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Clinical Anesthesia

Clinical Anesthesia. Part II. JUNYI LI, MD. April 2, 2009. lijunyiutmb@yahoo.com. Practice of anesthesiology. Practice of anesthesiology is the practice medicine Preoperative evaluation Intraoperative management Postoperative care Anesthesiology is perioperative medicine.

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Clinical Anesthesia

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  1. Clinical Anesthesia Part II JUNYI LI, MD April 2, 2009 lijunyiutmb@yahoo.com

  2. Practice of anesthesiology • Practice of anesthesiology is the practice medicine • Preoperative evaluation • Intraoperative management • Postoperative care • Anesthesiology is perioperative medicine

  3. Practice of anesthesiology • Preoperative evaluation and patient preparation • Intraoperative management - General anesthesia Inhalation anesthesia Total IV anesthesia - Regional anesthesia & pain management Spinal, epidural & caudal blocks Peripheral never blocks Pain management (acute and chronic pain) • Postanesthesia care (PACU management) • Anesthesia complication & management • Case study

  4. Preoperative anesthetic evaluation • History 1. Current problem 2. Other known problem 3. Medication history: allergies, drug intolerances, present therapy, alcohol, tobacco 4. Previous anesthetics, operations 5. Family history of anesthesia 6. Review of organ systems 7. Last oral intake • Physical examination: VS, airway, CV, lung, neuro • Lab evaluation, chest X-ray, ECG • ASA classification

  5. Physical status classification • Class I: A normal healthy patients • Class II: A patient with mild systemic disease (no functional limitation) • Class III: A patient with severe systemic disease (some • functional limitation) • Class IV: A patient with severe systemic disease that is a constant threat to life (functionality incapacitated) • Class V: A moribund patient who is not expected to survive without the operation • Class VI: A brain-dead patient whose organs are being removed for donor purposes • Class E: Emergent procedure

  6. Anesthetic plan Premed Type of Intraoperative Postoperative anesthesia management management General Monitoring Pain control Airway management Positioning Intensive care Induction Fluid management postop ventilation Maintenance Special techniques Hemodynanic monit Muscle relaxation Regional Technique Agents Monitored anesthesia care Supplement oxygen Sedation

  7. Preoperative management • Diabetes: hyperglycemia or hypoglycemia • Hypertension • Renal failure: HD patients – potassium level • Asthmatic patients • Chronic steroid use • Pregnant test • Preop medication: Sedation-benzodiazepine Aspiration precaution-H2 blockers, metoclopramide Antibiotics

  8. NPO status • NPO, Nil Per Os, means nothing by mouth • Solid food: 8 hrs before induction • Liquid: 4 hrs before induction • Clear water: 2 hrs before induction • Pediatrics: stop breast milk feeding 4 hrs before induction

  9. General Anesthesia • Monitor • Preoxygenation • Induction ( including RSI & cricoid pressure) • Muscle relaxants • Mask ventilation • Intubation & ETT position comfirmation • Maintenance • Emergence

  10. Airway exam Mallampati classification Class I: uvula, faucial pillars, soft palate visible Class II: faucial pillars, soft pillars visible Class III: soft and hard palate visible Class IV: hard palate visible

  11. Sniffing position

  12. Mask and airway tools

  13. Mask ventilation and intubation

  14. Oral and nasal airway

  15. Intubation

  16. Intubation

  17. Laryngeal view

  18. Laryngeal view scoring system

  19. Difficult airway

  20. Fiberoptic scope intubation

  21. Trachea view Carina view

  22. Glidescope

  23. Fast track LMA

  24. LMA

  25. Difficult Airway Algorithm

  26. Induction agents • Opioids – fentanyl • Propofol, Thiopental and Etomidate • Muscle relaxants: Depolarizing Nondepolarizing

  27. Induction • IV induction • Inhalation induction • Rapid sequence induction

  28. General Anesthesia • Reversible loss of consciousness • Analgesia • Amnesia • Some degree of muscle relaxation

  29. Intraoperative management • Maintenance Inhalation agents: N2O, Sevo, Deso, Iso Total IV agents: Propofol Opioids: Fentanyl, Morphine Muscle relaxants Balance anesthesia

