ANESTHESIA / ANESTHESIA / SEDATION SEDATION OUTSIDE OUTSIDE

OPERATING ROOMOPERATING ROOMDr.P.NARASIMHA REDDYDr.P.NARASIMHA REDDY

NARAYANA MEDICAL NARAYANA MEDICAL COLLEGE.COLLEGE.

INTRODUCTIONINTRODUCTION PROCEDURES DONE OUTSIDE O.R.PROCEDURES DONE OUTSIDE O.R. PLACES WHERE PROCEDURES PLACES WHERE PROCEDURES

ARE DONE.ARE DONE. PROBLEMS OF ANESTHETISTPROBLEMS OF ANESTHETIST

GENERAL PROBLEMS.GENERAL PROBLEMS. SPECIFIC PROBLEMS.SPECIFIC PROBLEMS.

WHAT ARE THE SAFETY WHAT ARE THE SAFETY STANDARDS?STANDARDS?

MONITORING AIDS.MONITORING AIDS. EQUIPMENT REQUIRED.EQUIPMENT REQUIRED. TYPES OF ANESTHESIA ? TYPES OF ANESTHESIA ?

SEDATION.SEDATION. DISCHARGE CRITERIA.DISCHARGE CRITERIA.

INTRODUCTIONINTRODUCTION:: Ultra short acting potent drugs.Ultra short acting potent drugs. Portable monitoring aids.Portable monitoring aids.PERIPATETICPERIPATETIC: “who walks from : “who walks from

place to place”place to place”

Essential criteria to anesthetist outside Essential criteria to anesthetist outside O.R.O.R.

1.Applicability – is it appropriate to 1.Applicability – is it appropriate to provide service?provide service?

2. Ability - does an anesthetist have to 2. Ability - does an anesthetist have to be present?be present?

3. Affordability – is it cost effective?3. Affordability – is it cost effective?

4.Availability – can we provide the 4.Availability – can we provide the service outside?service outside?

5.Affability – is it the desire of the 5.Affability – is it the desire of the doctor to have anesthetist services?doctor to have anesthetist services?

6.accountability – are we responsible 6.accountability – are we responsible for the quality & outcome results?for the quality & outcome results?

7.Altruism – is it devotion to humanity 7.Altruism – is it devotion to humanity or selfishness?or selfishness?

O.R – sterile,serene,peaceful.O.R – sterile,serene,peaceful. Anesthetist-- Anesthetist--

comfortable,comprehensive,conducticomfortable,comprehensive,conducting procedures.ng procedures.

He is familiar with He is familiar with equipment,medical,paramedical equipment,medical,paramedical persons,available drugs.persons,available drugs.

He can expect & delegate powers to He can expect & delegate powers to suitable persons. suitable persons.

Outside O.R - known & unknown Outside O.R - known & unknown problems .problems .

Vulnerable to mishaps.Vulnerable to mishaps.

PROCEDURES OUTSIDE PROCEDURES OUTSIDE O.RO.R

1.1. Diagnostic,interventional& Diagnostic,interventional& therapeutic radiology.therapeutic radiology.

2.2. Cardiac Cardiac catheterisation,implantation of catheterisation,implantation of defibrillators,coronary defibrillators,coronary angiography,stent replacements.angiography,stent replacements.

3.3. Cardioversions.Cardioversions.

4.4. E.C.T.E.C.T.

5.Bonemarrow aspiration & L.P.5.Bonemarrow aspiration & L.P.

6.Emergency airway management.6.Emergency airway management.

7.Transport of critically ill patients.7.Transport of critically ill patients.

8.Ortho procedures.8.Ortho procedures.

9.Removal of patients from rubble or 9.Removal of patients from rubble or accident vehicles.accident vehicles.

PLACES WHERE PLACES WHERE PROCEDURES ARE DONEPROCEDURES ARE DONE

1.1. Radiology suit..Radiology suit..

2.2. Cath lab.Cath lab.

3.3. I.C.U.I.C.U.

4.4. Psychiatry O.P.Psychiatry O.P.

5.5. Cancer wards.Cancer wards.

Contd..Contd..

6.Paediatric wards.6.Paediatric wards.

7.Field situations.7.Field situations.

8.Ortho O.P’s.8.Ortho O.P’s.

