This document discusses urolithiasis and treatments for kidney stones such as extracorporeal shockwave lithotripsy (ESWL). It provides details on the history and technique of ESWL, noting that it was first used successfully in 1980. It also discusses anesthetic considerations for ESWL and other stone removal procedures like percutaneous nephrolithotomy.
This document provides an overview of anesthesia considerations for laparoscopic surgeries. It discusses the history of laparoscopy, physiological effects of pneumoperitoneum including on the cardiovascular, respiratory, central nervous and renal systems. It also outlines respiratory complications like subcutaneous emphysema, pneumothorax, gas embolism and their treatment. The effects of patient positioning and conduct of anesthesia are summarized.
This document discusses different anaesthetic options for lithotripsy procedures to break up kidney stones. It begins by providing background on kidney stone prevalence and treatments such as lithotripsy. It then describes various lithotripsy techniques and considerations for the procedure. The main anaesthetic choices for lithotripsy are discussed in detail, including benefits and drawbacks of options like conscious sedation, monitored anaesthesia care, general anaesthesia, regional techniques like spinal or epidural anaesthesia, and intravenous analgesia with sedation. Patient factors and the lithotripsy device used help determine the most appropriate anaesthetic approach.
Chronic kidney disease is defined as kidney damage or decreased kidney function (GFR <60mL/min/1.73m^2) for more than 3 months. It is staged based on GFR from stage 1 to 5. Major causes include diabetes and hypertension. Patients experience cardiovascular, respiratory, immune, electrolyte, gastrointestinal, endocrine, hematological, neurological and acid-base abnormalities due to decreased kidney function. Anesthesia management focuses on optimizing fluid, acid-base, electrolyte and hemodynamic status as well as modifying dosages based on creatinine clearance. Regional techniques may be used but prolonged bleeding time is a contraindication.
This document discusses anaesthetic considerations for transurethral resection of the prostate (TURP). TURP requires large volumes of irrigating fluid which can cause complications if absorbed in large quantities. Regional anaesthesia is preferred to allow for early detection of issues like TURP syndrome. Close monitoring of fluid balance, electrolytes and vital signs is important to manage risks of fluid overload, hyponatremia and other imbalances from irrigating fluid absorption. Prevention involves limiting fluid volume and pressure and prompt treatment of any abnormalities that develop.
The document discusses monitored anesthesia care (MAC), which involves administering drugs to provide anxiolytic, hypnotic, amnestic, and analgesic effects without depressing consciousness below a certain level. It provides guidelines on drug selection and dosing for MAC, including opioids like fentanyl and remifentanil, benzodiazepines like midazolam, propofol, ketamine, and dexmedetomidine. It also discusses factors that can lead to patient agitation during MAC and principles of drug administration via continuous infusion or patient-controlled methods.
Anesthesia in Transurethral resection of prostateAshish Dhandare
1) The document discusses preoperative considerations and risks for anesthesia in transurethral resection of the prostate (TURP), with a focus on risks in elderly patients.
2) It provides details on TURP syndrome, a cluster of symptoms caused by absorption of irrigating fluid during surgery, and treatments for TURP syndrome and its complications like glycine toxicity, hemolysis, hypothermia, and bleeding.
3) Factors that can minimize risks of TURP syndrome are limiting surgery duration to under 1 hour, maintaining fluid bag height below 60cm, frequent bladder drainage, and careful surgical technique to preserve prostatic capsule integrity. Spinal anesthesia is recommended for its benefits in T
Perioperative Management of Hypertensionmagdy elmasry
This document discusses peri-operative hypertension and provides recommendations for its management. It defines peri-operative as referring to the pre-operative, intra-operative, and post-operative periods of surgery. While stage 1 or 2 hypertension alone may not increase perioperative risk, the presence of target organ damage from hypertension can affect outcomes. The guidelines recommend continuing most antihypertensive medications during surgery, with the exception of ACE inhibitors and ARBs. For patients with grade 1 or 2 hypertension, there is no evidence delaying surgery to optimize therapy provides benefits. Acute postoperative hypertension is a frequent complication that should be treated to avoid adverse events.
1) Day case anesthesia, also known as ambulatory surgery or same-day surgery, allows patients to be admitted for a surgical procedure and investigation but return home the same day without an overnight hospital stay.
2) There has been a rapid expansion in the use of day case surgery over the last 30 years, with approximately 65% of surgeries in the United States now performed on an outpatient basis.
3) Day case anesthesia provides advantages like reduced costs, increased bed availability, and less risk of hospital-acquired infections compared to traditional inpatient surgery.
This document provides an overview of anesthesia considerations for laparoscopic surgeries. It discusses the history of laparoscopy, physiological effects of pneumoperitoneum including on the cardiovascular, respiratory, central nervous and renal systems. It also outlines respiratory complications like subcutaneous emphysema, pneumothorax, gas embolism and their treatment. The effects of patient positioning and conduct of anesthesia are summarized.
This document discusses different anaesthetic options for lithotripsy procedures to break up kidney stones. It begins by providing background on kidney stone prevalence and treatments such as lithotripsy. It then describes various lithotripsy techniques and considerations for the procedure. The main anaesthetic choices for lithotripsy are discussed in detail, including benefits and drawbacks of options like conscious sedation, monitored anaesthesia care, general anaesthesia, regional techniques like spinal or epidural anaesthesia, and intravenous analgesia with sedation. Patient factors and the lithotripsy device used help determine the most appropriate anaesthetic approach.
Chronic kidney disease is defined as kidney damage or decreased kidney function (GFR <60mL/min/1.73m^2) for more than 3 months. It is staged based on GFR from stage 1 to 5. Major causes include diabetes and hypertension. Patients experience cardiovascular, respiratory, immune, electrolyte, gastrointestinal, endocrine, hematological, neurological and acid-base abnormalities due to decreased kidney function. Anesthesia management focuses on optimizing fluid, acid-base, electrolyte and hemodynamic status as well as modifying dosages based on creatinine clearance. Regional techniques may be used but prolonged bleeding time is a contraindication.
This document discusses anaesthetic considerations for transurethral resection of the prostate (TURP). TURP requires large volumes of irrigating fluid which can cause complications if absorbed in large quantities. Regional anaesthesia is preferred to allow for early detection of issues like TURP syndrome. Close monitoring of fluid balance, electrolytes and vital signs is important to manage risks of fluid overload, hyponatremia and other imbalances from irrigating fluid absorption. Prevention involves limiting fluid volume and pressure and prompt treatment of any abnormalities that develop.
The document discusses monitored anesthesia care (MAC), which involves administering drugs to provide anxiolytic, hypnotic, amnestic, and analgesic effects without depressing consciousness below a certain level. It provides guidelines on drug selection and dosing for MAC, including opioids like fentanyl and remifentanil, benzodiazepines like midazolam, propofol, ketamine, and dexmedetomidine. It also discusses factors that can lead to patient agitation during MAC and principles of drug administration via continuous infusion or patient-controlled methods.
Anesthesia in Transurethral resection of prostateAshish Dhandare
1) The document discusses preoperative considerations and risks for anesthesia in transurethral resection of the prostate (TURP), with a focus on risks in elderly patients.
2) It provides details on TURP syndrome, a cluster of symptoms caused by absorption of irrigating fluid during surgery, and treatments for TURP syndrome and its complications like glycine toxicity, hemolysis, hypothermia, and bleeding.
