Practicing anesthesiologist high rezo


Published on

1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Practicing anesthesiologist high rezo

  1. 1. Greetings! • As a discipline we have come a long way • We have humble beginnings • Our forefathers did not have a fraction of the monitoring we have today and yet they took the challenge and managed with their clinical acumen
  2. 2. To think that the very first ‘official’ anaesthetic done by William T.G. Morton in 1846 was done with • No ECG • No Pulse Oximetry • No Capnography • No Intravenous infusion All this on a patient Mr Gilbert Abbott for resection of a vascular tumour on the Neck! Simply Amazing!!!!!!
  3. 3. Technology Has Advanced • Major difference in practice within 4 decades • As there was no pulse oximetry or capnography when Professor Ozinsky anesthetized the first heart transplant in 1968. Of Recent The Anaesthetist Has Transformed Into ‘The Swiss Knife’ Smart Clinician to the tech savvy type…….. Yes …….. 
  4. 4. Try to imagine today's health care without surgery. It's almost impossible. NOW TRY TO IMAGINE SURGERY WITHOUT ANESTHESIA….
  5. 5. However Despite The Assistance from our gadgets…. • Surgeons take more Risk • The Worlds Population is ever increasing • We are presented with an increasing number of cases with varying complexities • This and the pressing challenges of budgetary constraints and austerity puts pressure on us to cater for all our patients one at a time
  6. 6. Do Not Do Multiple Tasks At A Time We need to do one thing at a time to AVOID HUMAN ERROR!
  7. 7. Why is Anaesthesia Risky? • Anaesthesia is not a Therapeutic State • Strong Drugs Are Used To Induce & Maintain Sleep • Almost all Anaesthetic Drugs Depress the Cardiovascular System • Caution is needed as Certain Patients with poor functional capacity can decompensate • Functional Assessment is of Paramount Significance
  8. 8. Our Patients must have the endurance to withstand the Stress of an operation!
  9. 9. MET = METABOLIC EQUIVALENT 1 MET = 3.5ML/KG/MIN OF OXYGEN CONSUMPTION Functional unit of energy consumption To withstand the stresses of an operation the patient must pass 4 METS That is 14ml/kg per minute of Oxygen consumption
  10. 10. Failure to exercise caution with administering an anaesthetic can result in  Complications
  11. 11. That is why the Practicing Anesthesiologist….
  12. 12. But All these expectations on the Anesthesiologist Results in
  13. 13. That is why it is so important to work as a team..
  14. 14. The past 2 years has seen the forum of social media escalate exponentially..
  15. 15. In Order To Maintain Checks & Balances From Information Overload A Governing Body is needed to Regulate and Censor Information As We Need Guidance & Protection For • The Patient • The Public • Our Peers
  16. 16. Now that is where we come in…..
  17. 17. The Aims and Objects of the Indian Society of Anaesthesiologists 1. To associate together in one corporate body all reputable and registerable medical men and women practising or interested in the science and art of Anaesthesiology. 2. To promote the advancement of Medical Science. 3. To edit and publish a Journal of Anaesthesiology. 4. To determine the competence of specialists in Anaesthesiology and conduct examinations for certificates to be issued to voluntary applicants. 5. To protect the public against irresponsible and unqualified practitioners who profess to be specialists in Anaesthesiology. 6. To encourage scientific research and experimental work on anaesthetic problems.
  18. 18. 7. To hold scientific discussions and read papers on Anaesthesiology. 8. To watch and advise on legislations affecting the Anaesthesiology. 9. To hold periodically, conferences at various places, for the betterment of the cause of anaesthesia in India. 10. To receive donations and subscriptions from persons who are eligible and desire to join the society and to hold the funds for the advancement of Anaesthesiology and betterment of members. 11. To co-operate with other medical and scientific associations. 12. To arrange exhibitions of implements, appliances etc., pertaining to anaesthesia in different parts of the country and suggest improvements in these implements and appliances.
