manage a patient under anesthesia

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Manage a Patient UnderAnesthesia

Andi Salahuddin

SMF/Bag.Anestesiologi, Perawatan

Intensif dan Pengelolaan Nyeri FK-

UNHAS/ RSWS Makassar23 Pebruari 2011



Components of Anesthesia

( Trias Anesthesia )

Muscle Relaxation

Unconsciousness

Analgesia



REASON

1. Anesthetics have potent CNS, CV &

RESPIRATORY depressant in therapeutic

dose.

2. Severe depression is life threatening.

EMERGENCY STATE



MONITORING



Monitoring in the Past• Visual monitoring of

respiration and

overall clinical

appearance• Finger on pulse

• Blood pressure

(sometimes)



Monitoring in the Present• Standardized basic monitoring requirements

(guidelines) from the ASA (American Society of

Anesthesiologists), CAS (Canadian

Anesthesiologists’ Society) and other national

societies

• Many integrated monitors available

• Many special purpose monitors available

• Many problems with existing monitors (e.g., cost,

complexity, reliability, artifacts)



ASA Monitoring Guidelines

• STANDARD I

Qualified anesthesia personnel shall be

present in the room throughout theconduct of all general anesthetics,regional anesthetics and monitoredanesthesia care.

http://www.asahq.org/publicationsAndServices/standards/02.pdf



ASA Monitoring Guidelines

• STANDARD II

During all anesthetics, the patient’s

oxygenation, ventilation, circulation andtemperature shall be continuallyevaluated.

http://www.asahq.org/publicationsAndServices/standards/02.pdf



“The only indispensable monitor is the presence, at all

times, of a physician or an anesthesia assistant, under

the immediate supervision of an anesthesiologist, with

appropriate training and experience. Mechanical and

electronic monitors are, at best, aids to vigilance. Such

devices assist the anesthesiologist to ensure the

integrity of the vital organs and, in particular, the

adequacy of tissue perfusion and oxygenation.”

CAS Monitoring Guidelines



• The following are required: – Pulse oximeter

– Apparatus to measure blood pressure, either

directly or noninvasively

– Electrocardiography

– Capnography, when endotracheal tubes or

laryngeal masks are inserted.

– Agent-specific anesthetic gas monitor, wheninhalation anesthetic agents are used.




• The following shall be exclusivelyavailable for each patient:

– Apparatus to measure temperature

– Peripheral nerve stimulator, whenneuromuscular blocking drugs are used

– Stethoscope — either precordial, esophageal

or paratracheal

– Appropriate lighting to visualize an exposedportion of the patient.




• The following shall be immediately

available:

– Spirometer for measurement of tidal volume.




Detecting Mishaps Using Monitors

1. Disconnection2. Hypoventilation

3. Esophageal intubation

4. Bronchial intubation

5. Circuit hypoxia

6. Halocarbon overdose

7. Hypovolemia

8. Pneumothorax

9. Air Embolism

10. Hyperthermia

11. Aspiration

12. Acid-base imbalance

13. Cardiac dysrhythmias

14. IV drug overdose

Source: Barash Handboo k

These mishaps …



Basic Monitoring • Cardiac: Blood Pressure, Heart Rate, ECG

• ECG: Rate, ST Segment (ischemia), Rhythm

• Respiratory: Airway Pressure, Capnogram, Pulse Oximeter,

Spirometry, Visual Cues

• Temperature [pharyngeal, axillary, esophageal, etc.]

• Urine output (if Foley catheter has been placed)

• Nerve stimulator [face, forearm] (if relaxants used)

• ETT cuff pressure (keep < 20 cm H2O)

• Auscultation (esophageal or precordial stethoscope)

• Visual surveillance of the anesthesia workspace and some

exposed portion of the patient



Visual Surveillance

• Anesthesia machine / workspace checkout

• Patient monitor numbers and waveforms

• Bleeding/coagulation (e.g., are the su rgeons us ing a lo

of suct ion or sponges? )

• Diaphoresis / movements / grimaces

• Line quality (is my IV rel iable?)

• Positioning safety review

• Respiratory pattern (e.g. tracheal tug , accessory musc

use etc.)



High Tech Patient Monitoring

Examples of Multiparameter Patient Monitors



High Tech Patient Monitoring

Some Specialized Patient Monitors

Depth of Anesthesia Monitor

Evoked Potential Mon

Transesophageal

Echocardiography



Special Monitoring

• Pulmonary artery lines (Swan Ganz)

• Transesophageal echocardiography

• Intracranial pressure (ICP) monitoring

• Electrophysiological CNS monitoring• Renal function monitoring (indices)

• Coagulation monitoring (e.g. ACT)

• Acid-base monitoring (ABGs)

• Monitoring depth of anesthesia



PROCEDURES

• Review the principles of monitoring and

maintenance

• Review the components, clinical signs,

and depth of anesthesia

• Apply the principles of monitoring and

maintenance (Circle of Awareness)



Review the Principles of

Monitoring and Maintenance



Monitoring

Tasks

• Level of Anesthesia

• A• B

• C



Monitoring

Level of Anesthesia

• Unresponsive to pain stimuli

• Eyes fixed and pupils constricted• Muscles relaxed



Monitoring

Airway

• Must maintain positive control over the

patients airway (to include the tongue)

• Monitor the airway at all time while the patientis under general anesthesia.



