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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

Clinical Anesthesia

Part II

JUNYI LI, MD

April 2, 2009

lijunyiutmb@yahoo.com

practice of anesthesiology
Practice of anesthesiology
  • Practice of anesthesiology is the practice medicine
  • Preoperative evaluation
  • Intraoperative management
  • Postoperative care
  • Anesthesiology is perioperative medicine
practice of anesthesiology1
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
preoperative anesthetic evaluation
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
physical status classification
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
slide6

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

preoperative management
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

npo status
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

general anesthesia
General Anesthesia
  • Monitor
  • Preoxygenation
  • Induction ( including RSI & cricoid pressure)
  • Muscle relaxants
  • Mask ventilation
  • Intubation & ETT position comfirmation
  • Maintenance
  • Emergence
slide10

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

induction agents
Induction agents
  • Opioids – fentanyl
  • Propofol, Thiopental and Etomidate
  • Muscle relaxants:

Depolarizing

Nondepolarizing

induction
Induction
  • IV induction
  • Inhalation induction
  • Rapid sequence induction
general anesthesia1
General Anesthesia
  • Reversible loss of consciousness
  • Analgesia
  • Amnesia
  • Some degree of muscle relaxation
intraoperative management
Intraoperative management
  • Maintenance

Inhalation agents: N2O, Sevo, Deso, Iso

Total IV agents: Propofol

Opioids: Fentanyl, Morphine

Muscle relaxants

Balance anesthesia

intraoperative management1
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

intraoperative management emergence
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
postoperative management
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

general anesthesia complication and management
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

general anesthesia complication and management1
General AnesthesiaComplication and Management
  • Neurological complication

- Slow wake-up

- Stroke

  • Malignant hyperthermia
regional anesthesia
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
spinal anesthesia
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

physiology of spinal anesthesia
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
position
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

approach
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
technique
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
monitoring
Monitoring
  • Respiration
  • Heart rate
  • Blood pressure
slide47

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

factors affecting spread of la solution
Factors affecting spread of LA solution
  • Baricity of LA solution
  • Position of patient
  • Concentration volume injected
  • Level of injection
  • Speed of injection
complications
Complications
  • Common complications

Postdural punture headache

Transient radicular syndrome

Backache

Hypotension

Itching

complications1
Complications
  • Less common complications

Cauda equina syndrome

Total spinal

Urinary retention

Cardiac arrest

Spinal/epidural hematoma

Aseptic meningitis

Bacterial meningitis

Cranial nerve palsies

contraindications
Contraindications
  • Relative contraindications

Hypovolemia

Preexisting neurologic disorders

Chronic back pain

Localized infection peripheral to regional site

Patients taking ASA, NSAID, dipyridamole

contraindications1
Contraindications
  • Absolute contraindications

Patient refusal

Infection at puncture site

Generalized sepsis

Severe coagulation abnormalities

Raised ICP

epidural anesthesia
Epidural Anesthesia
  • Position
  • Approach: midline & paramedian
  • Location: cervical, thoracic, lumbar
  • Technique
  • Monitoring
  • Single dose - pain management
  • Continuous epidural - anesthesia & analgesia
  • Complication
  • Contraindication
  • Common LA for epidural anesthesia & analgesia

Bupivacaine and ropivacaine

complications2
Complications
  • Similar to spinal anesthesia
  • Wet tap – postpuncture headache
  • Total spinal anesthesia – apnea, hypotension, bradycardia
common la for epidural anesthesia
Common LA for Epidural Anesthesia
  • Bupivacaine:

0.125-0.25% for analgesia

0.5% for anesthesia

  • Ropivacaine:

0.2% for analgesia

0.5-1% for anethesia

  • Lidocaine:

2% for anesthesia

caudal anesthesia
Caudal Anesthesia
  • Common regional technique in pediatric pts
  • Caudal space is sacral portion of epidural space
  • Needle penetration of sacrococcygeal ligament from sacral hiatus
  • Caudal anesthesia technique is difficult or impossible due to calcification of sacrococcygeal ligament
peripheral nerve block
Peripheral Nerve Block
  • Injection of LA near the nerves to block sensation and motor function
  • Can be used as primary and sole anesthetic technique for selective surgery
  • Can be used for postop pain control
common nerve block
Common Nerve Block
  • Brachial plexus block

