The Practical guide for the everyday practices

Ahmad Mustapha Abou Leila

PGY5 -Anesthesiology

HOW TO SET YOUR ROOM

THE MUST-DOS

CHECK YOUR ANESTHESIA MACHINE

Turn onO2-Air-N2O attached(look at the pipes, the pressure monitor)Turn On the VentilatorCheck for circuit leakCheck the Soda Lime(purple or grey)The Scavenger is Open-the risk of pollutionThe Vaporizer –The level of gas

CHECK YOUR ANESTHESIA MACHINE

The Ventilator is different The Jet ventilator

Turn it ONCheck for the Pressure (keep the Pressure between 20-30)

RR between 18-20

ALWAYS PREPARE SET FOR GENERAL ANESTHESIA

You will need themFor the regular inductionFor emergent intubation

For sedationFor regional anesthesia conversion into general

anesthesia

ALWAYS PREPARE VASOPRESSOR SET

Specially Elderly

Spinal anesthesiaHypotensive patients

Pediatrics

ALWAYS PREPARE VASOPRESSOR SET

Neosynephrine (0.1mg/ml)-Hypotension+ TachyEPHEDRINE (6mg/ml)-Hypotension+ Brady

Atropine (0.1mg/ml)-symptomatic bradycardia

CHECK FOR THE SALT

S: Suction A : Ambu Bag-AirwayL:LaryngoscopeT:Tubes

CHECK THE MONITORS(THE MINIMAL MONITORING)

ECGBp

ETCO2SPO2Temp

For ev

ery ca

se …

every

case

..eve

ry ca

se

FOR PEDS CASESASK THE RN TO WARM UP THE ROOMASK THE ANESTHESIA ASSISTANT TO PREPARE THE BAIR HUGGER MAKE A CAPALL OF THESE TO PREVENT HYPOTHERMIA

THE OR TRIP FROM CHART READING TILL EXTUBATION

Read the chart thourghlyThe patient Name

The perop DxThe planned surgery

The consultationsThe anesthesia Preop note

Quick re-assessment:Air way

NPO hoursAnticoagulation

Allergies

Check for previous mastectomy, axillary dissection ,AV fistula, site of surgery before IV

prick

Otherwise choose the left hand (most patient are right handed and it is easier for us)

Avoid the positional IV (near joints )

IV SITE

Small gauge (pedatrics,HF,Renal failure ,local case)

Big gauage(work near big vessels,Trauma,spinal,Burn)

The Guage

LR most casesNSS for (renal failure,Neuro cases)Dextrose containing fluid in neonatal surgeriesVoluven for spinal cases, burn,risk of bleedingBlood(call for blood units if risk of bleeding, preop anemia)FFP(patient on warfarin,massive transfusion)Platelets(platelets dysfunction,Plavix)

The solution

IV fixation (pediatrics-prone position)

Transparent (phelbitis)Date

Three way directly on the AngiocathIf you plan to give

Precedex,Remifentanil,or post op PCA)

Give some sedation before u go into the room….the patent in extreme anxiety

Multivariable logistic regression analyses showed a significant increase in the odds of SSI when antimicrobial prophylaxis was administered less than 30 minutes

and 120 to 60 minutes as compared with the reference interval of 59 to 30 minutes before incision

Patient A M has infected arthritis ,he is admitted to OR for Knee Joint arthroscopy and lavage .

What is the optimal time for ABX administration ?

To the room

Always Baseline

Aspiration Pneumonitis

Patient positioning in case of regurgitation

check the OR table ….not working

call the Orderly….fix it before u induce GA

Machine checkedSALT checked Chart checkedIV secured

Vitals checked Table checked

Take off--------------induction

Propofol

Midazolam

Xylocaine

Fentanyl

Relaxants

1-2µg/kgPeaks after 5 min

This why we give it first

Abolish the pain reflex on intubation

More if high ICPLess if RSI

Patient cough

2mg/kgAbolish the laryngeal

reflexVein anesthesia

Analgesic ??Less if history of

seizure

1-2 mg Anterograde Amnesia

1-2mg/kgReal hypnosisLoss of corneal

reflexTime to do Trial of

ventilation Easy vent-go to

MR

Roc 0.6mg/kg1.2 mg/kg RSICis 0.15 mg/Kg

SUX 2mg/kg

The sequence of regular induction

Special scenarios Pediatrics …higher PropofolElderly …lower PropofolShock…ketamine,etomidate Mediastinal mass…sevo induction

