Perioperative Management of Diabetic Patient - Dr PSN Raju
Practicing anesthesiologist high rezo
1.
2.
3. Greetings!
• As a discipline we have come a long way
• We have humble beginnings
• Our forefathers did not have a fraction of
the monitoring we have today and yet they
took the challenge and managed with their
clinical acumen
4. To think that the very first ‘official’
anaesthetic done by William T.G. Morton in
1846 was done with
• No ECG
• No Pulse Oximetry
• No Capnography
• No Intravenous infusion
All this on a patient Mr Gilbert Abbott for
resection of a vascular tumour on the Neck!
Simply Amazing!!!!!!
5. Technology Has Advanced
• Major difference in practice within 4
decades
• As there was no pulse oximetry or
capnography when Professor Ozinsky
anesthetized the first heart transplant in
1968.
Of Recent The Anaesthetist Has
Transformed Into ‘The Swiss Knife’ Smart
Clinician to the tech savvy type……..
Yes ……..
6. Try to imagine today's health care without surgery.
It's almost impossible.
NOW TRY TO IMAGINE SURGERY WITHOUT ANESTHESIA….
7. However Despite The Assistance
from our gadgets….
• Surgeons take more Risk
• The Worlds Population is ever increasing
• We are presented with an increasing
number of cases with varying complexities
• This and the pressing challenges of
budgetary constraints and austerity puts
pressure on us to cater for all our patients
one at a time
8. Do Not Do Multiple Tasks At A Time
We need to do one thing at
a time to
AVOID HUMAN ERROR!
9. Why is Anaesthesia Risky?
• Anaesthesia is not a Therapeutic State
• Strong Drugs Are Used To Induce & Maintain Sleep
• Almost all Anaesthetic Drugs Depress the
Cardiovascular System
• Caution is needed as Certain Patients with poor
functional capacity can decompensate
• Functional Assessment is of Paramount Significance
10. Our Patients must have the endurance to
withstand the Stress of an operation!
11. MET = METABOLIC EQUIVALENT
1 MET = 3.5ML/KG/MIN OF OXYGEN CONSUMPTION
Functional unit of energy consumption
To withstand the stresses of an operation the patient must pass 4 METS
That is 14ml/kg per minute of Oxygen consumption
12. Failure to exercise caution with administering an anaesthetic can
result in
Complications
15. But All these expectations on the Anesthesiologist
Results in
16. That is why it is so important to work as
a team..
17. The past 2 years has seen the forum of
social media escalate exponentially..
18. In Order To Maintain Checks & Balances
From Information Overload
A Governing Body is needed to Regulate and
Censor Information As We Need Guidance &
Protection For
• The Patient
• The Public
• Our Peers
20. The Aims and Objects of the Indian Society of
Anaesthesiologists
1. To associate together in one corporate body all reputable and
registerable medical men and women practising or interested
in the science and art of Anaesthesiology.
2. To promote the advancement of Medical Science.
3. To edit and publish a Journal of Anaesthesiology.
4. To determine the competence of specialists in
Anaesthesiology and conduct examinations for certificates to
be issued to voluntary applicants.
5. To protect the public against irresponsible and unqualified
practitioners who profess to be specialists in
Anaesthesiology.
6. To encourage scientific research and experimental work on
anaesthetic problems.
21. 7. To hold scientific discussions and read papers on
Anaesthesiology.
8. To watch and advise on legislations affecting the
Anaesthesiology.
9. To hold periodically, conferences at various places, for the
betterment of the cause of anaesthesia in India.
10. To receive donations and subscriptions from persons who
are eligible and desire to join the society and to hold the
funds for the advancement of Anaesthesiology and
betterment of members.
11. To co-operate with other medical and scientific
associations.
12. To arrange exhibitions of implements, appliances etc.,
pertaining to anaesthesia in different parts of the country
and suggest improvements in these implements and
appliances.
22. 13. To make rules when deemed necessary, relating to the
discipline and professional conduct of Anaesthesiologists.
14. To make bye-laws, rules and regulations of the society and
to delete, change or add to the same as and when
necessary.
15. To add all such things as may be incidental or conducive to
the attainment of all or any of the above objects.
16. To prepare a directory of Anaesthesiologists in India and
abroad who are registered members. This directory shall be
compiled by the Hon. Secretary and will be circulated to the
members periodically.