3) Factors that can minimize risks of TURP syndrome are limiting surgery duration to under 1 hour, maintaining fluid bag height below 60cm, frequent bladder drainage, and careful surgical technique to preserve prostatic capsule integrity. Spinal anesthesia is recommended for its benefits in T
Perioperative Management of Hypertensionmagdy elmasry
This document discusses peri-operative hypertension and provides recommendations for its management. It defines peri-operative as referring to the pre-operative, intra-operative, and post-operative periods of surgery. While stage 1 or 2 hypertension alone may not increase perioperative risk, the presence of target organ damage from hypertension can affect outcomes. The guidelines recommend continuing most antihypertensive medications during surgery, with the exception of ACE inhibitors and ARBs. For patients with grade 1 or 2 hypertension, there is no evidence delaying surgery to optimize therapy provides benefits. Acute postoperative hypertension is a frequent complication that should be treated to avoid adverse events.
1) Day case anesthesia, also known as ambulatory surgery or same-day surgery, allows patients to be admitted for a surgical procedure and investigation but return home the same day without an overnight hospital stay.
2) There has been a rapid expansion in the use of day case surgery over the last 30 years, with approximately 65% of surgeries in the United States now performed on an outpatient basis.
3) Day case anesthesia provides advantages like reduced costs, increased bed availability, and less risk of hospital-acquired infections compared to traditional inpatient surgery.
This document discusses anesthesia considerations for renal transplantation. It begins by outlining the history of anesthesia used in kidney transplantation, noting the early use of spinal anesthesia and limited monitoring. It then discusses:
- Kidney transplantation being the most common transplant procedure worldwide.
- Indications and contraindications for transplantation.
- Outcomes being greatly improved compared to remaining on dialysis.
- Types of donors including living and cadaveric.
- Anesthesia goals for living donors focusing on safety.
- Evaluation, induction, maintenance and monitoring for recipients.
- Positioning, fluid management and hemodynamic goals.
This document discusses non-operating room anesthesia (NORA). It begins by defining NORA as anesthesia provided outside the operating room, such as in radiology, endoscopy suites, MRI, and dental clinics. It then outlines a three step approach to NORA involving thorough patient assessment, appropriate monitoring and anesthesia care, and post-procedure management. Several ASA guidelines for equipment and facilities in NORA locations are also reviewed. Complications associated with NORA and special considerations for procedures like X-rays, MRIs, and IV contrast administration are discussed. The document emphasizes choosing anesthesia techniques based on patient factors and needs for each specific non-operating room procedure.
Anaesthetic considerations for laser surgeryAnamika yadav
This document discusses anaesthetic considerations for laser surgery. It begins by outlining the objectives which are to discuss the types of lasers used, preoperative assessment and preparation, airway management and ventilation options, laser hazards and prevention, and crisis management for airway fires. It then provides details on the types of lasers used clinically, biological effects of lasers, and clinical applications of lasers. The role of anesthesiologists is to maintain oxygenation, remove carbon dioxide, keep the patient anesthetized, and reduce risks. Various airway management techniques and their advantages/disadvantages are discussed such as intubation, spontaneous ventilation, insufflation, and jet ventilation. Laser hazards like atmospheric contamination, perforation
This document discusses low-flow and minimal-flow anesthesia techniques. It begins by defining low-flow as a fresh gas flow of 1 L/min and minimal-flow as 0.5 L/min. Rebreathing systems allow reuse of exhaled gases after removal of carbon dioxide. Using these techniques can reduce costs by 55-75% and minimize environmental pollution from volatile anesthetic gases. Proper monitoring and maintenance of breathing gas conditions is important for patient safety when using low fresh gas flows.
This document discusses day care anaesthesia, which involves providing anaesthetic care for elective outpatient surgical procedures and discharging patients on the same day. Key benefits include reduced hospital bed usage, lower costs, and fewer hospital-acquired infections. Patients must meet selection criteria like being ASA physical status I-III with controlled medical conditions, over 6 weeks old, able to recover at home, and having a low-risk procedure under 90 minutes. Contraindications include procedures with major fluid shifts or blood loss, significant postoperative pain or nausea/vomiting, uncontrolled medical issues, or substance abuse.
Cardiovascular physiology for anesthesiamarwa Mahrous
This document discusses cardiovascular physiology including the structure and function of the heart, regulation of the cardiovascular system, blood flow through the pulmonary and systemic circulations, factors that influence cardiac output and stroke volume, and regulation of the systemic vasculature. Key points include:
- The cardiovascular system consists of the heart, blood vessels, and mechanisms that regulate blood circulation and pressure.
- Cardiac output is determined by stroke volume and heart rate. Stroke volume depends on preload, afterload, and contractility.
- The pulmonary circulation has low pressure and resistance while the systemic circulation has higher pressure and resistance.
- Autonomic nervous system and chemical factors regulate heart rate and contractility. Venous return and vascular
Postoperative nausea and vomiting (PONV) is a common complication following surgery. It can increase patient discomfort, medical costs, and length of hospital stay. Multiple factors contribute to PONV risk, including patient characteristics like female gender or prior history of nausea, as well as anesthetic and surgical factors. A variety of drug classes have been used to prevent and treat PONV, including antihistamines, anticholinergics, dopamine antagonists, corticosteroids, and newer 5-HT3 receptor antagonists and neurokinin-1 receptor antagonists. Non-drug approaches such as acupuncture, aromatherapy, and supplemental oxygen may also help reduce PONV. Hospitals have developed
The document discusses the management of difficult airways. It defines difficult mask ventilation and difficult laryngoscopy/intubation. It describes various tests that can be used to assess a difficult airway, such as the Mallampati test, thyromental distance, sternomental distance, and neck mobility tests. Radiographic predictors of a difficult airway are also discussed, along with causes of difficult intubation related to patient anatomy and various medical conditions.
(1) Postoperative nausea and vomiting (PONV) is a common complication following anesthesia and surgery, with incidence rates of 22-38% for nausea and 12-26% for vomiting. (2) The vomiting center located in the brainstem plays a key role in coordinating the vomiting reflex in response to various emetogenic stimuli. (3) Identifying patient, anesthesia, and surgery risk factors can help determine those at higher risk of PONV and guide prophylaxis.
The document provides guidelines from the American Society of Regional Anesthesia (ASRA) on placing and removing epidural catheters in patients taking anticoagulant and antiplatelet drugs. It lists recommended minimum times to wait after the last dose of various medications before catheter placement and removal, as well as when to restart anticoagulation therapy after removal. The medications are grouped into heparins, low molecular weight heparins, factor Xa and direct thrombin inhibitors, antiplatelet agents, fibrinolytics, and glycoprotein IIb/IIIa inhibitors. For each group, it provides the drug names and recommended waiting times.
The document discusses the role of anesthesiologists in cardiac catheterization laboratories. It covers:
1) Anesthesiologists must work in a small space not designed for anesthesia and must become familiar with the workspace and personnel.
2) They provide anesthesia support for a variety of cardiac and non-cardiac specialists performing procedures and must consider issues like radiation exposure, patient comorbidities, and different anesthesia approaches for each type of procedure.
3) Radiation exposure is a risk in catheterization labs and anesthesiologists must take precautions like protective equipment, monitoring radiation doses, and obtaining radiation safety certificates.
