Outline
1.Anesthesia Drugs / Monitors.
2. Anesthesia Events in the OR.
3. Anesthesia Consults.
Am I missing something ?
Miller - 6th ed, 3204 pages (subtract about
800 pages for regional / pain)
Sabiston 18th ed, 2353 pages.
Am I missing something ?
Am I missing something ?
Miller - 3204 pages. We
can cover
this in 60 to 90 minutes.
ANESTHETIC DRUGS /
MONITORS
Routine Monitors
ECG.
BP.
Oximetry (use the ear probe in shock).
End Tidal CO2 .
ETCO2
Continuous monitor in OR.
Monitor of position of ETT (after 6 breaths).
Monitor acute decrease - Cardiac Output,
Embolism.
Monitor acute rise - for M.H.
Intravenous Drugs
1 .Propofol - less hangover, good anti emetic . Very
easily contaminated. Pain on injection,
2 .Pentothal and Propofol - potent anti- convulsants
and ICP.
- BP
- resp depressants
3. Ketamine - maintains BP, maintains respiration, but
ICP. IM useage.
Nitrous Oxide
MAC - 104%.
Enlarges air containing closed spaces e.g.
obstructed bowel, middle ear, eye with SF 6 ,
pneumothorax, VAE.
Negative outcomes large studies
High FIO2 and wound infection
Not often used - air /oxygen
Vapours
All C / I in MH.
Lipid solubility important so awaken
quickest from Desflurane.
Pungency - Sevoflurane least (epiglottitis).
For inhalation induction /kids
Toxicity vapours
ANESTHETIC INTRAOPERATIVE
EVENTS
ASA Score
1 - Healthy.
2 - Mild systemic disease, no functional
limitations.
3 - Severe systemic disease that limits activity.
4 - Incapacitating disease that is a constant threat
to life.
5 - Moribund, not expected to survive 24 hrs, with
or without surgery.
E - Emergency
Failed Intubation
Management depends on whether can
ventilate or not.
Different blades and smaller tube.
LMA , Bronchoscope , Bougie, Glidescope
Cannot intubate , Cannot ventilate - need
surgical airway.
Aspiration
Risk factors - Morbid obesity, Pregnancy,
Massive ascites, Diabetes, Pain esp. trauma.
Prophylaxis H 2 blockers, Prokinetic agents,
Sodium Citrate.
Rapid Sequence Induction (RSI).
Presents as desaturation or wheezing.
Guidelines : 6 hrs for light meal (clear fluid and
toast) to 8 hrs. (meat) and 2 hours for clear
fluids.
Malignant Hyperthermia
Triggered by vapours and Succinylcholine.
Hypermetabolic state of muscles.
ET CO2 , tachycardia (metabolic storm).
Arrhythmias from K+ release VT,VF
Muscle rigidity and temp -LATE signs.
Rx- Dantrolene (2,5mg/kg up to 10mg/kg),
Airway fire
1. Ignition source cautery, laser, flammable
ointment alcohol based prep solution.
2. Fuel drapes , PVC ETT.
3. Oxidizer near surgical site Oxygen or Nitrous
Oxide.
Laser surgery, Tracheotomy.
Disconnect patient from machine, extubate and
extinguish with saline,ventilate or reintubate,
evaluate airway damage (rigid bronchoscopy).
Gas Embolism
Air, Helium, CO 2 .
Operative site above heart, low CVP.
Presents as ETCO2, SaO2, millwheel
murmur, BP, PA pressures.
Rx - D/C Nitrous, Trendelenburg, flood field,
aspirate from CVP catheter, left side down
(airlock RV), consider hyperbaric oxygen.
Latex Allergy
Multiple procedures, health care esp. dental
workers, spina bifida, food sensitivity.
Prevent - glass syringes, remove top of vial, 1st
case of day, premed optional.
Onset after 20 - 60 minutes.
Airway and 100% O2.
Volume.
Epinephrine - 0,1 micrograms / kg boluses
Massive Transfusion
All complications of 1 unit -TRALI,
Immunosuppression.
Hypothermia.
Hypocalcemia from citrate.
K + abnormalities (> 120 ml/ min).
Dilutional coagulopathy.
Autologous donation
Hypothermia
Core and peripheral component ,with tonic
constriction normally.
1st hour rapid drop 1,5 C vasodilation.
2nd stage - slow linear decrease for 2 -4 hours of
1,5 -2,5 C as heat loss exceeds metabolic heat
gain . (radiation*,convection, evaporation,
conduction)
3rd stage - plateau after 2- 4 hours
Positional Injuries
Ulnar - commonest (male, >4hrs, BMI<20
or >40). 27% used extra padding.Often
delayed onset, at day 3. Occurs in regional
anesthesia also.
