9. Physical examination
Vital
sign
BT 36.0⁰, BP 120/80 mmHg, PR 80
bpm, RR 14/min , O2sat 98 %RA
Measure-
ment
Weight 56.4 kg, Height 160 cm,
BMI 22.03 kg/m²
GA Active
HEENT No pale conjunctiva
Heart Normal S1 S2, No murmur
Lung Clear and equal breath sound both
lung
Abdomen Uterus 8-10wk size, Pelvic mass firm,
not tender, 2/3 > PS
Back & CVA No CVA tenderness
Extremities
& Skin
No rash, no kyphoscoliosis, no
local skin infection, no bruising,
no petechiae, abdominal surgical
scar at midline
Neuro sign E4V5M6
MIUB Vagina : Normal mucosa,
No bleeding per vagina
Cervix : no lesion
Uterus : uterus 12-14 wk size,
nodular surface
Adnexa : No mass, not tender
10. Airway Assessment
Airway Mouth opening : > 4 cm
Neck movement : > 90⁰
Thyromental distance : > 6.5 cm
Mallampati : 1
Ability to prognath : Yes
Weight : < 90 kg
History of difficult intubation : None
Dental : No loose tooth/teeth, No fall out tooth/teeth
Total : 0 point => less difficult direct laryngoscopy
11. - Anemia
- Normal WBC count
- Normal Plt count
- Normal electrolyte level
Hb 11 g/dl
Hct 33.9 %
Plt 335,000 cells/mm3
WBC 6,760 cells/mm3
Na 139 mEq/L
K 4.0 mEq/L
Cl 103 mEq/L
CO2 26 mEq/L
Laboratory Evaluation
CBC Electrolyte
12. - Normal renal function test - Normal liver function test
BUN 8 mg/dl
Cr 0.61 mg/dl
eGFR 105 ml/min/1.73m2
AST 36 U/L
ALT 21 U/L
ALP 63 U/L
Laboratory Evaluation
Renal Function Test Liver Function Test
20. ● NPO AMN (รวม 9 hr)
At OR
● Antiemitic drug :
Ondansetron 8 mg iv
● Anti-inflammatory drug :
Dexamethasone 8 mg iv
Ketorolac 30 mg
Preanesthetic Preparation
Prevent Aspiration
Pharmacological Preparation
21. ● Blood prepared : G/M PRC 2 U
● ATB prepared : Ceftriaxone 2 g
● IV fluid prepared : Acetar 1,000
ml rate 100 ml/hr
● Accessories prepared :
Foley catheter
● Prep skin at surgical area
● Care during transport
Preanesthetic Preparation
ยาและอุปกรณ์ที่ต้องเอาไปOR Other
22. Operation : TLH c BSO
Anesthesia Plan : General
Anesthesia with ET
Intubation with Balanced
Anesthesia
28. Preparation : Anesthetic equipment
Face mask
Self-inflating bag
Laryngoscope
Endotracheal tube
Stethoscope
Oropharyngeal
airway Suction catheter
Laryngeal mask
airway
29. Preparation : IV fluid & Blood component
Fluid management
1. Maintenance : 2cc/kg/hr *BW
2. Deficit (Total) : 2cc/kg/hr * BW * Hours of NPO
3. Surgical loss : 4-6 ml/kg/hr
4. Blood loss
a. Crystalloid 3 ml/ blood loss 1 ml
b. Colloid 1 ml/ blood loss 1 ml
30. Preparation : Positioning
● Often used during childbirth and surgery in the pelvic area.
● Patient is lying on their back with their legs flexed 90
degrees at hips. Their knees will be bent at 70 to 90 degrees,
and padded foot rests attached to the table will support legs.
● Complication
○ Acute compartment syndrome (ACS)
○ Nerve injury
● Most commonly used during lower abdominal
surgeries and central venous catheter placement.
● The patient is laid supine on the surgical table, and
their head is angled down.
● This position provides the surgical team with
access to the patient’s abdominal organs by moving
other organs in the abdominal cavity away from the
surgical site.
35. Maintenance
Sevoflurane : Volatile anesthetic agent
SE : Hypotension,Agitation,N/V
N20 : Adjuvant in combination with volatile.
