The document discusses standards of post-anesthesia care in the post-anesthesia care unit (PACU), including continually monitoring patients' vital signs, oxygenation, and level of consciousness. It also covers potential physiological disorders that can manifest in the PACU, such as respiratory complications, hemodynamic instability, and residual neuromuscular blockade. Guidelines for safe discharge from the PACU include using standardized scoring systems to evaluate patients' status and readiness for discharge.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
This document discusses anesthesia considerations for procedures performed outside the operating room. It notes that the number and complexity of such procedures has increased, bringing additional responsibilities for anesthesiologists. Special challenges include limited space, equipment, and support staff unfamiliar with patient management. Proper equipment, monitoring, and planning are important when providing anesthesia or sedation in remote locations. The document discusses various locations like radiology suites, specific procedures like ECT, and choices of anesthetic agents and techniques. Patient safety is the top priority for remote location anesthesia.
Delayed recovery from anesthesia can have multiple contributing factors and causes. It is important to consider potential drug interactions, metabolic abnormalities, and organic causes that may cause prolonged unconsciousness and have serious health implications. Signs and symptoms of metabolic issues may not present normally in an anesthetized patient. The Glasgow Coma Scale provides an objective measure of conscious state regardless of cause.
Anaesthetic considerations in cardiac patients undergoing nonomar143
1. The document discusses the perioperative management of patients with ischemic heart disease (IHD) and risk of perioperative myocardial infarction.
2. It defines myocardial ischemia and infarction and describes different types of angina and acute coronary syndromes.
3. The preoperative evaluation involves assessing cardiac history and risk factors, examination, investigations, and risk stratification to guide medical optimization and potential revascularization before elective surgery.
Postoperative vision loss (POVL) is an uncommon complication associated with nonocular surgeries like cardiac surgery and spine surgery done in the prone position. It results from ischemia to the visual pathway, particularly the optic nerve and retina, which receive their blood supply from the ophthalmic artery. The posterior portion of the optic nerve is more susceptible due to less vascular supply. Causes of POVL include ischemic optic neuropathy, central retinal artery occlusion, cortical blindness, and posterior reversible encephalopathy syndrome. Risk factors for POVL after cardiac and spine surgery include low hematocrit, vascular disease, long bypass or surgery time, blood transfusions, and direct eye compression during prone positioning. Prevention strategies focus on maintaining adequate hematocrit,
Post anesthesia care unit for Residents of Anesthesiamansoor masjedi
The document discusses the post anesthesia care unit (PACU). It provides standards for PACU including that all patients receiving anesthesia should receive post-anesthesia management in the PACU. Upon arrival in the PACU, patients should be re-evaluated and the nurse provided a verbal report. Patients should be continually evaluated in the PACU and a physician is responsible for discharging the patient. The document discusses various early postoperative physiologic changes that can occur including hypoxia, hypothermia, shivering, and cardiovascular instability. It focuses on issues like upper airway obstruction from loss of muscle tone and potential residual neuromuscular blockade.
Laryngectomy involves removing the larynx and parts of the trachea for laryngeal cancer. It requires a team approach and optimizing cardiac, respiratory, and nutritional status preoperatively. The procedure involves creating a permanent tracheostomy and repairing the pharynx. Postoperatively, careful monitoring of the airway, ventilation, nutrition, and rehabilitation is needed.
This document discusses anaesthetic considerations for morbidly obese patients undergoing non-bariatric surgery. Key points include:
1. Morbid obesity is associated with increased risks for the cardiovascular, respiratory, gastrointestinal and other body systems. It can make airway management more difficult and increase postoperative complications.
2. A thorough pre-anaesthetic assessment is important to evaluate co-morbidities and challenges like reduced lung function. Airway evaluation helps predict intubation difficulty.
3. Techniques like awake fiberoptic intubation and rapid sequence induction may be considered. Maintaining oxygenation during intubation in this high risk group is critical. Close monitoring is needed during and after surgery due to respiratory and
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
This document discusses anesthesia considerations for procedures performed outside the operating room. It notes that the number and complexity of such procedures has increased, bringing additional responsibilities for anesthesiologists. Special challenges include limited space, equipment, and support staff unfamiliar with patient management. Proper equipment, monitoring, and planning are important when providing anesthesia or sedation in remote locations. The document discusses various locations like radiology suites, specific procedures like ECT, and choices of anesthetic agents and techniques. Patient safety is the top priority for remote location anesthesia.
Delayed recovery from anesthesia can have multiple contributing factors and causes. It is important to consider potential drug interactions, metabolic abnormalities, and organic causes that may cause prolonged unconsciousness and have serious health implications. Signs and symptoms of metabolic issues may not present normally in an anesthetized patient. The Glasgow Coma Scale provides an objective measure of conscious state regardless of cause.
Anaesthetic considerations in cardiac patients undergoing nonomar143
1. The document discusses the perioperative management of patients with ischemic heart disease (IHD) and risk of perioperative myocardial infarction.
2. It defines myocardial ischemia and infarction and describes different types of angina and acute coronary syndromes.
3. The preoperative evaluation involves assessing cardiac history and risk factors, examination, investigations, and risk stratification to guide medical optimization and potential revascularization before elective surgery.
Postoperative vision loss (POVL) is an uncommon complication associated with nonocular surgeries like cardiac surgery and spine surgery done in the prone position. It results from ischemia to the visual pathway, particularly the optic nerve and retina, which receive their blood supply from the ophthalmic artery. The posterior portion of the optic nerve is more susceptible due to less vascular supply. Causes of POVL include ischemic optic neuropathy, central retinal artery occlusion, cortical blindness, and posterior reversible encephalopathy syndrome. Risk factors for POVL after cardiac and spine surgery include low hematocrit, vascular disease, long bypass or surgery time, blood transfusions, and direct eye compression during prone positioning. Prevention strategies focus on maintaining adequate hematocrit,
Post anesthesia care unit for Residents of Anesthesiamansoor masjedi
The document discusses the post anesthesia care unit (PACU). It provides standards for PACU including that all patients receiving anesthesia should receive post-anesthesia management in the PACU. Upon arrival in the PACU, patients should be re-evaluated and the nurse provided a verbal report. Patients should be continually evaluated in the PACU and a physician is responsible for discharging the patient. The document discusses various early postoperative physiologic changes that can occur including hypoxia, hypothermia, shivering, and cardiovascular instability. It focuses on issues like upper airway obstruction from loss of muscle tone and potential residual neuromuscular blockade.
Laryngectomy involves removing the larynx and parts of the trachea for laryngeal cancer. It requires a team approach and optimizing cardiac, respiratory, and nutritional status preoperatively. The procedure involves creating a permanent tracheostomy and repairing the pharynx. Postoperatively, careful monitoring of the airway, ventilation, nutrition, and rehabilitation is needed.
This document discusses anaesthetic considerations for morbidly obese patients undergoing non-bariatric surgery. Key points include:
1. Morbid obesity is associated with increased risks for the cardiovascular, respiratory, gastrointestinal and other body systems. It can make airway management more difficult and increase postoperative complications.
2. A thorough pre-anaesthetic assessment is important to evaluate co-morbidities and challenges like reduced lung function. Airway evaluation helps predict intubation difficulty.
3. Techniques like awake fiberoptic intubation and rapid sequence induction may be considered. Maintaining oxygenation during intubation in this high risk group is critical. Close monitoring is needed during and after surgery due to respiratory and
The document discusses the history and importance of post-anesthesia care units (PACUs) and outlines their design, equipment, staffing needs, and standard procedures for patient care and monitoring. Key aspects of PACU care include criteria for patient transfer from the operating room to PACU, routine post-anesthesia monitoring and treatment, potential post-operative complications, discharge criteria, and scoring systems used to evaluate patient recovery status.
