscultation of breath and Steam sterilization, if available, can also be used on plastic disposables
heart sounds with a precordial stethoscope. In some rural areas, moni- once washed, but repeated treatments tend to discolor and weaken the
toring may consist only of a precordial stethoscope and the vigilance plastic. Any equipment that has been washed should be completely dry
of an anesthesia provider with a “finger on the pulse.” before reuse.
Pulse oximetry was recognized as an international standard in anes- Hospitals in LMICs frequently have poorly organized storage and
thetic care in 2009, and it is the only piece of technological equipment distribution of health care–related disposable products and drugs. Often
required by the WHO Surgical Safety Checklist. stock supply levels are unknown, and a continuous supply of disposables
Temperature monitoring is often not available in LMICs. Temperature and essential drugs is not reliable. Many anesthetic and resuscitation
monitoring should be utilized for cases in which the patient is at risk medications that are standardly stocked in operating room pharmacies
CHAPTER 1.3 General Anesthesia 17
A B
FIG. 1.3.5 (A and B) Portable anesthesia machines.
in the developed countries may be unavailable in LMICs. It is vitally must check in equipment and supply boxes with personal luggage,
important to check all drug labels for the concentration before admin- paying for any excess baggage charges. Drugs and supplies traveling
istering, because drug concentrations found abroad may differ from with the teams require government agency permission before travel,
the standard concentrations seen in the United States. When diluting and are usually subject to extra fees. Transportation through customs
medications to a certain concentration, a standard dilution should be can be facilitated with government agency approval letters, obtained
chosen and used for every case as a measure to avoid drug-dosing error. once the drugs and equipment have been guaranteed to meet govern-
Surgical teams should create a list of the names and amounts of ment requirements. This may require that certain drugs and supplies
medications required to provide anesthesia for the number of expected not be transported (i.e., flammable explosive volatile anesthetics, outdated
cases, and specific to the procedures being performed. When general or illegal drugs).17 Often supplies may be confiscated if pre-approval
anesthesia is being performed, this usually consists of premedications, has not occurred. Narcotics and schedule II drugs may be restricted
induction agents, analgesics, volatile anesthetics, muscle relaxants, local from transport to certain countries, or may require an official letter
anesthetics, antibiotics, anti-nausea medications, and drugs required from the host country’s government agency. Transported equipment
for resuscitation. and drugs should be of the same quality that would be standard use
When preparing and packing medications and disposable supplies in the United States. Outdated medications are wasted in the United
for a surgical trip, it is wise to consider bringing anything thought to States due to possible sub-therapeutic potency. It is inappropriate, and
be essential for providing safe general anesthesia. Packing lists will vary in some countries illegal, to transport in outdated medications.
depending on the number and type of surgical procedures being per-
formed. Box 1.3.1 is an example of an anesthesia supply list of items PREPARATION OF THE OPERATING ROOM AND
necessary for a plastic reconstructive surgical mission. PATIENT FOR GENERAL ANESTHESIA
PREPARATION FOR GENERAL ANESTHESIA Team Anesthesia Providers
Surgical team anesthesia providers should have previous experience
Preliminary Site Visit/Report caring for the patients having the planned surgical procedures, with
A preliminary site visit is crucial to allow for the assessment of the knowledge of all perioperative issues specific to these procedures and
anesthesia equipment (machine, monitors, suction equipment, and other of methods to deal with them. Those providing general and regional
anesthesia equipment and disposables), physical operating room space, anesthesia (anesthesiologists or anesthetists) who anticipate caring for
and PACU availability on-site. It also allows for an introductory visit young children should have extensive pediatric experience and be com-
with the host physicians, sponsors, and hospital administration before petent in the care of this group of patients.14 Teams should perform
provision of team care. Review of the host hospital site should also practice emergency scenarios and should conduct brief training sessions
include the accessibility of a clinical laboratory, blood bank and access to familiarize both themselves and the local staff with safety protocols
to blood products, pharmacy, and radiology services. Certain more before performing the first surgical procedure.