This document discusses low flow anaesthesia. It defines low flow as 500-1000 ml/min of fresh gas flow. The document outlines the technical requirements for safely conducting low flow anaesthesia, including monitors for inspired oxygen, end tidal CO2 and anaesthetic concentrations. It describes the initiation, maintenance and emergence phases of low flow anaesthesia, emphasizing achieving and maintaining an appropriate anaesthetic depth. The document discusses advantages like reduced cost and pollution compared to higher fresh gas flows.
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Anaesthetic management of tracheoesophageal fistula and congenital diaphragmaticIqraa Khanum
The document discusses the anesthetic management of tracheoesophageal fistula (TEF) and congenital diaphragmatic hernia (CDH) in neonates. It covers the embryology, clinical presentation, diagnosis, and preoperative, intraoperative and postoperative anesthetic considerations for repair of each condition. TEF results from imperfect division of the foregut during development, while CDH occurs due to failure of the diaphragm to fully form, allowing abdominal organs to herniate into the chest cavity. Proper management requires careful attention to the neonate's respiratory status and minimizing risks of aspiration or overdistention.
The document discusses the approach to anesthesia for patients with cardiac disease undergoing non-cardiac surgery. It emphasizes the importance of preoperative evaluation and risk stratification to determine the safest anesthetic plan. During surgery, careful monitoring is recommended to detect any deterioration in cardiac function. The appropriate selection of anesthetic drugs and techniques can help minimize stress on the heart. Overall, the key is choosing an anesthetic that provides stability for the patient's cardiac condition.
Anesthesia for coronary artery bypass graftingaparna jayara
Anesthesia for coronary artery bypass grafting (CABG) has evolved significantly since the first open heart surgery in 1952. Key developments include the first successful CABG without bypass in 1961, widespread use of cardiopulmonary bypass in the 1960s-1970s, and the clinical introduction of off-pump CABG and minimally invasive techniques in the late 1990s. CABG is commonly performed for symptomatic multi-vessel coronary artery disease. Precise intraoperative monitoring and optimization of patient comorbidities are important for reducing complications of CABG.
This document discusses anaesthesia considerations for obese patients. It covers physiological disturbances in obese patients that impact anaesthesia like reduced lung volumes, cardiac strain and risk of pulmonary embolism. It recommends pre-operative evaluation, premedication to reduce aspiration risk, induction and maintenance techniques like using ideal body weight for dosing and PEEP to improve oxygenation. Post-operative monitoring is important due to risks of hypoventilation, wound infections and thromboembolic events. Analgesia should be dosed based on ideal body weight and include multimodal options. Safety features of anaesthesia machines like pressure regulators, flow meters and vaporizers are highlighted.
This document discusses strategies for optimizing preoxygenation prior to endotracheal intubation. It notes that conventional preoxygenation techniques provide safe intubation for most ED patients but that a subset may still desaturate. To safely intubate this higher risk group, the document recommends optimizing preoxygenation through techniques like non-invasive ventilation, apneic oxygenation through nasal cannula, positioning patients in a head-up position, and breaking the sequence of rapid sequence intubation administration. The goal is to prevent deoxygenation and extend the safe apneic period for patients undergoing endotracheal intubation.
Low flow anaesthesia systems aim to reuse exhaled gases and minimize fresh gas flow. John Snow recognized in 1850 that most inhaled anaesthetics are exhaled unchanged, and rebreathing exhaled gases could prolong their effects. Developments over the 20th century led to widespread use of circle absorption systems. Factors like cost and pollution concerns have renewed interest in low flow anaesthesia. It requires a well-functioning circle system, gas monitoring, and attention to factors like circuit volume and gas solubility when initiating and maintaining the desired anaesthetic concentrations with minimal fresh gas flows.
The 2000 ASTM F1850-00 standard states that anesthesia gas supply devices must be designed so that whenever oxygen supply pressure is reduced below the manufacturer's minimum specification, the delivered oxygen concentration does not decrease below 19% at the common gas outlet. The standard also requires alarms to sound within 5 seconds if oxygen supply pressure falls below approximately 200 kPa. Safety features of anesthesia machines include oxygen/nitrous oxide proportioning systems, oxygen failure safety devices, oxygen supply failure alarms, and vaporizer interlocks.
1. Common procedures for treating nephrolithiasis include cystoscopic procedures like ureteroscopy with stone extraction and lithotripsy, as well as extracorporeal shock wave lithotripsy (ESWL) and percutaneous or laparoscopic nephrolithotomy.
2. ESWL uses focused acoustic shockwaves to fragment stones within the kidney without invasive surgery. It is commonly used for stones 4-20mm in size.
3. Radical prostatectomy and cystectomy are major surgeries for urological cancers that require extensive dissection and carry risks of significant blood loss. Robotic assistance and laparoscopic approaches are now commonly used.
This document discusses extracorporeal shock wave lithotripsy (ESWL), a treatment for kidney and ureteral stones. It describes how ESWL works to fragment stones using shock waves, and compares older lithotripters that used water baths to newer generations that do not. It outlines factors affecting successful ESWL treatment and discusses preparations, potential effects of shock waves, and anesthetic considerations and choices for pain management during the procedure.
This document discusses anesthesia considerations for renal transplantation. It begins by outlining the history of anesthesia used in kidney transplantation, noting the early use of spinal anesthesia and limited monitoring. It then discusses:
- Kidney transplantation being the most common transplant procedure worldwide.
- Indications and contraindications for transplantation.
- Outcomes being greatly improved compared to remaining on dialysis.
- Types of donors including living and cadaveric.
- Anesthesia goals for living donors focusing on safety.
- Evaluation, induction, maintenance and monitoring for recipients.
- Positioning, fluid management and hemodynamic goals.
This document discusses non-operating room anesthesia (NORA). It begins by defining NORA as anesthesia provided outside the operating room, such as in radiology, endoscopy suites, MRI, and dental clinics. It then outlines a three step approach to NORA involving thorough patient assessment, appropriate monitoring and anesthesia care, and post-procedure management. Several ASA guidelines for equipment and facilities in NORA locations are also reviewed. Complications associated with NORA and special considerations for procedures like X-rays, MRIs, and IV contrast administration are discussed. The document emphasizes choosing anesthesia techniques based on patient factors and needs for each specific non-operating room procedure.
Anaesthetic considerations for laser surgeryAnamika yadav
This document discusses anaesthetic considerations for laser surgery. It begins by outlining the objectives which are to discuss the types of lasers used, preoperative assessment and preparation, airway management and ventilation options, laser hazards and prevention, and crisis management for airway fires. It then provides details on the types of lasers used clinically, biological effects of lasers, and clinical applications of lasers. The role of anesthesiologists is to maintain oxygenation, remove carbon dioxide, keep the patient anesthetized, and reduce risks. Various airway management techniques and their advantages/disadvantages are discussed such as intubation, spontaneous ventilation, insufflation, and jet ventilation. Laser hazards like atmospheric contamination, perforation
This document discusses low-flow and minimal-flow anesthesia techniques. It begins by defining low-flow as a fresh gas flow of 1 L/min and minimal-flow as 0.5 L/min. Rebreathing systems allow reuse of exhaled gases after removal of carbon dioxide. Using these techniques can reduce costs by 55-75% and minimize environmental pollution from volatile anesthetic gases. Proper monitoring and maintenance of breathing gas conditions is important for patient safety when using low fresh gas flows.
