Perioperative Anesthetic CareM1 (2)

8/3/2019 Perioperative Anesthetic CareM1 (2)

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Presented byDr. Mustafa Ahmed Jerjess

Senior lecturer/ Faculty of Medicine

UiTM


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This is one of important subjects in

anesthesia discipline and career because it

makes the line of demarcation between a

good and bad Anaesthesiologist.

It represent the sum of duties of

Anesthesiologist towards the patient.


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Q: What is Perioperative Anesthetic Care? A: Its the art of:

1. Maintaining safety and comfort of patient intra

and postoperatively.2. Avoiding any anticipated complication due to

type of surgery and/or anesthesia or due to

patient general health condition.

3. Treating any complication or critical event that

may occur intra or postoperatively.

4. Providing the most favorable conditions for the

success of operation.


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So from the definition the care takes place in

intra and postoperative so why it is called

perioperative care?

The answer is simple and practical because

the 1st step of care is started preoperatively

by optimizing the patient condition and

setting the anesthesia care plan.


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So what are the component of anaesthetic care?

1. Preoperative optimization of patient health condition.

2. Monitoring.

3. Administration anaesthesia drugs and procedures.

4. Protection of body against any internal or external risk.

5. Maintenance of body organs function in preoperative

state or even improving them.

6. Maintenance of body essential requirements.7. Replacement of any loss.

8. Treatment of any critical event.


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In this lecture we will concentrate on

monitoring subject because the other

subjects are covered by other lectures in

surgery module.

So lets go for monitoring.


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Monitoring is an essential issue in anaesthetic

care helping anaesthesiologist to avoid and early

detect any complication and critical eventperioperatively.

Appropriate monitoring should be available

whenever and wherever anaesthesia is

conducted, whether in anaesthetic room,

operation theatre, psychiatry or X-ray department

or in dental surgeries.


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Anaesthetic monitoring is 2 types :

1.Anaesthetic equipment monitoring:

a.Clinical.b.Instrumental.

2.Patient monitoring.

a.Clinical.b.Instrumental.


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a. Clinical: this includes reviewing check list

for the function integrity of all anaesthetic

equipments (e.g. anaesthetic machine,

ventilator, patient monitor, laryngoscope).

This should be done before the start of

induction.

Clinical monitoring also include continuous

correlating the function anaesthetic

equipment to effects seen on the patient.


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b. Instrumental: we have monitors or

equipments that give us parameters of

other equipment function e.g. percentage

of inspired (O2, volatile anaesthetic, N2O, CO2 etc) ventilator monitoring screen and

many other equipments.


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a. Clinical: this is very important because we

dont depend completely on the instrument

on the contrary we always depend on our

analysis of parameters shown by themonitor in addition to the continuous

examination of patient by inspection,

palpation, auscultation and to limitedextent percussion.


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b. Instrumental: today we have a lot of

monitoring devices and every year a device

is added to the set of monitors in

anaesthesia.

Because of complicated nature of some

monitoring devices and invasiveness of

others the use of monitoring devices isdivided to 2 groups.


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1. Basic group: this includes an essential monitoring devices for thesafe conduct of anesthesia that should available whenever and

wherever anaesthesia is administrated.

This includes:

1) ECG monitor(with respiratory rate measurement).2) Pulse oximeter.

3) Non-invasive blood pressure.

4) Capnography.

5) Inspired O2 concentration analyser.

6) Temperature measurement.


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Also we have additional devices in the basicgroup:

1) Ventilator monitor: (if ventilator is used).

2) Peripheral nerve stimulator: (if muscle relaxant isgiven).

3) Inspired anaesthetic vapour concentration

analyser: (if available).


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2. Specialized: these monitoring devices are useonly when there is special surgery or patient

condition. This includes:

a. Invasive blood pressure.b. Urine output.

c. Central venous pressure.

d. Pulmonary artery pressure.

e. Cardiac output.


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Pulse oximeter: is a device used to measure thepercentage of hemoglobin (Hb) that is saturated

with oxygen. This oxygen saturation (SpO2) is a

measure of how much oxygen the blood iscarrying.

It also measure the pulse rate and waveform. The

later give us an idea about the character of thepulse.


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The contraction and relaxation of cardiac muscle

results from the depolarisation and repolarisation ofmyocardial cells.

These electrical changes are recorded via electrodes

placed on the limbs and chest wall and displayed as

a wave on the monitor screen. Usually the monitordisplay one lead only but in some advanced

monitors they can display all 12 leads ECG.

In addition to displaying any arrhythmias it can alsobe used to detect the possibility of myocardial

ischemia, electrolyte imbalances, assess pacemaker

function and calculate heart rate . But not the

cardiac out put or myocardial function.


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The capnogram is a direct monitor of the inhaled and

exhaled concentration or partial pressure of CO2, and anindirect monitor of the CO2 partial pressure in the arterial

blood.

Capnography provides a rapid and reliable method to

detect life-threatening conditions (malposition of tracheal

tubes, unsuspected ventilatory failure, circulatory failure

and defective breathing circuits) and to circumvent

potentially irreversible patient injury. Capnography and pulse oximeter together could have

helped in the prevention of 93% of avoidable anesthesia

mishaps according to (American Society of

Anesthesiologists) closed claim study.
http://en.wikipedia.org/wiki/American_Society_of_Anesthesiologistshttp://en.wikipedia.org/wiki/American_Society_of_Anesthesiologistshttp://en.wikipedia.org/wiki/American_Society_of_Anesthesiologistshttp://en.wikipedia.org/wiki/American_Society_of_Anesthesiologists


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This is the most common method of obtaining the

patients blood pressure during anesthesia and

surgery. A pneumatic cuff with a width that is 40% of

the arm circumference must be used and the internal

inflatable bladder should encircle at least half the arm.

An electrical pump inflates the cuff, which then

undergoes controlled deflation. A microprocessor-

controlled pressure transducer detects variations in cuff

pressure resulting from transmitted arterialpulsations. Initial pulsations represent systolic blood

pressure and peak amplitude of the pulsations equates

to mean arterial pressure. Diastolic is calculated using

an algorithm.


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Continuous monitoring of the oxygenconcentration in the inspired gas mixture is

considered essential. This is usually achieved

using an oxygen analyser that displays a

numeric value of oxygen concentration.

Its essential because it prevents the

administration of hypoxic gas mixture (low O2

concentration) to patient which caused a lot of

tragic accidents during anaesthesia in the past.


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This is became one of the essential

monitors because of the progressive

evolution of anesthetic ventilators withmore complexity sophistication of

functions.


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After the spread of closed circuit anesthesia (a

modality that reduces the amount of volatile

anesthetic usage) with invention of multiple

volatile anesthetic agents it was mandatory tomonitor the inspired concentration of these

agents.


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Note: Now it no longer we use multiple

devices for monitoring of multiple

parameters, instead of that we use a single

monitor to monitor all parameters we want.


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Usually the recovery which is a part of intraoperativecare takes place in recovery room and takes short time

(most of the time less than 1 hour), but in special

cases(e.g. neurosurgical patient) where the recovery

may take more than usual or the patient condition iscritical then we refer the patient to Intensive care unit

where full monitoring facility is available just like

intraoperative monitoring in addition to full analgesia

and other maintenance therapy.

Otherwise if the patient condition is satisfactory then we

send the patient to general ward with full prescription

of postoperative analgesia and fluid therapy.


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Perioperative Anesthetic CareM1 (2)