complex reconstructive surgical procedures cannot be performed safely Universal precautions should be followed at all times. The use of
if the hospital is lacking these. Also included in the assessment, and personal and protective equipment should abide by the same standards
critical to provision of general anesthesia, is the availability of electric as in the United States. Sufficient supplies of sterile gloves, gowns, masks,
power, oxygen, running water, and sterilization processes. and protective eyewear should be available for the entire team. Safety
devices such as blunt needle and sharps dispensers are also recom-
Transportation of Anesthesia Supplies and Equipment mended to help decrease the risk of inadvertent needlestick.18 Providers
Supplies may be shipped in advance or transported with the team. In should take precautions to prevent the spread of infectious diseases
past years, airlines were very generous in allowing for free transport of that have a high prevalence in many of the LMICs, such as HIV and
equipment and supplies used for volunteer medical and surgical mis- hepatitis, by using a syringe and needle only once, as suggested by the
sions. This generosity has long disappeared, and many groups now Centers for Disease Control and Prevention.19 When drawing up
18 SECTION 1 Perioperative Management
medications from multi-dose vials, the use of clean needles with no procedures should be taken into account. It would be prudent to provide
previous patient exposure should be adhered to. initial oral doses in smaller amounts than those given in the United
States, such as for midazolam (0.1–0.25 mg/kg) and ketamine (2–3 mg/
Anesthesia Documentation kg), because it has been shown that these lower doses can still provide
At a minimum, anesthetic records should consist of documentation of decreased separation anxiety yet offer earlier recovery.20 Intravenous
a pre-operative health and physical examination, consent to receive premedication dosing for older children and adults is also acceptable.
anesthesia after explanation of benefits and risks, and an intra-operative
anesthetic record containing anesthetic type, interval between patient
vital signs, estimated blood loss and fluids given, medications given,
INDUCTION OF ANESTHESIA
and documentation of procedures performed by the anesthesia team Intravenous ketamine alone has often been successfully used to provide
(i.e., intubation, invasive line placement, axial or peripheral nerve blocks). general anesthesia or deep sedation for surgical procedures in LMIC
Post-operative orders for patient monitoring and pain control and a rural areas where complex monitoring, anesthesia equipment, electricity,
post-operative assessment note are also essential. and oxygen may all be in short supply or unavailable.21,22 Advantages
include allowing for maintenance of spontaneous ventilation, avoidance
NPO Guidelines of airway manipulation, and maintenance of blood pressure. Disad-
The ASA guidelines for nil per os (NPO) times should be observed vantages are that when used alone, it may not be sufficient for surgeries
before general anesthesia for elective cases. These include 2 hours for on the head and neck, which may require a secured, protected airway,
clear liquids, 4 hours for breast milk, and 6 hours for formula, milk, or for cases requiring ventilatory control, muscle relaxation, or the
and light solid meals. Younger children should be encouraged to drink prevention of movement during the procedure. In these cases, induction
clear liquids up to 2 hours before anesthesia induction to prevent dehy- of anesthesia may be accomplished by mask induction with volatile
dration, hypotension, and difficult intravenous access, particularly in anesthetic agents or, if an IV is present, with an induction agent such
hot climates where air conditioning is not available. as propofol.
Premedication Airway
The use of pre-operative sedative and anxiolytic medications may provide For most procedures, the airway is secured after induction. Choice of
for comfort to patients when both they and, if they are children, their airway is dependent on the procedure. It is generally the preference of
parents have a decreased understanding of the procedures and process the surgeon to have an oral RAE ETT in place for cleft lip, palate, and
due to limited medical knowledge or language barriers. Oral midazolam nose surgery. This allows for insertion of the Dingman retractor and
or ketamine may be utilized for pediatric patients; however, consider- allows for a symmetrical view of the face without traction on one side
ation for increased risk of prolonged post-operative sedation after short of the lip. Often RAE tubes are not available in LMICs, so if they are
20 SECTION 1 Perioperative Management
FIG. 1.3.7 Training local providers to use the GlideScope video laryn-
MAINTENANCE ANESTHESIA goscope in Leon, Nicaragua.