1. Anesthesia for spine surgery presents several challenges including patient positioning, increased blood loss, and spinal cord protection.
2. Pre-operative assessment focuses on airway evaluation, neurological and cardiovascular status, and determining risk factors for complications.
3. During surgery, careful positioning, maintenance of stable anesthesia and hemodynamics, and monitoring for changes like abnormal SSEPs are important considerations.
4. Post-operative care involves managing pain, monitoring for complications, and addressing issues like respiratory function, neck edema, and injury risks from prolonged prone positioning.
1) Airway management is challenging in patients with cervical spine injuries or trauma due to the risk of worsening spinal injuries during intubation attempts. 2) Manual in-line stabilization is the preferred technique for intubating these patients to minimize head and neck movement, but it can impair the laryngoscopic view and increase intubation difficulties. 3) Awake fiberoptic intubation allows for intubation without cervical spine movement but requires patient cooperation. Overall the goal is to secure the airway while preventing further cervical spine injury.
Dr. Kumar presented on extubation problems and their management. Some key points:
1. Tracheal extubation requires careful planning and preparation to prevent complications like laryngospasm, laryngeal edema, and pulmonary aspiration.
2. Patients should generally be extubated awake to allow for airway protection, but deep extubation may be considered to reduce cardiovascular stimulation.
3. Potential problems include mechanical issues removing the tube, cardiovascular changes, respiratory complications, and airway obstruction. Management depends on the specific issue but may include medications, positioning, or alternative extubation techniques.
4. Careful evaluation of each patient's risk factors and planning is necessary to safely perform extubation and prevent
The document discusses sedation, analgesia, and paralysis in the ICU. It describes the goals of sedation as patient comfort while allowing interaction. The challenges include assessing sedation and altered drug pharmacology. An ideal sedation agent would have rapid onset and offset and lack respiratory depression. Monitoring scales like the Richmond Agitation Scale are used to standardize treatment. Dexmedetomidine, propofol, opioids and paralytics may be used. The optimal sedation approach balances adequate treatment while avoiding oversedation risks.
Anesthetic Management of Nasopharyngeal Angiofibroma Resection with Carotid I...Carlos D A Bersot
This document describes the anesthetic management of a 13-year-old patient undergoing resection of a nasopharyngeal angiofibroma tumor invading the carotid artery and facial sinuses. Key aspects included:
1) Preoperative embolization of feeding arteries to reduce bleeding risk.
2) Intraoperative profuse bleeding requiring massive transfusion during tumor resection near the ethmoid cells.
3) A long 9-hour procedure with careful hemodynamic management and volume resuscitation.
4) Postoperative tracheostomy to protect the airway given risk of edema from surgical manipulation.
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.
AN UNUSUAL CAUSE OF DELAYED RECOVERY FROM NEUROMUSCULAR PARALYSIS DURING GENE...Ankit Raiyani
1) A 38-year-old woman experienced delayed recovery from neuromuscular paralysis during general anesthesia for surgery. She was unable to be extubated for 8 hours after surgery despite being conscious and having normal vital signs and metabolic function.
2) Tests revealed she had a pseudocholinesterase deficiency, which causes slower breakdown of neuromuscular blocking drugs like succinylcholine. This deficiency can be inherited and explains her prolonged paralysis after receiving these drugs during anesthesia.
3) Pseudocholinesterase deficiency is a rare but important cause of delayed recovery that requires prolonged mechanical ventilation. Identifying the deficiency prevented use of medications that could prolong paralysis in the future.
The document discusses cricoid pressure, which was first described in 1774 and popularized in 1961 as a way to prevent regurgitation during anesthesia induction. It examines the controversies around cricoid pressure, including whether it truly occludes the esophagus, causes airway problems, and reduces regurgitation. While early studies on cadavers seemed to validate it, more recent reviews find little evidence that it is effective or that not using it increases risk. Proper application is also inconsistent. The risks and benefits must be weighed for each patient, and strategies may need to change during difficult intubations to prioritize ventilation and gas exchange over cricoid pressure.
The document discusses anesthesia considerations for orthopedic joint replacement surgeries, which are commonly performed in elderly patients. It outlines various challenges in caring for geriatric patients including co-morbidities and decreased organ function. However, improvements in monitoring, techniques, analgesia, and early mobilization have led to better outcomes. The document compares regional versus general anesthesia and discusses intraoperative concerns like blood loss, hypotension from bone cement, and fat embolism. Postoperative concerns include pain, delirium, hypoxemia, and infection risk, emphasizing the need for multimodal pain control and early mobilization.
Post operative care complication managementAftab Hussain
This document discusses standards of care for post-anesthesia care units (PACUs). It provides guidelines for monitoring patients, staffing PACUs appropriately, locating PACUs near operating rooms, and equipping PACUs with necessary medical equipment. Common complications in the PACU like pain, nausea, and respiratory issues are also reviewed. Optimal methods for pain management are outlined, including patient-controlled analgesia, regional techniques like epidurals, and multimodal analgesia.
Negative pressure pulmonary edema (NPPE) or postobstruction pulmonary edema (POPE) is a clinical entity of great relevance in anesthesiology and intensive care. The presentation of NPPE can be immediate or delayed, which therefore necessitates immediate recognition and treatment by anyone directly involved in the perioperative care of a patient.
Anaesthesia for cardiopulmonary bypass surgery [autosaved]Nida fatima
This document discusses cardiopulmonary bypass (CPB), which involves diverting blood away from the heart and through an external circuit that oxygenates the blood and returns it to the body. CPB allows surgery to be performed on an unbeating heart while still providing circulation. The key components of a CPB machine and roles of the perfusionist in managing it are described. Steps in CPB like priming, hypothermia, myocardial preservation via cardioplegia, and monitoring techniques are summarized.
Bronchial asthma and COPD are chronic respiratory conditions characterized by airway inflammation and obstruction. Bronchial asthma involves reversible airflow limitation due to bronchospasm while COPD involves irreversible airflow limitation from lung damage. Key differences are that asthma typically presents earlier in life and has a family history, while COPD is mainly caused by smoking. Preoperative treatment aims to prevent bronchospasm during anesthesia and surgery by optimizing lung function and suppressing airway reflexes.
This document discusses the management of sedation and analgesia for critically ill patients on mechanical ventilation. It outlines 8 steps: 1) identifying the need for sedation/analgesia, 2) considering commonly used agents, 3) choosing an appropriate agent based on factors like indications and patient needs, 4) assessing pain, sedation, and delirium using scales, 5) titrating medications to target levels on scales, 6) doing daily awakening trials, 7) weaning from sedation/analgesia as patients improve, and 8) reversing oversedation if needed using agents like flumazenil or naloxone. The goal is to provide adequate pain control and sedation while minimizing risks and facilitating
Anesthesia consideration in intestinal obstruction is gastric aspiration, rapid sequence induction, electrolyte and acid base disorder, hydration, AKI and hemodynamic status.
Anesthesia For Congenital Diaphragmatic Herniakrishna dhakal
This document discusses congenital diaphragmatic hernia (CDH), a birth defect where organs protrude into the chest cavity due to a hole in the diaphragm. It covers the embryology, pathophysiology, diagnosis, and management of CDH. Surgical repair is the only treatment, but stabilization of the patient's respiratory and general status is needed first. Extracorporeal membrane oxygenation (ECMO) has improved survival for CDH. Long-term follow up is also important due to potential complications. A regional anesthesia method without opioids allowed early operating room extubation for CDH repair in one study.
