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ANESTHESIA 101 Surgery Core program Nov 4, 2008

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ANESTHESIA 101 Surgery Core program Nov 4, 2008 Desiree Persaud MD FRCPC Associate Professor University of Ottawa Regional Anesthesia Director, The Ottawa Hospital – PowerPoint PPT presentation

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Title: ANESTHESIA 101 Surgery Core program Nov 4, 2008


1
ANESTHESIA 101Surgery Core program Nov 4, 2008
  • Desiree Persaud MD FRCPC
  • Associate Professor University of Ottawa
  • Regional Anesthesia Director, The Ottawa Hospital
  • Resident Coordinator, Dept of Anesthesiology
  • The Ottawa Hospital Civic/Riverside Campus

2
Overview
  • History
  • Anesthetic principles
  • Case presentations

3
Surgery prior to Anesthesia
  • The last resort
  • Medieval torture chamber restraints/gags
  • Physical assault blow to the jaw
  • Ice freezing/conduction anesthesia
  • Plants marijuana, belladonna
  • Alcohol, opium
  • Hypnosis, distraction

4
Anesthesia
  • 1846 ether anesthesia

5
Who are we and what do we do?
  • Perioperative acute care physicians
  • Perioperative pain management experts
  • Direct manipulation of physiology
  • Intricate knowledge of pharmacology
  • Expert laryngoscopist/backup A/W methods
  • Regional/invasive line placement/anatomy
    knowledge
  • Equipment ventilators/monitors/gas delivery
    systems
  • Interventional anesthesiology TEE, TTE, U/S
    guided nerve blocks/line placement, flouroscopic
    chronic pain blocks,

6
Definition
Awake
Unconscious
  • Anesthesia Greek No sensation
  • Types Alone or in combo
  • General anesthesia
  • Neuraxial anesthesia
  • Spinals and Epidurals lower extremity/bowel
    surgery
  • Peripheral Nerve Blocks
  • Paravertebral breast surgery
  • Femoral - knee replacement/muscle biopsies

7
General Anesthesia
Awake
Unconscious
x Not an On/Off Switch
  • Suppression of consciousness with profound
    systemic effects
  • Lipid theory
  • Protein theory

8
General Anesthesia - continued
  • X Not going to sleep
  • Is a chemically induced coma
  • Direct CNS system depression
  • Lack of A/W reflexes
  • Depression of the respiratory centres
  • Direct CVS depression
  • Multiple pharmacologic effects influencing every
    system gut/liver/renal/endocrine/neuromuscular

9
Neuraxial anesthesia
  • Neuraxis spinal cord
  • Benefits
  • No direct CNS, Resp, CVS depression
  • No need for muscle relaxants
  • Provides analgesia
  • Problems
  • SNS blockade hypotension
  • Spinal hematoma - anticoagulants

10
Spinal
  • Pros
  • Quick onset
  • Dense surgical anesthesia
  • Cons
  • Limited duration - lt 4 hours
  • Limited cephaled spread
  • Rapid sympathectomy
  • Limited post op analgesia

11
Epidural
  • Catheter placed can extend duration of block
  • Most often used in combo with GA
  • Post-op analgesia
  • Less need for systemic narcotic
  • Bowel function preserved

12
Peripheral Nerve blocks
  • Mainly for orthopedic and vascular surgery
  • Unlike neuraxialvirtually no systemic side
    effects
  • Provides site specific post-op analgesia

13
  • Patients/pathology come in different
    packages
  • 4 case presentations same surgical pathology
  • BUT 4 very different anesthetic plans!!

14
Case 1
  • 25 yr old male for open appendectomy
  • Issues
  • Emergency case
  • Acute abdomen risk perforation/sepsis
  • full stomach aspiration risk
  • Dehydration Nausea and Vomiting
  • General (or neuraxial anesthesia)

15
Pre-anesthetic assessment
  • Assess level of hydration
  • General anesthesia will depress CVS reflexes
  • Potential for hypotension
  • Assess Airway aspiration risk
  • Assess for other comorbid conditions
  • Resp/CVS

16
Intra-op management
  • Functioning IV volume replacement
  • Optimal airway positioning
  • Rapid intubation with muscle relaxant and cricoid
    pressure
  • Narcotic, IV induction agent, relaxant
  • Maintain with volatile/narcotics
  • Extubate reversed and awake

17
Is an appendix always an appendix?
  • Case 2 Change age to 75 yr old male
  • Additional issues
  • Compensatory mechanisms less
  • More likely to have resp/CVS comorbidities
  • More sensitive to CNS depressants
  • Less tolerance of physiologic stressors

18
Intra-operative management
  • IV fluids pre-op fluid hydration more careful
    and essential
  • Monitors include ST seg monitoring
  • Slow, titrated induction
  • Minimize volatile predispose to hypotension
  • Great risk of hypotension while the surgeon is
    scrubbing!!!
  • Non-compliant vasculature rapid swings of BP
  • Delayed emergence possible

19
Change approach to laparoscopic appendectomy?
Does it matter?
  • Case 3 Laparoscopic approach
  • Trocar vessel/viscous perforation
  • Relaxation, large IV
  • Pneumoperitoneum
  • Restrictive resp defect high PAW, atelectasis
  • Vagal efferent relfex
  • Reduction in preload hypotension
  • Incr gastric pressure aspiration risk
  • S/C emphysema
  • pneumothorax

20
Laparoscopy considerations - cont.
  • Carbon dioxide
  • SNS stimulant ?BP, ? HR
  • Pulmonary V/C predispose to PH
  • Cerebral V/D ?ICP
  • Acidosis ?K, enzyme dysfunction
  • Embolus CV Collapse
  • Positioning loss of Airway, lines,

21
Intraoperative management
  • Fluid hydration keyreduction in preload
  • Trocar insertion must ensure patient does not
    move
  • Communicate
  • Difficulty with trocar insertion
  • Communicate
  • Avoid too high intrabdominal pressures
  • Avoid too steep trendelenburg

22
Case 4 Change patient morbidly obese for
laparoscopic appendectomy
  • BMI gt 35
  • CNS sensitive to depressants/apnea
  • A/W obstruction/difficult to secure
  • Resp restrictive defect/ PH
  • CVS HP, LVH, CAD
  • GI reflux
  • Endo DM

23
Intraoperative management
  • Meticulous airway positioning
  • Prone to desaturation
  • Trendelenburg poorly tolerated ventilatory
    difficulty atelectasis-shunting
  • Pre-existing PH high CO2/low O2
  • Delayed emergence
  • Prolonged PACU/overnight stay

24
Emergence
  • Reversal of anesthesia just as risky as
    induction
  • Patients responsive, protect A/W
  • Stable BP/temp
  • Adequate reversal

25
Post-operative care
  • Monitoring
  • LOC/hemodynamic/O2saturation
  • Pain control
  • Nausea/Vomiting
  • Ambulation/movement

26
Why are they so slow?
  • Pre-operative assessment
  • Difficult IV access MO, cancer pt
  • Epidural/Spinal placement
  • Difficult A/W positioning/adjuncts/awake
    intubation topicalizaton
  • Hemodynamic instability BP, HR, rhythm
  • Line placement CVP/A. line
  • Delayed Emergence excess narcotics/relaxant/hypot
    hermia

27
Take home messages
  • Anesthetics are tailored to both the patient and
    procedure
  • Patients and procedures come in different
    packages
  • General anesthesia is not an on/off switch
  • General anesthesia is not going to sleep
  • Multiple dynamic physiologic effects
  • Communication is KEY
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