A simple anesthetic with as few drugs as possible is the safest choice
when monitoring or post-operative recovery may be minimal or
absent. Typically, most anesthetics in underdeveloped countries consist EMERGENCE FROM ANESTHESIA
of an induction agent (propofol or mask induction with volatile
anesthetic), maintenance anesthesia with a volatile anesthetic (sevoflu- Emergence from anesthesia involves the discontinuation of administra-
rane, isoflurane, halothane), and scant amounts of narcotic. It is best tion of general anesthesia and adjuvant agents at the end of the surgical
to avoid muscle relaxants if not needed for the surgery. Often the anes- procedure and the return of consciousness afterward.
thetic is supplemented with regional anesthesia blocks or wound infil- Most patients transition smoothly within a short period of time
tration by the surgeon to allow for a decrease in narcotic analgesics from a surgical anesthetic state to the awake state. Before anesthetic
and other general anesthetics the patient is receiving. The use of smaller emergence and removal of the ETT or LMA, the anesthesiologist should
amounts or no narcotic or muscle relaxants will decrease the risk of ensure that the patient has adequate hemodynamic stability, oxygenation,
post-operative apnea, airway compromise, and hypoxia; however, one ventilation, and temperature. Reversal of any neuromuscular blockade
should be aware that increased incidence of emergence delirium may given (typically assessed with a peripheral nerve stimulator) and veri-
be seen. fication of spontaneous ventilation with adequate tidal volume, minute
CHAPTER 1.3 General Anesthesia 21
KEY REFERENCES 13. Kaul TJ, Mittal G. Mapleson’s breathing systems. Indian J Anaesth.
2013;57(5):507–515.
1. American Society of Anesthesiologists. Standards for basic anesthetic 14. Fischer QA, Politis GD, Tobias JD, Proctor LT. Pediatric anesthesia for
monitoring. Approved by ASA house of delegates October 21, 1986. Last voluntary services abroad. Anesth Analg. 2002;95:336–350.
amended October 25, 2005. 15. Dubowitz G, Detlefs S, McQueen K. Global anesthesia workforce crisis: a
2. Ariyo P, Trelles M, Helmand R, et al. Providing anesthesia care in preliminary survey revealing shortages contributing to undesirable
resource-limited settings: a 6-year analysis of anesthesia services provided outcomes and unsafe practices. World J Surg. 2010;34(3):438–444.
at Medecins Sans Frontieres Facilities. Anesthesiology. 2016;124:561–564. 16. World Health Organization. WHO guidelines for safe surgery. 2009: Safe
3. Mgbakor AC, Adou BE. Plea for greater use of spinal anaesthesia in Surgery; SavesLives. http://apps.who.int/iris/bitstream/handle/10665/
developing countries. Trop Doct. 2012;42:49–51. 44185/9789241598552_eng.pdf. pp. 15–18. Accessed April 29, 2018.
4. Rosseel P, Trelles M, Guilavogui S, Ford N, Chu K. Ten years of 17. Sherman J, Gaal D. Materials management and pollution prevention. In:
experience training non-physician anesthesia providers in Haiti. World J Roth R, ed. The Role of Anesthesiology in Global Health. New York:
Surg. 2010;34:453–458. Springer; 2015:97.
5. Ouro-Bang’na Maman AF, Kabore RA, Zoumenou E, Gnassingbé K, 18. Chackungal S, Nickerson JW, Knowlton LM, et al. Best practice guidelines
Chobli M. Anesthesia for children in sub-Saharan Africa–a description of on surgical response in disasters and humanitarian emergencies: report
settings, common presenting conditions, techniques and outcomes. of the 2011 Humanitarian Action Summit Working Group on Surgical
Paediatr Anaesth. 2009;19(1):5–11. Issues within the Humanitarian Space. Prehosp Disaster Med.
6. McCormick BA, Eltringham RJ. Anaesthesia equipment for resource-poor 2011;26(6):1–8.
environments. Anaesthesia. 2007;62(suppl 1):54–60. 19. Centers for Disease Control and Prevention. Injection safety; the one and
7. Javis GA, Brock-Utne JG. Use of an oxygen concentrator linked to a only campaign. https://www.cdc.gov/injectionsafety/1anonly.html.
draw-over vaporizer (anesthesia delivery system for underdeveloped Accessed April 29, 2018.
nations). Anesth Analg. 1991;72(6):805–810. 20. Darlong V, Shende D, Subramanyum MS, Sundar R. Oral ketamine or
8. http://www.anaesthesiauk.com/article.aspx?articleid=100149. Accessed midazolam or low dose combination for premedication in children.
April 29, 2018. Anaesth Intensive Care. 2004;32(2):246–249.
9. Simpson S, Wilson IH. Draw-over anaesthesia review. Update in 21. Craven R. Ketamine. Anesthesia. 2007;62(suppl 1):48–53.