The document discusses post-extubation stridor, which is upper airway obstruction that can occur after a patient is extubated from a ventilator. It defines post-extubation stridor and reviews risk factors such as duration of intubation and cuff pressures. The cuff leak test is presented as a way to identify patients at risk. Studies are reviewed showing steroids given before extubation can reduce the risk of stridor. Clinically, it recommends identifying at-risk patients, performing the cuff leak test, and considering steroid treatment for high-risk patients before extubation.
This document discusses considerations for anaesthetists regarding patients with epilepsy. It notes that anaesthetists should be concerned about potential drug interactions, predisposition to seizures during surgery, and certain anaesthetic drugs having epileptogenic properties. It then covers classifications of seizures, diagnostic investigations like EEG and MRI, medical and surgical management options, the pharmacophysiology of epilepsy treatment, preferred anti-epileptic drugs, status epilepticus, and surgical options. It concludes with specific considerations for various anaesthetic drugs and muscle relaxants regarding their propensity to cause seizures.
The PACU is designed to monitor and care for patients recovering from anesthesia and surgery. Specially trained nurses make up the PACU staff and are skilled in recognizing postoperative complications. When patients arrive, pertinent medical details are provided. Vital signs are closely monitored including oxygenation, ventilation, circulation, consciousness and temperature. Standards require appropriate post-anesthesia management and evaluation until patients are no longer at risk for complications before discharge from the PACU. Common complications include PONV, upper airway obstruction, hypoxemia, hypertension, hypotension, and delirium.
Daycare surgery involves operations where the patient is discharged on the same day. General anaesthesia is commonly used, while central neuraxial blocks are discouraged due to delayed discharge from motor block. Local and plexus blocks are good options. Anaesthetic goals include smooth onset, adequate intraoperative analgesia/amnesia, and rapid recovery. Common daycare surgeries include hernia repair, hemorrhoidectomy, laparoscopic procedures, otoplasty, and cystoscopy. Monitored anaesthesia care involves anaesthesiologist oversight during planned procedures. Non-operating room anaesthesia presents challenges due to unfamiliar environments but can be addressed through thorough patient evaluation, appropriate monitoring, and careful planning for procedures such as cardiac catheter
The document discusses the history and importance of post-anesthesia care units (PACUs) and outlines their design, equipment, staffing needs, and standard procedures for patient care and monitoring. Key aspects of PACU care include criteria for patient transfer from the operating room to PACU, routine post-anesthesia monitoring and treatment, potential post-operative complications, discharge criteria, and scoring systems used to evaluate patient recovery status.
1. Anesthesia for spine surgery presents several challenges including patient positioning, increased blood loss, and spinal cord protection.
2. Pre-operative assessment focuses on airway evaluation, neurological and cardiovascular status, and determining risk factors for complications.
3. During surgery, careful positioning, maintenance of stable anesthesia and hemodynamics, and monitoring for changes like abnormal SSEPs are important considerations.
4. Post-operative care involves managing pain, monitoring for complications, and addressing issues like respiratory function, neck edema, and injury risks from prolonged prone positioning.
1) Airway management is challenging in patients with cervical spine injuries or trauma due to the risk of worsening spinal injuries during intubation attempts. 2) Manual in-line stabilization is the preferred technique for intubating these patients to minimize head and neck movement, but it can impair the laryngoscopic view and increase intubation difficulties. 3) Awake fiberoptic intubation allows for intubation without cervical spine movement but requires patient cooperation. Overall the goal is to secure the airway while preventing further cervical spine injury.
Dr. Kumar presented on extubation problems and their management. Some key points:
1. Tracheal extubation requires careful planning and preparation to prevent complications like laryngospasm, laryngeal edema, and pulmonary aspiration.
2. Patients should generally be extubated awake to allow for airway protection, but deep extubation may be considered to reduce cardiovascular stimulation.
3. Potential problems include mechanical issues removing the tube, cardiovascular changes, respiratory complications, and airway obstruction. Management depends on the specific issue but may include medications, positioning, or alternative extubation techniques.
4. Careful evaluation of each patient's risk factors and planning is necessary to safely perform extubation and prevent
The document discusses sedation, analgesia, and paralysis in the ICU. It describes the goals of sedation as patient comfort while allowing interaction. The challenges include assessing sedation and altered drug pharmacology. An ideal sedation agent would have rapid onset and offset and lack respiratory depression. Monitoring scales like the Richmond Agitation Scale are used to standardize treatment. Dexmedetomidine, propofol, opioids and paralytics may be used. The optimal sedation approach balances adequate treatment while avoiding oversedation risks.
Anesthetic Management of Nasopharyngeal Angiofibroma Resection with Carotid I...Carlos D A Bersot
This document describes the anesthetic management of a 13-year-old patient undergoing resection of a nasopharyngeal angiofibroma tumor invading the carotid artery and facial sinuses. Key aspects included:
1) Preoperative embolization of feeding arteries to reduce bleeding risk.
2) Intraoperative profuse bleeding requiring massive transfusion during tumor resection near the ethmoid cells.
3) A long 9-hour procedure with careful hemodynamic management and volume resuscitation.
4) Postoperative tracheostomy to protect the airway given risk of edema from surgical manipulation.
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.
AN UNUSUAL CAUSE OF DELAYED RECOVERY FROM NEUROMUSCULAR PARALYSIS DURING GENE...Ankit Raiyani
1) A 38-year-old woman experienced delayed recovery from neuromuscular paralysis during general anesthesia for surgery. She was unable to be extubated for 8 hours after surgery despite being conscious and having normal vital signs and metabolic function.
2) Tests revealed she had a pseudocholinesterase deficiency, which causes slower breakdown of neuromuscular blocking drugs like succinylcholine. This deficiency can be inherited and explains her prolonged paralysis after receiving these drugs during anesthesia.
3) Pseudocholinesterase deficiency is a rare but important cause of delayed recovery that requires prolonged mechanical ventilation. Identifying the deficiency prevented use of medications that could prolong paralysis in the future.
The document discusses cricoid pressure, which was first described in 1774 and popularized in 1961 as a way to prevent regurgitation during anesthesia induction. It examines the controversies around cricoid pressure, including whether it truly occludes the esophagus, causes airway problems, and reduces regurgitation. While early studies on cadavers seemed to validate it, more recent reviews find little evidence that it is effective or that not using it increases risk. Proper application is also inconsistent. The risks and benefits must be weighed for each patient, and strategies may need to change during difficult intubations to prioritize ventilation and gas exchange over cricoid pressure.
The document discusses anesthesia considerations for orthopedic joint replacement surgeries, which are commonly performed in elderly patients. It outlines various challenges in caring for geriatric patients including co-morbidities and decreased organ function. However, improvements in monitoring, techniques, analgesia, and early mobilization have led to better outcomes. The document compares regional versus general anesthesia and discusses intraoperative concerns like blood loss, hypotension from bone cement, and fat embolism. Postoperative concerns include pain, delirium, hypoxemia, and infection risk, emphasizing the need for multimodal pain control and early mobilization.
Post operative care complication managementAftab Hussain
This document discusses standards of care for post-anesthesia care units (PACUs). It provides guidelines for monitoring patients, staffing PACUs appropriately, locating PACUs near operating rooms, and equipping PACUs with necessary medical equipment. Common complications in the PACU like pain, nausea, and respiratory issues are also reviewed. Optimal methods for pain management are outlined, including patient-controlled analgesia, regional techniques like epidurals, and multimodal analgesia.
Negative pressure pulmonary edema (NPPE) or postobstruction pulmonary edema (POPE) is a clinical entity of great relevance in anesthesiology and intensive care. The presentation of NPPE can be immediate or delayed, which therefore necessitates immediate recognition and treatment by anyone directly involved in the perioperative care of a patient.