9.Transport vehicles – road/air.9.Transport vehicles – road/air.

PROBLEMS OF PROBLEMS OF ANESTHETIST.ANESTHETIST.

GENERAL PROBLEMSGENERAL PROBLEMS::

- environment – new place,remote - environment – new place,remote area,narrow lanes,low lighting,no back-area,narrow lanes,low lighting,no back-up facility.up facility.

- personnel – not trained & less number.- personnel – not trained & less number.

-equipment – anesthesia machine may -equipment – anesthesia machine may be present or absent.be present or absent.

Contd..Contd..

- May be old or not used for long time.May be old or not used for long time.- Cyllinders – less or empty.Cyllinders – less or empty.- Outlets for power – O2,N2O may not Outlets for power – O2,N2O may not

be present.be present.- Laryngoscope may be present / Laryngoscope may be present /

absent, may not be working.absent, may not be working.- Proper size of tubes & airways – not Proper size of tubes & airways – not

available.available.

Contd..Contd..

- Suction – present /not working.Suction – present /not working.- Parking – narrow crowded Parking – narrow crowded

places,difficult to transport the places,difficult to transport the patient in case of emergency.patient in case of emergency.

- Communication system may not be Communication system may not be good.good.

- Resuscitation facilities – not adequate.Resuscitation facilities – not adequate.- Post anesthetic care – not available.Post anesthetic care – not available.

PATIENT PROBLEMSPATIENT PROBLEMS::- Not well prepared.Not well prepared.- No fasting guidelines.No fasting guidelines.- PAC not done.PAC not done.- May be on some medications.May be on some medications.- Comorbid conditions presentComorbid conditions present

patient must be ASA 1 & 2.patient must be ASA 1 & 2.

SPECIFIC PROBLEMSSPECIFIC PROBLEMS::

--C.T SCANC.T SCAN : :

-Needs immobile patient for 20-40 mts.-Needs immobile patient for 20-40 mts.

--children,unconscious,noncooperative,head children,unconscious,noncooperative,head injury,convulsions,communication injury,convulsions,communication problems – requires sedation / anesthesia.problems – requires sedation / anesthesia.

-airway obstruction-airway obstruction

-kinking of tube -kinking of tube

Contd..Contd..

- - apnoea.apnoea.

- cyanosis & cardiac arrest.- cyanosis & cardiac arrest.

-radiation to anesthetist.-radiation to anesthetist.

- allergic reactions to contrast - allergic reactions to contrast dyesdyes..

M.R.IM.R.I::- Narrow tunnel.Narrow tunnel.- Access to the patient is difficult.Access to the patient is difficult.- Claustrophobia.Claustrophobia.- Strong magnetic fields.Strong magnetic fields.- Ferromagnetic implants,monitoring Ferromagnetic implants,monitoring

aids.aids.- Loud noise.Loud noise.

Contd..Contd..

- Image degradation.- Image degradation.- Absolute immobility for long time.- Absolute immobility for long time.- Cannot see the airway & chest movements.- Cannot see the airway & chest movements.- Modified anesthesia machine & monitors.- Modified anesthesia machine & monitors.- No coil cables.- No coil cables.- Alluminium trolleys & alluminium - Alluminium trolleys & alluminium

cyllinders.cyllinders.- Plastic laryngoscope with batteries which - Plastic laryngoscope with batteries which

are wrapped with plastic covers.are wrapped with plastic covers.

Interventional radiologyInterventional radiology::- Laporotomies & craniotomies for Laporotomies & craniotomies for

accurate tumor resection.accurate tumor resection.- Intermittent imaging.Intermittent imaging.- Scanning time may be significantly Scanning time may be significantly

longer.longer.- Patient access limited.Patient access limited.- Contrast dyes produce diuresis.Contrast dyes produce diuresis.- Hypo-hypertensive.Hypo-hypertensive.

Neuro radiologyNeuro radiology::

-Embolisation :-Embolisation :

- long procedures, embolic events.- long procedures, embolic events.

- airway management urgent.- airway management urgent.

- G.A ideal.- G.A ideal.

- hemorrhage ,hemodynamic - hemorrhage ,hemodynamic disturbances & aspiration can occur.disturbances & aspiration can occur.

