clinical anaesthesiology qiu wei fan associate professor department of anaesthesiology rui jin...
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Clinical Anaesthesiology
Qiu Wei FanAssociate Professor
Department of AnaesthesiologyRui Jin Hospital
Shanghai Second Medical University
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General Anaesthesia
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Classification of General Anaesthesia Methods
Inhalation anaesthesiaIntravenous anaesthesiaIntramuscularlyRectallyOrallyBalanced anaesthesia
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Clinical PharmacologyInhalational anaesthetic agents
Agent MAC% Vapor Pressure Blood/Gas Partition Nitrous oxide 105 - 0.47 Halothane 0.74 243 2.4 Enflurane 1.68 175 1.9 Isoflurane 1.15 240 1.4 Desflurane 6.0 681 0.42
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Clinical PharmacologyIntravenous anaesthetic agents
Agent Induction dose (mg·kg-1)
Thiopentone 3-5 Methohexitone 1-1.5 Etomidate 0.3 Propofol 1.5-2.5 Ketamine 2
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Clinical PharmacologyDrugs used to supplement anaesthesia
AnalgesicsOpioid agonists Natural opium alkaloids: Morphine,Codeine Semisynthetic opium alkaloid: Diamorphine Synthetic opioids:Pethidine, Fentanyl, Alfent
anil, Sufentanil, RemifentanilPartial opioid agonists Buprenorphine
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Clinical PharmacologyDrugs used to supplement anaesthesia
Opioid agonist/antagonists PentazocineOpioid antagonists Naloxone
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Clinical PharmacologyMuscle Relaxants
Neuromuscular blocking agents are dividedinto two classes:
Depolarizing Nondepolarizing
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Clinical PharmacologyMuscle Relaxants
Depolarizing Short-acting Succinylcholine Decamethonium
Nondepolarizing Long-acting Tubocurarine Metocurine doxacurium Pancuronium Pipecurium Intermediate-acting Atracurium Vecuronium Short-acting Mivacurium
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Clinical PharmacologyDrugs affecting the autonomic nervous
system Sympathomimetic drugs Adrenaline(low-α,β1+2)(higher- α) Isoprenaline(β1+2) Noradrenaline(α,β1 ) Phenylephine(α) Dopamine (low-δ,moderate-δ ,β1+2, mode
ratehigh-α,β1 ) Dobutamine(β1 )
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The practical conduct of anaesthesia
Preparation for anaesthesia Equipment for monitoring The anaesthetic machine Equipment required for trache
al intubation
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Anaesthetic apparatusThe anaesthesia machine
Gas inlets & pressure regulators Oxygen pressure failure devices & oxygen
flush valves Flow control valves Flowmeters & spirometers Vaporizers Vantilators & disconnect alarms Waste gas scavengers Humidifiers & nebulizers Oxygen analyzers
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Airway management equipment
Oral & Nasal airway Mask Endotracheal tube Rigid laryngoscopes Flexible fiberoptic laryngosco
pes
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Equipment required for tracheal intubation Correct size of laryngosco
pe and spare Tracheal tube of correct si
ze + an alternative smaller size
Tracheal tube connector Wire stilette Gum elastic bougies Magill forceps Cuff-inflating syringe Artery forceps
Securing tape or bandage Catheter mount Local anaesthetic spray Cocaine spray/gel for nas
al intubation Tracheal tube lubricant Throat packs Anaesthetic breathing sys
tem and face masks-tested with oxygen to ensure no leaks present
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Induction of Anaesthesia
Inhalational induction Intravenous induction
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Inhalational induction agents
Sevoflurane Desflurane
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Induction of anaesthesiaIndications for inhalational induction
Young children Upper airway obstruction Low airway obstruction with fore
ign body Bronchopleural fistula or empye
ma No accessible veins
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Induction of anaesthesia Difficulties and complications
Slow induction of anaesthesia Problems particularly during stage
2 Airway obstruction, bronchospasm Laryngeal spasm, hiccups Environmental pollution
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Intravenous inductionDoses of the intravenous agents
Agent Induction dose (mg·kg-1)
Thiopentone 3-5 Methohexitone 1-1.5 Etomidate 0.3 Propofol 1.5-2.5 Ketamine 2
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Intravenous induction Complications and difficulties
Regurgitation and vomiting Intra-arterial injection of thiopentone Perivenous injection Cardiovascular depression Respiratory depression Histamine relea
se Porphyria Other complications
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Maintenance of anaesthesiaInhalation anaesthesia with spontaneous ventilation
Conduct Minimum alveolar concentration
(MAC): MAC is the minimum alveolar concentration of an inhaled anaesthetic agent, which prevents reflex movement in response to surgical incision in 50 % of subjects.
