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Clinical Anesthesia for nonclinical
anesthesia colleagues
by James H. Philip
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Clinical Anesthesia for nonclinical anesthesia colleagues
James H. Philip, M.E.(E.), M.D., C.C.E. Anesthesiologist and
Director of Clinical Bioengineering, Department of Anesthesia, Brigham and Women's Hospital
Medical Liaison for Anesthesia, Department of Biomedical Engineering Partners HealthCare System
Professor of Anaesthesia Harvard Medical School
© 1984 - 2016, James H Philip, all rights reserved.
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Objectives Understand who anesthesiologists and nurse anesthetists are Understand what anesthesiologists and nurse anesthetists do Understand the fundamental components of an anesthetic Understand the choices of drugs and equipment Understand the anesthesia gas delivery system, esp. circuit Understand, speak, and write, using anesthesia terminology correctly
and appropriately Appreciate the thinking process behind anesthesia decisions Appreciate the role of anesthesia care providers in the perioperative
process Understand the need for clinical technology support Understand the need for information technology support Understand the need for supply and equipment management support
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The Operating Room
Personnel The sterile field Equipment Generic vs. specialized environments
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Personnel Surgeons Anesthetists (Anaesthetists (G.B. and MGH) Scrub Nurses or Scrub Technicians Circulating Nurses Anes Technicians Biomedical Engineering Technicians Clinical Engineers
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Surgeons Classic surgeons - operate with a scalpel Modern surgeons - use newer technology
Scope to visualize Fluoroscopy, Ultrasound to visualize Insufflation to show organs (Laparoscopy) Robot to perform tiny procedures magnified and without tremor or organ motion
Interventionalists Trained in other field and doing the above modern surgery
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Anesthetists Anesthetist = one who administers anesthesia
MD Anesthesiologist CRNA Nurse Anesthetist (USA only) AA Anesthesia Assistant (USA only)(some states)
Administer = Give to patient Anesthesiologist = One who studies anesthesia
and administers anesthesia to patients Anesthesia Care Team
Anesthesiologist AKA Attending is supervisor CRNA, AA, or Resident directly administers
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OR Utilities
Electrical Gases Vacuum
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Surgical Equipment Lighting system OR table Electro Surgical Unit (ESU)
Electrocautery Clean Area More
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Specialized OR Equipment Cardiovascular
CPB or Pump LVAD, RVAD (L,R Ventricular Assist Devices
IAB (intra-aortic balloon to support blood pressure) Lasers, Argon Plasma Coagulators (APCs) Microscopes Imaging systems Navigation systems EEG (brain wave monitor) Robots�to assist with surgery More
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If you visit
Key Principle
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S
Door D
oor
ST Anesthesia
Machine
Surgical Table
A2
A1
C
Sterile E
quipment
Typical OR Layout
Personnel A1 = Anes Resident A2 = Anes Attending/Faculty C = Circulating RN SR = Surgical Resident S = Surgeon ST = Surgical Scrub Technician
SR
OmniCell Drug Cabinet
Doo
r
Red supply C
art
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Sterile Field
Don’t touch anything green or blue !!! Generally, don’t touch anything....
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Specialty Environments
Operating Rooms Cardiac Thoracic Vascular General Gynecology Day Surg Obstetrics
Other Rooms Pain Management Diagnostic Radiology Therapeutic Radiology MRI/MRT - the Magnet PACU (Post Anes Care) RR ICU (Intensive Care Unit)
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The Perioperative Process
Peri = around. Now it means during, also Preoperative evaluation of the patient Case preparation The anesthetic Post-operative care Follow-up
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Booking (Scheduling) a Case
Internist diagnoses disease and refers to Surgeon determines if and what surgery is
required Preoperative visit - Anesthesia component
Evaluate patient Consider anesthesia options Meet patient’s needs Satisfy patient’s desires
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Preoperative Evaluation
Surgery planned Patient disease related to surgery Patient disease irrespective of surgery Patient physical attributes (size, shape) Patient emotional attributes and needs
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ASA Physical Status classification 1 Healthy patient with localized surgical disease
no organic, physiologic, biochemical, or psychiatric disease
2 Mild to moderate disease - non-limiting 3 Severe systemic disease - limiting 4 Life threatening systemic disease 5 Moribund (very sick) with little change of survival
without immediate surgery
E Added if emergency operation is required (3E)
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Preoperative Preparation Communication
surgeon & OR team (equipment, orientation, …) patient & family (NPO p Midnight, …..) Safety Pause
Room setup Anesthesia supplies present and checked Anesthesia equipment present and checked Surgical supplies present and checked
Patient IV access, informed consent, premedication sometimes.