This document discusses day care anaesthesia, which involves providing anaesthetic care for elective outpatient surgical procedures and discharging patients on the same day. Key benefits include reduced hospital bed usage, lower costs, and fewer hospital-acquired infections. Patients must meet selection criteria like being ASA physical status I-III with controlled medical conditions, over 6 weeks old, able to recover at home, and having a low-risk procedure under 90 minutes. Contraindications include procedures with major fluid shifts or blood loss, significant postoperative pain or nausea/vomiting, uncontrolled medical issues, or substance abuse.
Cardiovascular physiology for anesthesiamarwa Mahrous
This document discusses cardiovascular physiology including the structure and function of the heart, regulation of the cardiovascular system, blood flow through the pulmonary and systemic circulations, factors that influence cardiac output and stroke volume, and regulation of the systemic vasculature. Key points include:
- The cardiovascular system consists of the heart, blood vessels, and mechanisms that regulate blood circulation and pressure.
- Cardiac output is determined by stroke volume and heart rate. Stroke volume depends on preload, afterload, and contractility.
- The pulmonary circulation has low pressure and resistance while the systemic circulation has higher pressure and resistance.
- Autonomic nervous system and chemical factors regulate heart rate and contractility. Venous return and vascular
Postoperative nausea and vomiting (PONV) is a common complication following surgery. It can increase patient discomfort, medical costs, and length of hospital stay. Multiple factors contribute to PONV risk, including patient characteristics like female gender or prior history of nausea, as well as anesthetic and surgical factors. A variety of drug classes have been used to prevent and treat PONV, including antihistamines, anticholinergics, dopamine antagonists, corticosteroids, and newer 5-HT3 receptor antagonists and neurokinin-1 receptor antagonists. Non-drug approaches such as acupuncture, aromatherapy, and supplemental oxygen may also help reduce PONV. Hospitals have developed
The document discusses the management of difficult airways. It defines difficult mask ventilation and difficult laryngoscopy/intubation. It describes various tests that can be used to assess a difficult airway, such as the Mallampati test, thyromental distance, sternomental distance, and neck mobility tests. Radiographic predictors of a difficult airway are also discussed, along with causes of difficult intubation related to patient anatomy and various medical conditions.
(1) Postoperative nausea and vomiting (PONV) is a common complication following anesthesia and surgery, with incidence rates of 22-38% for nausea and 12-26% for vomiting. (2) The vomiting center located in the brainstem plays a key role in coordinating the vomiting reflex in response to various emetogenic stimuli. (3) Identifying patient, anesthesia, and surgery risk factors can help determine those at higher risk of PONV and guide prophylaxis.
The document provides guidelines from the American Society of Regional Anesthesia (ASRA) on placing and removing epidural catheters in patients taking anticoagulant and antiplatelet drugs. It lists recommended minimum times to wait after the last dose of various medications before catheter placement and removal, as well as when to restart anticoagulation therapy after removal. The medications are grouped into heparins, low molecular weight heparins, factor Xa and direct thrombin inhibitors, antiplatelet agents, fibrinolytics, and glycoprotein IIb/IIIa inhibitors. For each group, it provides the drug names and recommended waiting times.
The document discusses the role of anesthesiologists in cardiac catheterization laboratories. It covers:
1) Anesthesiologists must work in a small space not designed for anesthesia and must become familiar with the workspace and personnel.
2) They provide anesthesia support for a variety of cardiac and non-cardiac specialists performing procedures and must consider issues like radiation exposure, patient comorbidities, and different anesthesia approaches for each type of procedure.
3) Radiation exposure is a risk in catheterization labs and anesthesiologists must take precautions like protective equipment, monitoring radiation doses, and obtaining radiation safety certificates.
This document discusses low flow anaesthesia. It defines low flow as 500-1000 ml/min of fresh gas flow. The document outlines the technical requirements for safely conducting low flow anaesthesia, including monitors for inspired oxygen, end tidal CO2 and anaesthetic concentrations. It describes the initiation, maintenance and emergence phases of low flow anaesthesia, emphasizing achieving and maintaining an appropriate anaesthetic depth. The document discusses advantages like reduced cost and pollution compared to higher fresh gas flows.
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Anaesthetic management of tracheoesophageal fistula and congenital diaphragmaticIqraa Khanum
The document discusses the anesthetic management of tracheoesophageal fistula (TEF) and congenital diaphragmatic hernia (CDH) in neonates. It covers the embryology, clinical presentation, diagnosis, and preoperative, intraoperative and postoperative anesthetic considerations for repair of each condition. TEF results from imperfect division of the foregut during development, while CDH occurs due to failure of the diaphragm to fully form, allowing abdominal organs to herniate into the chest cavity. Proper management requires careful attention to the neonate's respiratory status and minimizing risks of aspiration or overdistention.
The document discusses the approach to anesthesia for patients with cardiac disease undergoing non-cardiac surgery. It emphasizes the importance of preoperative evaluation and risk stratification to determine the safest anesthetic plan. During surgery, careful monitoring is recommended to detect any deterioration in cardiac function. The appropriate selection of anesthetic drugs and techniques can help minimize stress on the heart. Overall, the key is choosing an anesthetic that provides stability for the patient's cardiac condition.
Anesthesia for coronary artery bypass graftingaparna jayara
Anesthesia for coronary artery bypass grafting (CABG) has evolved significantly since the first open heart surgery in 1952. Key developments include the first successful CABG without bypass in 1961, widespread use of cardiopulmonary bypass in the 1960s-1970s, and the clinical introduction of off-pump CABG and minimally invasive techniques in the late 1990s. CABG is commonly performed for symptomatic multi-vessel coronary artery disease. Precise intraoperative monitoring and optimization of patient comorbidities are important for reducing complications of CABG.
This document discusses anaesthesia considerations for obese patients. It covers physiological disturbances in obese patients that impact anaesthesia like reduced lung volumes, cardiac strain and risk of pulmonary embolism. It recommends pre-operative evaluation, premedication to reduce aspiration risk, induction and maintenance techniques like using ideal body weight for dosing and PEEP to improve oxygenation. Post-operative monitoring is important due to risks of hypoventilation, wound infections and thromboembolic events. Analgesia should be dosed based on ideal body weight and include multimodal options. Safety features of anaesthesia machines like pressure regulators, flow meters and vaporizers are highlighted.
This document discusses strategies for optimizing preoxygenation prior to endotracheal intubation. It notes that conventional preoxygenation techniques provide safe intubation for most ED patients but that a subset may still desaturate. To safely intubate this higher risk group, the document recommends optimizing preoxygenation through techniques like non-invasive ventilation, apneic oxygenation through nasal cannula, positioning patients in a head-up position, and breaking the sequence of rapid sequence intubation administration. The goal is to prevent deoxygenation and extend the safe apneic period for patients undergoing endotracheal intubation.
Low flow anaesthesia systems aim to reuse exhaled gases and minimize fresh gas flow. John Snow recognized in 1850 that most inhaled anaesthetics are exhaled unchanged, and rebreathing exhaled gases could prolong their effects. Developments over the 20th century led to widespread use of circle absorption systems. Factors like cost and pollution concerns have renewed interest in low flow anaesthesia. It requires a well-functioning circle system, gas monitoring, and attention to factors like circuit volume and gas solubility when initiating and maintaining the desired anaesthetic concentrations with minimal fresh gas flows.
