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Regional and General Anesthesia for the Tropics David E. Byer, M.D. Assistant Professor of Anesthesiology Mayo Clinic College of Medicine CONTRASTS Mayo Clinic Macha Hospital CONTRASTS Road to Mayo Road to Macha CONTRASTS Mayo Anesthesia Macha Anesthesia

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Regional and General Anesthesia for the Tropics

David E. Byer, M.D.

Assistant Professor of Anesthesiology

Mayo Clinic College of Medicine


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CONTRASTS

Mayo Clinic

Macha Hospital


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CONTRASTS

Road to Mayo

Road to Macha


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CONTRASTS

Mayo Anesthesia

Macha Anesthesia


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Come with me to Macha Hospital!

Problems with anesthesia

Patients we may encounter

The unique properties of ketamine

The use of ketamine in various circumstances

The use of spinal anesthesia



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OUR FIRST PATIENT

A 22-year-old man has been admitted with a gunshot wound to the abdomen. He is shocked from major internal bleeding and requires a laparotomy. We have only a very small supply of inotropes and want to try not to use them. What will you do for induction and maintenance of anesthesia?


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OUR SECOND PATIENT

A 2-year-old boy needs repair of his hernia. He is extremely frightened of the hospital and its staff. You think that obtaining intravenous access will be very difficult and that an inhalation induction will be difficult as well. How will you anesthetize this child?


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OUR THIRD PATIENT

A 37-year-old woman is recovering from 45% burns; she needs dressing changes every two days which are very painful. She has very few sites left for IV access and we don’t want to use them as she has further surgery to come. She is very scared of needles. How will you manage the sedation she requires for her dressing changes?


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OUR FIRST PATIENT

Our laparotomy patient (gunshot wound) is back on the ward. He has severe postoperative pain but we have been unable to get any morphine this month. How can we manage his postoperative pain?


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OUR FOURTH PATIENT

An 18-year-old girl has been admitted with severe asthma. You have been asked to see her as she has not improved with subcutaneous injections of salbutamol or intravenous aminophylline. She is getting tired and her oxygen saturation is falling. Can you do anything to help?


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Ketamine

The only anesthetic available which is

Analgesic

Hypnotic

Amnesic

Ketamine may be given IM, IV, or orally

An anesthetic machine is not required for administration

Resuscitation equipment needs to be at hand


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Ketamine

Available in three different concentrations

10mg/ml

50mg/ml

100mg/ml


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Ketamine: the respiratory system

The airway is usually well maintained with protective reflexes preserved.

Respiration is well maintained if ketamine injected slowly

Ketamine is an effective bronchodilator


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Ketamine: the cardiovascular system

There is an increase in both blood pressure and heart rate, reaching a maximum about two minutes after IV injection. There may be a wide variation in individual response

A large rise in blood pressure usually responds to doses of IV diazepam


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Ketamine: central nervous system

Ketamine produces dissociative anesthesia (detachment from surroundings). Unlike other anesthetics patients may have their eyes open and may make reflex movements during the operation.

Ketamine has a slower onset of action after intravenous injection (1-5 minutes) compared to other intravenous anesthetics


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Ketamine: central nervous system

Ketamine provides very good analgesia

Upon recovery the patient may be agitated due to hallucination. Reduce by premedication with benzodiazepines (diazepam 0.2mg/kg orally one hour before, or 0.1mg/kg IV) or by decreased ketamine dosing

Ketamine increases intracranial pressure: avoid when possible in recent head injury


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Ketamine: GI system

Ketamine increases salivation. This may lead to airway problems. Be prepared to suction

Reduce salivation with atropine as a premed (10-20mcgm/kg) IM 30 minutes before, or at the time of induction (10mcg/kg) IV


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Routes of administration

Intravenous administration: induction dose (0.5-2mg/kg), maintenance (0.5mg/kg) for anesthesia

Intramuscular administration: induction dose (5-10mg/kg), maintenance (3-5mg/kg) for anesthesia

Oral administration sedation:(5-10mg/kg) for a child to a max of 500 mg for an adult


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IV ketamine for induction and maintenance (gunshot wound)

Ketamine ideal due to its cardiovascular effects of raising the blood pressure and heart rate.

