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Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
Mmr presentation anaesth
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Mmr presentation anaesth

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  • 1. MMR PRESENTATION Presenter : Dr Ahmad Jaihan Bin Ismail Moderator: Dr Aisai Abdul Rahman
  • 2. HISTORY
    • MJ
    • 33 YEARS OLD MALAY MAN
    • ADMITTED 5/7 IN WARD FOR NECROTIZING FASCITIS OF RT LOWER LIMB – PLAN FOR WD
    • ACTIVE IVDU
      • LAST INJECTION 2/7 PTA
      • ADDICTED TO HEROIN
  • 3.
    • PRESENTED WITH
      • FEVER FOR 2/7 PTA
      • RT LEG SWELLING
    • A/W
      • CHILLS AND RIGORS
      • LETHARGIC AND POOR ORAL INTAKE
      • PROGRESSIVE WORSENING OF RT LEG SWELLING WITH REDNESS AND PAIN UPON WALKING.
  • 4.
    • CARDIOVASCULAR
      • HX OF SOB SINCE 3 YEARS AGO WHEN HE WAS TOO EXHAUSTED
      • ABLE TO LIE FLAT AND SLEEP WITH 1 PILLOW
      • NO PND, NO ORTHOPNOEA
      • NYHA CLASS II
    • RESPIRATORY
      • OLD PTB 2010- COMPLETED RX AT HOSP KAJANG
      • NO HX OF ICU ADMISSION
  • 5.
    • RENAL
      • DEVELOPED ARF 2 TO SEPSIS
      • UNDERGONE HD TWICE
    • MUSCULOSKELETAL
      • HX OF MVA TWICE
        • 2005
          • CALCANEUM FRACTURE
          • ORIF WAS DONE UNDER SPINAL- UNEVENTFUL
        • 1/2/2012
          • RT ANKLE DISLOCATION WITH A/W
          • NO ADMISSION
  • 6.
    • Drug therapy
      • Completed iv unasyn 1.5g tds for 5/7
      • Currently on iv cloxacillin 500mg qid
  • 7. examination
    • General condition
      • Alert, concious and pink
      • Mild dehydrated
      • Tachypnoea but able to talk in full sentence, not on oxygen therapy
    • Vital sign
      • T : 37
      • BP : 100/65
      • PR : 68
      • RR : 25-30B/MIN
    • Weght : estimated 60 kg.
    • Airway : normal
    • CVS : DRNM,S1S2
  • 8.
    • Lung
      • reduce air entry Rt side
    • Musculoskeletal
      • Rt LL swelling and erythematous up to mid thigh
      • Blackish discolouration dorsal of rt foot
  • 9. INVESTIGATION
    • FBC
    • COAGULATION PROFILE
      • PTTK : 39.4
      • INR : 1.27
    6/2 7/2 8/2 9/2 TWC 26.8 34.9 42.6 37.8 Hb 11.2 10 9.46 10.7 PLT 184 107 93 80 HCT 24.1 23.1 22.9 24.3
  • 10.
    • BUSE/SE CREAT
    POST 1 ST HD POST 2 ND HD 6/2 7/2 8/2 8/2 9/2 UREA 34.9 41.1 46 33.9 20.6 Na 128 131 126 132 137 K 4.1 4.1 4.5 3.6 3.2 CL 98 97 98 97 98 CREAT 509 602 594 444 265
  • 11.
    • ABG
      • PH 7.37, PCO2 31, PA02 81, SAO2 95, HCO3 17, BE -7
    • ECG: SR, ISOLATED T INVERSION AT AVL
    • CXR: FIBROTIC CHANGES > RT LUNG, NO CARDIOMEGALY
    • CARDIAC ENZYME
      • CK 1934, LDH 1032, AST 264
    • HIV RAPID TEST: NEGATIVE
  • 12.
    • PROBLEM LIST
      • SEPSIS SECONDARY TO RT LL NECROTIZING FASCITIS
      • ARF SEC TO SEPSIS
      • RHABDOMYOLISIS
      • ACTIVE IVDU
      • OLD PTB
    • ASA CLASSIFICATION
      • III,E
  • 13.