  19. 19. 13. To make rules when deemed necessary, relating to the discipline and professional conduct of Anaesthesiologists. 14. To make bye-laws, rules and regulations of the society and to delete, change or add to the same as and when necessary. 15. To add all such things as may be incidental or conducive to the attainment of all or any of the above objects. 16. To prepare a directory of Anaesthesiologists in India and abroad who are registered members. This directory shall be compiled by the Hon. Secretary and will be circulated to the members periodically. 17. To run programmes for the welfare of the members like Family Benefit Fund etc
  20. 20. Pre-requisites Professional Status: Only qualified Anaesthesiologists are permitted to administer anaesthesia Facilities and Equipment's: Resuscitation equipment conforming to National standards must be available in the workplace in adequate quantity / quality Professional Organization: Appropriate 'Anaesthesia Forums' may be established and will form links with the needed Authority for Training, Certification and Accreditation. Institutional, Regional or National Protocols on Anaesthesia practices may be instituted and facilities for updating of knowledge may be ensured to improve quality Monitoring Standards- ISA
  21. 21. Records and Statistics: A record of details and course of each Anaesthesia procedure should be made and preserved along with the patients medical record Personnel and Workload: Sufficient number of trained Anaesthesiologists should be available at major Hospitals and the workload should be distributed so as to avoid over or under utilization The Anaesthetist should take the responsibility for the transport of the patient to post-anaesthesia recovery area as well as for later consultation if needed until the patient makes adequate recovery from Anaesthesia
  22. 22. Basic Standards of Monitoring Pre-anaesthetic evaluation and adherence to a protocol is mandatory. Service should be administered by qualified Anaesthesiologist possessing registration in modern medicine Availability of resuscitation equipment, uninterrupted supply of oxygen and minimum Anaestheisia equipment should be confirmed before starting the procedure Clinical Monitoring of colour and pulse should be done every 5 minutes during conduct of Anaesthesia A light source, Stethoscope, BP apparatus and Thermometer should be available. Basal recording should be made before the start of procedure Cardioscope with Defibrillator capable of displaying the rate and wave pattern should be available
  23. 23. Desirable Standards (Essential Standards for higher surgical works) 1.All basic standards detailed above should be met with. 2.Anaesthetic machine and equipment used should have failure warning facility as well as check list for failure correction. Every operating Theatre should have at least one operable Anaesthestitic machine. 3.Periodically calibrated vaporiser (Drug Specific) should be available. 4.Every procedure should be monitored with pulse Oxymeter to observe oxygen saturation. 5.Major procedure undertaken should be monitored with as many varying equipments such as Airway Pressure Alarm, Oxygen, Concentration Analyser, Neuro-Muscular Monitor, Respiratory Volume Monitor, Non-invasive BP Monitor, Capnometer, etc.
  24. 24. Recommended Minimum Essentials In Operation Theatre Continuous supply of oxygen cylinders Boyle’s machine with two oxygen and a nitrous oxide input connections One small oxygen cylinder mounted on Boyles other than jumbo or central line and nitrous oxide cylinder along with cylinder valve opener should be available Boyles machine with hypoxic guard safety system Working suction machine with all connectors, tubing's, and catheters Multi-parameter monitors including pulse oxymeter, ECG, NIBP, EtCO2,in Laparoscopy, thermo probe for temperature monitoring for pediatric patient.  Adequate no of protective lead aprons with C-arm, protective glasses with laser Defibrillator
  25. 25. Ambu bag with all size of masks Working laryngoscope with all sizes of blades, set of oral, nasal airway and endotracheal tubes with stylets Magill’ s forceps, scissors, ampoule cutter, torch, thermometer Vein flows14,16,18, 20, 22, 24, spinal needles 23, 24, 25, 26, 27, epidural set 16,18, cvp line, 3 way cannulas I.V. sets, micro drip sets, blood transfusion set IV fluids crystalloids RL, DNS, D5, colloids For difficult airways elastic bougie, LMA, Igel, tracheostomy tube  Flexible OT table with Radiant warmer/ blanket, heating mattress , fluid warmer Postoperative recovery room with oxygen supply and monitors
  26. 26. Recommended Anaesthetic Drugs Sodium Thiopentone Inhalational Tramadol Profofol Halothane Ketami Iso/Sevoflurane Succlinylcholine Ondansetron Fantanyl Vacuaronium Renitidine Buprenorphine Butorphanol Pentazocin Dexmeditomidine Atracurium Clonidine Diclofenac Neostigmine Bupivacaine 0.5% Heavy Atropine Bupivacaine 0.5% ,0.25% Vial Glycopyrolate Ropivacaine Medazolam Nebuliser Asthalin Budeort Iv Paracetomal Esmolol
  27. 27. Emergency Medicines Atropine,Glycopyrolate Adrenaline Amiodarone Dextrose 25% Dopamine, Dobutamine Noradrenaline Nitroglycerine Sodabicarb 8.4% Hydrocartisone Chlorphenaramine Insuline Furosemide KCL Deriphylline Calcium Gluconate Vasopressine Mephenteramine Aminophylline Oxytocine Prostaglandin Xylocard 2% Dexamethazone Adenosine Metoprolol Methylergometrin Tranexamic Acid Magsulph 25% & 50% IV Fluids Ringer lactate 5% Dextrose Normal Saline DNS Colloids 3% Saline
  28. 28. In December 1999, the report of the Institute of Medicine (IOM) in America, “To err is human”, raised the alarm to the public that medical care could cause harm. It concluded that medical errors were responsible for up to 98,000 deaths and 1 million injuries each year in the United States. Assuming these figures to be constant and taking todays Indian population this equates to 456414 deaths/year or 1250 deaths/day.