Anaesthesia. 1992;2:3–4. 22. Bonanno FG. Ketamine in war/tropical surgery (a final tribute to the
10. Bosenberg AT. Pediatric anesthesia in developing countries. Curr Opin racemic mixture). Injury. 2002;33:323–327.
Anesthesiol. 2007;20:204–210. 23. Jerome EH. The Pediatric Airway. In: Gregory G, ed. Anesthesia Care of
11. Tobias JD, Kim Y, Davis J. Anesthetic care in developing countries: Pediatric Patients in Developing Countries. https://storage.googleapis.com/
equipment and techniques. South Med J. 2002;95(2):239–247. global-help-publications/books/help_anesthesiapediatricsbw.pdf. p. 159.
12. Kampalath L. Induction and maintenance of anesthesia. In: Gregory G, Accessed April 29, 2018.
ed. Anesthesia Care of Pediatric Patients in Developing Countries. 24. Arora MK, Karamchandani K, Trikha A. Use of a gum elastic bougie to
https://storage.googleapis.com/global-help-publications/books/help facilitate blind nasotracheal intubation in children: a series of three cases.
_anesthesiapediatricsbw.pdf. p. 189. Accessed April 29, 2018. Anaesthesia. 2006;61:291–294.
1.4
Regional Anesthesia
Rachel C. Steckelberg, Frederick Mihm, Ryan Derby
SYNOPSIS 2. Equipment:
1. US probe: High-frequency linear probe (10–15 MHz)
The use of ultrasound (US) has revolutionized regional anesthesia and 2. Needle: 100-mm insulated needle
become an important component of surgical anesthesia and acute pain a. There are several regional anesthesia needles commercially
management.1–4 Its relative safety and ease of performance make it a available that all share these qualities
perfect option for surgeries in resource-poor settings. Specifically, regional 3. An extension tube to attach a syringe of LA
anesthesia is used to desensitize a precise body part to painful stimulus. 4. Blunt tip to minimize risk of nerve or vascular injury
Research suggests that acute post-operative pain continues to be under- 5. Skin preparation: chlorhexidine, Betadine, or alcohol
treated.5,6 US-guided regional anesthesia (UGRA) may be used to address 6. Probe cover: helpful to maintain strict aseptic technique. When
acute post-operative pain and improve outcomes as well as provide using a probe cover, limit air bubbles from gel because they will
surgical anesthesia for specific procedures. There are several applications distort the US image.
for UGRA that are beyond the scope of this text. This chapter will focus 7. Monitors: pulse oximeter (audible heart rate tone), continuous
on upper- and lower-extremity blocks. The overall purpose of this ECG, and non-invasive blood pressure
chapter is to provide step-by-step instruction on how to perform the 8. Sedation: titrate to the needs of your patient. Nerve blocks can
most commonly used nerve blocks and to highlight their contribution be performed with little or no sedation. Midazolam 2 mg, fentanyl
in the context of reconstructive surgery in resource-poor settings. 100 mcg, or propofol 20 to 50 mg are commonly used dosages.
3. Preparation:
CLINICAL ISSUES 1. Position: ensure proper and comfortable patient positioning as
well as ergonomic positioning of the US machine.
Presentation 2. US image: obtain best US image of the target by adjusting depth,
Acute post-operative pain is a recognized and challenging problem. gain, focus, and frequency of the probe.
UGRA is appropriate whenever post-operative pain control is a concern 3. Skin preparation: strict aseptic technique is important at needle
and can sometimes be used as the sole anesthetic, avoiding a general insertion site to minimize risk of infection.
anesthesia altogether. 4. Safety pause: immediately before performing block, confirm:
a. Correct patient
General Risks b. Correct surgery and side
The most worrisome risks for all peripheral nerve blocks include: c. Correct block and side
1. Nerve injury d. No contraindications to nerve block
2. Bleeding e. All equipment including resuscitation equipment is available,
3. Infection including 20% lipid emulsion.
5. Injection technique:
Associated Conditions a. An in-plane needle technique is described for all blocks included
Patients with an existing nerve injury, or with skin or systemic infection in this chapter, except for the ankle block.
(i.e., sepsis), or who have a coagulopathy of any etiology may not be b. Incremental injection of 5 mL with frequent aspiration for
good candidates for UGRA. The risks and benefits of a nerve block blood is important to minimize risk of complications.
must always be considered. c. High injection pressures may signify an intraneural injection,
and redirection of the needle may be necessary.