Anaesthesia for cardiopulmonary bypass surgery [autosaved]Nida fatima
This document discusses cardiopulmonary bypass (CPB), which involves diverting blood away from the heart and through an external circuit that oxygenates the blood and returns it to the body. CPB allows surgery to be performed on an unbeating heart while still providing circulation. The key components of a CPB machine and roles of the perfusionist in managing it are described. Steps in CPB like priming, hypothermia, myocardial preservation via cardioplegia, and monitoring techniques are summarized.
Bronchial asthma and COPD are chronic respiratory conditions characterized by airway inflammation and obstruction. Bronchial asthma involves reversible airflow limitation due to bronchospasm while COPD involves irreversible airflow limitation from lung damage. Key differences are that asthma typically presents earlier in life and has a family history, while COPD is mainly caused by smoking. Preoperative treatment aims to prevent bronchospasm during anesthesia and surgery by optimizing lung function and suppressing airway reflexes.
This document discusses the management of sedation and analgesia for critically ill patients on mechanical ventilation. It outlines 8 steps: 1) identifying the need for sedation/analgesia, 2) considering commonly used agents, 3) choosing an appropriate agent based on factors like indications and patient needs, 4) assessing pain, sedation, and delirium using scales, 5) titrating medications to target levels on scales, 6) doing daily awakening trials, 7) weaning from sedation/analgesia as patients improve, and 8) reversing oversedation if needed using agents like flumazenil or naloxone. The goal is to provide adequate pain control and sedation while minimizing risks and facilitating
Anesthesia consideration in intestinal obstruction is gastric aspiration, rapid sequence induction, electrolyte and acid base disorder, hydration, AKI and hemodynamic status.
Anesthesia For Congenital Diaphragmatic Herniakrishna dhakal
This document discusses congenital diaphragmatic hernia (CDH), a birth defect where organs protrude into the chest cavity due to a hole in the diaphragm. It covers the embryology, pathophysiology, diagnosis, and management of CDH. Surgical repair is the only treatment, but stabilization of the patient's respiratory and general status is needed first. Extracorporeal membrane oxygenation (ECMO) has improved survival for CDH. Long-term follow up is also important due to potential complications. A regional anesthesia method without opioids allowed early operating room extubation for CDH repair in one study.
The document discusses post-extubation stridor, which is upper airway obstruction that can occur after a patient is extubated from a ventilator. It defines post-extubation stridor and reviews risk factors such as duration of intubation and cuff pressures. The cuff leak test is presented as a way to identify patients at risk. Studies are reviewed showing steroids given before extubation can reduce the risk of stridor. Clinically, it recommends identifying at-risk patients, performing the cuff leak test, and considering steroid treatment for high-risk patients before extubation.
This document discusses considerations for anaesthetists regarding patients with epilepsy. It notes that anaesthetists should be concerned about potential drug interactions, predisposition to seizures during surgery, and certain anaesthetic drugs having epileptogenic properties. It then covers classifications of seizures, diagnostic investigations like EEG and MRI, medical and surgical management options, the pharmacophysiology of epilepsy treatment, preferred anti-epileptic drugs, status epilepticus, and surgical options. It concludes with specific considerations for various anaesthetic drugs and muscle relaxants regarding their propensity to cause seizures.
The PACU is designed to monitor and care for patients recovering from anesthesia and surgery. Specially trained nurses make up the PACU staff and are skilled in recognizing postoperative complications. When patients arrive, pertinent medical details are provided. Vital signs are closely monitored including oxygenation, ventilation, circulation, consciousness and temperature. Standards require appropriate post-anesthesia management and evaluation until patients are no longer at risk for complications before discharge from the PACU. Common complications include PONV, upper airway obstruction, hypoxemia, hypertension, hypotension, and delirium.
Daycare surgery involves operations where the patient is discharged on the same day. General anaesthesia is commonly used, while central neuraxial blocks are discouraged due to delayed discharge from motor block. Local and plexus blocks are good options. Anaesthetic goals include smooth onset, adequate intraoperative analgesia/amnesia, and rapid recovery. Common daycare surgeries include hernia repair, hemorrhoidectomy, laparoscopic procedures, otoplasty, and cystoscopy. Monitored anaesthesia care involves anaesthesiologist oversight during planned procedures. Non-operating room anaesthesia presents challenges due to unfamiliar environments but can be addressed through thorough patient evaluation, appropriate monitoring, and careful planning for procedures such as cardiac catheter
General anesthesia involves inducing a state of unconsciousness through administration of anesthetic agents to provide analgesia, amnesia and muscle relaxation for surgical procedures. It allows treatment of uncooperative patients or those with medical conditions making local anesthesia unsuitable. Proper pre-operative evaluation, monitoring during induction and maintenance of anesthesia, and post-operative care are essential for safe administration of general anesthesia.
The document defines status epilepticus and discusses its treatment. Status epilepticus is traditionally defined as continuous seizure activity lasting over 30 minutes, but the working definition is now 5 minutes to minimize risk. Treatment involves initial stabilization, then 1) benzodiazepines like lorazepam or diazepam, 2) second line drugs like fosphenytoin or valproic acid, and 3) third line anesthetic drugs like midazolam or pentobarbital via infusion if seizures remain uncontrolled. Mechanical ventilation may be needed for airway protection or raised intracranial pressure. The goal is to rapidly control seizures while monitoring for complications.
The document discusses various post-operative complications related to the cardiovascular system (CVS), central nervous system (CNS), and recovery in the post-anesthesia care unit (PACU). Some key points include: common CVS complications are hypotension and hypertension, which can be treated with fluid administration or vasopressors/antihypertensives respectively; arrhythmias are also common after cardiac surgery; common neuropsychiatric complications in PACU include delirium, delayed arousal, and failure to arouse due to various medical causes; and hypothermia is another potential complication addressed by maintaining normothermia.
This document provides guidance on the perioperative management of neurological patients. It discusses special considerations for patients with epilepsy, myasthenia gravis, Parkinson's disease, stroke, dementia and various muscular dystrophies. Key recommendations include continuing antiepileptic drugs up to and after surgery, using nondepolarizing neuromuscular blockers cautiously in myasthenia gravis, continuing dopamine replacement in Parkinson's disease, and postponing elective surgery for at least 3 months following a stroke. Care must be taken to avoid triggers of seizures, myasthenic crisis, and exacerbation of neurological symptoms in the perioperative period.
Clinical use of neuromuscular blocking agents in critically ill patients - NMDAAreej Abu Hanieh
1. Neuromuscular blocking agents (NMBAs) are used in critically ill patients to facilitate intubation, improve oxygenation in acute respiratory distress syndrome (ARDS), and prevent shivering during therapeutic hypothermia after cardiac arrest.
2. NMBAs work by either depolarizing or non-depolarizing the neuromuscular junction. Succinylcholine is the only depolarizing agent used in the US, while rocuronium, vecuronium, and cisatracurium are commonly used non-depolarizing agents.
3. When using NMBAs, patients must be deeply sedated to prevent awareness and monitors like train-of-four must be
General anesthesia involves inducing a state of unconsciousness through medications that provide amnesia, analgesia, muscle paralysis and sedation in order to perform surgical procedures, it has advantages like reducing awareness and allowing procedures of variable duration but also risks like physiological fluctuations and complications from the anesthetic agents, proper pre and post operative nursing management is required to monitor vitals, airway, pain levels, and encourage early mobility.
1. Vascular surgery patients present unique challenges due to multiple comorbidities. Anesthesia aims to provide analgesia, amnesia, and muscle relaxation while minimizing physiologic stress.
2. Regional techniques like epidurals combined with light general anesthesia result in better outcomes for aortic and infrainguinal surgery compared to general anesthesia alone by reducing sympathetic activation.
3. Strict intraoperative monitoring of vital signs, oxygenation, ventilation, and neurologic function is important due to the physiologic perturbations of vascular surgery. Tight glycemic control and maintenance of normothermia and hemostasis also impact outcomes.
