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Anaesthesia Small Group Discussion

Anaesthesia Small Group Discussion. Festejo , Katrina Marie Ho, Beverly Lorraine Hugo, Larimer Ignacio, Anna lore. Gen Data. Vicky Bragais 59/F Married R-handed Roman Catholic Manila . Chief Complaint. Low back pain. History. 2 years PTA

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Anaesthesia Small Group Discussion

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  1. AnaesthesiaSmall Group Discussion Festejo, Katrina Marie Ho, Beverly Lorraine Hugo, Larimer Ignacio, Anna lore

  2. Gen Data • Vicky Bragais • 59/F • Married • R-handed • Roman Catholic • Manila

  3. Chief Complaint • Low back pain

  4. History • 2 years PTA • Low back pain, hematuria, dysuria, fever • No chills, lithuria • Consulted at Martinez Memorial Hospital • A> Renal Calculi R>L • P> Surgery • Patient opted to seek 2nd opinion but was lost to follow up until…

  5. History • 1 year PTA • Still with hematuria, low back pain • No lithuria, no fever, no chills • Now with crampy abdominal pain VAS 9/10 • Rushed to Martinez Hospital • UTZ: Non-obstructing nephrolithiasis, bilateral • U/A: (+) sugar, RBC 10-15/hpf, PMN TNTC, EC occ, Bacteria many • Again, advised surgery but refused

  6. History • 1 month PTA • Persistence and progression prompted consult at Chinese General Hospital • CT Stonogram: Bilateral staghorn calculi with hydronephrosis R>L • Admitted with the following working impression • Urosepsis secondary to Staghorn Calculi • Discharged improved after 4 days

  7. History • Few days PTA • Recurrence of low back pain prompted consult at the Philippine General Hospital DFCM Clinic

  8. Review of Systems • (-) headache • (-) BOV • (-) nausea/vomiting • (-) anorexia • (-) weight loss • (-) cough or colds • (-) chest pain • (-) dyspnea • (-) orthopnea • (-) constipation • (-) muscle or joint pains • (-) polyuria, polydipsia, polyphagia

  9. Past Medical • (+) Rheumatoid Arthritis, 2009 • Maintained on pain meds PRN basis

  10. Family Medical • (+) Rheumatoid Arthritis – father

  11. Personal Social • Married to fellow retiree • Former school teacher • No vices

  12. Physical Examination • Lying on a stretcher, conscious, coherent, oriented, not in cardio-respiratory distress • Vital signs stable • BP 130/80 mmHg • HR 90 • RR 18 • Temperature

  13. Physical Examination • HEENT: anictericsclerae, pink palpebral conjunctivae, no cervical masses or lymphadenopathy • Chest and Lungs: symmetric chest expansion, no deformities, no retractions, clear breath sounds • CVS: adynamicprecordium, distinct heart sounds tachycardic, regular rhythm, no murmurs • Abdomen: flabby, no direct tenderness, (+) CVA tenderness on R>L • Extremities: full and equal pulses, no cyanosis, no clubbing, no edema

  14. Neurologic Exam • GCS 15, coherent, cooperative • Oriented to time place and person • No sensory and motor deficit

  15. Assessment • Nephrolithiasis, bilateral

  16. Plan • SAPOD Clearance • Surgery: • Pelvolithotomy, L • Radial nephrolithotomy, R

  17. Course

  18. Anaesthesia Pre-op • NPO 6 hours PTOR • IVF D5NR 1L x 8 hours • Meds 1 hour PTOR • Nalbuphine 10mg IM • Promethazine 25mg

  19. Anaesthesia Intra-op • XT • LLDS, SAAS • Local infiltration with lidocaine 2% • LP at L4-L5 using TNG18 2 attempts • 1st attempt (+) CSF • 2ndatttempt (+) LDLTH @ L3-L4 (-) blood (-) TD • X2 • Fentanyl 500, Propofol 10, Atracurium 30s • Intraoperatively, NO hypotensive episodes, MINIMAL blood loss