    • PLAN
      • FOR ICU BACK UP
      • TO TRANSFUSE 2 UNIT PLATLET INTRAOP
      • DECIDED FOR PERIPHERAL NERVE BLOCK IN OT
        • SCIATIC NERVE BLOCK
        • FEMORAL NERVE BLOCK
  • 14. PROCEDURE
    • UNDER ASEPTIC TECHNIQUE
    • WITH USG GUIDED
    • USING NERVE STIMULATOR
    • TOTAL VOLUME
      • SCIATIC NERVE:
        • ROPIVACAIVE 0.75% 15CC ( 112.5 mg)
        • LIGNOCAINE 2% 15CC (300mg)
      • FEMORAL NERVE:
        • ROPIVACAINE 0.75% 10CC (75 mg)
        • LIGNOCAINE 2% 10CC (200 mg)
  • 15. PROGRESS
    • CLINICALLY NO EPISODE INADVERTENT OF INTRAVASCULAR INJECTION
    • HEMODYNAMICALLY STABLE THROUGHOUT PROCEDURE AND PT WAS WELL COMMUNICATED
  • 16. AFTER 1 MINUTE
    • C/O
      • DIFFICULTY IN SWALLOWING
      • SWOLLEN AND NUMBNESS OF THE LIPS
      • IMMEDIATELY FOLLOWED BY JERKY MOVEMENT FOR A FEW SECONDS
        • ABORTED SPONTENEOUSLY
        • NOT REGAIN CONCIOUSNESS POST FIT
    • IMP : LA TOXICITY
    • DECIDED FOR INTUBATION
      • IV FENTANYL 100MCG, IV STP 200MG, IV SUXAMETHONIUM 100MG
  • 17. PROGRESS
    • HEMODYNAMICALLY STABLE
    • NO EPISODE OF HYPOTENSION OR BRADYCARDIA
    • PROCEED WITH OP
    • INTRAOPERATIVELY NO COMPLICATION
    • ADMITTED TO ICU FOR FURTHER STABILIZATION AND WEANING
    • EXTUBATE AND T/O TO GEN WARD THE NEXT DAY.
  • 18. LOCAL ANAESTHESIA
    • DEFINITION
      • A drug which reversibly prevents transmission of the nerve impulse in the region to which it is applied without affecting conciousness.
      • ( hilary edgcombe, graham hocking)
    • CLASSIFICATION
      • Ester
        • Lipid soluble & hydrophobic aromatic group
      • Amide
        • Hydrophilic group
  • 19. ester amides hydrophobic hydrophilic Molecule linkage is more easily broken less Less stable More stable- longer stored Not heat-stable- cant Heat-stable- can be autoclave Metabolism mostly produces PABA >allergic reaction rare Short duration of action longer Rarely used Commonly used Eg: chloroprocaine cocaine dimethocaine procaine tetracaine/amethocaine Eg: bupivacaine cinchocaine/dibucaine levobupivacaine lidocaine/lignocaine mepivacaine prilocaine ropivacaine
  • 20. Preparation of LA
    • Available as solution for injection, sprays, cream and gels
    • Mostly prepared as the HCL salt----dissolved in water
    • Additive
      • Adrenaline - vasoconstrict effect
      • - minimized vasodilator effect
      • - 1 : 200 000
      • Sodium bicarbonate - 0.15ml of 8.4%
      • - ↑ pH– > ↑ unionised
      • Glucose – 80mg/ml for bupivacaine
  • 21. Pharmacodynamic
    • MECHANISM OF ACTION
      • 2 theories
        • Disruption of voltage gated Na channel function within neuron cell membrane
          • Ionised form intracellularly
        • Membrane expansion theory
          • Unionised form extracellularly
  • 22.  
  • 23.
    • pKa
      • All local anesthetic agent is a weak base
      • At physiological pH (7.4), all LA are more ionised than unionised
      • Proportions vary between the drugs
        • Pka lidnocaine 7.9---- 25% unionised
        • Pka bupivacaine 8.1----15% unionised
      • In infective tissue (abscess)
        • More acidic environment
        • Fraction of unionised reduce---the effect delayed & reduced
        • Increase vascularity---increase systemic absorption----> reduce local effect on neuron
  • 24. Pharmacokinetic
    • Absorption
      • skin, subcuteneous tissue, intrathecal and epidural space
      • Depend on
        • Vascularity of the area
        • Intrinsic effect of the drug and its additives
    • Distribution
      • Depend on the degree of tissue and plasma protein bound
      • >protein bound--->longer the duration of action
  • 25.