Neuro…thiopentoneHigh ICP..add β-blockers

RSI…Propofol and SUX only

Air way management

Patient related:• female tube 7-7.5• Male tube 8-8.5• pediatrics age/4+4

Surgery relatedENT:preformed tubeSML:MLT tubeThyroid: Reinforced tubeThoracic: DLT

Uncuffed till age of 8…..what about our practice in AUB ?Depth of insertion

Adult :height/10 + 5Peds :age in years + 10

Nasal intubationSmaller size tubeDepth of insertion: Oral depth + 3

Tube selection and insertion

The surest sign of correct intubation

Tube fixation

The time of BP and hemodynamics fluctuationUp and downBP q 1min till stabilize

Now u can put your invasive monitors if needed

Baseline ABGSAssess PaCo2-ETCO2 gradientOxygenation PaO2/fiO2..>200 it is OKHctElectrolytes

Patient Positioning

What nerve at risk of injury?

After prone positioning you noticed increase in Peak air way pressure and hypoventilation What will you check?

Patient placed in Trendelenburg position …then you noticed desaturation and increase in the Peak airway pressureWhat is the explanation? And what will you do?

ENT surgeon extended the neck for Tonsillectomy

What are the risks?

FlexionFurther

ExtensionExit

Maintenance phase

Q 5minutes

UOP Q 1 hr

Baseline kidney dysfunctionCHFAge > 70DMContrast injection

Nerve stimulatorTOF=0 in Neuro,Eye

TOF =1 in other cases Deep parlysis needed PTC 0

Face more resistant than thumb(twitch in the face doesn’t mean twitch in

the thumb)

Apply FAWS as soon as possibleMore effective intraop than Post op

HpothermiaIncrease solubility of inhalation agentsDecrease metabolismIncrease risk of bleedingIncrease risk of wound infectionAcidosisPost operative shiveringArrythmias

Watch for the blood loss

The bleed that you hear is more serious from the bleed that you see

1. Infection trasmission(viral,bacterial,parasitic,prions)2. Fever(bacterial sepsis,AHTR,febrile non hemolytic transfusion reaction)3. TRALI4. TACO(transfusion associated circulatory overload)5. Anaphylaxis6. PTP7. Transfusion –(GVHD) 8. Transfusion thrombocytopenia9. Transfusion neutropenia10. Citrate toxicity11. Hyperkalmia12. Adenine toxicity13. Hypothermia14. Dilutional coagulopathy15. Decrease 2,3 DPG16. Acid base Changes17. Microaggregate delivery(ARDS)………………………18. Immune supression 19. Allergic reactions

Long list

Infectious and non infectious

Immunlogic and non imunologic

TRICC study:Liberal transfusion associated with longer hospital stay,and higher mortality and morbidity

recommendation Hb level

> 10 inappropriate

7-10Likely to be appropriate if signs Of impaired O2 Delivery

<7appropriate

<6Highly recommended

Transfusion triggers

Regardless these numbers if patient showed sign of inadequate oxygenation• Hemodynamic instability• SVO2<50%• Myocardial ischemia(new ST

depression>0.1mV,new ST elevation >0.2

Transfuse Antibiotics Re-dose after 4 hoursIf bleeding after 3 hours

BP HR Explanation

High sympathetic statePain, awarness, adrenaline injection ,pheo,thyroid storm

Hypovolemic, septic patient, carcinoid crisis,anaphylaxis

High fentanyl dose,Neostigmine,B-blockers ,spinal shock

After Neosynephrine,Cushing reflex

Patient SD undergoing LAP gastric BYPASS ,MV settings TV 700 RR 14After 1 hr u noticed desaturation?

Check for Disconnection

NO disconnection

Check for FiO2

FiO2 :40%

Chest Auscultation

BIL equal breathing soundsNO wheezes or crackles

Check BP

BP:120/80

u noticed high peak airway pressure

Delivered TV is 35o ml

TOF 3/4

4 causes of hypoxemia Hypoventilation

Impaired diffusionShunt

V/Q mismatch