The 2000 ASTM F1850-00 standard states that anesthesia gas supply devices must be designed so that whenever oxygen supply pressure is reduced below the manufacturer's minimum specification, the delivered oxygen concentration does not decrease below 19% at the common gas outlet. The standard also requires alarms to sound within 5 seconds if oxygen supply pressure falls below approximately 200 kPa. Safety features of anesthesia machines include oxygen/nitrous oxide proportioning systems, oxygen failure safety devices, oxygen supply failure alarms, and vaporizer interlocks.
1. Common procedures for treating nephrolithiasis include cystoscopic procedures like ureteroscopy with stone extraction and lithotripsy, as well as extracorporeal shock wave lithotripsy (ESWL) and percutaneous or laparoscopic nephrolithotomy.
2. ESWL uses focused acoustic shockwaves to fragment stones within the kidney without invasive surgery. It is commonly used for stones 4-20mm in size.
3. Radical prostatectomy and cystectomy are major surgeries for urological cancers that require extensive dissection and carry risks of significant blood loss. Robotic assistance and laparoscopic approaches are now commonly used.
This document discusses extracorporeal shock wave lithotripsy (ESWL), a treatment for kidney and ureteral stones. It describes how ESWL works to fragment stones using shock waves, and compares older lithotripters that used water baths to newer generations that do not. It outlines factors affecting successful ESWL treatment and discusses preparations, potential effects of shock waves, and anesthetic considerations and choices for pain management during the procedure.
- Extracorporeal shockwave lithotripsy (ESWL) uses shockwaves to fragment kidney stones noninvasively. It was discovered in the 1980s during military research.
- ESWL uses different generators (electrohydraulic, electromagnetic, piezoelectric) to focus shockwaves on stones. Ultrasound and fluoroscopy are used for imaging. Stone fragmentation occurs through mechanisms like spall fracture and squeezing.
- While usually low risk, ESWL can potentially cause acute extrarenal or renal injuries. Chronic risks include higher blood pressure and stone recurrence. Techniques like adequate anesthesia and coupling aim to optimize outcomes.
This document provides an overview of urolithiasis (urinary stones). It discusses the epidemiology, risk factors, types, pathogenesis, clinical presentation, diagnosis, and management of urinary stones. The main types of stones are calcium oxalate, calcium phosphate, uric acid, infection stones, and cystine stones. Diagnosis involves urinalysis, blood tests, radiography, ultrasound, and CT. Treatment options include medical expulsive therapy, extracorporeal shockwave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and open surgery. Recurrence risks are reduced through lifestyle changes like increased fluid intake and dietary modifications.
Anesthesia for Genitourinary Surgery.pptxTadesseFenta1
This document provides information about anesthesia for genitourinary surgeries and procedures. It discusses considerations for cystoscopy, transurethral resection of the prostate (TURP), lithotripsy, and the lithotomy position. Regional or general anesthesia is typically used depending on the procedure and patient factors. Complications of TURP can include hemorrhage, TURP syndrome from fluid absorption, bladder perforation, hypothermia, septicemia, and disseminated intravascular coagulation. Careful monitoring is important to detect issues like fluid overload and hyponatremia.
Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement...Enrique Moreno Gonzalez
Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS.
TURP is a common procedure to relieve BPH symptoms by resecting prostate tissue. Key considerations for anesthesia include assessing cardiac, respiratory and renal function due to the elderly patient population. Regional anesthesia is preferred to allow early detection of complications like TURP syndrome. Potential intraoperative complications are hypotension, hemorrhage, bladder/capsule perforation, hypothermia, and infection. Careful fluid management and warming are important due to large irrigation fluid volumes.
Transurethral resection of the prostate (TURP) is a common surgery performed to relieve urinary symptoms caused by an enlarged prostate. Regional anesthesia such as spinal anesthesia is generally preferred over general anesthesia for TURP. Key complications during the procedure include hypotension from sympathetic blockade, hemorrhage, perforation of the bladder or prostate capsule, hypothermia from cold irrigation fluids, and potential for developing TURP syndrome from fluid absorption. Careful patient assessment, fluid management, and monitoring are important to help prevent complications during this common urological procedure.
TURP is a procedure to relieve urinary symptoms from an enlarged prostate. It carries risks due to the elderly patient population and long duration. A thorough pre-op assessment helps determine anesthesia technique, with subarachnoid block preferred. Potential complications include hypotension, hemorrhage, bladder perforation, hypothermia, and the rare but serious TURP syndrome caused by excessive fluid absorption. Close monitoring is needed to rapidly identify and treat any issues.
Use focusing Shock Waves to breakdown
a stone into small pieces.
Shock waves are acoustic pulses.
Pass through better in water and solid but
not in air.
Introduce in 1980 by Dornier which is a supersonic aircraft company
The document discusses urolithiasis (urinary tract stones). It defines urolithiasis and describes the types of urinary calculi (stones) that can form. Risk factors that favor stone formation include urinary tract infections, stasis, immobility, hypercalcemia, and hypercalciuria. Stones can cause obstruction of urine flow and symptoms like flank pain, nausea, vomiting and hematuria. Diagnosis involves imaging tests and urine/blood analysis. Treatment includes medical management with fluids, analgesics and dietary changes, as well as surgical procedures like ureteroscopy, ESWL (extracorporeal shock wave lithotripsy), and percutaneous nephrolithotomy to remove
Anesthetic implications of TOTAL HIP REPLACEMENT and TOTAL KNEE Replacement s...Farooq Yadwad
This document provides an overview of anesthetic considerations for total hip and knee replacement surgeries. It discusses the anatomy of the hip and knee joints and their blood supply and innervation. It outlines common patient populations for these surgeries like the elderly and those with osteoarthritis or rheumatoid arthritis. It also discusses challenges like co-morbid conditions and decreased organ function. Finally, it provides details on preoperative optimization and considerations including screening for conditions like MRSA, assessing cardiopulmonary and musculoskeletal function, and managing comorbidities like diabetes, obesity, cardiovascular disease, anemia, malnutrition, tobacco use, and medications.
The document discusses urinary tract stones (calculi) including their formation, types, symptoms, diagnosis, and treatment. Key points:
- Stones form when urinary concentrations of minerals like calcium, oxalate, and uric acid increase.
- Symptoms include sharp pain (renal colic) radiating from the back to the groin as stones pass through the urinary tract.
- Diagnosis involves imaging tests like CT scans, X-rays, and ultrasounds to detect radiopaque stones.
- Treatment depends on stone size but may include shock wave lithotripsy, ureteroscopy, or open surgery to remove stones. Recurrence rates after treatment remain high.
Urinary tract obstruction can damage the kidneys and is a common cause of acute and chronic renal failure. It occurs when urine flow is blocked, elevating pressure in the urinary tract. Early diagnosis and treatment are important to minimize damage. Causes include congenital abnormalities, tumors, infections, stones, and prostate enlargement. Symptoms may include pain, difficulty urinating, and kidney damage leading to fluid and mineral imbalances. Diagnosis involves medical history, physical exam, urine tests, ultrasound, CT, and cystoscopy. Treatment goals are relieving obstruction through drainage or surgery and treating any infections to prevent further kidney damage. Prognosis depends on how much reversible damage has occurred to the kidneys.