This document discusses delayed recovery from anesthesia. It defines recovery as a state of consciousness where the patient is awake and aware of their surroundings. It then outlines several factors that can cause delayed recovery, including patient factors like age, comorbidities, and genetics, as well as drug factors like residual effects of anesthetic agents, drug interactions, and types of anesthetics used. Specific drugs that can cause delayed recovery, like opioids, benzodiazepines, propofol, and muscle relaxants are also discussed. Metabolic causes such as hypoglycemia, hyperglycemia, hyponatremia, hypernatremia, and hypokalemia are covered.
sedation in neuro icu requires frequent interruptions for serial neurological examination. incorporation of inhalational agents in icu improves sedation practices.
status epilepticus is medical emergency ,it can be convulsive or non convulsive
febrile convulsions are the most common provoked seizures in children of age 6 to 60 months
Pheochromocytoma is a catecholamine-secreting tumor that arises from chromaffin tissue in the adrenal medulla or sympathetic ganglia. It presents with a classic triad of severe headaches, diaphoresis, and palpitations. Biochemical testing of urine or plasma is used to diagnose pheochromocytoma. Patients undergo preoperative pharmacological preparation using alpha-blockers to control hypertension. Intraoperatively, antihypertensives like nicardipine and sodium nitroprusside are used. Postoperatively, patients are monitored for rebound hypotension due to decreased catecholamine levels and hypoglycemia in tumors secreting epinephrine. Long-term follow up is needed
This document provides a summary of a patient admitted to the ICU with acute toxic encephalopathy, hypoxic respiratory failure, aspiration pneumonia, acute kidney injury, and rhabdomyolysis due to polysubstance abuse. The patient required intubation. Key points include: sedation goals in the ICU; common sedative medications like fentanyl, propofol, and dexmedetomidine; monitoring tools like RASS; and complications of long-term sedative use. The patient was treated with antibiotics, underwent a liberation trial but had to be reintubated due to worsening hypoxia.
Conscious sedation involves using drugs to induce a state of depressed consciousness while maintaining the patient's ability to respond appropriately to stimulation. It provides advantages for both patients and surgeons by reducing anxiety, pain and recovery time while allowing optimal operating conditions. Common drugs used include opioids, benzodiazepines, propofol and ketamine which provide analgesia, anxiolysis and amnesia. Careful monitoring of vital signs and appropriate precautions are needed, especially in high risk patients. The goal is rapid onset and recovery with minimal side effects.
Sedation monitoring and post sedation recovery and dischargetaem
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2. Post anaesthesia care unit(pacu)
• PACU : also referred as recovery room
• It is designed and staffed to monitor and care for patients who are
recovering from the immediate physiologic effect of anaesthesia and
surgery
• PACU care spans the transition from delivery of anaesthesia in operating
room to less acute monitoring on the hospital ward and in some cases at
home
• Must be equipped to monitor and resuscitate unstable pt. while providing a
comfortable calm tranquil environment for the recovery of stable pt.
• It should be in close proximity with operating room and with easy access of
post operative pt. by anesthesia provider and surgical caregivers
3. Standards of postanesthesia care
• ASA has given 5 standards which can be apply to post anesthesia care in all locations
• STANDARD 1
All pt. who have received GA,RA,or MAC shall receive appropriate
postanesthesia care
• STANDARD 2
✓ A pt.transported to the PACU shall be accompanied by a member of the
anesthesia team who is knowledgeable about the pt. condition
✓ continually evaluated and treated during transport with monitoring and
appropriate support needed
• STANDARD 3
upon arrival in PACU, Pt. shall be re evaluated and a verbal report provided to the responsible pacu
nurse
• STANDARD 4
✓ The patient’s condition shall be evaluated continually in the PACU by the methods appropriate to pt.
medical condition
✓ Particular attention should be given to monitor OXYGENATION, VENTILATION,CIRCULATION,level of
CONSIOUSNESS, and TEMPERATURE
• STANDARD 5
A physician is responsible for the discharge of the patient from the PACU
4. PHASES OF RECOVERY
• Phase 1:
• Immediate recovery phase requires intensive nursing care to detect early
signs of complications
• Receive a complete pt. record from operative room to plan postoperative care
• It is for pt. requiring close monitoring
• Phase 2:
• care of surgical pt. Who has been transferred from phase 1
• Less observation and less nursing care
• Step down or progressive care unit
9. Fast track recovery
• Increased use of short acting drugs
and technique
• Pt. already match the discharge
criteria at the time they reach PACU
• These pt. may bypass phase 1 unit
and go directly to phase 2
10. Physiological disorder manifested in
PACU
❑ Respiratory :
▪ Upper airway obstruction
⮚ Loss of pharyngeal muscle tone
⮚ Residual neuromuscular blockade
⮚ Laryngospasm
⮚ Edema and hematoma
⮚ Obstructive sleep apnea
▪ Arterial hypoxemia
⮚ Ventilation perfusion mismatch
⮚ Alveolar hypoventilation
⮚ Increase venous admixture
⮚ Decreased diffusion capacity
▪ Pulmonary edema
⮚ Post obstructive pulmonary edema
⮚ Transfusion related acute lung injury
12. Physiological disorder manifested in
PACU
❑ Renal
▪ Oliguria
▪ Contrast nephropathy
▪ Intraabdominal hypertension
▪ Rhabdomyolysis
❑ Others
▪ Bleeding
▪ Decreased body temperature
▪ Shivering
▪ Delerium
▪ Delayed awakening
▪ Nausea and vomiting
▪ pain
13. Clinical features:
Clinical features:
• Difficulty in breathing
• Desaturation
• Tachypnoea
• Tracheal tug
• Paradoxical breathing
pattern
• Reduced or absent
breath sounds
Upper airway obstruction…
1. Loss of pharyngeal muscle tone due to residual effects of drugs
Management:
• Head tilt, Jaw thrust
• CPAP with face mask
• Nasopharygeal airway
• Oxygen supplementation
14. Case 2
60year male, 60 kg
PAC: Diabetic controlled with oral hypoglycemics
Airway: WNL
Investigations; Hb 12 gm%,RBS: 122, Hb A1C: 8.2, B U; 52, s.cr..1.8, CXR & ECG ..WNL
For Umbilical hernia repair
GA with endotracheal tube and controlled ventilation
Induction: Propofol, fentanyl, rocuronium
Maintenance: O2 + N2O+ Isoflurane with boluses of rocuronium
Uneventful surgery….duration 75 minutes
Reversal: Glyco 0.6 mg + Neostigmine 3.0 mg….. extubated
15. • Saturation 90% on 100% oxygen given through face mask Bain circuit
• Making incomprehensible noises, looks jittery, eyes open, obeying commands
• RR 35/min
• Shallow breathing
• Chest clear on auscultation
• Pulse 125/min
• BP 190/106 mmHg
16. FURTHER EXAMINATION
• Not able to lift legs
• Able to hold head off the head ring for 3 seconds
• Bain circuit with 2 litre bag tidal volume 220 ml
DIAGNOSIS??
17. Residual neuromuscular blockade
DEFINITION
Defined using quantitative neuromuscular monitoring
Train of four ratio of < 0.9 according to recent opinions
As opposed to TOF ratio <0.7 previously
Small degree of residual paralysis at TOF ratio 0.7-0.9:
• Impaired pharyngeal function
• Increased risk of aspiration
• Weakness of upper airway muscles
• Airway obstruction
• Attenuation of hypoxic ventilator response
• Unpleasant symptoms of muscle weakness
18.