Additional Considerations d. Use slow injection of LA.
Although this guide describes single-injection techniques, it is possible
to place perineural catheters at the nerve targets to provide longer TECHNIQUES
analgesia. Special equipment and pumps to provide continuous infu-
sions are necessary and beyond the scope of this chapter. I. Facial Block
Infra-Orbital Block2
Intro: The infra-orbital block anesthetizes the infra-orbital nerve, a
MANAGEMENT branch of the maxillary division (V2) of the trigeminal nerve, and
1. Choice of local anesthetic (LA): There are many acceptable LAs that provides sensory innervation to the upper lip, lower eyelid, and nasal
can be used to meet specific patient needs. In general, LA can be vestibule area in between. It is easy to perform and can provide sub-
classified by duration and depth of block. The most commonly used stantial analgesia for cleft lip surgeries in children.
LAs and their concentrations are listed in Table 1.4.1. Indications: Cleft lip surgery
23
24 SECTION 1 Perioperative Management
Long-Acting
Ropivacaine 0.25% 0.5%
Bupivacaine 0.25% 0.5%
Technique
1. Patient Positioning:
a. Supine, anesthetized patient
2. Technique: FIG. 1.4.1 Infra-Orbital Block.
a. Draw an imaginary line parallel to midline at mid-pupillary
location.
b. Palpate the infra-orbital foramen just below the infra-orbital 2. Home Base:
margin on the mid-pupillary line. This is your target. a. Supraclavicular fossa. The nerve plexus and relevant vasculature
c. Rest the index finger of your other hand on the infra-orbital are easily identifiable here by US. This is the same position as
ridge during injection to prevent inadvertent needle entry into with a supraclavicular nerve block. Identify the subclavian artery
the globe. and surrounding plexus, which appears as a “bunch of grapes.”
d. Injection: using a 30-gauge needle, start needle at mid-pupillary 3. Scanning:
line even with the lateral border of nares and angle upward toward a. Slide the probe in the cephalad direction while keeping the nerve
the infra-orbital foramen. Walk off bone into foramen; then plexus in the center of the screen, holding the probe perpendicular
deposit 0.5 to 1 mL of LA just outside foramen. to the skin.
See Fig. 1.4.1: Infra-Orbital Block. b. The nerve plexus will begin to appear as discrete hypoechoic or
dark circles between the scalene muscles.
4. Target:
KEY PRINCIPLES a. Scan cephalad until the three distinct nerve roots are viewed
• Injection near the infra-orbital foramen allows sensory block of all branches stacked on top of one another within the interscalene groove.
of the infra-orbital nerve, which branches quickly after exiting the foramen. These are typically the C5 nerve root and two fascicles of C6.
• A finger on the orbital ridge protects against globe injury. 5. Needling:
• Avoid injection inside the foramen to protect against compartment pressure a. Advance the needle anteriorly toward the target. For safety, it is
and ischemic injury to the nerve. Be sure to pull out of the foramen before recommended to deposit the LA posteriorly to the plexus. It is
injection. not necessary to puncture between the dark circles.
• Bilateral blocks are recommended even for unilateral cleft lip, because b. The needle may be redirected above or below the target to obtain
surgery often crosses the midline. adequate spread.
• For routine cleft lip repair, this block can enable avoidance of any opioids 6. Injection:
in small infants. a. 15 to 20 mL.
• This block may not be completely effective if significant nasal reconstruction See Fig. 1.4.2: Interscalene Block.
is required.
C5 nerve root
Middle scalene m.
Anterior scalene m.
C6 nerve root
Carotid
artery
Vertebral
A C artery
FIG. 1.4.2 Interscalene Brachial Plexus Block. (A) Needle/probe/patient position for block on right shoul-
der. (B) Ultrasound image. (C) Ultrasound anatomy labeled with needle path (dashed black arrow).
