COURSE OUTLINES THE FORMAT OF THE COURSE KNOWLEDE AND SKILLS THAT CAN BE GAINED. COURSE PROGRAME COURE OBJECTIVES REQUIRE MATERIALS:TEXT BOOKS Anesthesia Rotation book ASSESSMENT
POLICY OF MISSED WORK (ATTENDENCE REQUIREMENT) FINAL EXAM CONTACT INFORMATION DEPARTMENT 71597 Dr walid tel 71816 Dr osama bleep 2158 QUESTIONS
Clinical Objectives for Medical Students in (044) Anesthesia and CPR Course At the end of the course the student will be able to understand and practice: 1- Pre-anesthesia assessment and evaluation Able to take history from patient Able to open PAC System to get information and investigation. Interpretation of preoperative data relevant to anesthetic plan. Consultations
2- Orientation with anesthesia equipment in O.R. Anesthesia machine Anesthesia circuits Laryngoscopes – tubes – LMA – Airways Epidural set Spinal set Monitors - Anesthesia Record Anesthetics Drugs : I.V. drugs Inhalational & Muscle Relaxants Resuscitation Drugs During Anesthesia Crystalloids & Colloids Fluids
3- Post-operative Care Unit Orientations Case Scenarios: Interactive Case Discussion
4- Surgical ICU Rounds & Discussions about Management of critically I’ll patient Monitoring of critically I’ll patient Ventilators Common Cases in ICU Head injury management Sepsis management
Role Of Anesthesiologist In pre-Opertiveperiod
Anesthesia The word is derived from the Greek words an, which means “without” and aithesia which means “feeling” The use of medical anesthesia was first reported in 1846 The development of anesthesia has made today’s modern surgical techniques possible
Basic Principles of Anesthesia “Triad of General Anesthesia” need for unconsciousness need for analgesia need for muscle relaxation and loss of reflexes
Anesthetic assessment andpreparation for surgery
Purposes of the Preoperative Evaluation Obtain medical history Review current physical status Order additional tests / consultation Answer questions
Overview. The preanesthetic evaluation has specific objectives including: - Establishing a doctor-patient relationship, - Becoming familiar with the surgical illness and coexisting medical conditions,
Developing a management strategy for perioperative anesthetic care, - Obtaining informed consent for the anesthetic plan. The overall goals of the preoperative assessment are to reduce perioperative morbidity and mortality and to allay patient anxiety.
Stages of the Peri-Operative Period Pre-Operative From time of decision to have surgery until admitted into the OR theatre.
Stages of the Peri-Operative Period Intra-Operative Time from entering the OR theatre to entering the Recovering Room or Post Anesthetic Care Unit (PACU)
Stages of the Peri-Operative Period Post-Operative Time from leaving the RR or PACU until time of follow-up evaluation (often as out-patient)
Purposes of thePreoperative Evaluation Reassure patient / allay anxiety Order preoperative medications Obtain informed consent Document the record Develop anesthetic care plan
Medical History Review the chart Review previous records Interview the patient
The Chart Review Demographic Data Height / weight Vital signs Diagnosis
The Chart Review History and Physical Exam Note any abnormalities Don’t assume that all problems are listed
The Chart Review Medications Routine medications at home Meds ordered in hospital Lab / x-ray results Consultations
Old Hospital Records Available in same institution Previous diagnosis Previous treatment
Old Hospital Records Review prior anesthesia record Induction doses Airway difficulty Work-up
Benefits from surgery ←-> Risk of complications
Age Obesity Smoking General health status Chronic obstructive pulmonary disease (COPD) Asthma Patient related risk factors(pulmonary)
Smoking Important risk factor Smoking history of 40 pack years or more->↑risk of pulmonary complications stopped smoking < 2 months : stopped for > 2 months4:1(57% : 14.5%) quit smoking > 6 months : never smoked = 1:1 (11.9% : 11%)
Risk Stratification Revised Cardiac Risk Index High risk surgery (vascular, thoracic) Ischemic heart disease Congestive heart failure Cerebrovascular disease Insulin therapy for diabetes Creatinine >2.0mg/dL
Active Cardiac Conditions Unstable coronary syndromes Unstable or severe angina Recent MI Decompensated HF Significant arrhythmias Severe valvular disease
Minor Cardiac Predictors Advanced age (>70) Abnormal ECG LV hypertrophy LBBB ST-T abnormalities Rhythm other than sinus Uncontrolled systemic hypertension
Surgical Risk Stratification High Risk Vascular (aortic and major vascular) Intermediate Risk Intraperitonealand intrathoracic, carotid, head and neck, orthopedic, prostate Low Risk Endoscopic, superficial procedures, cataract, breast, ambulatory surgery
Risk Stratification ASA physical status ASA 1 – Healthy patient without organic biochemical or psychiatric disease. ASA 2- A Patient with mild systemic disease. No significant impact on daily activity. Unlikely impact on anesthesia and surgery. ASA 3- Significant or severe systemic disease that limits normal activity. Significant impact on daily activity. Likely impact on anesthesia and surgery.