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The Anesthetic Enter OR Anesthesia begins Induction Maintenance Emergence (awakening, tube removal) Recovery Anesthesia ends
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The Anesthetic
Enter OR Stretcher, wheelchair, walk Anesthesia begins Induction Going to sleep Maintenance Staying asleep Emergence Waking up Recovery Returning to normal Anesthesia ends
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Preparation Prepare Drugs Prepare and check Equipment
Laryngoscope, IV Pole; Anesthesia Machine Start IV (usually in Pre-Op area) Evaluate patient Formulate a plan Communicate with patient and surgeon
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Bring the Patient to the OR Enter OR Position patient on OR Table Attach Monitors, leads, tubes Final check Overlooked
OR Table control and interactions Suction functional
Forced Hot Air blanket in place ad with air
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Components of General Anesthesia
1. Sleep - unconsciousness 2. Amnesia - loss of memory/recall 3. Analgesia - loss of pain 4. Paralysis - muscles relaxed/soft 5. Autonomic block - no body response
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Anesthesia Types
General Regional Sedation
(MAC)
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Anesthesia Machine Evolution
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BWH Workspace 2000 (Ohmeda Central Display)
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Aestiva D-O Aesti
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Two Companies GE-Datex-Ohmeda Aestiva
Draeger Fabius GS
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Two Companies GE
Aisys Draeger Apollo GS
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Aisys with PIMS
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Normal flow in breathing circuit Normal use, not Circuit Prime Flow goes forward in circuit in the direction of the valves Emptying and filling reservoir bag may go backward and lungs, alternately
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Sampled
Exhaust
CO2
Ab- sorb- ant
200 mL/min
Fresh
Normal flow in the breathing circuit - Inspiration
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Sampled
Exhaust
CO2
Ab- sorb- ant
200 mL/min
Fresh
Normal flow in the breathing circuit - Expiration
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Anesthetic path from vaporizer to brain and beyond
Philip, Gas Man®, 1982 - 2010
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Technique Names
Inhalation anesthesia Intravenous anesthesia
usually with nitrous oxide Balanced Anesthesia - Inhaled + IV TIVA - Total Intra Venous Anesthesia MAC - sedation
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Technique - how do I choose
Minimum impact on patient Allow the planned surgery
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Anesthetic Techniques
Regional Anesthesia Spinal, Epidural, Extremity
Monitored Anesthesia Care = deep sedation = MAC
General Anesthesia see below
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General Anesthesia types
IV (intravenous) Drugs Inhaled (breathed) drugs Combination of IV and Inhaled
Balanced
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Airway Control Products
Room air Facemask with oxygen flow Laryngeal Mask Airway (LMA) Tracheal Tube
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Types of General Anesthetic Achieved with only IV drugs
TIVA = Total IntraVenous Anesthesia Achieved with only volatile liquids and gases
VIMA = Volatile Induction & Maintenance An. Achieved with one or more inhalants + more
Balanced Anesthesia Achieved with IV + Inhalation + Regional
Combined Anesthesia
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Choice of anesthetic technique
Must meet the surgical need Must be compatible with the patient’s health Controlled comparisons rarely show outcome differences Individual anesthesiologists have techniques that work best for them based on knowledge, skill, experience
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Typical General Anesthetic
Induction Maintenance Emergence Recovery to normal state
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Anesthesia Induction
Preoxygenate (denitrogenate) IV induction agents Adjuvant Monitor and Control
Airway Breathing Circulation
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Pre-oxygenation Why preoxygenate (denitrogenate)? Goal: Replace nitrogen in air with oxygen FRC = Lung volume after exhalation FRC = 2000 mL
Air: 0.21 x 2000 = 420 mL O2 100% O2: 2000 mL O2
Oxygen Uptake = 250 mL/min 100% O2 Safe time = 8 minutes Air (21% O2) Safe time < 2 minutes
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Anesthesia Induction
Preoxygenate (denitrogenate) IV induction agents Adjuvant Monitor and Control
Airway Breathing Circulation
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Preoxygenate
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IV Drugs
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Secure or Control Airway
Tracheal Tube Endotracheal Tube, ET
Laryngeal Mask Airway LMA
Natural airway with mask Oropharyngeal or Nasopharyngeal devices included
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Tracheal Intubation Tube in trachea (windpipe) Protects lungs from vomit Allows easy Ventilation
patient can breath I can assist, control, mechanically ventilate
Muscle Relaxant Succinylcholine, Vecuronium
Laryngoscopy (metal scope to see larynx) Intubation - place tube in trachea
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Intubate
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Secure Tracheal Tube
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Secure Tracheal Tube
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Maintenance
Airway Breathing Circulation Drugs for ongoing anesthesia Equipment for monitoring Fluid management Get it down (on paper) - Recordkeeping
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Real danger is ABC
Really AAA B C Airway, Airway, Airway Breathing Circulation
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Maintenance
IV drugs narcotics for pain - now and later muscle relaxants to soften muscles sleep drugs to maintain sleep & amnesia
Inhaled drugs nitrous oxide vapors - isoflurane, sevoflurane, desflurane, halothane (kids)
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Case
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Emergence Plan for wake-up Eliminate the inhalation anesthetic Await re-distribution of most IV drugs Await metabolism of a few IV drugs Establish or maintain analgesia (no pain) Reverse muscle relaxants Extubate Trachea (remove tracheal tube) Protect airway (Airway, again) Transfer to stretcher or wheelchair
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Recovery
Exit the OR Monitor ABC Oxygenate (treat or monitor SpO2) Transfer to PACU
Post Anesthesia Care Unit (aka RR) Manage pain
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Post-Op Pain Management Methods
Block response (analgesics), block signals (regional) Routes
Intravenous, intramuscular, oral, transdermal (patch), rectal Regional block (Epidural, Field, Local)
Medications Anti-inflammatory, opioids (narcotics), local anesthetics
Techniques Patient-controlled (PCA, PCEA [E for Epidural) Nurse-controlled (Intermittent injections by clock or request)
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Potential After-Effects of Surgery and Anesthesia
Sleepiness Respiratory depression Nausea, Vomiting (PONV) Pain Cardiovascular stress or depression Other Complications
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Follow-up
Manage Pain Visit post-op Determine quality of care
Look for complications Send bill to third party payer
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Thank you
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End