    • Metabolism & excretion
      • Ester
        • Rapidly metabolized by plasma esterases--- short ½ life
        • Except cocaine is hydrolysed in the liver
        • Metabolite is excrete by the renal
      • Amides
        • Metabolised hepatically by amidase
        • Slow process---Longer ½ life
        • Can accumulate if given in repeated doses or by infusion
        • Except prilocaine is also metabolised extrahepatically
  • 26.  
  • 27.
    • Degree of toxicity of the drug depend on protein bound
    • Therefore bupivacaine is > toxic than lidnocaine
  • 28. Procedure to do local/regional anaesthesia
    • Explaination and consent
      • Rule out any contraindication
      • Explained to the pt regarding procedure and the effect of LA
    • Preparation
      • Familiar with the relevant anatomy, the technique and possible complication
      • Anaesthetic drugs ( thiopentone, ephidrine, atropine, suxamethonium)
      • Anesthetic and airway equipment
      • Pt monitoring- ecg, bp and pulse oxymeter
      • Running IV access
      • Adequate preload
  • 29. cont
    • Performing block
      • Under aseptic technique
      • Under usg guided
      • Short bevelled needle for peripheral nerve block
      • Use nerve stimulator to determine end point of paraesthesia
      • Always aspirate before injecting to reduce chance of inadvertent intravascular
      • Injected small amount of LA 1 st to avoid intraneural injection
      • Injection must be little or no resistance
  • 30. cont
    • Use of nerve stimulator
      • To locate the nerve
      • Preferable to use an insulated needle & connected to –ve electrode
      • Initially use single twitch with current strength 2.0-4.0 mA
      • Reduce the current strength to 0.2-0.5 mA when nerve approached, present of muscle twitching
  • 31. cont
    • After block
      • Closed monitoring- BP, HR, saturation & amount of fluid
      • Test the level of sensory block using needle(pain) or spirit swab(temperature)
      • Give adequate time to the block to take effect
      • Be prepared to convert to GA
      • Watch for complication- circumoral tingling sensation, nausea or vomiting, hypotension, bradycardia, respiratory distress and institute early treatment
  • 32. Potential problem with LA
    • LA toxicity
    • Allergic reaction--- PABA
    • Methaemoglobinaemia--- prilocaine which is metabolised to O-toluidine
  • 33. LA TOXICITY
    • Factor predisposed to LA toxicity
      • Overdosage
      • Type of the drugs used- bupivacaine > levobupivacaine> ropivacaine> lidnocaine
      • Types of peripheral nerve block- brachial plexus
      • Concentration of the drugs
      • Rate of administration
      • Pharmacokinetics of the drug are altered by comorbidity such as cardiac or hepatic failure
      • Alterations in plasma protein binding/ degree of protein binding
      • Interactions with other drugs
  • 34. Clinical features
    • CNS
      • Tingling of lips
      • Slurred speech
      • Reduce concious level
      • seizure
    • CVS
      • Arrythmias
      • Reduce myocardial contractility
      • Bradycardia and hypotension
  • 35.  
  • 36. Management of LA toxicity
    • Based on the Association of Anesthetist of Great Britain & Ireland 2010
  • 37. Prevention
    • Have adequate knowledge of pharmacokinetic and pharmacodynamic of the drugs
    • Use appropriate dose for appropriate patient
    • Use correct technique as mention in a protocol of LA
    • Early recognition of complication
  • 38. Reference
    • Toxicity from Local Anaesthetic Drugs Dr David A Conn,Consultant Anaesthetist, Royal Devon & Exeter Hospital, Exeter, UK
    • Local anesthesia pharmacology, hillary edgcombe, graham hocking, consultant anaesthetist sir charles gairdner hospital perth, australia
    • Anaesthesia.uk
    • Manual of anaesthesia, Lee Choon Yee
    • Emergency medicine 7 th edition, Judith E. Tintinally
    • E- medicine
  • 39.  

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