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The document discusses various disorders of the genitourinary system including urological obstructions, disorders of the kidney, and disorders of the ureters, urinary bladder and urethra. It covers the etiology, risk factors, clinical presentation, diagnostic evaluation, and management of various conditions like urethral strictures, renal calculi, nephrotic syndrome, acute glomerulonephritis and more. Nursing management is also described which involves monitoring vitals, intake/output, administering medications as ordered, and educating patients.
The ureter is approximately 25-30 cm long and runs from the kidney to the bladder. It can be injured through external trauma, iatrogenic causes, or underlying conditions. Treatment for ureteral injuries depends on the location and severity of the injury. Options include primary repair, ureteroureterostomy, Boari flap, psoas hitch, intestinal interposition, or nephrectomy in some cases. Laparoscopic and robotic techniques are being used more often for ureteral reconstruction. The goal is always to preserve renal function through anatomical reconstruction of the urinary tract.
Hydronephrosis is the dilation of the renal pelvis and calyces caused by urinary outflow obstruction. It can result from anatomical or functional issues anywhere along the urinary tract. Chronic or severe hydronephrosis can lead to permanent kidney damage if not treated. Treatment depends on the cause and severity but may include ureteral stents, percutaneous nephrostomy tubes, or open surgery to bypass or remove the obstruction. The goal is to relieve obstruction and preserve kidney function.
Similar to Eswl, PCNL, MAC, Urological procedures (20)
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
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2. Urolithiasis
ᵹAlthough stone disease is one of the most common afflictions of
modern society, it has been described since antiquity. With
Westernization of global culture, however, the site of stone formation
has migrated from the lower to the upper urinary tract and the disease
once limited to men is increasingly gender blind.
ᵹWith the lifetime prevalence of stone disease estimated at 1% to
15%, varying according to age, gender, race, and geographic location, it
is one of the most common diagnosis a patient presents in a Urology
OPD other than stricture and prostatism.
ᵹRevolutionary advances in the minimally invasive and noninvasive
management of stone disease over the past 2 decades have greatly
facilitated the ease with which stones are removed. However, surgical
treatments do little to alter the course of the disease.
4. HIPPOCRATIC OATH :
“I Will not cut, even for the stone, but leave such
procedures for the practitioners of the craft”
5. ESWL
ᵹEngineers of Dornier Labs, Germany observed that during high
speed flight, shock waves generated by collision with raindrops
caused pitting on the metal surfaces of supersonic aircraft.
ᵹDr. Christian Chaussey and colleagues at Munich, succeeded in
using this principle to treat kidney stones by developing a lithotripsy
machine.
ᵹIt was Feb, 7th 1980 that this machine
was first used successfully for the cause,
and as always, improvements followed
suit.
6. All lithotripters share similar technologic principles in having
three main components:
(1) an energy source,
(2) a system to focus the shock wave; and
(3) fluoroscopy or ultrasound to visualize and localize the
stone in focus.
7. Three different generator types (energy sources) for Shockwave
lithotripsy can be distinguished:-
Electro hydraulic:- First generation lithotriper
Shockwave is generated by an
underwater spark discharge,
which is reflected by an ellipsoid.
Consists of a water bath and a
metal gantry chair.
Posed anaesthetic challenges due to
immersion in water.
Now nearly obsolete.
The second and third-generation lithotripters have evolved
mainly in the direction of multipurpose use, eliminating the
water bath and producing a pain-free lithotripter.
8. ESWL
Electromagnetic:- The shockwave is generated by an electromagnetic
coil, which moves a membrane.
-An acoustic lens system reflects and focuses the shockwave.
-The resulting shock wave is constant.
-The energy is focused to a smaller focal point with higher peak
energy.
Piezoelectric:- Shockwave generated by mechanical deformation of a
piezoelectric crystal.
-The crystals are aligned along spherical dish, which allows the focusing.
-It induces low pain and can be used without any analgosedation.
- The disadvantage is the large diameter of the source and the limited
total energy in the focus.
9. Shock wave generator
Waves travel through water
Body-water interface
Similar impedence
No energy dissipation
Entry surface of stone
Sudden change in impedence
Release compressive energy
Exit surface of the stone
Another impedence change
Shock wave energy released as a blast.
Repeat cycles cause the stone to disintegrate.
10. Classical description
- Patient immersed up to the clavicles, and
- An electrode placed at the base of the tub in an ellipse
- The electric energy creates a spark across the gap
causes
- Generation of a loud noise,
intense heat, and explosive
vaporization of water.
- The sudden expansion of air
bubbles created sets up a
pressure wave (shock wave)
- Focused onto F2 focus
- Exponential reduction in
energy of wave beyond F2.
12. Newer lithotripers
ᵹNewer devices generate shock waves within a “shock tube”
coupled to the body surface with a water cushion.
This eliminates the water bath and all problems associated
with patient immersion in water.
ᵹThey also have decreased power, causing less pain.
ᵹBut by decreasing power, efficiency of stone fragmentation is
reduced. Thus the prevalence of retreatment is higher.
ᵹNewer lithotripters use multifunctional tables that allow other
procedures, such as cystoscopy and stent placement, to be
accomplished without moving the patient off the table.
15. Effects of respiration:-
For shock waves to be most effective, the stone should remain in the
F2 focus during treatment.
Because of movements during respiration..
The stone is likely to move in and out of focus.
To increase the efficacy of the treatment advised techniques are,
- decreased tidal volumes with increased respiratory rates, and
- high-frequency jet ventilation
However, studies in sedated patients with intercostal blocks and local
infiltration anesthesia have documented that stone movement with
spontaneous respiration is mainly restricted to the F2 focal zone
during ESWL.
16. Pain:- The pathogenesis of pain is considered to be multifactorial.
- Both cutenous and visceral nociceptors are involved.
Visceral nociceptors may include periosteal, pleural, peritoneal, and/or
musculoskeletal pain receptors
ᵹVariables associated with pain :
the type of lithotriptor,
size and site of stone burden,
location of the shockwave front,
size of focal zone
shockwave peak pressure,
area of shockwave entry at the skin
17. Physiologic Changes During Immersion Lithotripsy
Cardiovascular changes
-Increase in central blood volume
-Increase in central venous pressure (about 10-14 cm H2O) and
-Increased pulmonary artery pressure.
Weber and colleagues observed that increases in central venous pressure
and pulmonary arterial pressure were directly correlated with the depth
of immersion.
A decrease in cardiac output and an increase in systemic vascular
resistance during immersion lithotripsy under general anesthesia has
been documented, mainly due to the sitting position.
18. Respiratory changes
FRC and vital capacity are reduced by 20% to 30%,
Pulmonary blood flow has been shown to increase, and
tight abdominal straps and the hydrostatic pressure of water on the
thorax impart a characteristic shallow, rapid breathing pattern.
Ventilation-perfusion mismatch and hypoxemia are more likely.
Renal changes
Diuresis, natriuresis, and kaliuresis.
A decrease in antidiuretic hormone and renal prostaglandins occurs.
ᵹThe temperature of the bath water can cause profound changes in
the patient's temperature. This heat transfer is augmented further by
the vasodilation produced by general or epidural anesthesia.
Hypothermia and hyperthermia have been reported.
