how to set your room
DESCRIPTION
65 slides describing the every day practice in the OR.It is a helpful guide for all anesthesia residentsTRANSCRIPT
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The Practical guide for the everyday practices
Ahmad Mustapha Abou Leila
PGY5 -Anesthesiology
HOW TO SET YOUR ROOM
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THE MUST-DOS
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CHECK YOUR ANESTHESIA MACHINE
Turn onO2-Air-N2O attached(look at the pipes, the pressure monitor)Turn On the VentilatorCheck for circuit leakCheck the Soda Lime(purple or grey)The Scavenger is Open-the risk of pollutionThe Vaporizer –The level of gas
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CHECK YOUR ANESTHESIA MACHINE
The Ventilator is different The Jet ventilator
Turn it ONCheck for the Pressure (keep the Pressure between 20-30)
RR between 18-20
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ALWAYS PREPARE SET FOR GENERAL ANESTHESIA
You will need themFor the regular inductionFor emergent intubation
For sedationFor regional anesthesia conversion into general
anesthesia
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ALWAYS PREPARE VASOPRESSOR SET
Specially Elderly
Spinal anesthesiaHypotensive patients
Pediatrics
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ALWAYS PREPARE VASOPRESSOR SET
Neosynephrine (0.1mg/ml)-Hypotension+ TachyEPHEDRINE (6mg/ml)-Hypotension+ Brady
Atropine (0.1mg/ml)-symptomatic bradycardia
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CHECK FOR THE SALT
S: Suction A : Ambu Bag-AirwayL:LaryngoscopeT:Tubes
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CHECK THE MONITORS(THE MINIMAL MONITORING)
ECGBp
ETCO2SPO2Temp
For ev
ery ca
se …
every
case
..eve
ry ca
se
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FOR PEDS CASESASK THE RN TO WARM UP THE ROOMASK THE ANESTHESIA ASSISTANT TO PREPARE THE BAIR HUGGER MAKE A CAPALL OF THESE TO PREVENT HYPOTHERMIA
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THE OR TRIP FROM CHART READING TILL EXTUBATION
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Read the chart thourghlyThe patient Name
The perop DxThe planned surgery
The consultationsThe anesthesia Preop note
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Quick re-assessment:Air way
NPO hoursAnticoagulation
Allergies
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Check for previous mastectomy, axillary dissection ,AV fistula, site of surgery before IV
prick
Otherwise choose the left hand (most patient are right handed and it is easier for us)
Avoid the positional IV (near joints )
IV SITE
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Small gauge (pedatrics,HF,Renal failure ,local case)
Big gauage(work near big vessels,Trauma,spinal,Burn)
The Guage
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LR most casesNSS for (renal failure,Neuro cases)Dextrose containing fluid in neonatal surgeriesVoluven for spinal cases, burn,risk of bleedingBlood(call for blood units if risk of bleeding, preop anemia)FFP(patient on warfarin,massive transfusion)Platelets(platelets dysfunction,Plavix)
The solution
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IV fixation (pediatrics-prone position)
Transparent (phelbitis)Date
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Three way directly on the AngiocathIf you plan to give
Precedex,Remifentanil,or post op PCA)
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Give some sedation before u go into the room….the patent in extreme anxiety
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Multivariable logistic regression analyses showed a significant increase in the odds of SSI when antimicrobial prophylaxis was administered less than 30 minutes
and 120 to 60 minutes as compared with the reference interval of 59 to 30 minutes before incision
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Patient A M has infected arthritis ,he is admitted to OR for Knee Joint arthroscopy and lavage .
What is the optimal time for ABX administration ?