  29. 29. Ten years later in 2009 questions about the effectiveness of these quality improvement initiatives were raised, and a new study was performed in North Carolina . The study conclusions were that, despite efforts, harm to patients remains common (18.1%) and that not all quality improvement interventions seem to be effective. Therefore, there is a need for a better understanding of effective approaches that are able to minimise risk and improve the overall safety of patient care. The specialty is
  30. 30. The specialty is often cited as a role model for its achievements in the field of patient safety improvements. Major improvements were mainly observed during recent past decades, with mortality figures continuously dropping to 1/124,212 in the nineties, and to 1/146,341 five years later, reaching 1/249,321 in 2005. This represents a 100-fold decrease in the anaesthesia mortality rate between the 1950s and today Therefore, anaesthesia is often cited as the only speciality in healthcare to have reached the 6 sigma defect rate, which is used to describe a 99.99966% defect- free process (3.4 defects per million] and is often seen as the critical target to be reached by any manufacturing process or transport industry.
  31. 31. Pre-operative check up Make it a habit to examine preoperatively. Introduce yourself to the patient and the attendants that you are the person responsible to relieve pain and safety of the patient during operation. Then ask the Nurse take the consent. Make it a habit to visit the patient post operatively and advise the nursing staff clearly regarding the postoperative analgesia
  32. 32. Safety Checklist
  33. 33. Kakinada city branch
  34. 34. INDIAN SOCIETY OF ANAESTHESIOLOGIST'S The following information is vital for smooth conduct of your surgery so please spend some time in reading & understanding about the science of Anaesthesia which has been designed so as to necessitate & facilitate optimum conditions to make it possible for the surgeon to operate successfully on a patient. Anaesthesia is reversible loss of consciousness with loss of pain, amnesia & good muscular relaxation to facilitate good surgical outcome. An Anaesthetist is a qualified consultant doctor- MBBS followed by MD or DA like any Consultant. He is the leader in the O.T. & his management of the patient during the surgery ultimately decides the postoperative well being of the patient as also the result of the surgery. He is the physician & Intensivist in the O.T managing all critical events such as cardiac arrest, heart attack, changes in blood pressure, excessive bleeding, pulmonary embolism, irregular heart beats, reduced urine output that can all occur during any operation. Hence proper information of Anaesthesia & counseling by a qualified Anaesthetist can be vital for the patient. Patient name , ___________________________________________________Age _______, Sex : M/F Address ________________________________________________________________________________ Surgery planned __________________________________________________________________________________ Anaesthetist for surgery is Dr ________________________________Mobile No. (optional)______________________ If you have any query as to the mode, type or risk of Anaesthesia please contact him or you can also ask him to give you a pre-operative visit on day prior to the scheduled surgery as per his convenience ( visit fees to be paid immediately). Please fill in this questioner to increase your own safety. Q-1. Is this your first operation? Y/N. If yes, when & where were you operated previously. ___________________________________________________________________ Q-2. Do you have medical history of any major illness in the past? Y/N. If yes please give details ___________________________________________________________________ Q-3. Have you or any member of your family had any complications to anaesthesia or had any allergic reaction to any drugs? Y/N if yes give details. __________________________________________________________________ Q-4. Have you ever received blood transfusion or blood products in the past? Y/N. if yes give details __________________________________________________________________ Q-5. Have you ever tested your blood for HIV( AIDS), HEPATITIS VIRUS, ? Y/N. Are you a carrier of any disease as hepatitis__________________________________________________
