Prepare a Patient for General Anesthesia 081-833-4522

1. Prepare a Patient for General Anesthesia081-833-4522 INSTRUCTOR SFC HILL NONENONE

2. Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.

3. REASON As a Special Forces Medic preparation of the patient and yourself will be a critical task in the successful performance of general parenteral anesthesia Have a student read this slide out loud to the rest of the class. Failure to prepare will certainly increase the possibility of an unsuccessful procedure.Have a student read this slide out loud to the rest of the class. Failure to prepare will certainly increase the possibility of an unsuccessful procedure.

4. PROCEDURES The Preanesthetic Visit Prep for general parenteral anesthesia Emergency prep for general parenteral anesthesia Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.

5. The Preanesthetic Visit The preanesthetic visit is conducted so the anesthetist can meet with the patient for the purpose of identifying any possible complications prior to the anesthetic procedure and alleviating the patients possible anxiety or fear of anesthesia/surgery Have student read the slide out load to rest of class. This will probably be the first time the anesthetist meets with the patient. Establish good communications with the patient right away. Put the patient at ease and inform the patient that they may ask questions at any time during the preanesthetic visit. Ensure that you honestly tell the patient about the risks and possible side effects of the anesthesia. At the same time put the patient at ease with your self confidence, professionalism, candor, and knowledge of your skill.Have student read the slide out load to rest of class. This will probably be the first time the anesthetist meets with the patient. Establish good communications with the patient right away. Put the patient at ease and inform the patient that they may ask questions at any time during the preanesthetic visit. Ensure that you honestly tell the patient about the risks and possible side effects of the anesthesia. At the same time put the patient at ease with your self confidence, professionalism, candor, and knowledge of your skill.

6. Preanesthetic Visit Should take place at least 24 hours prior to the scheduled procedure If possible, it should be conducted prior to emergency administration of anesthesia Why 24 hours prior? Must set NPO period. Need to process a detailed history. EMERGENCY: Even during an emergency situation, still attempt to elicit a good history (if possible) in order to avoid possible complications. The ordering performing physician should have just recently preformed a complete and thorough exam and ordered all the proper labs. The patient�s records and labs should be reviewed by the anesthetist during or prior to the visit. The anesthetist has the ability and the authority to order new or previously non-ordered labs.Why 24 hours prior? Must set NPO period. Need to process a detailed history. EMERGENCY: Even during an emergency situation, still attempt to elicit a good history (if possible) in order to avoid possible complications. The ordering performing physician should have just recently preformed a complete and thorough exam and ordered all the proper labs. The patient�s records and labs should be reviewed by the anesthetist during or prior to the visit. The anesthetist has the ability and the authority to order new or previously non-ordered labs.

7. Preanesthetic Visit What are some possible problems or complication that can be identified prior to the administration of anesthesia? QUESTION: Anybody have any ideas?QUESTION: Anybody have any ideas?

8. Preanesthetic Visit Tracheal Intubation Problems Allergies Drug interactions Previous Exposure to Anesthesia Concurrent Illnesses Classification of Physical Status Here they are.Here they are.

9. Tracheal Intubation Problems Short Thick Neck Disease of Pharynx or Larynx Tracheal Deviation Small Mouth Stiff Temporomandibular Joint Prominent Upper Incisors Inability to manipulate the trachea. Large amounts of fat occlude vision of the trachea.Inability to manipulate the trachea. Large amounts of fat occlude vision of the trachea.

10. Tracheal Intubation Problems Chipped or Cracked Enamel Caries Loose Teeth Dentures, Crowns Weakened state of tooth from the outside protective layer (enamel) being weakened or damaged. Maybe this patient has been recently intubated by SOCM student?Weakened state of tooth from the outside protective layer (enamel) being weakened or damaged. Maybe this patient has been recently intubated by SOCM student?

11. Allergies All Pharmacological Agents are potential allergens Emergency drugs for anaphylactic shock must be on hand prior to administration of any drug Take detailed History to differentiate between side effects and allergic reaction *Do not administration any drug without the presents of emergency drugs for anaphylactic shock! This will result in relief from the 18 delta course!*Do not administration any drug without the presents of emergency drugs for anaphylactic shock! This will result in relief from the 18 delta course!

12. DRUG INTERACTIONS Note present drug therapy Research any present drug therapies verses the anesthetic therapy plan for this procedure Many drugs will not interact well with anesthetic agents Also note any other pharmaceutical therapies that might complicate the procedure. For Example: Aspirin therapy for cardiovascular disease will equate to increased bleeding during procedure due to anti-platelet effects of aspirin.Also note any other pharmaceutical therapies that might complicate the procedure. For Example: Aspirin therapy for cardiovascular disease will equate to increased bleeding during procedure due to anti-platelet effects of aspirin.

13. Previous Exposure to Anesthesia Repeat use of certain anesthetic agents may cause hepatic damage or stress Take a detailed History of previous use of anesthesia Agents that caused problems in the past should not be repeated Take a detailed History of any previous difficulties Why would repeat use cause hepatic damage or stress? Metabolism! Take a detailed History of previous difficulties. What exactly happened?Why would repeat use cause hepatic damage or stress? Metabolism! Take a detailed History of previous difficulties. What exactly happened?