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To the room
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Always Baseline
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Aspiration Pneumonitis
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Patient positioning in case of regurgitation
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check the OR table ….not working
call the Orderly….fix it before u induce GA
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Machine checkedSALT checked Chart checkedIV secured
Vitals checked Table checked
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Take off--------------induction
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Propofol
Midazolam
Xylocaine
Fentanyl
Relaxants
1-2µg/kgPeaks after 5 min
This why we give it first
Abolish the pain reflex on intubation
More if high ICPLess if RSI
Patient cough
2mg/kgAbolish the laryngeal
reflexVein anesthesia
Analgesic ??Less if history of
seizure
1-2 mg Anterograde Amnesia
1-2mg/kgReal hypnosisLoss of corneal
reflexTime to do Trial of
ventilation Easy vent-go to
MR
Roc 0.6mg/kg1.2 mg/kg RSICis 0.15 mg/Kg
SUX 2mg/kg
The sequence of regular induction
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Special scenarios Pediatrics …higher PropofolElderly …lower PropofolShock…ketamine,etomidate Mediastinal mass…sevo induction
Neuro…thiopentoneHigh ICP..add β-blockers
RSI…Propofol and SUX only
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Air way management
Patient related:• female tube 7-7.5• Male tube 8-8.5• pediatrics age/4+4
Surgery relatedENT:preformed tubeSML:MLT tubeThyroid: Reinforced tubeThoracic: DLT
Uncuffed till age of 8…..what about our practice in AUB ?Depth of insertion
Adult :height/10 + 5Peds :age in years + 10
Nasal intubationSmaller size tubeDepth of insertion: Oral depth + 3
Tube selection and insertion
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The surest sign of correct intubation
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Tube fixation
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The time of BP and hemodynamics fluctuationUp and downBP q 1min till stabilize
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Now u can put your invasive monitors if needed
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Baseline ABGSAssess PaCo2-ETCO2 gradientOxygenation PaO2/fiO2..>200 it is OKHctElectrolytes
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Patient Positioning
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What nerve at risk of injury?
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After prone positioning you noticed increase in Peak air way pressure and hypoventilation What will you check?
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Patient placed in Trendelenburg position …then you noticed desaturation and increase in the Peak airway pressureWhat is the explanation? And what will you do?
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ENT surgeon extended the neck for Tonsillectomy
What are the risks?
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FlexionFurther
ExtensionExit
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Maintenance phase
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Q 5minutes
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UOP Q 1 hr
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Baseline kidney dysfunctionCHFAge > 70DMContrast injection
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Nerve stimulatorTOF=0 in Neuro,Eye
TOF =1 in other cases Deep parlysis needed PTC 0
Face more resistant than thumb(twitch in the face doesn’t mean twitch in
the thumb)
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Apply FAWS as soon as possibleMore effective intraop than Post op
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HpothermiaIncrease solubility of inhalation agentsDecrease metabolismIncrease risk of bleedingIncrease risk of wound infectionAcidosisPost operative shiveringArrythmias
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Watch for the blood loss
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The bleed that you hear is more serious from the bleed that you see
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1. Infection trasmission(viral,bacterial,parasitic,prions)2. Fever(bacterial sepsis,AHTR,febrile non hemolytic transfusion reaction)3. TRALI4. TACO(transfusion associated circulatory overload)5. Anaphylaxis6. PTP7. Transfusion –(GVHD) 8. Transfusion thrombocytopenia9. Transfusion neutropenia10. Citrate toxicity11. Hyperkalmia12. Adenine toxicity13. Hypothermia14. Dilutional coagulopathy15. Decrease 2,3 DPG16. Acid base Changes17. Microaggregate delivery(ARDS)………………………18. Immune supression 19. Allergic reactions
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Long list
Infectious and non infectious
Immunlogic and non imunologic
TRICC study:Liberal transfusion associated with longer hospital stay,and higher mortality and morbidity
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recommendation Hb level
> 10 inappropriate
7-10Likely to be appropriate if signs Of impaired O2 Delivery
<7appropriate
<6Highly recommended
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Transfusion triggers
Regardless these numbers if patient showed sign of inadequate oxygenation• Hemodynamic instability• SVO2<50%• Myocardial ischemia(new ST
depression>0.1mV,new ST elevation >0.2
Transfuse Antibiotics Re-dose after 4 hoursIf bleeding after 3 hours
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BP HR Explanation
High sympathetic statePain, awarness, adrenaline injection ,pheo,thyroid storm
Hypovolemic, septic patient, carcinoid crisis,anaphylaxis
High fentanyl dose,Neostigmine,B-blockers ,spinal shock
After Neosynephrine,Cushing reflex
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Patient SD undergoing LAP gastric BYPASS ,MV settings TV 700 RR 14After 1 hr u noticed desaturation?
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Check for Disconnection
NO disconnection
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Check for FiO2
FiO2 :40%
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Chest Auscultation
BIL equal breathing soundsNO wheezes or crackles
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Check BP
BP:120/80
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u noticed high peak airway pressure
Delivered TV is 35o ml
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TOF 3/4
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4 causes of hypoxemia Hypoventilation
Impaired diffusionShunt
V/Q mismatch
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