  35. 35. Q-6. Do you consume alcohol, drugs or nicotine or tobacco in any form? Y/N __________________________________________________________________________________ Q7. Do you have any denture, loose teeth, Contact lenses, Hearing aid, Pacemaker implanted.? Y/N Details __________________________________________________________________________________ Q8. Did you have any Viral infection recently-cold, flu, fever, cough. Y/N __________________________________________________________________________________ Q-9. Do you have complaints like Chest pain with sweating/ Swelling on feet/ Breathlessness / Cough with sputum/ Blood in sputum/ Bleeding Tendencies/Nausea, Vomiting / Migraine / Chronic headache __________________________________________________________________________________ Q10.Are you a known patient of Heart attack/Blood pressure/ Diabetes/ Jaundice / Cancer / Convulsions Tuberculosis / Arthritis / Asthma / Sleep apnea / Snoring / Psychiatric illness. If yes give details. ___________________________________________________________________________________ Q11.Are you taking any medicine s- if yes give details ___________________________________________________________________________________ Q12.Details of your family doctor - name / telephone number. ___________________________________________________________________________________ Q13.Have you received Anaesthesia in the past ? Y / N any problems encountered ___________________________________________________________________________________ Importants Do's & Don't's 1) Please be, 'Nil by mouth' 6 hours before surgery 2) Know your Anaesthetist & Anaesthesia before the surgery. 3) Remove all lipstick, nail polish, ornaments before surgery. 4) Keep mobiles, keys, valuables with responsible relatives. 5) Do not consume alcohol, tobacco & do not smoke before or after the surgery. 6) Do not take anything by mouth without doctors permission after surgery. 7) Do not go home alone after surgery. 8) Do not drive vehicle, cooking or use equipment on day of surgery. 9) Please contact the doctor for any problem.
  36. 36. COMPLICATIONS AND PROVISION OF CARE Anaesthesia Care: Your anaesthetist is a qualified post graduate & is well versed with dealing with all types of situations that can occur during any life threatening situation one may see in the ICU. Complications: Anaesthesia has become safer and safer; however, there remains the risk of complications with any anaesthetic rendered. There remains a risk of death or organ injury; however, this risk is extremely low for the vast majority of patients. Below we list some of the more common side effects or complications of specific anaesthetic techniques. It is always possible that a general anaesthetic may be employed if another technique is not satisfactory. Spinal or epidural block •Headache: if your headache is severe, contact your anaesthesia team for further evaluation l •Pain in one or both legs: this is usually self-limited, improving within 1-2 days; contact your anaesthesia for concerns •Team Temporary difficulty with emptying your bladderl Nausea and/or itching when opioids are added for postoperative pain relief Complications such as neurologic injury or complications secondary to bleeding or infections are very rare. It is important for your anaesthesia team to be aware of any coexisting infections or the use of any blood thinners, including aspirin, Coumadin (Warfarin),Plavix (Clopidogrex), and related drugs. Occasionally self limiting Backache . General Anaesthesia Nausea : your anaesthesia team tries to recognize those at highest risk for nausea in order to minimize this risk. Alert us if you have a history of postoperative nausea. Dental trauma: teeth, especially when in poor repair or when there is dental work or dental prostheses, can be injured during or after anaesthesia. A sore throat is common after general anaesthesia because of placement of a breathing tube. Nerve injury : we make every effort to prevent injury to nerves while in the operating room; however, there remains a small risk of nerve injury with surgery and anesthesia, though most of these injuries improve within days. Incidence of nerve injury may be increased with certain surgical positions, duration of procedure, and body habitus.
