general anaesthesia katarina zadrazilovafn brno, nov 2010
TRANSCRIPT
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GENERAL ANAESTHESIA
Katarina Zadrazilova FN Brno, Nov 2010
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..aims
•What do anaesthetists do•Basic anaesthetic management•Drugs, gases, monitoring, machines
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The role of anaesthetist
•Ensures safe anaesthesia for surgery•Is responsible for patient safety in theatre•Ensures the anaesthetic machine and
drugs are checked and correct•Liase with the surgeon and scrub team –
ensure that the operation can proceed smoothly
•Keep an anaesthetic record•Makes a postoperative plan
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Anaesthetic plan
•Preoperative•Intraoperative •And postoperative management
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Anaesthetic plan
•Preoperative•Intraoperative •And postoperative management
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Preoperative management
•Anaesthetic assessment :history and examination
•Relevant investigations : lab, CXR, ECG•Optimise chronic condition•Plan for intra and post op pain refief•Discuss ev. HDU/ICU post op bed for
patient •Consent the patient•Prescribe premedication
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Anaesthetic assessment
•Previous surgery (GA, LA, complications)•Medical hx, Medication, FH•Allergies•Last meal, drink !•Teeth•Pregnancy•Examination: airway assessment, neck,
back + general physical exam.
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Risk assessment – ASA gradeI Healthy patient II Mild systemic disease, no functional
limitations III Severe systemic disease- definite
functional limitation IV Severe systemic disease that is a
constant threat to life V Moribund patient not expected to
survive 24 hours with or without operation
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Premedication
•Sedation/anxiolysis (Benzodiazepines)•Analgesia only if pain (opioids)•Reduce airway secretions + heart rate
control + hemodynamic stability •Prevent bronchospasm •Prevent and/or minimize the impact of
aspiration •Decrease post-op nausea/vomiting
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Consent
•Discuss all options GA/regional•Risks versus benefits•Complications – common, rare and serious•Make pain relief plan
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Complications
NO RISK = NO ANAESTHESIA
•Common (someone in a street)▫PONV, sore throat, backache, headache,
dizziness
•Rare and serious (someone in a big town)▫Damage to the eyes, anaphylactic shock,
death, equipment failure
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Mortality of anaesthesia (ASA I) •Risk of death or brain damage
▫ 1: 100 000 – 200 000
•Dying in a plane crash▫ 1 : 200 000
•Dying in a car crash▫ 1 : 5000
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Anaesthetic plan
•Preoperative•Intraoperative •And postoperative management
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Teamwork !
anaesthetist ODP
surgeon
scrub nurse
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Operating theatre
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Operating theatre
•Allow surgery, ECT
•Allow diagnostic method (CT, MRI)
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History•Opium (Egypt, Syria)
▫ Hippokrates 400 BC ease pain
•1555 Andreas Vesalius - arteficial ventilation through tube between vocal cords, ventricular fibrilation (animals)
•Valerius Cordus (1546) ether •1773 N2O Joseph Priestley (1733-
1804)
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Beginning of GA•October 16th 1846 ether general
anaesthesia Boston dentist William Thomas Green Morton to Gilbert Abbott (tumor of mandibule)
•February 6th 1847 Prague - first czech ether anaesthesia - Celestýn Opitz
•1895 direct laryngoscopy Alfred Kirstein in Berlin.
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AIMS OF ANAESTHESIA
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Triad of anaesthesia
•Neuromuscular blocking agents for muscle relaxation
•Analgesics/regional anaesthesia for analgesia
•Anaesthetic agents to produce unconsciousness
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Stages of anaesthetics
•Induction – putting asleep•Maintenance – keeping the patient
asleep •Reversal – waking up the patient
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Intravenous anaesthetics
•Onset of anaesthesia within one arm – brain circulation time – 30 sec
•Effect site brain▫Propofol▫Thiopentale▫Etomidate
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Anaesthetic gases
•Isoflurane•Sevoflurane
•Halothane•Enflurane•Desflurane
•N2O – nitrous oxide
Inhalational anaesthetics
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Anaesthetic gases
•Used for maintainance, sometimes induction
•Anaesthetic ‘gases’ are administered via vaporizers
Inhalational anaesthetics
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Induction + maintenance
Intravenous anaesthetics
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Muscle relaxants - NMBs•Tracheal intubation•Surgery where muscle
relaxation is essential•Mechanical ventilation
•Place of effect - neuromuscular junction
•History - South American Indians (kurare)
Neuromuscular blocking agents
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Analgesics
•Simple : paracetamol, NSAID•Opioids : morhine, fentanyl
▫Via opioid receptors
MORPHEUS- GREAK GOD OF DREAMS
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Monitoring•Basic:
▫NIBP, ECG, Sat, ETCO2, FiO2
•Extended:▫Nerve stimulator, temperature, diuresis,
IBP, CO, CVP, perioperative acid-base, lab
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• Mix gases, ventilate, preserve heat and moisture
High pressure central gas supply/ cylinder
Low pressure system• Flowmeters• Vaporisers• Breathing circuit:
▫ bag + tubes▫ valves (uni directional)▫ CO2 absorber
• Ventilator
Anaesthetic machine
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Anaesthetic machine
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Airway managementIndication for intubation:
• Need of relaxation or PPV
• Full stomach
• Orotracheal intubation, nasotracheal intubation with direct laryngoscopy
• Tracheotomy
• Laryngeal mask
• Cricothyreotomy
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Intubation
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Laryngeal Mask
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Anaesthetic plan
•Preoperative•Intraoperative •And postoperative management
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Postoperative care•ICU/HDU or ward•Monitoring according to type of surgery
and patient’s condition •Post-operative pain control•Lab check up •Infusion therapy, blood loss monitoring
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Questions ?