SE : Diffusion hypoxia
Hypnosis
Nalbuphine : opioid pain medication that is used to treat
moderate to severe pain
SE : drowsiness,dizziness, spinning sensation,dry
mouth,headache
Analgesic
Cisatracurium : Non depolarizing muscle relaxant
Dose : 0.04-0.05 mg/kg
Muscle
Relaxation
38. Fluid Management
2 ml/kg/hr * NPO
2*60*9 = 1080 cc
Ward 200 cc
>1080-200 =880 cc
Deficit
2 ml/kg/hr
2*60 = 120 cc/hr
Maintenance
4-6 cc/kg/hr
4*60 = 240
Surgical Loss
3cc/blood loss 1cc for
crystalloid
1cc/blood loss 1cc for
colloid
Blood Loss
ACETAR
39. Deficit = 440 cc
Maintenance = 120 cc
Surgical loss = 240 cc
Total = 800 cc
Actual replacement = 500 cc
1st Hour
Deficit = 220 cc
Maintenance = 120 cc
Surgical loss = 240 cc
Total = 580 cc
Actual replacement = 300 cc
2nd Hour
Deficit = 220 cc
Maintenance = 120 cc
Surgical loss = 240 cc
Total = 580 cc
Actual replacement = 100 cc
3rd Hour
Maintenance = 120 cc
Surgical loss = 240 cc
Blood loss = 300*3 =900 cc
Total = 1260 cc
Actual replacement = 600 cc
4th Hour
40. Keep > 0.5 ml/kg/hr
>30 ml/kg/hr Good Urine output
Urine output
ABL= (65*60) * (11-7) = 1,418 cc
11
Allowable Blood loss
45. Emergence
Emergence form GA
● Smooth and gradual awakening.
● Problem : Airway obstruction, Shivering, Agitation, Delirium, Pain, PONV,
Hypothermia, Autonomic lability.
Delayed emergence
● Fails to regain consciousness 30-60 min after GA
Transport to PACU
● Stable and patent airway, adequate ventilation and oxygenation and
hemodynamically stable.
● Transport with oxygen supplement.
46. Common problem
Respiratory system :
● Airway obstruction
● Hypoventilation
● Hypoxemia
Cardiovascular system :
● Hypotension
● Hypertension
● Arrhythmia
Pain control
Agitation
Nausea and vomiting
Shivering and hypothermia
Problem in this case
Respiratory system :
● Airway obstruction
● Hypoventilation
● Hypoxemia
Cardiovascular system :
● Hypotension
● Hypertension
● Arrhythmia
Pain control
Agitation
Nausea and vomiting
Shivering and hypothermia
47. Hypotension
● BP < 20-30% of baseline.
(In this case 85/40 mmHg , baseline 100/60 mmHg)
● Cause
○ Most common cause : Hypovolemia.
○ Absolute hypovolemia : Inadequate fluid replacement, continuing third space
loss or wound drainage, post operative bleeding.
○ Relative hypovolemia : associated with RA, venodilator, and alpha blockade.
○ Sepsis
● Treatment
○ Mild hypotension : not require treatment
○ Significant hypotension : require treatment
■ Hypovolemia : confirm by fluid bolus
-> BP increased
■ Vasopressor or inotrope
○ Fix cause Ex.bleeding
In this case
● Closed monitor : V/S q 5 min
● Vasopressor : Ephedrine 10 mg IV
-> improve
48. Shivering and hypothermia
Cause
○ Heat loss
○ Intraoperative hypothermia or the effects of anesthetic agent.
○ Prolong exposure of large wound, unwarmed high flow of dehumidifier gas.
Treatment
○ Hypothermia : heating blanket,
forced air warming
○ Intense shivering : oxygen,
pethidine
In this case
● Closed monitor : V/S q 5 min
● Warmer
● Pethidine 25 mg IV
● Cannula 3 LPM
-> improve
50. CRÉDITOS: Esta plantilla para presentaciones es una creación de Slidesgo, e incluye
iconos de Flaticon e infografías e imágenes de Freepik
Thank You
Have any Questions?
