Anaesthesia Outside O.R

1

Anaesthesia outside Operating room

Dr.Shailendra.V.L. Specialist in Anaesthesia, Al-Bukariya general

hospital.

2

Introduction“ Modern Anaesthesia is quite safe”

1. Well trained anaesthesiologists2. Well trained anaesthesia technician3. Fail-proof anaesthesia machine4. Monitoring aids5. Newer and versatile drugs

3

Introduction Handicap for anaesthesia

outside Operating Room:1. Geographical2. Logistics3. Material4. Manpower

4

Problems faced by the Anaesthesiologists1. Lack of adequate space2. Unfamiliar surroundings & equipment3. Central pipeline will be missing & cylinders

have to be used4. Un-physiological postures needed for some

procedures5. Out-patients for investigations are

inadequetely prepared/ investigated/ have associated medical illness

6. Adverse reactions to contrast media7. Lack of post-anaesthetic care

5

Areas of need outside the O.R.

1. Cardiology: Cardiac Cathetherisation Lab (Cath Lab):

1. Coronary angiogram2. Percutaneous Transluminal Coronary

Angioplasty (PTCA)

2. Radiology: 1. C.T.Scan2. MRI3. Radio-therapy

6

Areas of need outside the OR3. Psychiatry:

1. Electro-convulsive therapy (ECT)

4. Plastic Surgery:1. Burn’s dressing

7

Anaesthetic Plan

1. Good Anaesthetic machine2. Minimum monitoring standards3. Resuscitation equipment / drugs4. Manpower (anaesthetic /

technical)5. Simple & safe anaesthetic

technique

8

Anaesthesia machine1. O2 supply failure alarm2. Automatic N2o cut-off system3. Back-lit fluorescent back for the

flowmeters4. Bain’s circuit with long tubings5. Well serviced anaesthesia machine6. Anaesthesia ventilator

9

Monitoring standards1. ECG – electro cardiogram2. NIBP- non-invasive blood pressure3. SpO2 – pulse-oximetry4. FI02 – inspired oxygen fraction5. ETCO2- end-tidal carbon-di-oxide6. Ventilator disconnect alarm

10

Special procedures in Cardiology department1. Coronary Angiogram2. Per-cutaneous Trans-luminal Angioplasty

1. Done under local anaesthesia 2. Painless procedure3. Only minimal sedation needed

3. Problems: 1. Severe coronary artery disease 2. Injury to coronary vessels needs emergency

CABG

11

Special procedures in Psychiatry department

1. Electro-convulsive therapy: Non-pharmacological mode of treatment Commonly used for depression 70-130 volts current is passed for 1 second

through two cerebral hemispheres Shock produces muscular contraction Causes initial parasympathetic discharge

followed by sympathetic surge Causes retrograde amnesia

12

Anaesthesia for E.C.T.1. Pre-anaesthetic assessment difficult in un-

communicative patients2. MAO inhibitors & tricyclic anti-depressants

have drug interaction with pethidine and barbiturates

3. No pre-medication is given4. Plan: Induction: Thiopentone – 4mg/kg5. Relaxant: Suxamethonium 1mg/Kg6. Patient is manually ventilated with the

bite-block in place7. ECT given8. Patient is ventilated till he recovers from

the relaxant effect

13

Plastic surgery-Burn’s dressing Problems posed by a burn’s patient:1. Pre-existing psychological trauma2. Problems in positioning & transfer3. Difficulty in vascular access4. Repeated anaesthetics5. Altered pharmacological response

14

Anaesthetic plan for burn’s dressing

Preoperative evaluation: Check airway Check vascular access Check volume status

Routine monitoring O2 by face mask Total Intravenous Anaesthesia (TIVA)

Ketamine 1.5mg/Kg IV Diazepam 0.1mg/Kg IV Atropine 0.01mg/Kg IV

15

Anaesthesia for burn’s dressing

Halothane avoided as repeated anaesthetics is necessary

Suxamethonium is avoided Development of extra-junctional

receptors on the muscle surface which will lead to hyperkalemic response

(develops 1 week following burns & lasts till 6 months post- burns)

16

Anaesthesia in Radiology department1. C.T. scan2. M.R.I. scan3. Radio-therapy

17

Anaesthesia for C.T. scan

Procedure lasts for 10 minutes Non-invasive procedure Patient to lie motionless only Contrast injected to do studies

Acute anaphylaxis to contrast media can be disastrous

18

Anaesthesia for C.T.Scan Sedation with Chloral Hydrate 50mg/kg

orally half an hour prior to the procedure TIVA: Ketamine 1mg/kg with diazepam

0.1mg/kg & Atropine 0.01mg/Kg TIVA: Propofol 1mg/Kg with Atropine

0.01mg/Kg (Tracheal intubation is a must when Oral

radio opaque is used) Head injury patients with low GCS needs

intubation and control of ventilation

19

Monitoring for CT Scan ECG Spo2 NIBP End-tidal CO2 Ventilator disconnect alarm

20

Problems in C. T. scan room

Dark / poorly lit room Radiation exposure Very cold environment Limited access to the patient Contrast medium anaphylaxis

21

Anaesthesia for MRI Scan Painless procedure Children only need anaesthesia

services Procedure lasts for 60 – 75 minutes Scary feeling staying inside the

tube

22

Anaesthesia for MRI Scan

Mandatory to intubate all patients and control ventilation using ventilator

Need for anaesthesia machine & monitors compatible with MRI environment-Expensive

Routine anaesthesia technique is done Minimal Motoring Standards is a must

23

Anaesthesia for Radio-therapy

Children need sedation to stay motionless

Repeated anaesthetics necessary Painless procedure Procedure lasts for 10 minutes Plan:- TIVA using Ketamine/ Propofol

24