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Clinical PharmacologyInhalational anaesthetic agents
Agent MAC% Vapor Pressure Blood/Gas Partition
Nitrous oxide 105 - 0.47
Halothane 0.74 243 2.4
Enflurane 1.68 175 1.9
Isoflurane 1.15 240 1.4
Desflurane 6.0 681 0.42
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Signs of anaesthesia
Stage 1(Stage of analgesia): From start of induction of anaesthesia to loss of consciousness.
Stage 2 (Stage of excitement): From loss of consciousness to beginning of regular respiration.
Stage 3 (Surgical anaesthesia): From the beginning of regular respirationto respiratory arrest.
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Signs of anaesthesia The stage 3 is divided into four planes.
Plane 1: From the onset of regular breathing to the cessation of eyeball movements.Plane 2: From the cessation of eyeball movements to the beginning of intercostal paralysis.Plane 3: From the beginning of intercostal paralysis to the completion of intercostal paralysis.Plane 4: From completion of intercostal paralysis to diaphragmatic paralysis.
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Signs of anaesthesia
Stage 4: Stage of impending respiratory and circulatory failure (Medullary paralysis), from the onset of diaphragmatic paralysis to cardiac arrest.
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Inhalation anaesthesia with spontaneous ventilation Complications and difficulties
Airway obstruction Laryngeal spasm Bronchospasm Malignant hyperthermia Raised intracranial pressure (I
CP) Atmospheric pollution
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Delivery of inhalational agents-airway maintenance
Use of the facemask Use of the laryngeal mask air
way (LMA) Use of the oropharyngeal airw
ay Tracheal intubation
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Use of the laryngeal mask airway (LMA) Indications
Provide a clear airway without the need for the anaesthetist’s hands to support a mask.
Avoid the use of tracheal intubation during spontaneous ventilation.
In a case of difficult intubation to facilitate subsequent insertion of a tracheal tube either via the LMA or after use of a gum elastic bougie.
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Use of the laryngeal mask airway (LMA) Contraindications
A patient with a “full stomach” or with any condition leading to delayed gastric emptying,
A patient in whom regurgitation of gastric contents into the esophagus is possible,
Where surgical access is impeded by the cuff of the LMA.