17. To run programmes for the welfare of the members like
Family Benefit Fund etc
23. Pre-requisites
Professional Status:
Only qualified Anaesthesiologists are permitted to
administer anaesthesia
Facilities and Equipment's:
Resuscitation equipment conforming to National
standards must be available in the workplace in adequate
quantity / quality
Professional Organization:
Appropriate 'Anaesthesia Forums' may be established
and will form links with the needed Authority for Training,
Certification and Accreditation. Institutional, Regional or
National Protocols on Anaesthesia practices may be instituted
and facilities for updating of knowledge may be ensured to
improve quality
Monitoring Standards- ISA
24. Records and Statistics:
A record of details and course of each Anaesthesia
procedure should be made and preserved along with the
patients medical record
Personnel and Workload:
Sufficient number of trained Anaesthesiologists should
be available at major Hospitals and the workload should be
distributed so as to avoid over or under utilization
The Anaesthetist should take the responsibility for the
transport of the patient to post-anaesthesia recovery area as
well as for later consultation if needed until the patient makes
adequate recovery from Anaesthesia
25. Basic Standards of Monitoring
Pre-anaesthetic evaluation and adherence to a protocol
is mandatory. Service should be administered by qualified
Anaesthesiologist possessing registration in modern medicine
Availability of resuscitation equipment, uninterrupted
supply of oxygen and minimum Anaestheisia equipment should
be confirmed before starting the procedure
Clinical Monitoring of colour and pulse should be done
every 5 minutes during conduct of Anaesthesia
A light source, Stethoscope, BP apparatus and
Thermometer should be available. Basal recording should be
made before the start of procedure
Cardioscope with Defibrillator capable of displaying the rate and
wave pattern should be available
26. Desirable Standards (Essential Standards for higher surgical
works)
1.All basic standards detailed above should be met with.
2.Anaesthetic machine and equipment used should have
failure warning facility as well as check list for failure
correction. Every operating Theatre should have at least one
operable Anaesthestitic machine.
3.Periodically calibrated vaporiser (Drug Specific) should be
available.
4.Every procedure should be monitored with pulse Oxymeter
to observe oxygen saturation.
5.Major procedure undertaken should be monitored with as
many varying equipments such as Airway Pressure Alarm,
Oxygen, Concentration Analyser, Neuro-Muscular Monitor,
Respiratory Volume Monitor, Non-invasive BP Monitor,
Capnometer, etc.
27.
28. Recommended Minimum Essentials In Operation Theatre
Continuous supply of oxygen cylinders
Boyle’s machine with two oxygen and a nitrous oxide input
connections
One small oxygen cylinder mounted on Boyles other than
jumbo or central line and nitrous oxide cylinder along with
cylinder valve opener should be available
Boyles machine with hypoxic guard safety system
Working suction machine with all connectors, tubing's, and
catheters
Multi-parameter monitors including pulse oxymeter, ECG, NIBP,
EtCO2,in Laparoscopy, thermo probe for temperature
monitoring for pediatric patient.
Adequate no of protective lead aprons with C-arm, protective
glasses with laser
Defibrillator
29. Ambu bag with all size of masks
Working laryngoscope with all sizes of blades, set of oral,
nasal airway and endotracheal tubes with stylets
Magill’ s forceps, scissors, ampoule cutter, torch,
thermometer
Vein flows14,16,18, 20, 22, 24, spinal needles 23, 24, 25, 26,
27, epidural set 16,18, cvp line, 3 way cannulas
I.V. sets, micro drip sets, blood transfusion set
IV fluids crystalloids RL, DNS, D5, colloids
For difficult airways elastic bougie, LMA, Igel, tracheostomy
tube
Flexible OT table with Radiant warmer/ blanket, heating
mattress , fluid warmer
Postoperative recovery room with oxygen supply and
monitors
32. In December 1999, the report of the Institute of Medicine
(IOM) in America, “To err is human”, raised the alarm to
the public that medical care could cause harm. It
concluded that medical errors were responsible for up to
98,000 deaths and 1 million injuries each year in the
United States. Assuming these figures to be constant and
taking todays Indian population this equates to 456414
deaths/year or 1250 deaths/day.
33. Ten years later in 2009 questions about the
effectiveness of these quality improvement
initiatives were raised, and a new study
was performed in North Carolina . The
study conclusions were that, despite
efforts, harm to patients remains common
(18.1%) and that not all quality
improvement interventions seem to be
effective. Therefore, there is a need for a
better understanding of effective
approaches that are able to minimise risk
and improve the overall safety of patient
care.