  37. 37. INFORMED CONSENT AND AUTHORIZATION FOR ANAESTHESIA.  I, _________________________________________, for______________________________________________ as Parent,/Guardian/ Representative acting on his/her or my behalf, am seeking to receive anaesthesia during his/her or my pending procedure/operation/treatment. I want to have anaesthesia in order to lessen the pain I would therwise experience.  I understand that regardless of the type of anaesthesia used there may be some unforseen risks and consequences which may occur. The following are some but not all of the common foreseeable risks and consequences which I have been told can occur: sore throat and hoarseness, nausea and vomiting, muscle soreness. Further, I understand instrumentation in the mouth to maintain an open airway during anesthesia might unavoidably result in dental damage including fracture or loss of teeth, bridgework, dentures, crowns and fillings, laceration of the gums or lips.  I understand that medications that I am taking may cause complications with anaesthesia or surgery. I understand that it is in my best interest to inform my doctors about the nature of any medications Allopathic / Homoeopathic / Ayurvedic / Unani.  I understand the more serious risks and consequences of anaesthesia include but are not limited to changes in blood pressure, allergic/drug reaction, awareness of the surgery, injury to my baby if pregnant, excessive bleeding, cardiac arrest, brain damage ,embolism, paralysis or death.  I acknowledge that Dr. has told me that in his/her medical judgment the type(s) of anaesthesia I could receive is/are General Anaesthesia /Spinal / Epidural Anaesthesia /MAC (Monitored Anaesthesia Care) / Sedation / Regional anaesthetic block. I have listened to the doctor's explanation of the type(s) of anaesthesia I may receive, its benefits and common foreseeable risks and consequences as well as those of its alternatives and now accept his/her recommendation .  I understand that during my procedure/operation/treatment invasive monitoring may be necessary. I understand the risks and benefits associated with this type of monitoring which have been fully explained to me.  I understand that while I am receiving anaesthesia, conditions may develop which require modifying or extending this consent. I therefore authorize modifications or extension of this consent that professional judgment indicates to be necessary under the circumstances.  I understand that I must not eat or drink anything 6 hours prior to surgery unless directly permitted by the anesthesia-staff.
  38. 38.  I consent to appropriate tests and treatments which may better evaluate my risk and prepare me for surgery as part of my medical care associated with this procedure/operation/treatment.  I understand that my anaesthesia care will be given under the supervision of Dr __________________a member of KAKINADA SOCIETY OF ANAESTHESIOLOGIST'S Affliated to ISA. I also understand that medical center personnel such as anaesthesia technicians may be involved in my anaesthesia care.  I, the undersigned patient, give my consent to discuss my personal health information with any person that accompanies me or is present with me that I have identified in advance of any procedure as active in my mental, physical, emotional, or spiritual care, including, but not limited to family, close personal friends, and patient advocates.  I am aware of the facilities which are available and not available in this hospital. I may have to be shifted to another hospital for treatment of complications and I am bound to pay the bill of that hospital.
