anaesthetics Flashcards
what does the pre-op care depend on
Patient co-morbidities & medication
- Type of surgery : minor/intermediate/ complex (including
haemorrhage risk)
- Setting: elective OR emergency
what are the different ASA levels
ASA 1: Healthy patient
• ASA 2: Mild systemic disease. No functional
limitation ie exercise tolerance - no problem climbing 2flights
• ASA 3: Moderate systemic disease. Have
functional limitation
• ASA 4: Severe systemic disease that is a constant
threat to life
• ASA 5: Moribund patient. Unlikely to survive 24
hours, with or without treatment
• Postscript E indicates emergency surgery
summarise POSSUM
o Based on physiological parameters at time, whether emergency or not, operative variables
o Number produced has been validated
o Risk discussion with pt – risk benefit ratio in favour – and if not what does that mean
In peri-op have more invasive monitoring
Post-op if mortality >5% - ITU or high dependency unit (HDU)
If surgeon quotes 1% mortality risk for pt – high risk but for HDU guidelines its 5%
what is important when considering comorbidities
optimisation and peri-operative control
control for dm
look at HbA1c and see how well controlled
think when to use insulin sliding scales
control for HTN
optimisation - when to treat (>160/80)
control - maintain within 20% of normal BP in primary care settings, not in hospital – often high when come in for surgery.
= reduced morbidity and mortality. If 1 hypotensive episode = morbidity and mortality
IHD control
optimisation - Symptomatic (or major
procedure) /ECG anomaly
BP & HR control. Consider post
operative HDU
asthmatic and COPD control
optimisation: Symptomatic? Signs?
Medication – BTS Guideline
anti-coagulants control
optimisation - why are they on them, can we stop them or not
INR/APTR <1.5
Anti-platelets/LMWH
resumption?
sickle cell control
haematology review
good care - warm, hydrated, analgesia, infection free
considerations for day surgery
social - Patient consent, carer, home setup, can they manage at home
medical - Fitness, stable chronic, obesity not
preclude, comorbidities
surgical - Complication risks, controllable post op
symptoms, mobile, how major the surgery is
when should you consider further investigations
dependant on pt and background state
Bloods test anomalies : anaemia, renal dysfunction
Lung function tests : Baseline ABG’s, FEV1<40% (predictor for
postoperative ventilation)
cardiac:
ECG - ischemia, arrhythmia, dm - multisystem disease, HTN
echo - poor functional status (LV function and valves) and reasonable size op/GA
stress echo - gives low/intermediate/high risk index of ischemia - used to quantify ischemia
things to ask in an anaesthetics Hx
o Whether had anaesthetic before and problems o FH of problems o Malignant hyperpyrexia o Suxamethonium apnoea o Both genetically based and run in fam o Drug rn/longer to recover, or awareness, or not take long to recover comorbidities, Ex tolerance medication/allergies smoking/Etoh/recreational drugs teeth - dental work airway - mallampati, neck movement NBM
mallampati socre
1 - Should be able to see all soft pallet and uvula
2 – still uvula, not all of soft pallet
3 – some uvula and not all, ie just base
4 – complete obliteration – no uvula or soft pallet
Ask open mouth and stick tongue out
why do you ask about neck extension
makes a difference for intubation
why starve before surgery
reduce aspiration risk – if when put to sleep have food in stomach/acid that comes up into mouth – airway reflex don’t work – go into lungs – high mortality attached to it – strict about NBM
how long do you starve for
food 6hr
Water 2hrs
caveat if reflux, obese, slow gastric transit eg trauma = reduced transit time – different times
how do you prescribe opioids
o Make sure on form – dose, strength, formulation, total quantity – dosage in words and figures and quantity need supplied for that period of time
o Length and duration time required for
handwritten
summarise oropharyngeal airway
called guedel airway
3 4 5 size - from angle of mandible to side of mouth
Airway adjuncts (not airway in own right) - used with bag mask ventilation
Slits in behind the tongue – allow passage to continue and makes ventilation easier
summarise bag-mask-valve airway
For pt apnoeic/resp failure
One way valve – drive against the lungs
Cant breathe against
So doesn’t work with spontaneous ventilation
Reservoir opens up more ox to be drawn in
FiO2 60-90% – fraction of inspired oxygen
endotracheal tube
o Connector on R hand side
o Labelled with internal diameter
o Markings along tell you how long at teetc
o Pilot balloon – where but air in – connected to balloon at end of tube
o Black marker should be at cords
o Balloon sit below
o This is a definitive airway – cuffed tube in trachea sealing it off (ET, tracheolaryngeal tube)
supraglotic airway
o Igel – sits above the vocal cords o LMA o At bottom- gastric port - traverse in parallel to main ox conduit o Different size 3 4 5 o Paed smaller 1 2 o Single use o Latex not definitive airway
benefits and features of Igel
15mm connector - reliable connection to any standard catheter mount or connection
clearly displayed product info- quick easy reference, confirmation of size and weight preference
position guide - adult size only - confirmation of optimum insertion depth
non-inflatable cuff - made from soft gel-like material allowing ease of insertion and reduced trauma
gastric channel - enhance safety - allows for suctioning, passing of NG tube and venting
integral bite block - reduces possibility of airway channel occlusion
buccal cavity stabiliser - aids insertion and elimates potential for rotation
epiglottic rest - reduces possibility of epiglottis down folding and airway obstruction
what is the need for the 5 steps to safer surgery
o Safety checklist by WHO in developed and non-developed countries – benefits 30-40% improvement in mortality
o Allows a rolling team – communicate with everybody from different teams
steps in the 5 steps to safer surgery
team brief - go through list and introduce yourself, go through order
when pt comes - sign in in the anaesthetics room - check no major allergies, all monitoring in place, have blood if needed, site marked, difficult airway/anaesthetic risk
time out before incision - pts name, allergy, metal work, make sure surgeon know operating on the correct side, equipment sterile, count correct, anaestetics set up, special requirements and concerns, ASA, essential imaging/tests available, duration of op, expected blood loss, any special equipment needed, hair removal, AB, pt warming, glycaemic control, VTE prophylaxis undertaken
sign out - comfirm procedure done and everything accounted for
sign out before pt leaves theatre - has throat pack been removed, swab insturment and needle/sharp count correct, any equipment issues, correct procedure performed and recorded, specimens labelled, post op - analgesia,AB, VTE prophylaxis, fluid management inc blood, care iof drain/NG
debrief - end of day
