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PRACTICAL CONDUCT OF ANAESTHESIA
DR ANIRBAN PAL Assistant professor
Dept of Anaesthesia CNMC, Kolkata, India
• PRE OPERATIVE CONSIDERATIONS
• INTRA OPERATIVE CONSIDERATIONS
• POST OPERATIVE CONSIDERATIONS
Conduct of anaesthesia
PRE OPERATIVE CONSIDERATIONS
• Pre anaesthetic assessment
a) History
b) Physical examination
airway assessment
examination of spine
c) Investigations
ASA grading• Pre operative preparation Optimization of co-morbid conditions
• Consent
PRE ANAESTHETIC ASSESSMENT
• SPECIFIC OBJECTIVES1. To establish a doctor-patient relationship2. To allay patient anxiety3. To become familiar with co-existing
medical condition4. To formulate anaesthetic plan5. To obtain informed consent
• Overall goal is to reduce peri-operative morbidity and mortality
HISTORY
• Review Surgical illness
• Co existing medical illness
• Medications
• Allergies and drug reaction
• Previous anaesthetic history
• Relevant family history
• Addiction
PHYSICAL EXAMINATION
• Vital signs• Cardiovascular system• Respiratory system• Other systems ( CNS, abdomen, extremities)
• Assessment of airway• Examination of spine• ASA physical status
INVESTIGATIONS
• ROUTINE– Complete haemogram– Sugar, urea, creatinine– ECG– Chest Xray
• SPECIAL– Serum electrolytes– Coagulation studies– LFT– Thyroid profile– Miscellaneous
PREOPERATIVE PREPARATION
• Optimization of co-morbid conditions– Cardiovascular diseases– Respiratory disease– Endocrine diseases
• Aspiration prophylaxis
• Sedative and analgesic
• Anti-cholinergics
INTRA OPERATIVE CONSIDERATIONS
• Checking of anaesthesia machine and equipments
• Securing IV lines• Attach the monitors• Selection of anaesthetic technique• Induction• Intubation • Positioning• Monitoring• Intravenous fluids & transfusion therapy• Reversal
CHECKING OF MACHINE
• Check pipeline and cylinder supplies
• Test flowmeter
• Perform leak check of machine and breathing system
• Check scavenging system
• Vaporiser
CHECKING OF EQUIPMENT
• Functioning laryngoscopes
• Proper size endotracheal tubes
• Others
SEQURE IV LINE
• Life line of the patient
SELECTION OF ANAESTHETC TECHNIQUE
• GENERAL ANAESTHESIA
• REGIONAL ANAESTHESIA
• TIVA
• MONITORED ANAESTHESIA CARE (MAC)
• HYPOTENSIVE ANAESTHESIA
CONNECTING THE MONITORS
INDUCTION OF ANAESTHESIA (GA)
• INTRAVENOUS
• INHALATIONAL
Intravenous Anaesthesia
• Suitable for most routine purposes
RAPID SEQUENCE INDUCTION ( used in patients at high risk for aspiration)
COMPLICATIONS
• Regurgitation and vomiting
• Intra arterial injection of Thiopentone
• Perivenous injection and tissue necrosis
• CVS, respiratory depression
• Anaphylaxis
• Aggravation of porphyria
• Others
Inhalation Anaesthesia
• Done in paediatric age group
• Patients with airway obstruction
COMPLICATIONS
• Slower induction
• Problem in stage 2 of anaesthesia
• Laryngospasm & bronchospasm
• Raises intracranial pressure
• Environmental pollution
LARYNGOSCOPY & INTUBATION
• Prior use of muscle relaxants
• Conduct of laryngoscopy
• Conduct of intubation– Oral – Nasal
DIFFICULT INTUBATION ???
LMA insertion
POSITIONING OF THE PATIENT
• SUPINE
• LATERAL
• PRONE
• LITHOTOMY
• TRENDELENBURG
• SITTING
MAINTAINENCE OF ANAESTHESIA
• Nitrous oxide or Medical air
• Inhalational agents
• Muscle relaxants
MONITORING OF THE PATIENT
• Pulse oximetry
• Non invasive blood pressure
• ECG monitoring
• Capnography
• Temperature
• Urine output
IV FLUIDS & TRANSFUSION THERAPY
• Ringer lactate ; most physiological
• Normal saline ; in neuro-anaesthesia
Transfusion therapy required when blood loss is more than 20% of the total blood volume
REVERSAL & EXTUBATION
• Must be smooth
• When patient fully awake or in deep plane
COMPLICATIONS
• Laryngeal spasm
• Regurgitation
POST OPERATIVE CONSIDERATIONS
• Management
• Complications
Management
• Oxygen therapy
• Analgesia
• IV fluids to continue
• Continue monitoring
• In critically ill patients, shift to ICU and provision for mechanical ventilation
COMPLICATIONS
• Post operative nausea and vomiting
• Pain
• Ventilatory depression
• Haemodynamic instability
• Acute renal failure
• Surgical complications
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