Trigeminal neuralgiaTrigeminal neuralgia::- Local block inducedLocal block induced- Neurolytic agent.Neurolytic agent.- Brief period of loss of consciousness is Brief period of loss of consciousness is

induced.induced.- Neurologic examination on awake Neurologic examination on awake

patient.patient.- Airway support may be difficult when Airway support may be difficult when

block needle is in place.block needle is in place.

Cyclotron therapyCyclotron therapy::- Proton beam radiation is used in the Proton beam radiation is used in the

treatment of A.V treatment of A.V malformations,pituitary tumors & malformations,pituitary tumors & retinoblastomas.retinoblastomas.

- Radiation is painless but positioning Radiation is painless but positioning may take several hours.may take several hours.

- Head fixation may be painful.Head fixation may be painful.- Standard T.V with CCTV.Standard T.V with CCTV.

Radiation therapyRadiation therapy::- Children often require G.A.Children often require G.A.- 3-4 times a week for 4 weeks.3-4 times a week for 4 weeks.- Planning of radiation on first day Planning of radiation on first day

takes long time.takes long time.- Standard monitoring with CCTV.Standard monitoring with CCTV.

E.C.TE.C.T::- Used in patients with depression not Used in patients with depression not

controlled by the drugs.controlled by the drugs.- Initial vagal discharge,later Initial vagal discharge,later

sympathetic discharge.sympathetic discharge.- HTN for 5-10 mts.HTN for 5-10 mts.- E.C.G – prolonged PR & QT E.C.G – prolonged PR & QT

intervals, T wave inversion.intervals, T wave inversion.

Contd..Contd..

- inc.intraocular & intra gastric inc.intraocular & intra gastric pressures.pressures.

- Absolute contraindicationAbsolute contraindication : : - intracranial HTN.- intracranial HTN.- Relative contraindicationsRelative contraindications:: - intracranial mass with normal ICT - intracranial mass with normal ICT -aneurysms-aneurysms - recent M.I,angina , CCF- recent M.I,angina , CCF - untreated glaucoma- untreated glaucoma

Contd..Contd..

- Major bone fractures.Major bone fractures.- Thrombophlebitis.Thrombophlebitis.- Pregnancy.Pregnancy.- Retinal detatchment.Retinal detatchment.

“ “Be careful with drug Be careful with drug interactionsinteractions””

CardioversionCardioversion::- Painful procedure.Painful procedure.- Must be unconscious.Must be unconscious.- Others should not touch the patient Others should not touch the patient

during shock.during shock.- Patient is ventilated with 100% O2 Patient is ventilated with 100% O2

till recovery.till recovery.

Contd..Contd..

Endoscopic suiteEndoscopic suite::- Patient must be evaluated.Patient must be evaluated.- Ideal fasting guidelines.Ideal fasting guidelines.- Glyco + topical L.A + benzo / propofol.Glyco + topical L.A + benzo / propofol.- ContraindicationsContraindications : : - achalasia,esophageal - achalasia,esophageal

stricture,corrosive esophagitis,intestinal stricture,corrosive esophagitis,intestinal obstruction,esophageal discoordination.obstruction,esophageal discoordination.

ESSENTIAL ESSENTIAL REQUIREMENTSREQUIREMENTS

1.1. O2 Piped / cylinders.O2 Piped / cylinders.

2.2. Anesthesia machine.Anesthesia machine.

3.3. Sufficient electrical outlets.Sufficient electrical outlets.

4.4. Adequate space & access to the Adequate space & access to the patient.patient.

5.5. Adequate illumination.Adequate illumination.

6.6. Emergency resuscitation cart.Emergency resuscitation cart.

Contd..Contd..

7.Adequate monitoring equipment.7.Adequate monitoring equipment.

8.Defibrillator.8.Defibrillator.

9.2way communication.9.2way communication.

10.Qualified anesthesiologist.10.Qualified anesthesiologist.

11.Transportation facility.11.Transportation facility.

MONITORING MONITORING EQUIPMENTEQUIPMENT

1.1. ECG.ECG.

2.2. Pulse oximeter.Pulse oximeter.

3.3. Blood pressure.Blood pressure.

4.4. ETCO2.ETCO2.

5.5. Oxygen analyser.Oxygen analyser.

OTHER EQUIPMENTOTHER EQUIPMENT

Bag mask ventilation.Bag mask ventilation. Airways – all sizes.Airways – all sizes. Laryngoscope with all blades.Laryngoscope with all blades. Correct size E.T tubes.Correct size E.T tubes. Drugs – anesthetic & resuscitation Drugs – anesthetic & resuscitation

drugs.drugs.