  30. Intraoperative management • Monitoring • Position – supine, lateral, prone, sitting, Litho • Fluid management - Crystalloid vs colloid - NPO fluid replacement: 1st 10kg weight- 4ml/kg/hr, 2nd 10kg weight-2ml/kg/hr and 1ml/kg/hr thereafter - Intraoperative fluid replacement: minor procedures 1-3ml/kg/hr, major procedures 4- 6ml/kg/hr, major abdominal procedures 7-10/kg/ml

  31. Intraoperative managementEmergence • Turn off the agent (inhalation or IV agents) • Reverse the muscle relaxants • Return to spontaneous ventilation with adequate ventilation and oxygenation • Suction upper airway • Wait for pts to wake up and follow command • Hemodynamically stable

  32. Postoperative management • Post-anesthesia care unit (PACU) - Oxygen supplement - Pain control - Nausea and vomiting - Hypertension and hypotension - Agitation • Surgical intensive care unit (SICU) - Mechanical ventilation - Hemodynamic monitoring

  33. General AnesthesiaComplication and Management • Respiratory complication - Aspiration – airway obstruction and pneumonia - Bronchospasm - Atelectasis - Hypoventilation • Cardiovascular complication - Hypertension and hypotension - Arrhythmia - Myocardial ischemia and infarction - Cardiac arrest

  34. General AnesthesiaComplication and Management • Neurological complication - Slow wake-up - Stroke • Malignant hyperthermia

  35. Regional Anesthesia • No absolute indication for spinal or epidural anesthesia • May improve outcome in selected situations • Blunt stress response to surgical stimulation • Decrease intraoperative blood loss • Lower the incidence of postoperative thromboembolic events • Decrease M&M in high risk patients • Extend analgesia into postoperative period

  36. Posterior and lateral view of spinal column Spinal cord terminates

  37. Human sensory dermatomes

  38. Spinal anesthesia • Patient position • Approachs: Midline & Paramedian • Technique • Monitoring during spinal anesthesia • Single dose spinal anesthesia • Continuous spinal anesthesia • Complications • Contraindications • Common local anesthetics for spinal anesthesia Lidocaine, Bupivacaine, Tetracaine, Ropivacaine

  39. Physiology of Spinal Anesthesia • LA blocks conduction of impulses along all with which it contacts • Autonomic and pain fibers block - early • Motor fibers block - late

  40. Position • Sitting position Sit straight first Chin on chest Arms resting on knees Footstool/table to support feet Back curving like banana or shrimp • Lateral position Shoulders perpendicular to bed Positioned with hips on edge of bed Knee chest position and back curving

  41. Approach • Median approach • Most common • Needle or introducer is placed midline • Perpendicular to spinous processes • Slightly cephalad • Paramedian approach • For pts who cannot adequately flex • Needle placed laterally(1.5cm) and slightly caudad to center • Needle aimed medially and slightly cephalad

  42. Midline approach to subarachnoid space

  43. Technique • Anatomic landmark identified • Superior iliac crests at L4 level • Spine is palpated • A sterile field estabolished • Skin wheel with LA • Introducer inserted and spinal needle passed • CSF presence • LA injection

  44. Procedure

  45. Monitoring • Respiration • Heart rate • Blood pressure

  46. Common local anesthetics LA & Concentration T10 level T4 level Duration Duration upper abd lower abd plain with epi Bupivacaine 0.75%12-14mg 12-18mg 90-120min 100-150min Tetracaine 1% 10-12mg 10-16mg 90-120min 120-240min Lidocaine 5% 50-75mg 75-100mg 60-75min 60-90min Ropivacaine 02-1% 12-16mg 16-18mg 90-120min 90-120min

  47. Factors affecting spread of LA solution • Baricity of LA solution • Position of patient • Concentration volume injected • Level of injection • Speed of injection

  48. Assessing the level of block

  49. Complications • Common complications Postdural punture headache Transient radicular syndrome Backache Hypotension Itching

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