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Anesthesia

Anesthesia. GHAZI ALDEHAYAT MD. Ancient and Mediaeval times. Which is the best face?. Anesthesia. Anesthesia Intensive care Chronic pain management. Anesthesia. Anesthesia CPR Acute Pain control Difficult Lines Evaluating critical patints. Anesthesia. Theatre Radiology

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Anesthesia

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  1. Anesthesia GHAZI ALDEHAYAT MD

  2. Ancient and Mediaeval times

  3. Which is the best face?

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

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

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

  7. Types Of Anesthesia

  8. Types of Anesthesia • General Anesthesia • Regional Anesthesia • Local Anesthesia • Sedation

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

  10. 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.

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

  12. • 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

  13. 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

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

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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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.

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

  22. 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 .

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

  24. 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)

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

  26. 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

  27. 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

  28. 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

  29. 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

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

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

  32. Inhalational Anaesthesia Halothane Enflurane Isoflurane Sevoflurane Desflurane N2o Xenon

  33. Inhalational Anesthesia induced by inhalational effec different in their potency, indicated by MAC. Different in rapidity of induction and recovery. Common pharmacological properties, CVS depression with tachy or bradycardia RESP Depression. CNS increased intracranial pressure Precipitate Malignant hyperthermia except N2o, Xenon

  34. Opioid Fentanyl Alfentanl Remifentanil Morphine Pethidine

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

  36. Muscle relaxant Depolarizing Suxamethonium Short acting, rapid onset, Many Side effects, hyperkalemia, arrythmias, Precipatate Malignant Hyperthermia. Muscle pain ,Scoline apnea.

  37. Non Depolarizing: Aminosteroid : Pancuronium, Vecuronium organ metabolism Benzylisoquinolonium: atracurium : Histamine release, Long acting. Never give Muscle relaxant without Anesthesia ( sleeping)

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

  39. 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)

  40. Reversal Neostigmine Atropine

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

  42. Awareness Awarness Definition Types Effect Causes Manegment

  43. Thank you

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