19. Residual neuromuscular blockade….
Strategies For prevention
Intraoperative
• Limit dose of NMBD by using regional nerve blocks
/supraglottic airway devices if feasible
• Use intermediate /short acting NMBD
• Use neuromuscular monitoring
• Depth of NM blockade as per surgical requirement
• Use TIVA for maintainace of anaesthesia rather than
inhalational agents
• Use boluses of NMBDs rather than continuous infusion
Emergence from anaesthesia
▪ Attempt reversal only if some evidence of
spontaneous recovery is there
▪ Anticholinesterase should be administered on
average 15 to 30 minutes before clinician anticipate
removal of ETT
Preoperative
Caution in
▪ Elderly
▪ Liver or renal dysfunction
▪ Disease affecting neuromuscular junction
▪ Drugs affecting NM junction
20.
21. NEOSTIGMINE…ADVERSE EFFECTS
• Paradoxical muscle weakness when given after neuromuscular
function completely recovered
• Nausea and vomiting
• Bradycardia, bradyarrhythmia,junctional rhythms,ventricular escape
beat,completeheart block
• Bronchoconstriction.
22. Reversal guidelines
Quantitative monitoring
e.g. acceleromyography
TOF count
0-1
Delay
reversal
TOF count
2-3
TOF ratio
>or=0.4
TOF ratio
0.4-0.7
TOF ratio
>0.7
Neostigmine
70 mcg/kg
Neostigmine
40-50mcg/kg
Neostigmine
20mcg/kg
Avoid
reversal
Qualitative monitoring
Peripheral nerve stimulator
TOF count
0-1
TOF Count
2-3
TOF count
4
With fade
TOF count
4
Without
fade
Delay
reversal
Neostigmin
70mcg/kg
Neostigmine
40-
50mcg/kg
Neostigmine
20mcg/kg
Extubate when TOF ratio >0.9
Allow 15-30 min before
tracheal extubation
Allow 10-15min before
Tracheal extubation
23. If NO neuromuscular monitoring used
• Anticholinesterase should be considered
• Anticholinesterase should be given until some evidence of recovery
of muscle strength
• Use or avoidance should not be on the basis of clinical tests for
muscle strength(5 sec head lift)
• Many pt. can perform these test even at TOF<0.5
24. Extubation using clinical sign
❑ TOF Ratio:
• 0.4 : unable to lift the head and arm
TV may be adequate
vital capacity and inspiratory force may be reduced
• 0.6 : head lift for 3 seconds
open eyes widely
VC and inspiratory forces reduced
• 0.7-0.75: able to cough sufficiently
head lift for 5sec
hand grip 60% control
• 0.8 or more: VC and inspiratory forces adequate
may have diplopia,generalized muscles weakness
25. Treatment of residual neuromuscular blockade
• Support ABC of patient
• Rule out other potential causes
• Is this really residual neuromuscular blockade?.......check nerve stimulator,
electrode, use different nerve muscle combination
• Have you given enough time for reversal agent to act?
• Treat potentiating factors†: hypothermia
Respiratory acidosis and metabolic alkalosis
Drugs administered in PACU; antibiotics, opioids
• Give small dose of neostigmine
• Use alternative agents(??)
26. Causes of prolonged neuromuscular blocakade
❑ Factors contributing to prolonged non depolarizing
NM blockade
• Drugs:
Inhaled anesthetic drugs
local anesthetics
cardiac antidysrhythmic
antibiotics; polymyxin aminoglycosides
lincosamine,metronidazole,tetracyclines
Corticosteroids
CCB
Dantrolene
Furosemide
• Metabolic and physiological states
Hypermagnesemia,hypocalcemia,hypothermia,
resp. acidosis,hepatic/renal failure,myasthenia syndromes
❑ Factors contributing to prolonged
depolarizing neuromuscular blockade
Excessive dose of succinylcholine
Reduced plasma cholinesterase activity
Decreased levels
Extreme of age
Disease states(hepatic,uremia,malnutrition,
plasmapheresis)
Harmonal changes
Pregnancy
Contraceptives
Glucocorticoids
Inhibited activity
Irreversible(echothiophate)
Reversible(edrophonium,neostigmine pyridostigmine)
Genetic variant(atypical plasma cholinesterase)
27. Case 1
4 year old boy
Preanaesthetic evaluation: unremarkable
For squint surgery
General anaesthesia with Proseal LMA with assisted spontaneous ventilation with O2+ N2O+Isoflurane
Intraoperative: Uneventful surgery lasted for 30 minutes
At conclusion of surgery, anaesthetic gases switched off
Surgical dressing done with head lifted
Suddenly SPO2 came down to 88% …………82%......70% DIAGNOSIS?
auscultation: diminished breath sounds
28. Upper airway obstruction
3. Laryngospasm
▪ Protective reflex glottic closure to prevent aspiration
▪ refers to sudden spasm of the vocal cord that completely occludes the
laryngeal opening
▪ Occurs in period when the pt. whose trachea has been extubated is
emerging from general anesthesia
▪ Although occurs in operating room but pt. who arrives in PACU after
G.A. are also at risk of laryngospasm when awakening
29. Upper airway obstruction
Laryngospasm….
• Trigger: Periglottic or distant visceral
stimulation
• Afferent arc: Sensory from laryngeal
receptor via internal branch of superior
laryngeal nerve (Vagus)
• Efferent arc: Motor to intrinsic
laryngeal muscles, lateral cricoarytenoids
and thyroarytenoids via recurrent
laryngeal nerve (vagus)