  39. 39. PATIENT AFFIRMATION By signing this document, I am indicating that I understand the contents of this document and its attachments, agree to its provisions and consent to the administration of anaesthesia during my procedure/operation/treatment. I know that if I have concerns or wou ld like more detailed information, I can ask more questions and get more information from my attending anaesthetist. I am also acknowledging that I know that the practice of anaesthesiology, medicine and surgery is not an exact science and that no one has given me any promises or guarantees about the administration of anaesthesia or its results. I fully understand what I am now signing of my own free will and the above 13 questions & 12 points in the consent form have been explained to me thoroughly in my own language. __________________________________________ SIGNATURE OF RELATIVE / WITNESS __________________________________________ SIGNATURE OF PATIENT DATE & TIME___________________ ANAESTHESIOLOGIST'S ATTESTATION I attest that this patient or the representative named above has been informed about the common foreseeable risks and benefits of undergoing the anaesthetic and related problems as well as its reasonable alternative(s), if any. Further questions with regard to this anaesthetic and related procedure have been answered to his/her apparent satisfaction in the patients own language ANAESTHESIOLOGIST'S SIGNATURE ____________________________________ ____________________________________
  40. 40. Remuneration
  41. 41. Specialty Median salary (USD)[6] Average hours work/week[7] Average salary/hour (USD)[8] Orthopedic surgery 397,879 to $600,000 58 Radiology (diagnostic) 377,300 to $478,000 58 Neurological surgery 350,000 to $705,000 132 Urology 331,192 to $443,518 60.5 Anesthesiology 331,000 to $423,507 61 Dermatology 313,100 to $480,088 45.5 103 Surgery (general) 284,642 to $383,333 60 Plastic surgery 265,000 to $500,000 114 Obstetrics and Gynecology 251,500 to $326,924 61 83 Gastroenterology 251,026 to $396,450 93 Pathology 239,000 to $331,842 45.5 Emergency medicine 239,000 to $316,296 46 87 Cardiac Surgery 218,684 to $500,000 55 Neurology 213,000 to $301,327 55.5 93 Otolaryngology 191,000 to $393,000 53.5 Internal medicine 184,200 to $231,691 57 58 Family medicine 175,000 to $220,196 52.5 58 Psychiatry 173,800 to $248,198 48 72 Pulmonology 165,000 to $365,875 72 Pediatrics 160,111 to $228,750 54 69 Ophthalmology 150,000 to $351,000 47
  42. 42. Proposed Charges Of ANESTHESIOLOGIST’S In KAKINADA Obstetrics & Gynaecology M.T.P/D&C /CERVICAL Stitch 1200-1500/- Tubectomy- Open 1500-2000/- Tubectomy- Lap 2500-3000/- L.S.C.S 2000-2500/- T.A.H/ V.H 3000-3500/- T.L.H/ L.A.V.H/ Myomectomy 4000-5000/- Ectopic- Open 3000-3500/- Ectopic- lap 4000-4500/- Wertheim’s Hysterectomy 5000-6000/- Labour Analgesia Basic charges 3000/- Per hour after that 1000/-
  43. 43. General Surgery Appendectomy- open 2500-3000/- Appendecectomy- lap 3000-3500/- Inguinal Hernia- open (unilateral) 2000-2500/- Inguinal Hernia- open-bilateral 3000-4000/- Inguinal Hernia- lap 4000-4500/- Cholecystectomy- open 3000-3500/- Cholecystectomy- lap 4000-4500/- Thyroid 3500-4000/- M.R.M 3000-3500/- Explorative Laporotomy 3000-4000/- Haemorrhoids/ Fistulectomy/ Hydrocoele -2000/- Endoscopy Sedation in Upper G.I Endoscopy 1500/- Colonoscopy 2000/- ERCP 2500-3000/- Oesophgeal Dilatation 2000-2500/- Variceal banding 2500-3000/-
  44. 44. Orthopedics M/R & K-WIRE 1500-2000/- D.H.S/ Bipolar/ Femur plates 4000-4500/- Tibia plating 3000-3500/- Humerus surgeries 4000-4500/- Radius & Ulna surgeries 3000-3500/- Arthroscopies (diagnostic) 3000-3500/- Arthroscopies (Procedures) 4000-5000/- T.K.R 4500-5500/- T.H.R 5000-6000/- Epidural Steroid-(lumbar) 2000-2500/- (Cervical) 3500-4000/- Adeno-Tonsillectomy 2000-2500/- Septoplasty 2500-3000/- FESS 3000-3500/- Mastoidectomy 3000-4000/- Tympanoplasty 3000-3500/- Vocal cord surgery 3500-4000/- Ca Larynx/Laser 5000-6000/- E.N.T
  45. 45. Urology TURP/TURBT 3000-3500/- PCNL 4000-5000/- Scopies 1500-2000/- Nephrectomy 4000-4500/- ESWL 2500-3000/- Stricture urethra 3000-3500/- Hypospadiasis 3500-4000/- Circumcision 1500-2000/- Laporotomy 4000-5000/- TOF/CDH 5000-6000/- Lap surgeries 4000-5000/- Hernia repair 2500-3500/- Pylorotomy 3500-4000/- Pediatric Surgery
  46. 46. Lumbar Discectomy 3500-4000/- Cervical Discectomy 4000-5000/- Spine Instrumentation 5000-6000/- Craniotomy E.D.H 4500-5000/- S.D.H 5000-6000/- Burr hole 4000/- Meningioma- (sol) 5000-7000/- V.P Shunt/ Meningocoele 3500-4000/- Neuro surgery Radiology IVP/CT CONTRAST 1000/- C.T Scan /MRI sedation 2000/-
  47. 47. Plastic surgery I.C.U Mandible/Maxilla 3500-4500/- Cleft lip & Palate 3000-4000/- Debridement &SSG 3000-3500/- Micro vascular surgery 8000-10,000/- Rhinoplasty 3500-4000/- Central line 2500/- Intubation 2500/- L.P 1000-1500/-