14. Concurrent Illnesses Common Cold Liver Disease Diabetes Mellitus Anemia COPD Heart Disease Essential Hypertension What is the Common Cold? Problems with HEENT and URI. WHY? Nasal congestion and/or irritation (increase edema). Inflammation of the larynx/pharynx (increase edema). Congestion of the chest/lungs (increase edema). Weakened state of the immune system.What is the Common Cold? Problems with HEENT and URI. WHY? Nasal congestion and/or irritation (increase edema). Inflammation of the larynx/pharynx (increase edema). Congestion of the chest/lungs (increase edema). Weakened state of the immune system.

15. Classification of Physical Illnesses Class I- fit and healthy Class II- Mild systemic illness Class III- Severe systemic illness that is not incapacitating Class IV- Incapacitating, systemic, life threatening illness Class V- Expectant, with or without surgery �E�- Emergency Examples: Class II: Giardia Class III: Secondary syphilis Class IV: Insulin shock Class V: ICP secondary to severe head wound.Examples: Class II: Giardia Class III: Secondary syphilis Class IV: Insulin shock Class V: ICP secondary to severe head wound.

16. Record information Record all the information from the preanesthetic visit into the preanesthetic summary of the patient�s SF 517 Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.

17. Patient Instructions Review the upcoming procedure with the patient Ensure the patient understands his/her responsibilities prior to the planned procedure QUESTION: What would some of the patient responsibilities prior to the planned procedure ANSWER: What time to arrive at the preanesthetic prep room, shaving and cleaning preparations, the NPO period. Ask if the patient will be able to get to the hospital the next day. Poor people sometimes have severe transportation problems. Ask the patient who is to be notified incase of emergency or on completion of the procedure.QUESTION: What would some of the patient responsibilities prior to the planned procedure ANSWER: What time to arrive at the preanesthetic prep room, shaving and cleaning preparations, the NPO period. Ask if the patient will be able to get to the hospital the next day. Poor people sometimes have severe transportation problems. Ask the patient who is to be notified incase of emergency or on completion of the procedure.

18. Prep for general parenteral anesthesia This is preparation for a scheduled procedure. This is preparation for a scheduled procedure.

19. Review and Prep Review the patients SF517 Prepare the anesthetist cart and all equipment to be utilized during the procedure to include back-up and emergency equipment Have a student read this slide out loud to the rest of the class. Preparation is the key to success. ENOUGH SAID!Have a student read this slide out loud to the rest of the class. Preparation is the key to success. ENOUGH SAID!

20. Receive the patient Identify patient and reconfirm type and location of procedure Converse with the patient to establish his or her mental status Establish the patients compliance with his or her preanesthetic orders Review the procedure once again with the patient Calm and reassure the patient ID of the patient can prevent embarrassing and tragic results, both for the patient and the anesthetist. Cases of mistaken identity and misdirected surgery are not just horror stories, they are true. Most patients will be apprehensive prior to anesthesia and surgery. Some patients will handle the stress differently than other patients. Attempt to identify those patients that are having problems dealing with their anxiety. Try to manage the anxiety with reassurance and understanding. Establish the patients compliance of the NPO orders. If the patient is suspect of non-compliance consider neutralizing gastric juices with a small volume (ml)/high power anti-acid (Alka Seltzer, Sodium Bicitrate) before induction procedures begin. ID of the patient can prevent embarrassing and tragic results, both for the patient and the anesthetist. Cases of mistaken identity and misdirected surgery are not just horror stories, they are true. Most patients will be apprehensive prior to anesthesia and surgery. Some patients will handle the stress differently than other patients. Attempt to identify those patients that are having problems dealing with their anxiety. Try to manage the anxiety with reassurance and understanding. Establish the patients compliance of the NPO orders. If the patient is suspect of non-compliance consider neutralizing gastric juices with a small volume (ml)/high power anti-acid (Alka Seltzer, Sodium Bicitrate) before induction procedures begin.

21. Prepare the patient Establish baseline set of vitals for the patient Establish the patient on 2 liters a minute, humidified oxygen Establish patient on monitors Establish IV access, Normal Saline, TKO Establish IV access for a route of premedication, induction, and emergency access.Establish IV access for a route of premedication, induction, and emergency access.