19. Changes on Immersion during Lithotripsy
Cardiovascular
Increased Central blood volume
Increased Central venous pressure
Increased Pulmonary artery pressure
Respiratory
Increased Pulmonary blood flow
Decreased Vital capacity
Decreased Functional residual capacity
Decreased Tidal volume
Increased Respiratory rate
20. ᵹFor effective stone disintegration, shock waves should reach the stone
unimpeded. Nephrostomy dressings be removed and Epidural and
nephrostomy catheters be taped clear of the blast path.
ᵹAlthough shock waves pass through most tissues relatively
unimpeded, they do cause tissue injury
- Skin bruising and
- Flank ecchymoses are common at the entry site.
- Painful hematoma in the flank muscles may occur.
- Hematuria is almost always present and results from shock wave–
induced endothelial injury to the kidney and ureter.
ᵹAdequate hydration is necessary to prevent clot retention.
21. ᵹLung tissue is especially susceptible to injury by shock waves.
Air trapped in alveoli presents the classic water (tissue)-air interface to the
shock wave and causes dissipation of energy with alveolar rupture and
hemoptysis.
Styrofoam sheet or Styrofoam board be placed under the back in children
to shield the lung bases from shock waves during ESWL.
ᵹMechanical stress on the conduction system exerted by the shock waves
may lead to arrhythmia, although rarely now-a-days.
ᵹBrachial plexus injuries have also occurred from improper positioning of
patients in the lithotripter chair.
22. Anaesthetic Management
Anesthetic regimens used successfully for lithotripsy
include
General anesthesia,
Epidural anesthesia,
Spinal anesthesia,
Flank infiltration with or without intercostal
blocks, Analgesia-sedation, including patient-
controlled analgesia.
23. ᵹGeneral Anesthesia:-
Advantages:-
-Rapid onset
-Control of patient movement.
-Ventilation parameters can be controlled decrease
stone movement with respiration, which translates into more effective
stone targeting and fragmentation.
Disadvantage:-
- Morbidity and potential mortality associated with GA
- Longer hospital stay, so expensive
Therefore, GA may be preferred in
- Children,
- Extremely anxious individuals,
- Anticipated lengthy treatment (bilateral
ESWL, concomitant renal and ureteral stones, or calculi composed of
cystine, or brushite).
24. ᵹNeuraxial blockage:-
Epidural anesthesia
Advantage: An awake patient can help with transfers, reducing the
likelihood of injury.
Saline , or only the smallest amount of air necessary should be
injected, for LOR :-
Air in the epidural space provides an interface and causes
dissipation of shock wave energy and local tissue injury.
Neurologic injury has never been seen.
However, increased procedural difficulty and slow onset of
action are the reasons against its use.
25. Spinal anesthesia
Rapid onset, simplicity and routineness of use.
Intrathecal sufentanil is a safer and an effective alternative to
lidocaine, resulting in
- early ambulation and discharge,
- ability to void,
most likely due to preservation of motor and sensory function.
However, its use results in undesirable pruritis .
The incidence of hypotension (the patient is in a sitting
position for treatment) is higher, however. In one series, the incidence of
hypotension with general, epidural, and spinal anesthesia was
13%, 18%, and 27%. Further, recovery is prolonged due to residual
sympathetic blockade.
26. Local anaesthesia
Adequate anesthesia when combined with intravenous sedation and
avoids hypotension.
When given 1-2 min before the procedure in the target area, it
results in better pain control with lesser supplementary analgesia
requirement, thus reducing side effects of the other drugs.
Prilocaine has been used in the form of subcutaneous
infiltration during ESWL. In comparison to lidocaine, it has a
- rapid onset of action,
- equal efficacy, and duration of effect
- with lesser toxic effects due to rapid metabolism.
Patient Controlled Analgesia may be used as well. It is said that PCA
provides a better compliance of treatment to the urosurgeons.
27. The EMLA cream : Used as an occlusive dressing
It can penetrate to a depth of 4 mm after 60 mins of application.
It reportedly reduces opioid requirement by 23% during ESWL
performed with newer lithotriptors.
However, its own analgesic effect is inefficient.
Recently, the use of dimethyl sulfoxide (DMSO) in
combination with lidocaine has been reported to provide better pain
control during ESWL as compared to EMLA cream, due to
- local anesthetic effect along with
- diuretic,
- anti-inflammatory,
- muscle relaxant, and
- hydroxyl radical scavenger effects of DMSO.
28. ᵹMonitored Anaesthesia Care: -
The anesthesiologist is in control of the patient's vital signs and is
available to administer anesthetics and provide other medical care as
appropriate.
ᵹThe fentanyl-propofol combination has been proven as an effective
IV analgesic option.
Adverse effects:
- centrally mediated respiratory depression along with
decrease in oxygen saturation,
- nausea, vomiting, drowsiness, and hypersensitivity
reactions.
Therefore, regular oxygen saturation measurement is
necessary, especially when this drug is used along with sedatives in
ESWL.
29. - Both remifentanil and sufentanil have been found to be of equal
efficacy with regards to analgesia, and patient's and surgeon's satisfaction
during ESWL.
Remifentanil has a short elimination half-life and a rapid analgesic
action.
- Lesser respiratory depression, nausea, and vomiting.
- It can be safely used in clinically significant hepatic or renal diseases.
- During MAC, this drug can be used as intermittent bolus doses or as a
continuous IV infusion as total intravenous anesthesia (TIVA) or as a
combination of the two.
However, all techniques of MAC require active patient monitoring during
and after the procedure for the potential adverse effects of opioid
usage, especially respiratory depression, postoperative
nausea, vomiting, and dizziness.
30. The ideal analgesia, which offers pain-free treatment, minimal
side effects, and adequate cost-effectiveness, remains to be established.
Combination therapy (oral NSAID and occlusive dressing of
EMLA, DMSO with lidocaine) offers an effective alternative mode for
achieving analgesia with minimal morbidity. This therapy avoids the
need for general anesthesia, injectable analgesics, and opioids along
with their side effects
However, any titrated, and well controlled
anaesthetic approach will always be better than A “Hit-and-
Trial” analgesia by the Urosurgeons.
31.
32. ᵹThomas Hillier in 1865 : first therapeutic
percutaneous nephrostomy
ᵹHillier: repeatedly aspirated the hydronephrotic
kidney of a young boy for symptom relief.
ᵹGoodwin and colleagues 1955: published their landmark report on
therapeutic percutaneous nephrostomy.
ᵹFernström and Johansson (1976): Percutaneous removal of renal
calculi.
33. TECHNIQUE
Access Removal
ᵹAccess: Fluoroscopic or ultrasonic control required.
ᵹGenerally through a lateral calyx, one of the lower polar calyces
in most instances.
ᵹApproach through the upper polar calyces is useful for access to
the pelvis and UPJ, but the risk of pleural injury is significantly
increased.
34. An 18--gauge needle is placed through the flank into the kidney
A guide wire of .035 or .038 size is passed through the needle.
The tract is enlarged by passing serial or telescopic Teflon or
metal dilators co-axially over the guide wire.
Amplatz sheath is passed over the last dilator,
The nephroscope is passed through
the sheath to visualize the inside of the
collecting system.
35. Stone Removal
Small stones can be removed intact with forceps or basket.
For Larger ones, Lithotripsy is required
Stone removal continues until the patient
is free of stone or until it is necessary to
stop the procedure.
Common reasons for this include
progressive bleeding and
extravasation of irrigating fluid.
Ultrasonic
Pneumatic
Electro-hydraulic
36. ᵹ. If the patient is not free of stone at the termination of the
procedure, the nephroscope can safely be reinserted through the
same tract after 48 hours.