Monitoring

Airway

• Oxygenation

pre-oxygenate for Intubation100% O2 - 6 L/minresuscitation 100% O2 - 15+ L/min

• Ventilation



Monitoring

Breathing

• The lungs and breathing must be

continuously monitored.

• Rate and depth of respirations

• Dry versus wet lungs? ( humidifier )



Monitoring

Breathing

• I Inspection

• A Auscultation

• P Palpation

• P Percussion



Monitoring

Circulation• Heart rate, character, and rhythm = 68

strong and regular

• Tissue perfusion

• Body temperature• Renal Function

Output = >25 to 50cc/hr



Components of General

AnesthesiaMuscle Relaxation

Amount of skeletal muscle relaxationrequirements depend on the type of

operation.




AnesthesiaAnalgesia/ Areflexia

Pain reflexes are subdued.




AnesthesiaUnconsciousness/Hypnosis

The patient is oblivious to all sensationbut pain reflexes can occur.

Depth of Anesthesia



Depth of Anesthesia

• Stages and Planes of Ether Anesthesia

Stage I AmnesiaStage II Excitement

Stage III Surgical Anesthesia

Plane 1 Plane 2 The Surgical Plane

Plane 3

Plane 4

Stage IV Impending Death



Stages and Planes of Ether

Anesthesia

• STAGE I Amnesia

From the onset of drowsiness to the loss of

the eyelash reflex.




Anesthesia

• STAGE II Excitatory Stage

Agitation, delirium, irregular respiration and

breath holding .

Pupils dilate, eyes diverge.




Anesthesia

• STAGE III Surgical Anesthesia

Plane 1

From the return of regular respirations to the

cessation of REM.




Anesthesia

• STAGE III

Plane 2 The Surgical Plane

From the cessation of REM to the onset of

paresis of the intercostal muscles.




Anesthesia

• STAGE III

Plane 3

From the onset to the complete paralysis of

the intercostal muscles.




Anesthesia

• STAGE III

Plane 4

From the paralysis of the intercostal muscles

to the paralysis of the diaphragm - at the end

of this plane the patient will be apneic.




Anesthesia

• STAGE IV Impending Death

From the onset of apnea to circulatory failure.



Why we need monitors?

1. Our sense is limited.

2. Free up the anesthetist hand.

3. Monitor many parameters simultaneously



The Circle of Awareness is the

anesthetist monitoring

management tool.

Th i l h l th th ti t



The circle helps the anesthetist

to monitor and manage:

• Vital signs

• Stage of general anesthesia

• Airway, respiratory and cardiac systems

• Input and output of all fluids and drugs

• Time

• Recording

• Communications



The circle of awareness shouldbegin a few moments after the

patient is placed on anesthesia

maintenance.



PATIENT

• Patient should be unresponsive to painful stimuli

• Eye’s should be: Fixed, pupils constricted (dilated =

caprine specific) and non-reactive to light

• Mandible and tongue: Relaxed

• Limbs: Relaxed, non-withdrawal to pain

• If being assisted by personnel within the OR,

request a temperature and blood pressure be takenat this time



AIRWAY

• Inspect Oxygen Tubing: From the wall to the

patient

• Inspect Endotracheal Tube: Secured, bulb

inflated, bite block present, and suction PRN• Inspect Patients Respiratory Effort: Note rate

and rhythm, one deep ventilation



BREATHING

• Inspect Trachea: Look for Tracheal deviation

or jugular vein distention (JVD)

• Inspect Chest: Rise and fall

• Auscultate Chest: Clear breath sounds, noterate and rhythm (again)



CIRCULATION

• Auscultate Heart: Note rate and rhythm

• Inspect All IV’s : Read labels and check fluid

levels, check drip rate, inspect tubing tocatheter, inspect IV site for infiltration



RECORD

• Record on the SF 517: Time, drug input,

suction, oxygenation, ventilation, level of

consciousness, vitals signs, fluid input/output,

all complications throughout surgery in otherremarks



REPORT

• Communicate: Communication the patients

status and vitals to surgical team.

• Insure you receive a response from the

surgeon• At this point, make improvements,

adjustments and corrections to any

deficiencies that you discovered during the

circle



SUMMARY OF

PROCEDURES• Review the principles of monitoring and

maintenance

• Review the components, clinical signs,and depth of anesthesia

• Apply the principles of monitoring and

maintenance (Circle of Awareness)

manage a patient under anesthesia

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