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Anesthesia

Anesthesia. GHAZI ALDEHAYAT MD . Ancient and Mediaeval times. Anesthesia. Anesthesia Intensive care Chronic pain management . Anesthesia. Anesthesia CPR Acute Pain control Difficult Lines Evaluating critical patints. Anesthesia. Theatre Radiology Interventional radiology

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Anesthesia

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  1. Anesthesia GHAZI ALDEHAYAT MD

  2. Ancient and Mediaeval times

  3. Anesthesia • Anesthesia • Intensive care • Chronic pain management

  4. Anesthesia • Anesthesia • CPR • Acute Pain control • Difficult Lines • Evaluating critical patints

  5. Anesthesia • Theatre • Radiology • Interventional radiology • Cardiology • ECT • GI

  6. Types Of Anesthesia

  7. Types of Anesthesia • General Anesthesia • Local Anesthesia • Sedation

  8. General Anesthesia • Preoperative evaluation • Intraoperative management • Postoperative management

  9. Purpose of preoperative visit • Medical assessment of the patient. • Decide the type of anesthesia. • Establish rapport with the patient. • Allay anxiety and decrease pain. • Obtain informed consent. • Ask for further investigation. • Decide risk versus benefit . • Prescribe medications.

  10. Pre-Operative Assessment History • Indication for surgery • Surgical/anesthetic hx: previous anesthetics/complications, previous intubations, • Medications, drug allergies

  11. • Medical history • CNS: seizures, CVA, raised ICP, spinal disease, arteriovenous malformations • CVS: CAD, MI, CHF, HTN, valvular disease, dysrhmias, PVD, conditions requiring endocarditis prophylaxis, exercise tolerance, CCS class, NYHA class • Resp: smoking, asthma, COPD, recent URTI, sleep apnea • GI: GERD, liver disease • Renal: insufficiency, dialysis

  12. Hematologic: anemia, coagulopathies, blood dyscrasias • MSK: conditions associated with difficult intubations – arthritis, RA, cervical tumours, cervical infections/abscess, trauma to C-spine, Down syndrome, scleroderma, obesity • Endocrine: diabetes, thyroid, adrenal disorders • Other: morbid obesity, pregnancy, ethanol/other drug use

  13. FHx: malignant hyperthermia, atypical cholinesterase (pseudocholinesterase), other abnormal drug reactions

  14. Physical Examination Physical exams of all systems. Airway assessment to determine the likelihood of difficult intubation

  15. Bony landmarks and suitability of areas for regional anesthesia if relevant • Focused physical exam on CNS, CVS and respiratory (includes airway) systems • General, e.g. nutritional, hydration, and mental status • Pre-existing motor and sensory deficits • Sites for IV, central venous pressure (CVP) and pulmonary artery (PA) catheters, • regional anesthesia

  16. Investigations: According to( ranged from none to most comlicated) • Age • Surgery • Medical condition As clinically indicated • Low risk – no further evaluation needed • Intermediate risk – non-invasive stress testing • High risk – proper optimization +/- delaying/canceling procedure

  17. American Society of Anesthesiology (ASA) classification • Common classification of physical status at time of surgery • A gross predictor of overall outcome, NOT used as stratification for anesthetic risk (mortality rates) • ASA 1: a healthy, fit patient (0.06-0.08%) • ASA 2: a patient with mild systemic disease, e.g. controlled Type 2 diabetes, controlled essential HTN, obesity (0.27-0.4%), smoker

  18. ASA 3: a patient with severe systemic disease that limits activity, e.g. angina, prior MI, COPD (1.8-4.3%), DM, obesity • ASA 4: a patient with incapacitating disease that is a constant threat to life, e.g. CHF, renal failure, acute respiratory failure (7.8-23%) • ASA 5: a moribund patient not expected to survive 24 hours with/without surgery, e.g. ruptured abdominal aortic aneurysm (AAA). • ASA 6 : Brain death patient • For emergency operations, add the letter E after classification

  19. Medications: • Pay particular attention to CVS and resp meds, narcotics and drugs with many side effects and interactions• prophylaxis. • Risk of GE reflux: Na citrate 30 cc PO 30 mins hour pre-op. • Risk of adrenal suppression – steroid coverage • Risk of DVT – heparin SC,LMW Heparin, Mechanical methods.