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Tracheal intubationIndications
Provision of a clear airway, An ‘unusual’ position, Operations on the head and neck, Protection of the respiratory tract, During anaesthesia using IPPV and muscle r
elaxants To facilitate suction of the respiratory tract During thoracic operations
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Tracheal intubation Contraindications
Few
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Anaesthesia for tracheal intubation
Inhalational technique for intubation
Relaxant anaesthesia for intubation
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Anaesthesia for tracheal intubation
Oral-tracheal intubation Nasotracheal intubation Flexible fiberoptic nasotracheal in
tubation
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Complications of intubationDuring laryngoscopy and intubation
MaipositioningEasophageal intubationEndobronctrial intubationLaryngeal position
Airway trauma Tooth damage Lip, tongue or mucosal laceration Sore throat Dislocated mandible
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Complications of intubationDuring laryngoscopy and intubation
Retropharyngeal dissection Physiologic reflexes
Hypertension, TachycardiaIntracranial hypertentionIntraocular hypertension
Laryngospasm Tube malfunction Cuff perforation
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Complications of intubation While the tube is in place
Malposition Unintentional e
xtubation Endobrochial in
tubation Laryngeal cuff p
osition
Airway trauma Mucosal
inflammation and ulceration
Excoriation of nose
Tube malfunction Ignition Obstruction
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Complications of intubation Following extubation
A) Airway trauma Edema and stenosis
(glottic, subglottic, or tracheal )
Hoarseness (vocal cord granuloma or paralysis )
Laryngeal malfunction and aspiration
B) Physiologic reflexesLaryngospasm
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Relaxant anaesthesiaIndications for relaxant anaesthesia
Major abdominal, intraperitoneal, thoracic, intracranial operations
Prolonged operations in which spontaneous ventilation would lead to respiratory depression
Operations in a position in which ventilation is impaired mechanically
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Clinical PharmacologyMuscle Relaxants
Depolarizing Short-acting Succinylcholine Decamethonium
Nondepolarizing Long-acting Tubocurarine Metocurine doxacurium Pancuronium Pipecurium Intermediate-acting Atracurium Vecuronium Short-acting Mivacurium
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Reversal of relaxation
Residual neuromuscular block is antagonized with neostigmine 2.5-5mg (0.05-0.08mg·kg-1 in children). Atropine 1.2mg or glycopyrronium 0.5mg counteracts the muscarinic side effects of the anticholinesterase and may be given before, or with, neostigmine.
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Conduct of extubation
Coughing Resistance to the
presence of the tracheal tube
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Complications of tracheal extubation
Laryngeal spasm Regurgitation
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Emergence and recovery
Testing hand grip tongue protrusion Lifting the head from the
pillow in response to command
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Monitoring during anaesthesia
Cardiac monitors Arterial blood
pressure Noninvasive
arterial blood pressure
Invasive arterial blood pressure monitoring
Electrocardiography Central venous
catheterization Pulmonary artery
catheterization Cardiac output
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Noninvasive arterial blood pressure monitoringTechnique
Palpation Doppler probe Auscultation Oscillometry Plethysmography Arterial Tonometry
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Selection of artery for cannulation Radial artery Brachial artery Ulnar artery femoral artery Dorsalis pedis Posterior tibial artery Axillary artery
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Invasive arterial blood pressure monitoringComplications
Hematoma Vasospasm Arterial thrombosi
s Embolization of ai
r bubbles or thrombi
Skin necrosis overlying the catheter
Nerve damage Infection
Unintentional intra-arterial drug injection
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Monitoring during anaesthesiaRespiratory system monitoring
Precordial & easophageal stethoscope Breathing circuit pressure & exhaled tid
al volume Pulse oximetry End-tidal carbon dioxide analysis Transcutaneous oxygen & carbon dioxi
de monitors Anaesthetic gas analysis
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Monitoring during anaesthesiaNeurologic system monitors
Electroencephalography Evoked potential
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Monitoring during anaesthesiaMiscellaneous monitors
Temperature Urine output Peripheral nerve
stimulation
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Complications during anaesthesiaArrhythmias Bradycardia Tachycardia Atrial arrhythmias Ventricular arrhythmias (Pre
mature ventricular contractions (PVCs))
Heart block
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Complications during anaesthesiaHypotention Decreased cardiac output: Decreased venous return Myocardial Vasodilation Drugs Septicaemia Hypovolaemia Haemorrhage
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Complications during anaesthesia Hypertension Hypervolaemia Myocardial ischaemia Cardiac arrest Embolism Hypoxaemia
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Complications during anaesthesia Hypercapnia Hypocapnia Respiratory obstruction Intubation problems Aspiration of ga
stric contents Hiccups Adverse drug effects
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Complications during anaesthesia Malignant hyperthermia (MH) Hyperthermia Hypothermia Acute intermittent porphyria(AIP) Awareness Injury
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Questions
What is the meaning of MAC? What are the Guedel’s classic signs of anaesth
esia? How many methods for the anaesthetists use t
o maintain the airway? What are they?
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Questions
What are the indications for tracheal intubation?
What are the complications during general anaesthesia?
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Any Question?
THANK YOU !