Brachial plexus
Subclavian
artery
A C
1st rib
FIG. 1.4.3 Supraclavicular Brachial Plexus Block. (A) Needle/probe/patient position for block on right
arm. (B) Ultrasound image. (C) Ultrasound anatomy labeled with needle path (dashed black arrow).
b. Not all patients will be able to comfortably position their arm KEY PRINCIPLES
in this way. Abduct the arm as much as is comfortable for the
patient. The block can still be done if no abduction is • Abducting the arm and flexing the elbow help to rotate the clavicle poste-
possible. riorly, allowing space for the needle. Performing the block with the arm
2. Home Base: adducted is possible but may require a steeper needle trajectory.
a. Place probe in sagittal plane in the delto-pectoral groove and • To improve needle imaging, insert the needle as parallel to the probe as
locate the pulsatile axillary artery. The axillary vein should be possible, taking advantage of the space created by abducting the arm. If
adjacent medially. the needle image is still poor, translating the probe along the curvature of
b. If artery is not visible, translate the probe in the medial-lateral the chest wall may improve the image.
and cephalad-caudad directions until it is in view. • The hyperechoic area immediately posterior to the artery may represent a
3. Scanning: US artifact (posterior acoustic enhancement) but may also hide the posterior
a. The three cords of the brachial plexus can be seen surrounding cord. Alternatively, the posterior cord may lie more laterally than this
the artery at this point. hyperechoic area.
b. Scan medially until the rib or lung is identified deep and caudad
to targets. It specifically targets the four main branches of the brachial plexus: the
c. Identify the neurovascular cluster between the pectoralis major median, ulnar, radial, and musculocutaneous nerves.
and minor. These blood vessels are branches of the thoraco- Indications: Surgery involving the distal forearm and hand
acromial trunk and care must be taken to avoid them. Technique:
4. Target: 1. Patient Positioning:
a. The lateral, posterior, and medial cords surround the axillary a. Supine with arm abducted 90 degrees with external rotation
artery. The lateral cord is often the most visible, whereas the 2. Home Base:
medial may be difficult to appreciate. a. Place transducer in the axilla and identify the pulsatile axillary
b. Although it is safe to perform the block with pleura in view as artery.
long as meticulous needle imaging is observed, it is often possible 3. Scanning:
to find a preferred image in which pleura is not visible. a. If the artery is not easily visible, scan cephalad and caudad until
5. Needling: it is in view.
a. Direct the needle from cephalad to caudad, aiming for the 6 b. Another useful landmark is the “conjoint tendon” of the teres
o’clock position to the artery. major and latissimus dorsi muscles. The terminal branches of
b. Small amounts of hydro-dissection once the needle pierces the the brachial plexus are often easily visualized and blocked at this
pectoralis minor can help to float the lateral and posterior cords level.
out of the needle’s path. 4. Target:
c. A single injection creating a large pocket of LA immediately a. Three of the four principal branches of the brachial plexus sur-
posterior to the artery is adequate. round the axillary artery: median (superficial and lateral to the
6. Injection: artery), ulnar (superficial and medial to the artery), and radial
a. 20 to 40 mL. (posterior to the artery).
See Fig. 1.4.4: Infra-Clavicular Block. b. The 4th branch of the brachial plexus, the musculocutaneous
nerve, is located between the coracobrachialis and biceps brachii
Axillary Block7 muscles. It is often described as a “pod of peas” in between the
Intro: The axillary nerve block is performed at the level of the terminal two muscles, but it has great anatomical variability and may be
branches of the brachial plexus via injection around the axillary artery. located closer to the artery.
CHAPTER 1.4 Regional Anesthesia 27
Pectoralis major m.
Laterial cord
Pectoralis minor m.
Medial cord
Art
Vein
Posterior cord
A C Pleura
FIG. 1.4.4 Infra-Clavicular Brachial Plexus Block. (A) Needle/probe/patient position for block on right
arm. (B) Ultrasound image. (C) Ultrasound anatomy labeled with needle path (dashed black arrow). Art,
subclavian artery; Vein, subclavian vein.
Median n.
Vein Vein
Art Vein
Coracobrachialis
muscle Ulnar n.
Vein
Radial n.
Musculocutaneous n.
A C
FIG. 1.4.5 Axillary Brachial Plexus Block. (A) Needle/probe/patient position for block on right arm. (B)
Ultrasound image. (C) Ultrasound anatomy labeled with needle paths (dashed black arrow). Note: multiple
needle passes indicated to obtain optimum local anesthetic spread.