IV induction with ketamine (0.5-2mg/kg), atropine (10-20mcg/kg) and diazepam (0.1mg/kg)

Endotracheal intubation could be helpful!

Maintain with intermittent boluses ketamine (0.5mg/kg) or ketamine infusion: ketamine 500 mg in 500ml bag of fluid. Run at (2-4mg/kg/hr) stop infusion 20 min before end of surgery




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IM ketamine (child hernia repair)

Induce anesthesia with IM ketamine (5-10mg/kg), atropine (20mcg/kg), diazepam (0.1mg/kg)

OR

Sedate with IM ketamine (2mg/kg), atropine (20mcg/kg), diazepam (0.1mg/kg) to start an intravenous line

If IV access impossible, maintain with IM ketamine (3-5mg/kg)


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Oral ketamine sedation (burns)

For an adult, give ketamine 500mg, diazepam 5mg

For a child use ketamine (5-10mg/kg), diazepam (0.2mg/kg)

The IV preparation of diazepam may be used for oral administration, it tastes bad, hide in juice.


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Ketamine for postoperative analgesia

Ketamine is a very good analgesic, may be used when morphine is unavailable

Avoid hallucinations by using relatively low doses.

Load with ketamine (0.1-0.3mg/kg) IV

Infusion 50 mg ketamine in 500 ml fluid (0.1mg/ml) and run at (0.1-0.5mg/kg/hr)


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Ketamine for treatment of asthma

Ketamine is an effect bronchodilator and can be used for the patient not responding to conventional bronchodilators

Low dose, hallucinations rare

Load with (0.2mg/kg) IV, follow with an infusion at (0.5mg/kg/hr) for 3 hours.


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Ketamine dosage review

Intravenous administration: induction dose (0.5-2mg/kg), maintenance (0.5mg/kg) for anesthesia

Intramuscular administration: induction dose (5-10mg/kg), maintenance (3-5 mg/kg) for anesthesia

Oral administration sedation:(5-10mg/kg) for a child to a max of 500 mg for an adult


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Spinal anesthesia

Injection of local anesthesia in the subarachnoid space below the second vertebral body

Easy to perform, best for surgery below the umbilicus

Inexpensive, preserves respiration, gives good muscle relaxation, less blood loss


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Spinal anesthesia disadvantages

Failure to obtain anesthesia

Hypotension – must be prepared to manage

Pre-anesthetic fluid load may help prevent

May not last long enough (2-3 hours)

Possible infection

Post-spinal headache


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Spinal anesthesia indications may include

Elderly

Cardiac or respiratory disease

C-section (dose reduction)

Trauma if fluid resuscitation has been carried out


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Spinal anesthesia contraindications

Lack of resuscitative drugs and equipment

Patient refusal

Bleeding disorders

Sepsis/septicemia

Hypovolemia

Neurologic disease

Reluctant surgeon


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Spinal anatomy

Source: Kleinman W, Mikhail M: Spinal, epidural, and caudal blocks. In: GE Morgan Jr., Mikhail MS, Murray MJ (editors), Clinical Anesthesiology, McGraw-Hill, New York, 2005, p. 302.


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Spinal anesthetic solutions

Bupivacaine heavy: bupivacaine 0.75% in dextrose 2 ml vial (hyperbaric)

Bupivacaine isobaric: bupivacaine 0.75%

The baricity of the anesthetic influences how it spreads. The hyperbaric solution does not diffuse as rapidly as the isotonic solution

Hyperbaric solution good for “saddle block”


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Hypotension/bradycardia

Manage aggressively

If moderate hypotension/bradycardia use ephedrine (5mg-10mg) IV May repeat

Phenylephrine (50-100mg) IV another choice

If severe hypotension/bradycardia use

epinephrine in increments of (20-40mcg) IV


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WORLD ANESTHESIA ONLINE

“Advancing Anaesthesia Throughout the Developing World “

Update in Anaesthesia:

An educational journal aimed at providing practical advice for those working in isolated or difficult environments.

http://www.nda.ox.ac.uk/wfsa/


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