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
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
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?
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
(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)
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
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