5. Needling: Technique:
a. Advance the needle from lateral to medial, aiming to pierce the 1. Patient Positioning:
fascia iliaca at the lateral-most aspect of the nerve. a. Lateral or supine with patient’s leg flexed and propped on pillows.
b. Continue to advance the needle either deep or superficial to the b. The lateral position is preferred when the patient has a large leg
nerve, depending on which direction the injectate courses. circumference, difficult-to-visualize anatomy, or limited room
c. Injecting deep to the nerve ensures that you have pierced the for the probe when in the supine position.
fascia iliaca. 2. Home Base:
6. Injection: a. Place the probe in the popliteal fossa and identify the pulsatile
a. 15 to 30 mL. popliteal artery.
See Fig. 1.4.6: Femoral Nerve Block. 3. Scanning:
a. The tibial nerve should be visible superficial to the popliteal
artery. If the nerve is not clearly visible, tilting the probe caudad
(i.e., direct the US beam toward the feet) should assist in bring-
KEY PRINCIPLES ing the nerve in view.
b. Once the tibial nerve is in view, translate the probe cephalad
• The block’s reliability rests on injecting deep to the fascia iliaca. In the
looking for the common peroneal nerve to enter laterally and
event that the nerve is difficult to see, injecting deep to the fascia iliaca
join the tibial nerve.
is a good end point.
4. Target:
• An important consideration of this block is that it results in quadriceps
a. There are two well-established locations to perform this block.
weakness, and patients are at risk of falling.
i. Scan until you reach the point where the common peroneal
• The hyperechoic area lateral to the femoral artery is often mistaken for the
and tibial components of the sciatic nerve just bifurcate. The
femoral nerve. The femoral nerve lies deep to the fascia iliaca.
ideal spot is where the two components are adjacent and still
• Remember the orientation of the important structures using the mnemonic
surrounded in a common fascial envelope.
NAVL (nerve, artery, vein, lymphatics, from lateral to medial).
ii. An alternative is to scan more proximally until there is one
distinct nerve, referred to as the sciatic nerve.
5. Needling:
a. Direct the needle from lateral to medial trying to achieve a parallel
Popliteal Sciatic Nerve Block needle-to-probe orientation by entering the skin approximately
Intro: A sciatic nerve block performed at the popliteal fossa provides the same distance from the probe as the depth of the target on
near-complete coverage of the lower leg. The sciatic nerve courses down the US image.
the posterior aspect of the leg and is easily visible as a superficial struc- b. To block at the sciatic nerve bifurcation:
ture at the popliteal crease. The sciatic nerve is composed of two distinct i. Advance the needle between the common peroneal and
nerves (common peroneal and tibial nerves). These distinct nerves are tibial components, being careful not to damage either
surrounded by a common fascial envelope until they branch near the nerve.
fossa. A saphenous or femoral nerve block must be performed to provide ii. If it is difficult to advance between the two components, target
complete coverage of the lower leg. each nerve separately or direct the needle to the medial aspect
Indications: Surgery below the knee of the tibial nerve.
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GENTSCHE GESLACHTSNAMEN.
En gelukkig! Wat men heden ten dage in de spelling onzer taal ook
moge veranderen, welke oude en schoone, alle recht [139]van
bestaan hebbende vormen ook uit de schrijftaal mogen verloren
gaan, in deze onze dagen van verbastering, verarming en
vervlakking der taal, de geslachtsnamen der Vlamingen, der
Gentenaren zijn in hunne, nu eenmaal vastgezette vormen
onveranderlijk, en blijven in deze hunne edele en volledige vormen
in leven, zoolang er Vlamingen zullen zijn, rechtzinnige,
ouderwetsche, vrome, degelijke Vlaamsche mannen, die ze zullen
voeren.
God geve, dat dit nog vele eeuwen, met volle eere, het geval moge
zijn!