ᵹAt the end of the procedure, a nephrostomy tube is placed
through the tract into the collecting system, large enough to
maintain an adequate tract to permit blood and clots to drain
readily.
37. -: Anaesthesia Considerations:-
ᵹPractically all varieties of anaesthesia techniques have been
successfully used ranging from General anaesthesia to local
infiltration with sedation.
ᵹPatient position: Usually prone position. In anesthetized
patients, it has advantages over the supine position with regard to
lung volumes and oxygenation without adverse effects on
mechanics, including obese and pediatric patients.
ᵹGA offers an advantage that the respiratory movements of the
patient may be synchronized with the procedure, so easing out
the surgeons job.
38. -: Anaesthesia Considerations:-
Regional Anesthesia: -
- The first description of PCNL with regional anesthesia was reported in
1988; The authors described 112 patients who underwent percutaneous
renal surgery with epidural anesthesia. Hemodynamic and respiratory
parameters were satisfactory in 88% of the cases.
- In 1991, Saied and colleagues found that an interpleural block produced
a totally pain-free operation and necessitated less frequent
administration in the postoperative period.
- General anesthesia can be a challenging in some situations such as
PCNL for staghorn calculi, because of the possibility of fluid absorption
and electrolyte imbalance. Therefore, regional anesthesia may be a good
alternative.
39. -: Anaesthesia Considerations:-
- In 2005, Singh and coworkers reported tubeless PCNL under
regional anesthesia. They considered that by omission of the
percutaneous nephrostomy tube and adopting regional (spinal
low-dose anesthesia, low-dose bupivacaine plus fentanyl) in place
of general anesthesia in selected patients, one may further reduce
the morbidity without compromising effectiveness and safety.
- Salonia and colleagues found that epidural anesthesia allowed
good muscle relaxation and a successful surgical outcome in these
patients. Moreover, it resulted in less intra-operative blood
loss, less postoperative pain, and a faster postoperative recovery
than general anesthesia.
40. Fluid management is important.
ᵹDuring nephroscopy procedures, continuous irrigation of fluid
through the endoscope is necessary to prevent blood and debris
from obscuring the surgeon's vision.
If a significant discrepancy exists between the amount of
irrigating fluid infused and output from the patient, then
clinical evaluation of the patient for extravasation of irrigation
fluid into the retroperitoneal, intraperitoneal, intravascular, or
pleural spaces is warranted.
ᵹIntravenous absorption of irrigation fluid can create a situation
similar to that seen with TUR syndrome, in which electrolyte
abnormalities and fluid overload can occur.
42. ᵹCarried out as Ambulatory cases.
ᵹBenefits of Ambulatory Surgery
- Patient preference, especially children and the elderly
- Lack of dependence on the availability of hospital beds
- Greater flexibility in scheduling operations
- Low morbidity and mortality
- Lower incidence of infection
- Lower incidence of respiratory complications
- Higher volume of patients (greater efficiency)
- Shorter surgical waiting lists
- Lower overall procedural costs
- Less preoperative testing and postoperative medication
43. Pre-Operative management
Minimize patient anxiety by using both pharmacologic (e.g., benzodiazepines)
and nonpharmacologic (e.g., relaxation therapies) approaches.
Patients should be encouraged to continue all their chronic medications up to
the time that they arrive at the surgery center. Oral medications can be taken
with a small amount of water up to 30 minutes before surgery.
NPO guidelines
Prolonged fasting does not guarantee an empty stomach at the time of
induction.
Due to short half-life of clear fluids in the stomach (10-20 minutes), residual
gastric volume after 2 hours is less in patients ingesting small amounts of clear
fluids than in fasted patients.
Furthermore, the ingestion of 150 mL of either coffee or orange juice 2 to 3
hours before induction of anesthesia had no significant effect on residual
gastric volume or pH even in obese adults.
Thus, arbitrary restrictions prohibiting outpatients from drinking
fluids on the day of surgery are completely unwarranted.
44. Basic Anesthetic Techniques
Quality, safety, efficiency, and the cost of drugs and equipment are all
important considerations in choosing an anesthetic technique for ambulatory
surgery.
The ideal outpatient anesthetic should:-
‐ Have a rapid and smooth onset of action,
‐Produce intraoperative amnesia and analgesia,
‐provide optimal surgical conditions and adequate muscle relaxation with a
short recovery period and
‐ no adverse effects in the postdischarge period.
45. General Anaesthesia
ᵹThe ability to deliver a safe and cost-effective general anesthetic with minimal
side effects and rapid recovery is critical in a busy outpatient surgery unit.
ᵹDespite a higher incidence of side effects than local or regional
anesthesia, general anesthesia remains the most widely used anesthetic
technique for ambulatory surgery.
ᵹTracheal intubation causes a more frequent incidence of postoperative
airway-related complaints, including sore throat, croup, and hoarseness than a
facemask or laryngeal mask airway (LMA). Most outpatients undergoing
superficial procedures under general anesthesia do not require tracheal
intubation unless they are at an increased risk for aspiration.
ᵹWhen compared with a facemask and oral airway, patients with an LMA had
fewer desaturation episodes, fewer intraoperative airway manipulations, and
fewer difficulties in maintaining a patent airway.
46. ᵹPreMedication :- A Combination of a short acting benzodiazepine with an
anticholinergic is usually preferred. An additional agent for preemptive
analgesia may be added as per doctors preference.
ᵹFor induction, the available options are
- Barbiturates
- Benzodiazepines
- Etomidate
- Ketamine
- Propofol
- Inhaled agents.
Propofol is the most favored agent. It has quick onset of induction, superior
and fast recovery, minimal post operative side effects, no PONV and no
residual effects.
Inhaled agents are as good choices. Changes in the depth of anesthesia can
be achieved readily because of the rapid uptake and elimination of these
anesthetics. The rapid elimination of anesthetic vapors also provides for fast
recovery and potentially earlier discharge from the outpatient facility.
51. Contraindications to Outpatient Surgery
1. Potentially life-threatening chronic illnesses (e.g., brittle
diabetes, unstable angina, symptomatic asthma)
2. Morbid obesity complicated by symptomatic cardiorespiratory
problems (e.g., angina, asthma)
3. Multiple chronic centrally active drug therapies (e.g., use of
monoamine oxidase inhibitors) and/or active cocaine abuse
4. Ex-premature infants less than 60 weeks’ postconceptual age
requiring general endotracheal anesthesia
5. No responsible adult at home to care for the patient on the
evening after surgery
52. ᵹMiller’s Anaesthesia, 7th edition
ᵹEndourology and stone disease.
Results and Complications of Spinal Anesthesia inPercutaneous
Nephrolithotomy by Sadrollah Mehrabi, Kambiz Karimzadeh Shirazi..
ᵹJournal of Endourology, Volume 23, Number 11, November 2009.
Percutaneous Nephrolithotomy Under General Versus Combined
Spinal-Epidural Anesthesia
ᵹClinical anaesthesia by Barash, Cullen and Stoelting.
ᵹhttp://www.nysora.com/peripheral_nerve_blocks/nerve_stimulator_t
echniques/3095-obturator-nerve-block.html
ᵹhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684259/
(Indian Journal Of Urology - Analgesia for pain control during
extracorporeal shock wave lithotripsy: Current status)