Brachial plexus- median sternotomy, steep
Trendelenburg with shoulder braces,prone
esp. head to opposite side (females)
Positioning
Arms < 90 when supine.
At side, neutral position.
On arm board supinate.
Chest roll risk brachial neuropathy.
DNR
Patient or SDM. 3 choices for OR:
1.DNR intact.
2. DNR partially rescinded .
3. DNR rescinded completely
Discuss specifics and goals - chest compressions,
pacing, defib, vasoactive drugs, postop ventilation,
postop ICU ( time limited).
Awareness
MAC. 50% dont respond in to pain in a
grossly purposeful manner. Use surgical
incision as stimulus.
Sandin 18 / 11785 ( 0,15%). Trauma, OB,
CV surgery.
B Aware trial . 2 vs. 11 cases using BIS
(bispectral index)
Laparoscopic Physiology
CVS - Trendelenburg or reverse
- tachycardia from venous
return,CO2
- bradycardia from insufflation
Resp - PCO 2 , atelectasis, subcutaneous
emphysema, pneumothorax, CO2
embolus,venous stasis
Laparoscopy
Hypothermia
Impaired renal flow
ICP
PONV
Risk factors female, nonsmoker, volatile
agents, nitrous oxide, opioids, laparoscopy,
middle ear, strabismus, breast surgery.
Prophylaxis Serotonin antagonists e.g.
Ondansetron.
- Dexamethasone 4 - 8 mg IV.
- Dimenhydrinate.
Anesthesia Consults
Risks of Anesthesia
CEPOD - Mortality rate total contribution :
1. Patient factors 1: 870.
2. Surgical factors 1: 2860.
3. Anesthesia 1: 185,056 totally.
Anesthesia partially 1: 1430.
Fleisher - 564 267 outpatient , ASC , Office. Had a
mortality of 25 -50 / 100 000.
Newland - intraop arrest 1/14 000.( 1/10 000)
Myocardial ischemia
Risk of surgery - High ,intermediate and
low.
> 4 Mets.
Beta blockade preoperatively- Atenolol, 200
patients - Noncardiac surgery. NEJM 1996
335, 1713.
Bisoprolol in vascular patients - NEJM
1999, 341, 1789.
POISE Trial
Beta blockers decreased myocardial
infarction , but increased stroke rate and
overall mortality likely from decreasing
blood pressure.
Risk / Benefit now much more uncertain
AHA guidelines
Five risk factors (Lee or RCRI):
-
History CAD
History heart failure
History of CVA
Renal insufficiency
Diabetes
Respiratory Disease
GA - FRC
GA - Diaphragmatic function
Shapiro score
Po2 on room air <50, Pco2 45
Active wheezing
Site of surgery especially upper abdomen
and thorax
Respiratory disease
Quit smoking > 8 weeks does resp
complications (14.5% vs. 33% in 200 ACB)
(Prospective, Mayo Clinic Proc 1989 ,64
609).
<48 hrs COHB levels and ciliary activity.
1-2 Weeks to sputum.
PFT- only to diagnose,not prognosticate.
Respiratory disease
Laparoscopic approach- better ABGs, PFT.
Epidural may be better- Meta analysis
showed less atelectasis.
Lung expansion manoevres postop work
Herbal remedies
CVS - Ginseng, Ephedra, St. Johns Wort,
dietary hyperadrenergic
Bleeding - Ginko, Vit E, Ginger
Hepato and nephro toxic
Natural herb CPS
www.herbnet. com
OSA
3 Scoring factors:
1. Severity - AHI (6-20, 21-40, >40).
2. Invasiveness surgery.
3. Narcotic needs postoperatively.
CPAP use or not?
Ward, ward with 24 hr oximetry, Step-down
Summary
Think ICU post-op especially for the
emergency list patients (sepsis).
Consult for multiple Lee cardiac risk
factors.
OSA beware need for step-down bed.
Being available and in the OR at the
beginning and end of the case is greatly
appreciated and noticed.
Sickle Disease
Hb AS -Trait - <40% S -only sickle at
extremes of O2 and temp, not anemic
Hb SC - 50%S -eye, hip , pregnancy
borderline anemia
Hb SS Disease > 80 %S, anemic
Get HBS < 40%
Keep warm and hydrated and oxygenated
MaVs Trial
496 patients for vascular surgery receive
metoprolol or placebo 2 hrs preoperatively
and for 5 days.
Blinded.
No difference in CV deaths or nonfatal MI
CJA 2004 51 .
Ann Int
Med Nov
2001