22. Administer Premedication Administer antisialagogue (Atropine, .4-.6mg deep IM 45 minutes prior to induction) Administer sedative (Promethazine, 25-50mg PO 30 minutes prior to induction) Continue to monitor the patients vitals every 15 minutes until induction Move the patient to the OR Remember the five rights prior to giving any medications. Right: Patient, Drug, Dose, Route, and Time. Remember to check patency of IV prior to administering any drugs, regardless of the drug route. When you administer medications to a conscious patient, inform the patient what you are doing and how the drug might effect the him or her. EXAMPLE: I am going to give you a shot of atropine into your muscle so your going to feel some pressure. This drug will make your mouth feel dry and your heart might speed up a little bit. Do not worry if you feel these effects, that is just what we want this drug to do. OR: I an going to give you a sedative through your IV. This might make you feel sleepy or dizzy. This might also make your arm above the IV site warm and tingle, or feel uncomfortable for a very short period. Do not worry if you feel these effects, that is just what we want this drug to do. DO NOT TELL THE PATIENT: Your going to feel your arm BURN or your HEART RACE Remember the five rights prior to giving any medications. Right: Patient, Drug, Dose, Route, and Time. Remember to check patency of IV prior to administering any drugs, regardless of the drug route. When you administer medications to a conscious patient, inform the patient what you are doing and how the drug might effect the him or her. EXAMPLE: I am going to give you a shot of atropine into your muscle so your going to feel some pressure. This drug will make your mouth feel dry and your heart might speed up a little bit. Do not worry if you feel these effects, that is just what we want this drug to do. OR: I an going to give you a sedative through your IV. This might make you feel sleepy or dizzy. This might also make your arm above the IV site warm and tingle, or feel uncomfortable for a very short period. Do not worry if you feel these effects, that is just what we want this drug to do. DO NOT TELL THE PATIENT: Your going to feel your arm BURN or your HEART RACE

23. Emergency prep for general parenteral anesthesia This is preparation for a unscheduled procedure.This is preparation for a unscheduled procedure.

24. Receive the patient Identify the patient and attempt to obtain a brief but thorough history Work with the surgical team to establish the patients condition (A-B-C) and level of consciousness Perform life saving measures If the patient is conscious and orientated X 3, converse with the patient to establish his or her mental status If the patient is conscious and orientated X 3, attempt to calm and reassure the patient If the patient is unconscious, look for important medical information such as dog tags, ID bracelets, and field medical card. In an immediate life-threatening situation time should not be wasted performing detailed investigations. The aim is to maintain life and so support of the respiratory and cardiovascular systems and brain function is vital. The anesthetist should be in charge of airway and breathing at the optimum. This will include, but is not limited too, establishing and maintaining the airway and breathing. In a trauma patient with a compromised thoracic cavity, the anesthetist will be required to IAPP the chest Q5 minutes until a chest-tube has been inserted and evaluated.If the patient is unconscious, look for important medical information such as dog tags, ID bracelets, and field medical card. In an immediate life-threatening situation time should not be wasted performing detailed investigations. The aim is to maintain life and so support of the respiratory and cardiovascular systems and brain function is vital. The anesthetist should be in charge of airway and breathing at the optimum. This will include, but is not limited too, establishing and maintaining the airway and breathing. In a trauma patient with a compromised thoracic cavity, the anesthetist will be required to IAPP the chest Q5 minutes until a chest-tube has been inserted and evaluated.

25. Prepare the patient Obtain vitals of the patient Establish and maintain the patients airway Establish the patient on 6 - 15 liters a minute, humidified oxygen All trauma victims and emergency or urgent patient must be treated as having a full stomachs. For this reason induction of anesthesia using rapid-sequence tracheal intubation should be used. Tracheal intubation should be secured as early as possible in an unconscious patient.All trauma victims and emergency or urgent patient must be treated as having a full stomachs. For this reason induction of anesthesia using rapid-sequence tracheal intubation should be used. Tracheal intubation should be secured as early as possible in an unconscious patient.

26. Prepare the patient Draw blood for grouping and cross-matching Establish large bore IV access and prepare for fluid resuscitation and possible transfusion Establish patient on monitors Establish nasogastric tube Establish IV access for a route of anesthesia maintenance, fluid resuscitation, and drug administration. Each established IV site should be maintained with as many ports of entry as possible (this means three-way stopcocks and med.-ports.) Establishment of a nasogastric tube prior to anesthesia and surgery will help decompress the stomach during the procedure.Establish IV access for a route of anesthesia maintenance, fluid resuscitation, and drug administration. Each established IV site should be maintained with as many ports of entry as possible (this means three-way stopcocks and med.-ports.) Establishment of a nasogastric tube prior to anesthesia and surgery will help decompress the stomach during the procedure.

27. Administer Premedication Administer antisialagogue (Atropine, .4-.6mg deep IM) Administer sedative (Promethazine, 25-50mg slow IV) Remember the five rights prior to giving any medications. Right: Patient, Drug, Dose, Route, and Time. Remember to check patency of IV prior to administering any drugs, regardless of the drug route. Remember the five rights prior to giving any medications. Right: Patient, Drug, Dose, Route, and Time. Remember to check patency of IV prior to administering any drugs, regardless of the drug route.

28. Prepare for induction Prepare for induction of anesthesia Emergency patients should be stabilized prior to induction of anesthesia whenever possible. With the unstable patient, induction should proceed when only the immediate surgical intervention will save the patients life NONENONE

29. SUMMARY OF PROCEDURES The Preanesthetic Visit Prep for general parenteral anesthesia Emergency prep for general parenteral anesthesia Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.

30. RESTATEDOBJECTIVE As a Special Forces Medic, prepare a patient for general parenteral anesthesia, in accordance with JSOMTC student manual of anesthesia. Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.