  20. Optimization of co-existing disease ^ bronchodilators (COPD, asthma), nitroglycerine and beta-blockers (CAD risk factors) • Pre-operative medications to stop: • Oral hypoglycemics – stop on morning of surgery • Antidepressants. • Pre-operative medication to adjust: Insulin, prednisone, coumadin, bronchodilator

  21. Decide, whether to proceed with surgery ,to send patient for further management or to cancel the operation. • Discus anesthetic options. • Decide which is the most useful for the patient. • Informed concent. • Risk stratification .

  22. Types of anesthesia GENRAL ANESTHESIA REGIONAL ANESTHESIA LOCAL ANESTHESIA.

  23. GENERAL ANESTHESIA Airway management • Endotracheal intubation( Body cavities, Full stomach, prone position, compromised, Very long operations, Airway involvment ) • Laryngeal mask Airway( peripheral, No indication for ETT) • Mask( very short, no indication for ETT) Ventilation • Spontaneous ( No muscle relaxant) • Controlled ( With muscle relaxant)

  24. GENERAL ANESTHESIA • PREPARATION • monitoring • position • Intravenous fluid • Warming • CONDUCT OF ANESTHESIA • PERIOPERATIVE MEDICINE

  25. Monitoring: according to paitent medical condition and surgery proposed • Basic: ECG, NIBP,SpO2, EtCO2, Temp,FiO2, Anesthetic gases, Airway pressure, The presence of anesthetist all throug procedure. • Others: Nerve stimulator, Invasive Bp, CVP, CO, BIS, PA Catheter, TEE, UOLab tests, ABGs, CBC, LFT , Coagulation, TEG

  26. Basic Principles of Anesthesia • Anesthesia defined as the abolition of sensation • Analgesia defined as the abolition of pain • “Triad of General Anesthesia” • need for unconsciousness • need for analgesia • need for muscle relaxation

  27. Intravenous Anesthetic Agents Thiopental • Thiobarbiturates • Uses for iduction, decrease ICP, Status epilepticus • CNS: Hypnosis within 30 seconds ,decreased intracrainial pressure. • CVS depression, hypotension, tachycardia • Respiratory depression, spasm • CI: porphyria • Arterial injection

  28. Intravenous Anesthetic Agents PROPOFOL ( Deprivan) • USES: induction, maintenance, sedation in the ICU, sedation • Contra indicated in children. • CNS: Hypnosis within 30 seconds ,decreased intracrainial pressure. • CVS: depression more than Thiopental • Respiratory: Depression, no spasm • Caloric load in the ICU, propfol infusion syndrome

  29. Intravenous Anesthetic Agents Ketamine • Phencyclidine • Uses, shock, burn, field. • CNS, dissociation, hallucination, analgesia, • Increased intracrainial pressure. • CVS Stimulation, hypertension, tachycardia • Respiratory, less depression.

  30. Intravenous Anesthetic Agents • Etomidate • Stable cardiovascular • Steroid depression

  31. Inhalational Anaesthesia Halothane Enflurane Isoflurane Sevoflurane Desflurane N2o Xenon

  32. Inhalational Anesthesia induced by inhalational effec Tdifferent in their potency, indicated by MAC. Different in rapidity of induction and recovery. Common pharmacological properties, CVS depression with tachy or bradycardia REP Depression. CNS increased intracranial pressure

  33. Opioid Fentanyl Morphine Alfentanl Remifentanil

  34. All have almost the same pharmacodynamics of , Morphine, Analgesia, Sedation , Respiratory depression, Nausea and vomiting, meiosis, constipation. Different in their pharmakokinitcs.

  35. Muscle relaxant Depolarizing Suxamethonium Short acting, rapid onset, Many Side effects, hyperkalemia, arrythmias, Muscle pain ,Scoline apnea.

  36. Non Depolarizing: Aminosteroid ; organ metabolism Benzylisoquinolonium: Histamine release, Long acting

  37. Local anaesthetics Lidocaine, lignocaine,xylocaine Bupivacaine ( marcaine) Cocaine Procaine

  38. Regional ( spinal , epidural) • Local • Different side effects • Marcaine CI by intravenous • LA toxicity. Maximum doses, • Perioral numbness, tinnitus, conulsions, resp depression, Cardiac arrest • Treatment, ABC, symptomatic, intralipid( propofol)

  39. Reversal Neostigmine Atropine

  40. Monitoring Basic ( ECG, BP, SPO2, EtCO2) Observation Advanced ( IBP , CVP, CO ….ETc

  41. Awareness Awarness Definition Types Effect Causes Manegment

  42. Thank you

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