TYPES OF ANESTHESIATYPES OF ANESTHESIA

INHALATIONAL INHALATIONAL I.V anestheticsI.V anesthetics M.A.C M.A.C RegionalRegional Sedation Sedation

Contd..Contd..

Is the procedure painful?Is the procedure painful? What is the duration of procedure?What is the duration of procedure? Patient needs to be motionless?Patient needs to be motionless? Many times procedures are done Many times procedures are done

under sedation.under sedation. Rarely G.A with E.T tube with Rarely G.A with E.T tube with

relaxant.relaxant.

SEDATIONSEDATION::- Guidelines for sedation:Guidelines for sedation:

- - chloral hydratechloral hydrate : : -non-narcotic.-non-narcotic. - no resp.depression.- no resp.depression. - no addiction.- no addiction. -50-70 mg/kg orally 30-60 mts before the -50-70 mg/kg orally 30-60 mts before the

procedure.procedure. - not analgesic.- not analgesic. -15% failure rate.-15% failure rate.

Rectal methohexitalRectal methohexital::- 20-30 mg/kg 20-30 mg/kg - Rapid onset 5-10 mts.Rapid onset 5-10 mts.- Prolonged action 30-60 mts.Prolonged action 30-60 mts.- Unpredictable sedation.Unpredictable sedation.

BenzodiazepinesBenzodiazepines::- MidazolamMidazolam -0.01mg/kg. -0.01mg/kg.

can be given by all routes.can be given by all routes.

sedative ,anxiolytic,anticonvulsant.sedative ,anxiolytic,anticonvulsant.

amnesia .amnesia .

minimal hemodynamic effects.minimal hemodynamic effects.

not an analgesic.not an analgesic.

I.V anesthetic agentsI.V anesthetic agents::

- Pentothol sodiumPentothol sodium:: 5-7mg/kg.5-7mg/kg. careful with full stomach & airway.careful with full stomach & airway.

- ketamineketamine:: 1-2 mg/kg i.v, 2-4 mg/kg i.m1-2 mg/kg i.v, 2-4 mg/kg i.m perfect analgesia.perfect analgesia. reflexes retained.reflexes retained.

Contd..Contd..

- Broncho dilator.Broncho dilator.- Resp.activity maintained.Resp.activity maintained.- Raised i.c.tRaised i.c.t- Ketatonia.Ketatonia.- Emergency delirium.Emergency delirium.

PropofolPropofol::- 1-2 mg/kg.1-2 mg/kg.- Shorter duration of action.Shorter duration of action.- Complete recovery.Complete recovery.- Early apnea & hypotension.Early apnea & hypotension.- Pain during injection.Pain during injection.

G.AG.A::- Premed – atropine/ glyco.Premed – atropine/ glyco.- Rapid sequence induction.Rapid sequence induction.- Induction agents – Induction agents –

thio/propo/ketamine.thio/propo/ketamine.- Muscle relaxants – succi/ vec/E.T Muscle relaxants – succi/ vec/E.T

tube.tube.- Reversal – neo+ glyco.Reversal – neo+ glyco.

REGIONALREGIONAL::- EMLAEMLA ( ligno+ prilo) ( ligno+ prilo)- Occlusive dressing for 60mts.Occlusive dressing for 60mts.- L.P ,bone marrow aspiration,ICD,i.v L.P ,bone marrow aspiration,ICD,i.v

cannula.cannula.- Methemoglobinemia.Methemoglobinemia.

DISCHARGE CRITERIADISCHARGE CRITERIA

1.1. Stable C.V.S .Stable C.V.S .2.2. Satisfactory airway.Satisfactory airway.3.3. Patient easily arousable.Patient easily arousable.4.4. Reflexes intact.Reflexes intact.5.5. Patient can talk, can sit up.Patient can talk, can sit up.6.6. Patient can void urine.Patient can void urine.7.7. Young & handicapped – Young & handicapped –

preanesthetic level.preanesthetic level.8.8. Hydration must be adequate.Hydration must be adequate.