- Interscalene approach

- Axillary approach

- Infroclavicular approach

  • Intravenous regional anesthesia (Bier block)
  • Lumbar plexus block - Femoral block
  • Sacral plexus block - Sciatic nerve block
peripheral nerve block1
Peripheral Nerve Block
  • Complications:

- Intravascular injection and toxicity

- Chronic paresthesias and nerve damage

- Respiratory failure due to phrenic nerve block

- Others: infection, bleeding, allergic reaction

- The greatest immediate risk is systemic toxicity

from inadvertent intravascular injection

peripheral nerve block2
Peripheral Nerve Block
  • Contraindications:

- Uncooperative patient

- Coagulopathy

- Local skin infection

- Peripheral neuropathy

- Local anesthetic toxicity

pain management
Pain Management
  • Most common symptom that brings patients to see a physician
  • Pain is “an pleasant sensory and emotional experience associated with actual or potential tissue damage” (IASP)
  • Component of anesthesia practice outside OR
  • “Nociception” (latin for harm or injury) is used to describe the neural response only to traumatic or noxious stimuli
pain management1
Pain Management
  • Classification:

Persistent time: acute and chronic pain

Pathophysiology: nociceptive and neuropathic pain

Etiology: postoperative, cancer pain

Affected area: headache, low back pain

Presentation: local, radiate, diffuse

Characteristic: burning,sting,blunt,distended,angina

pain management2
Pain Management
  • Medicine for Acute pain:

NSAIDS: Ibuprofen, Ketorolac, Naproxen

Opioids: Morphine, Fentanyl, Meperidine,

Hydromorphone

Local anesthetics: Lidocaine, Bupivacaine,

Ropivacaine

pain management3
Pain Management
  • Administration route of pain medicine:

- Oral - opioids, NSAIDs

- IV - single dose IV push or PCA(opioids, NSAIDs)

- IM - injection (opioids, NSAIDs)

- Local infiltration with LA

- Peripheral nerve block - intercostal, intrapleural

- Epidural - continuous or PCA with opioids, LA

- Intraspinal route with opioids

pain management chronic pain
Pain Management - Chronic Pain
  • Psychological and behavioral factors play a major role in chronic pain
  • Psychology, neurosurgery consultation
  • Antidepression
  • Treatment of insomnia
  • Muscle relaxant
  • Oral NSAIDs and/or opioids
  • Neural blockade - somatic, sympathetic blocks
  • Radiofrequency ablation & cryoneurolysis
  • Spinal cord stimulation
  • Intraspinal pump for opioids and/or NSAIDs
  • Physical therapy: acupuncture
case study
Case Study
  • 73 years old male presents for 6 cm AAA repair
  • PMH: CAD, HTN, DM
  • PSH: CABG, appendectomy
  • Social Hx: smoke 1ppd for 50 years
  • Current Med: Nitro patch, ASA, lisinopril, clonidine, glucophage
case study1
Case Study
  • Preop evaluation:

- Current medical problems: CAD, HTN, DM,

long term smoke

- Past anesthesia history

- Preop test: ECG, CXR, cardiac function,

pulmonary function

- Preop lab: CBC, Chemistry, coagulation

case study2
Case Study
  • Preop evaluation:

- Airway exam

- NPO

- Home med on the day of operation

- Blood glucose on the day of operation

- Premedication

- Blood products

case study3
Case Study
  • Intraoperative management:

- Monitor:

Noninvasive: ECG, pulse O2 saturation, BP

Invasive: A-line, CVP, PAC

Urine output

- Induction and intubation

- Fluid management

case study4
Case Study
  • Intraoperative management:

- Aortic clamp increases afterload, significantly

increases BP, may cause myocardia ischemia

and heart failure, vasodilator may needed

- Kidney protection: furosemide, mannitol

- Aortic clamp release decreases afterload,

significantly decreases BP, vasoconstrictor,

calcium usually are used

case study5
Case Study
  • Postoperative care:

- Postop ventilation:

Ventilator setting

Weaning from ventilator

- Hemodynamic monitor

- Lab: H/H, electrolytes, coagulation

case study6
Case Study
  • Complication:

- Bleeding: intra & postoperative

surgical & nonsurgical

- Cardiac complication

- Respiratory failure

- Renal insufficency