  20. Anaesthesia Post-op • Ketorolac 30mg IV Q6 hours x 4 doses • Morphine sulfate 0.03% 10cc/epidural Q12 hours

  21. At the PACU • Received with stable vital signs • BP 110/70, HR 88, RR 18, UO>0.5cc/hr • 1 hour post-op • BP 110/70, HR 90, RR 18, UO>0.5cc/hr • 2 hours post-op • (+) vomiting of yellowish clear liquid • BP 110/80, HR 92, RR 18, UO > 0.5cc/hr • Patient observed, reassured • (-) recurrence of vomiting • The rest of her PACU stay was unremarkable

  22. Vomiting

  23. Pathophysiology • coordination of the respiratory, gastrointestinal and abdominal musculature • vomiting center: lateral reticular formation • in close proximity to the nucleus of the solitary tract in the brain stem • access to the motor pathways that are responsible for the visceral and somatic output involved in vomiting

  24. Vomit Detectors • gastrointestinal tract (GIT) • vagus nerve •  mechanoreceptors - muscular wall of the gut, activated by contraction and distension of the gut •  chemoreceptors - mucosa of the upper gut, sensitive to noxious chemicals • chemoreceptor trigger zone (CTZ) • area postrema • U-shaped structure a few millimeters long located on the dorsal surface of the medulla oblongata at the caudal end of the fourth ventricle • Outside BBB and CSF barrier: can be activated by chemical stimuli received through the blood as well as the cerebrospinal fluid

  25. CTZ Area Postrema CNS (cerebral cortex, labyrinthine, visual, vestibular apparatus) Oropharynx Mediastinum Peritoneum Genitalia GIT

  26. Receptors • vomiting center and vestibular nuclei: cholinergic receptors • area postrema: dopamine (D2), opioid and serotonin (5HT3) receptors • nucleus tractussolitarius: enkephalins, histaminic (H1), muscarinic cholinergic and NK-1 receptors • dorsal motor nucleus of the vagus nerve: NK-1 receptors

  27. Risk Factors • Patient related factors • female • history of PONV or motion sickness • non-smoking status • High levels of anxiety and postoperative pain, (pelvic or visceral origin)

  28. Risk Factors SURGERY - Adults: • intra-abdominal surgery • major gynecological surgery • laparoscopic surgery • breast surgery • neurosurgery • eye and ENT surgery SURGERY - Pediatrics: • Strabismus • adenotonsillectomy • hernia repair • orchidopexy • penile surgery • middle ear procedures

  29. Risk factors • Anesthesia related risk factors: • volatile agents • nitrous oxide • opioids • high doses of neostigmine (>2.5 mg) for the reversal of neuromuscular blockade

  30. Risk Scoring Systems • Palazzo and Evans • logit postoperative sickness = -5.03 + 2.24 (postoperative opioids) + 3.97 (previous sickness history) + 2.4 (gender) + 0.78 (history of motion sickness) – 3.2 (gender × previous sickness history) • Koivuranta • Score=0.93 (if female) + 0.82 (if previous PONV) + 0.75 (if duration of surgery over 60min) + 0.61 (if nonsmoker) + 0.59 (if history of motion sickness) • Apfel et al • four predictors: female gender, history of motion sickness or PONV, non-smoking status and the use of opioids for postoperative analgesia • none, one, two, three or four of these risk factors present, the incidences of PONV: 10, 21, 39, 61 and 79 %

  31. Review of Anesthetic Meds

  32. Nalbuphine • Synthetic opioid used commercially as an analgesic • SIDE EFFECTS • CNS effects: Nervousness, depression, restlessness, crying, euphoria, floating, hostility, unusual dreams, confusion, faintness, hallucinations, dysphoria, feeling of heaviness, numbness, tingling, unreality. The incidence of psychotomimetic effects, such as unreality, depersonalization, delusions, dysphoria and hallucinations • Cardiovascular: Hypertension, hypotension, bradycardia, tachycardia, pulmonary edema. • Gastrointestinal: Cramps, dyspepsia, bitter taste. • Respiration: Depression, dyspnea, asthma. • Dermatological: Itching, burning, urticaria.