• Effect: Glottic closure by either true vocal
cord adduction alone or in combination
with adduction of false vocal cords
30. Incidence
• Rare but mostly seen during anesthesia emergence 48%,induction
28%,maintenance 24%
• Overall incidence 8.7/1000
• Incidence: infants >>children>>adults
• Adolescence : male > female ,male 12.1/1000 female 7.2/1000
• Children with URI or bronchial asthma : 98/1000
31. Laryngospasm….
Triggers
• Inadequate depth of anaesthesia
• Local stimulation of larynx: LMA
IPPV in inadequate depth
Secretions
Blood
Vocal cord trauma/surgery
• Distal stimulation Brewer-Luckhardt reflex
32. Risk factors
❑ Patient related:
• Young age
• Anxiety
• GERD
• URI or active br.asthma
• Chronic smoker,voice abuse
• Airway anomaly,sleep apnea syndrome
▪ Unsupervised pt. in recovery room
❑ Surgery related
• Throat and airway surgery,laryngeal surgery,tonsil surgery,thyroid surgery
• SLN injury
• Hypoparathyroidism due to hypocalcemia
• Reflex stimulation: anal surgery,cervical stimulation
33. Anesthesia related
• Insufficient depth of anesthesia during induction
• LMA > ETT
• IV anesthetic like thiopentone >propofol
• Barbiturate
• Ketamine
• Airway irritation
• Irritant volatile anesthetic:desfluran> isoflurane>>halothan/sevofluran
• Mucus and blood after extubation
• Airway handling
• Residual paralysis
• Vomiting and regurgitation
34. Diagnosis
• Harsh breathing inspiratory sound(stridor)
• Exclude other causes of obstruction like tounge drop,bronchospasm,
blood clot
• Fall in spo2 usually late
❑ Partial laryngospasm
• Signs of inspiratory airway obstruction:
• Suprasternal retraction
• Use of accessory muscles
• Paradoxical movement of chest and abdomen
• Auscultation : inspiratory obstruction
37. Upper airway obstruction
❑ Airway Edema
Risk factors
▪ Prolonged procedures in prone or trendelenburg position
▪ Large amount of blood loss requiring aggressive intravascular fluid resuscitation
▪ Surgeries on tongue,pharynx,and,neck
Airway patency must precede removal of ETT
▪ Cuff Leak test
▪ Steroids
▪ Tracheal tube exchange catheter can be used for safe extubation
▪ Elective Mechanical ventilation to allow edema to settle
38. Cuff leak test
Spontaneously breathing
Cuff is deflated and for first 30 seconds monitored for cough
Only cough associated with gurgling is taken into account
ETT is then occluded at proximal end while the patient continues to breath
Ability to breath around tube is assessed by auscultation
On mechanical ventilation
Set TV to 10-12ml/kg
Measure expired TV
Deflate cuff of ETT
Remeasure expire TV(average of 4-6 breaths)
Difference in tidal volumes with cuff inflated and deflated is LEAK
39. Cuff leak test
Cuff leak test
Miller & Cole < 110 ml
< 130 ml
Jaber et al Leak
> 12-15% OK
< 12-15% Edema
De Bast et al <15.5%
40. UPPER AIRWAY OBSTRUTION
❑ Obstructive Sleep Apnea
▪ increased risk for post op desaturation,respiratory failure,postop. Cardiac event ,
and need for ICU
▪ STOP BANG questionnaire : screening tool for predicting OSA
▪ extubatION: fully awake and following commands
▪ Postop analgesia
-They are exquisitely sensitive to opiods,so minimize opiods consumption in PACU
-Regional anesthesia and multimodal anesthesia should be used for post op
analgesia
▪ Monitoring
-Provide CPAP in immediate postop period,should ask the pt. to bring there
machines if using at home
-Continous pulse oximetry monitoring
42. FIVE CAUSES OF HYPOXEMIA
1. Hypoventilation
• Residual effects of opioids, inhalational agents and other anaesthetic agents on CNS
• Generalized weakness due to residual effect of relaxants leading to decreased inspiratory efforts
• Postoperative abdominal binding
• Postoperative abdominal distention
• Pain leading to splinting
2. Low inspiratory oxygen pressure
Unrecognized disconnection of oxygen source, improper oxygen prescription, empty oxygen tank
3.Shunt
Blood going to alveoli-capillary interface not exposed to air/ventilation(wasted blood)
(Atelectasis,pulmonary edema,pulmonary emboli, pneumonia, aspiration )
Blunting of hypoxic pulmonary vasoconstriction in PACU by residual inhalational agents, vasodilator like NTG
4.Dead space ventilation: Air reaching alveoli-capillary interface not exposed to blood(wasted ventilation)
5. Diffusion limitation
43.
44. • Case 3
• 65 years old male, weight 75 kg
• PAC: Unremarkable
• For laproscopic cholecystectomy
• GA with Proseal LMA with controlled ventilation
• Induction : fentanyl 150 mcg, thiopentone 200 mg, vecuromium 7 mg
• Maintenace : O2 + N2O + isoflurane; boluses of vec and fenta
• Duration of sx: 90 minutes
• Intraoperative ..Blood pressure raised after creation of pneumoperitoneum
• Controlled with Isoflurane increased upto 2%
• Extubated… Patient arousable, responding to verbal commands, maintaining vitals
45. • Shifted to recovery room
• 10 minutes later…Nursing staff called
• SPO2 is 90%..... ABG PH---7.42, PO2– 75, PCO2..48, HCO3..22
• Patient bit sleepy,arousable, opening eyes on commands, able to vocalize, pupils miotic
• Chest clear RR 10/minutes
• Oxygen supplementation through venturi mask FIO2 0.5, FLOW 12 l/min
• SPO2 97%
• 40 minutes later….cardiac arrest ?????
• ABG PH—7.01
• PO2- 120
• PCO- 103
46. Alveolar hypoventilation
• Hypoventilation alone may lead to arterial hypoxemia in a pt. breathing room air
• At sea level in a normocapnic pt. breathing room air
PAO2 is 100mmHg in health pt. without significant A-a gradien PaO2 is 100 mmHg
If PACO2 rises from 40 to 80 due to alveolar hypoventilation it decreases PaO2 to 50 mmhg
• Normally minute ventilation increases by approximately 2L/min for 1mmHg increase in paco2
• This normal response to paco2 is depressed in immediate post operative period by the residual
effect of inhaled anesthetics,opiods,sedative-hypnotics
• treatment:
• Supplimental O2
• External stimulation to wakefulness
• Pharmacological reversal
• Controlled ventilation
47.
48. • Case# 5
A 84 years woman with COPD on MDI inhalers; h/o old pulmonary Kochs
Emergency surgery for Left leg bimalleolar fracture
O/E: PR=96/min, BP=112/74 mmHg, SPO2= 93-94% ORA
RR= 18/min, Chest= bilateral clear, CVS=WNL
Spinal anaesthesia with 2.0 ml of 0.5% hyperbaric bupivacaine
Maximum sensory block achieved T10
Intraop: Uneventful, duration 1 hour, Blood loss minimal
Post op: Patient conscious oriented
PR=80/min, BP= 128/86 mmHg, SPO2=91% ORA, Oxygen through face mask given, SPO2=98%
Chest & CVS= WNL
49. • After 1 hour
• Patient is somnolent ,minimally arousable
• PR=90/min, BP=118/78 mmHg, SPO2=98% on face mask at 4 L/min
• ABG=
PH 7.21
PCO2= 101
PO2=85
HCO3= 21
?????
50. • Recommended target SPO2 in COPD
• 88-92%
• Selected patients with a history of respiratory acidosis may require lower target range 85-90%
• OXYGEN ALERT CARD
• High doses of oxygen in COPD patients
V/Q mismatch
Absorption atelectasis
? Blunting of hypoxic drive
51. Ventilation perfusion mismatch
• Hypoxic pulmonary vasoconstriction refers to attempt of normal lung to
match ventilation and perfusion
• It constricts vessels in poorly ventilated areas in lung and directs blood to well
ventilated alveoli
• In PACU residual effect of inhaled anesthetics and vasodilators(to treat and
improve hemodynamics will blunt HPV and contribute to arterial hypoxemia
• Causes of postoperative pulm. Shunt:
• Atelectasis: mcc in immediate post op period
• Pulmonary edema
• Gastric aspiration
• Pulmonary emboli
• Pneumonia
• Treatment of atelectasis:
• Sitting position
• Incentive spirometry
• Positive airway pressure by face mask
53. Post obstructive pulmonary edema
Promotion of transudation of fluid
Increased the hydrostatic pressure gradient across the pulmonary
vascular bed
Increased venous return + negative intrathoracic pressure
Exaggerated negative intrathoracic pressure
Inspiratory efforts against closed glosttis
It’s a transudative edema
The alveolocapillary unit. In health (left), the alveolus
remains fluid-free, because liquid filtered by Starling
transcapillary forces is cleared by interstitial lymphatics.
In negative-pressure pulmonary edema (right), negative
interstitial pressure results in an increased hydrostatic
gradient and alveolar flooding. The afterload-increasing
effect of the Müller maneuver increases this gradient
because of elevated left ventricular, left atrial, and thus
pulmonary capillary pressures. Pi ¼ interstitial pressure;
Pmv ¼ microvascular pressure.
54.