Risk Stratification ASA 4- Severe disease that is a constant threat to life or requires intensive therapy. Serious limitation of daily activity. ASA 5- Moribund patient who is equally likely to die in the next 24 hours with or without surgery. ASA 6- Brain-dead organ donor “E” – added to the classifications indicates emergency surgery.
Step #1:Is the surgery emergent? yes Is the surgery emergent? Operating room* no (Next Step) Consider beta-blockade, pain control and other peri-operative management
Step 2: Determine Presence of Active Cardiac Conditions If none are present, proceed with surgery Presence of one of these delays surgery for evaluation Many patients need a cardiac cath
Step #2: Active Cardiac Conditions Evaluate and treat per current guidelines yes Active Cardiac conditions no Consider Operating Room (Next Step)
Step 3: Surgery Low Risk? Low risk surgery includes: Endoscopic procedures Superficial procedures Cataract surgery Breast surgery Ambulatory surgery Cardiac risk <1% Testing does not change management
Step #3: Surgery Low Risk? yes Operating room Low risk surgery No (Next Step)
Airway Evaluation Take very seriously history of prior difficulty Head and neck movement (extension) Alignment of oral, pharyngeal, laryngeal axes Cervical spine arthritis or trauma, burn, radiation, tumor, infection, scleroderma, short and thick neck
Airway Evaluation Jaw Movement Both inter-incisor gap and anterior subluxation <3.5cm inter-incisor gap concerning Inability to sublux lower incisors beyond upper incisors Receding mandible Protruding Maxillary Incisors (buck teeth)
Preoperative Testing Routine preoperative testing should not be ordered. Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management.
Preoperative Testing5 Procedure based. Low risk Baseline creatinine if procedure involves contrast dye. Intermediate risk Base line creatinine if contrast dye or >55yr of age. High risk CBC, lytes & S, creatinine as above. PFTs for lung reduction surgery.
Obtaining a Consult Ask specific questions which you want answered Talk directly to the consultant
Informed Consent Frequently questioned in malpractice cases Risks / benefits Alternatives Answer all questions Do not deceive the patient
Risks of Anesthesia Determine what the patient wants to know - Do not frighten patients Start with minor risks Proceed to serious risks
Risk associated with anesthesiaand surgery The question that patients ask is ‘Doctor, what are the risks of having an anaesthetic?’ These can be divided into two main groups.
Minor These are not life threatening and can occur even when anaesthesia has apparently been uneventful. They include: • failed IV access; • cut lip, damage to teeth, caps, crowns; • sore throat; • headache; • postoperative nausea and vomiting; • retention of urine.
Major These may be life-threatening events. They include: • aspiration of gastric contents; • hypoxic brain injury; • myocardial infarction; • cerebrovascular accident; • nerve injury; • chest infection Death
Document the Visit Complete the evaluation form Enter progress notes Have patient sign consent Write appropriate orders