  33. Promethazine • first-generation H1 receptor antagonist • SIDE EFFECTS: • confusion in the elderly; drowsiness, dizziness, fatigue, more rarely vertigo; dry mouth; respiratory depression; constipation; chest discomfort; euphoria (very rare, except with high IV doses and/or co-administration with opioids/CNS depressants); restless legs; paresthesia

  34. Fentanyl • Opioid • 100x more potent than morphine • USE: Anaesthetic and analgesic • SIDE EFFECTS • SERIOUS: weak, shallow breathing, severe weakness, drowsiness, or confusion; cold, clammy skin; or feeling light-headed or fainting. • LESS SERIOUS: nausea, vomiting, stomach pain, constipation; dizziness, drowsiness, headache; swelling; or pain or mouth sores where the tablet was placed.

  35. Propofol • short-acting, intravenously administered hypnotic agent • SIDE EFFECTS: • Pain on injection • Low blood pressure • Transient apnea • (Rare) Dystonia

  36. Atracurium • intermediate-duration, nondepolarizing, skeletal muscle relaxant for intravenous administration

  37. Ketorolac • NSAID • Inhibits COX-1 and COX-2 thereby inhibiting PG production • USE: short term management of severe to acute pain • SIDE EFFECTS: • rash, ringing in the ears, headaches, dizziness, drowsiness, abdominal pain, nausea, diarrhea, constipation, heartburn, and fluid retention. stomach ulceration and intestinal bleeding renal impairment allergic reactions

  38. Morphine • Phenanthreneopioid receptor agonist • Interacts with μ-opioid receptor • Induces analegsia by mimicking endogenous endorphin release • principal effect on CNS and GI • Analgesia, sedation, euphoria

  39. Morphine • SIDE EFFECTS • Bradycardia, Cardiac arrest, Hypotension, Palpitation,syncope, Flushing of the face, Orthostatic hypotension, Pruritus or itching, Xerostomia or dry mouth, Intermittent blurring, miosis, Visual distortions, Constipation, Nausea and vomiting or emesis, Hepatotoxicity, Renal failure, Bradypnea, dyspnea or respiratory depression

  40. Differentials for Post-op Nausea and Vomiting

  41. Differentials • Anaesthetic-induced • Opioid: fentanyl and morphine • Hypotension • Secondary to anaesthetic agent or to blood loss during surgery • Highly unlikely

  42. Opioid-inducedNausea and Vomiting

  43. Opioids • highly effective analgesics • WHO's pain ladder • step-wise approach to the use of analgesics • third and final step for severe pain.  • Nausea and vomiting • undesirable side effects associated with the use of the opioid analgesics

  44. Etiology & Risk Factors • Medication with opioids is a major contributory factor to post-operative nausea and vomiting.  • For example the incidence of nausea and vomiting in patients undergoing minor gynaecological surgery has been reported to increase from 18% in a control group to more than 60% in patients receiving morphine or pethidine • Factors: type of opioid analgesic used, time course, route of administration; previous exposure to opioids

  45. Cause • Opioids have direct action on the CTZ thru the 3 receptors (kappa - κ, delta - δ and mu - μ)

  46. Consequences • When opioids are used post-operatively patients have little opportunity to develop tolerance to the emetic effects • compared to chronic opioid users i.e. cancer patients 

  47. Consequences • *Audit Commission Report: most common cause for unplanned overnight hospiltalization after surgery is PONV

  48. Management • Anti-histamines • Anti-muscarinics • Dopamine receptor antagonists • Opioid receptor antagonists • But will inhibit desired analgesic effect

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