55. Post obstructive pulmonary
edema
• Laryngospasm is m/c cause
• May occur by any cause that obstruct upper
airways
• Hypoxemia observed within 90 min
• Bilateral fluffy infiltrates on chest radiograph
Treatment:
▪ Supplemental O2
▪ Diuresis
▪ In severe cases positive pressure ventilation
56. Transfusion related acute lung injury(
TRALI)
• D/D of any pt. with pulm.edema who intraoperatively received blood
products
• 1-2 hrs after (upto 6hrs) of blood products transfusion
• Fever and hypotension
• Acute drop in WBC count ( sequestration of granulocytes within lung
and lung exudative fluid)
• Treatment :
• Supplemental O2,diuresis,and mechanical ventilation(if needed)
• Vasopressers may be required for refractory hypotension
58. Post op hypertension
• Pt. with a h/o essential hypertension are at greater risk for systemic HTN
• Will require pharmacological blood pressure control
• Carotid endarterectomy and intra cranial procedures at greater risk
59. Case 4:
• 55 years old female weight 50 kg
• PAC : history of bronchial asthma on MDI inhales budecort and salbutamol x 3 years
• Chest clear
• For bipolar hemiarthroplasty of left hip joint
• Under combined spinal epidural anaesthesia with 2.5 ml of 0.5% hyperbaric bupivacaine
• Intraop…uneventful…. Vitals stable…..duration of surgery 90 minutes
• Blood loss… 800 ml
• IVF given …3 units RL
• After completion of surgery, patient shifted to PACU
• During shifting to transfer trolley…. BP 75/40 mm Hg, HR 106/min, patient complained of dizziness
61. Cardiac dysrhythmias
• Transient and multifactorial
• Reversible causes are :
• Hypoxemia
• Hypoventilation and hypercaphnea
• Endogeneous or exogeneous catecholamines
• Electrolyte abnormalities
• Acidemia
• Fluid overload
• Anemia
• Substance withdrawl
62. Cardiac dysrhythmias
• Atrial dysrhythmias
• 10% after non cardiothoracic surgry
• Incidence higher in cardio thoracic surgeries
• Risk increased by :
• Pre existing cardiac risk factors
• Positive fluid balance
• Dyselectrolytemia
• Oxygen desaturation
New onset dysrhythmias are ass. With increased mortality
63. Cardiac dysrhythmias
• Ventricular dysrhythmias
• Pvc and bigeminy common in PACU
• PVC: b/c of sympathetic stimulation( tracheal intubation,pain and high Pco2
• V tach: rare but indicative of cardiac problems
• Torsedes de pointes : consider Qt prolongation( drugs..)
• Bradyarythmias :
• Drugs: B- blockers,opiods ,anticholinesterase( for reversal),dexmedetomidine
• procedure: bowel distension,raised icp,iop,spinal anesthesia
• Atrial fibrillation :
• Control of rate immediate goal in new onset AF
• Hemodynamic instable: prompt cardioversion
• Mostly rx with b-blocker,ccb
• Amiodarone: consider QT prolongation,decr. HR,decr.BP
64. Myocardial ischemia: evaluation and t/t
• Pt. At low risk:
• ECG interpretation is influenced by pt. cardiac history and risk index
• Low risk pt.: <45 yr,no known cardiac dis ,only one risk factors
• ST segment changes in ECG,do not usually indicate myocardial ischemia
• Relative benin cause of ST changes:anxity esophagial reflux,hyperventilation
and hypokalemia
• RX: routine PACU observation unless sign and symptoms
• More aggressive evaluation if changes accompanied by rhythm disturbance
and hemodynamic instability
65. Myocardial ischemia
• In high risk pt.
• ST changes are significant in absence of sign and symptoms
• Post op myocardial ischemia rarely ass. With chest pain,confirmation depends
on sensitivity of cardiac monitoring
• Lead 2 and V5: detect 80% of ischemic events but visual interpretation is
often inaccurate
Any ST- T changes compatible with myocardial ischemia
Serum troponin
12 lead ECG
Cardiac monitoring
Cardiology follow up
66. Delayed recovery from GA
DRUG RELATED
• Anaesthetic drug overdose
• Wrong drug, wrong dose, wrong routes
• Susceptible patient- extremes of age, debilitated
• Delayed metabolism-hepatic disease
• Delayed excretion-renal disease
• Faulty technique- vaporizer not switched off
• Equipment malfunction-anaesthesia machine,
anesthesia circuits, vaporizers
• Drug interactions-MAOI,SSRI,oral contaceptives
• Atypical cholinesterases
• Central anticholinergic syndrome
Metabolic and endocrine causes
• Hyper/hypoglycaemia
• Electrolyte imbalaces;Hyponatremia
Hypocalcemia
• Uraemia
• Hypothermia
• Acidosis
• Hypothyroidism, Myxedema,thyroid storm
• Adrenal insufficiency
Neurological complications
Cerebral embolism
Cerebral haemorrhage
Cerebral ischemia-delibrate hypotension
, improper positioning
Hypoxic insults
Undiagnosed CNS lesions
67.
68.
69. Prevention of delirium after surgery
• Cognitive stimulation orientation(clock, calender)
• Improve sensory input glasses, hearing aids
• Mobilzation early mobilization and rehabilitation
• Avoidance of psychoactive medication lighys off, creating a relaxing
environment, minimizing nighttime interruptions, dedicated time for
sleep
• Fluid and nutrition
• Avoidance of
70. Anaesthetic specific intervention for
prevention of delirium
BEFORE SURGERY
• Correction of metabolic and electrolyte abnormalities
• Perioperative continuation of pharmacological therapy for neuropsychiatric disorders
DURING SURGERY
• Decrease exposure of drugs triggering delirium- opioids, benzodiazepams, antihistaminics,
dihydropyridines
• GA Vs RA- ↓ incidence by RA with light sedation
• Prevention of large intraoperative blood loss; Hct >30
AFTER SURGERY
• Postoperative pain management: Opioids- AVOID mepridine, opioid rotation
Preferable - Peripheral nerve blocks
-Multimodal regime featuring gabapentin
71.
72. Shivering
• Incidence: G.A. 5-65%, Epidural: 33 %
• Risk factors :male gender and induction agent(propofol>>thiopent)
• Accurate core body temp: at tympanic membrane( rest all are less accurate )
• Immediate consequences
• ↑ O2 consumption,↑CO2 production,↑sympathetic tone( ↑CO,HR,BP,)
• Inhibit platelet function,cogulation factor activity,drug metabolism
• Post op bleeding,prolonged NM blocade,delayed awakening
• Long term effect:
• Myocardial ischemia
• Delayed wound healing
• ↑ peri op mortality
• RX:
• Forced air warmer
• Opiods in adults (meperidine is m/C used)
• Ondansetron
• Clonidine
• Ketamine: 0.5 mg/kg I.v. before G.A.and R.A
73. PONV
• Without prophylactic intervention: 1/3 pt. develop PONV with
inhalational
• Consequences:
▪ Delayed discharge from PACU
▪ Unanticipated hospital admission
▪ Pulmonary aspiration risk
▪ Post op discomfort to pt.
Prophylaxis for PONV:
▪ Anesthetic intervention:
▪ Propofol benefits over inhalational
▪ Nitrogen benefits over nitrous oxide
▪ Remifentanil benefits over fentanyl
▪ Pharmacological intervention :
▪ Droperidol 1.25 mg,ondansetron 4mg,dexamethasone 8mg
78. ROUTINE ADMINISTRATION OF O2 IN PACU
Arguments against
1.Costly
2. Unnecessary as routinely SPO2 is
monitored in PACU
Arguments in favour
1.A significant number of pts develop hypoxia at
some point of stay in PACU
(positive correlation with age, ASA class, weight,
obesity, GA, IVF >1500ml)
2. Safe practice of PACU care with routine O2
care requires unrealistic ideal conditions
82. WHAT TO DO….?
• Oxygen supplementation in surgical patients has both benefits and risk
• Benefits of O2 supplementation- prevention of surgical site infection and PONV
• Hyperoxia has numerous harms
• As PACU frequently has inadequate resources( staff and monitors), it is acceptable to provide O2
routinely to surgical patients in early postoperative period(2-6 hours)
• The dose and duration of O2 should be individualized for each patient, e.g. an obese patient, patient
who received GA of long duration , O2 supplementation of relatively higher FIO2 and of longer duration
compared to a normal weight patient
• Oxygen to be PRESCRIBED according to target saturation range and should be monitored