Als namen die juist niet aan handwerk of ambacht of nering, maar
dan toch aan een bedrijf hun ontstaan te danken hebben, vindt men
te Gent: D e C l e r c k en D e C l e r c q met D e S c h r ij v e r , D e
R u y t e r , enz. En deze namen vormen den geleidelijken overgang
tot die geslachtsnamen, welke aan waardigheden, aan ambten en
bedieningen ontleend zijn. Dezen zijn nog al talrijk, en schier volledig
vertegenwoordigd onder de burgerij van Gent. Men vindt er:
C a r d i n a e l , B i s s c h o p en D e B i s s c h o p , D e P r o o s t ,
D e P a e p e , D e M u y n c k , en D e C o s t e r . Dan D e
K e y s e r , D e C o n i n c k (met D e K o n i n c k en D e
C e u n i n c k ), D e P r i n c e , D e G r a e v e , D e
B o r c h g r a v e met B u r g g r a e v e , H a r t o g h , D e
L a n t s h e e r e en J o n c k h e e r e . Dan komt D e
M a e s s c h a l k , D e R i d d e r en D e R u d d e r , S e r g e a n t
[141]en D e K r ij g e r . Eindelijk D e M e e s t e r , B a a s en D e
G h e s e l l e , D e P o o r t e r en B u r g e r . Ten slotte D e
Boeve.
Sommige namen van deze groep maken als ’t ware eenen overgang
uit tot die van de volgende groep, omdat zij, ofschoon oorspronkelijk
van volkseigenen, van Germaanschen oorsprong zijnde, toch ook
voorkomen als Kerkelijke namen, dewijl de Heiligen, die deze namen
gedragen hebben, Germaansche mannen geweest zijn. Bij
voorbeeld: de geslachtsnaam L a m b r e c h t s , zoon van
L a m b r e c h t of L a m b e r t (’t is het zelfde), een Kerkelijke naam,
maar die toch, in zijnen oudsten, oorspronkelijken vorm
L a n d b r e c h t of L a n d b e r c h t , van Germaanschen oorsprong
is. Zoo is het ook gesteld met den geslachtsnaam H u y b r e c h t s ,
zoon van H u y b r e c h t , in verlatijnschten Kerkelijken vorm
H u b e r t u s ; maar, volgens zijnen Oud-Germaanschen oorsprong,
H u b r e c h t of H u b e r c h t , voluit H u g i b e r c h t . En eveneens is
dit het geval met Beernaerts, zoon van B e e r n a e r t , den Oud-
Vlaamschen vorm van den naam die als B e r n h a r d van Oud-
Germaanschen oorsprong is, maar als B e r n a r d u s in Kerkelijk
Latijn voorkomt, en heden ten dage als B e r n a r d en als B a r e n d
aan Holland, als B e r e n d , B e a r n (B e e r n ) of B e a r t (B e e r t )
aan Friesland eigen is. B e e r t komt ook als geslachtsnaam te Gent
voor; en de geslachtsnaam B a e r t s o e n , zoon van B a a r t , mede
een Gentsche geslachtsnaam, dankt zijnen oorsprong vermoedelijk
ook aan den, in alle Germaansche landen veelvuldig verspreiden
mansvóórnaam B e r n h a r d , B e e r n a e r t , B a r e n d , B e e r t ,
Baart.
Ten slotte willen we uit alle drie de hoofdgroepen (zie bladzijden 145
en 146) eenige namen uitkiezen, om die den Lezer voor te stellen, in
hunnen oorsprong en in hunne beteekenis, en in hunnen
samenhang met andere namen en naamsvormen, bij den Vlamingen
verwante volken en volksstammen in gebruik.
Uit den aard der zaak vinden we onder de Friezen de namen, aan
A l l e ontleend, het menigvuldigst vertegenwoordigd. Vooreerst
vermelden oude Friesche geschriften den hedendaagschen vorm
A l l e als A l l o , A l l a , A l l en A l . Dan is A l l e in den
vrouwelijken vorm (eigenlijk anders niet als een verkleinvorm) A l t j e
en A l k e , oudtijds ook geschreven A l t j e n en A l k e n , nog heden
aan menige Friezin als vóórnaam eigen. Vervolgens komen de
geslachtsnamen A l l e m a , A l m a en A l l e s , nog heden in leven,
en A l l i n g a (de Friesche weêrga van den Vlaamschen, eigenlijk
Sassischen vorm A l l i n k , A l l i n c k x ) met A l l a m a , reeds
uitgestorven. Eindelijk de plaatsnamen A l l i n g a w i e r , een dorp in
Wonseradeel; en een ander A l l i n g a w i e r , eene sate
(boerenhofstede) bij den dorpe Grouw; A l l i n g a - s a t e te Arum en
te Tietjerk, A l l e m a - of A l m a - s t a t e bij Oudwoude, A l l e m a -
s a t e te Wirdum, A l m a - s a t e te Minnertsga en te Blya. Dit alles
is Friesland.