The specialty is
34. The specialty is often cited as a role model for its achievements in the field of patient safety improvements. Major
improvements were mainly observed during recent past decades, with mortality figures continuously dropping to
1/124,212 in the nineties, and to 1/146,341 five years later, reaching 1/249,321 in 2005. This represents a 100-fold
decrease in the anaesthesia mortality rate between the 1950s and today Therefore, anaesthesia is often cited as the
only speciality in healthcare to have reached the 6 sigma defect rate, which is used to describe a 99.99966% defect-
free process (3.4 defects per million] and is often seen as the critical target to be reached by any manufacturing
process or transport industry.
35. Pre-operative check up
Make it a habit to examine preoperatively. Introduce yourself to
the patient and the attendants that you are the person
responsible to relieve pain and safety of the patient during
operation. Then ask the Nurse take the consent.
Make it a habit to visit the patient post operatively and advise the
nursing staff clearly regarding the postoperative analgesia
41. INDIAN SOCIETY OF ANAESTHESIOLOGIST'S
The following information is vital for smooth conduct of your surgery so please spend some time in reading
& understanding about the science of Anaesthesia which has been designed so as to necessitate &
facilitate optimum conditions to make it possible for the surgeon to operate successfully on a patient.
Anaesthesia is reversible loss of consciousness with loss of pain, amnesia & good muscular relaxation to
facilitate good surgical outcome.
An Anaesthetist is a qualified consultant doctor- MBBS followed by MD or DA like any Consultant. He is
the leader in the O.T. & his management of the patient during the surgery ultimately decides the
postoperative well being of the patient as also the result of the surgery. He is the physician & Intensivist in
the O.T managing all critical events such as cardiac arrest, heart attack, changes in blood pressure,
excessive bleeding, pulmonary embolism, irregular heart beats, reduced urine output that can all occur
during any operation. Hence proper information of Anaesthesia & counseling by a qualified Anaesthetist
can be vital for the patient.
Patient name , ___________________________________________________Age _______, Sex : M/F
Address ________________________________________________________________________________
Surgery planned
__________________________________________________________________________________
Anaesthetist for surgery is Dr ________________________________Mobile No.
(optional)______________________
If you have any query as to the mode, type or risk of Anaesthesia please contact him or you can also
ask him to give you a pre-operative visit on day prior to the scheduled surgery as per his convenience
( visit fees to be paid immediately).
Please fill in this questioner to increase your own safety.
Q-1. Is this your first operation? Y/N. If yes, when & where were you operated previously.
___________________________________________________________________
Q-2. Do you have medical history of any major illness in the past? Y/N. If yes please give details
___________________________________________________________________
Q-3. Have you or any member of your family had any complications to anaesthesia or had any allergic
reaction to any drugs? Y/N if yes give details.
__________________________________________________________________
Q-4. Have you ever received blood transfusion or blood products in the past? Y/N. if yes give details
__________________________________________________________________
Q-5. Have you ever tested your blood for HIV( AIDS), HEPATITIS VIRUS, ? Y/N. Are you a carrier of any
disease as hepatitis__________________________________________________
42. Q-6. Do you consume alcohol, drugs or nicotine or tobacco in any form? Y/N
__________________________________________________________________________________
Q7. Do you have any denture, loose teeth, Contact lenses, Hearing aid, Pacemaker implanted.? Y/N Details
__________________________________________________________________________________
Q8. Did you have any Viral infection recently-cold, flu, fever, cough. Y/N
__________________________________________________________________________________
Q-9. Do you have complaints like Chest pain with sweating/ Swelling on feet/ Breathlessness / Cough with
sputum/ Blood in sputum/ Bleeding Tendencies/Nausea, Vomiting / Migraine / Chronic headache
__________________________________________________________________________________
Q10.Are you a known patient of Heart attack/Blood pressure/ Diabetes/ Jaundice / Cancer / Convulsions
Tuberculosis / Arthritis / Asthma / Sleep apnea / Snoring / Psychiatric illness. If yes give details.
___________________________________________________________________________________
Q11.Are you taking any medicine s- if yes give details
___________________________________________________________________________________
Q12.Details of your family doctor - name / telephone number.
___________________________________________________________________________________
Q13.Have you received Anaesthesia in the past ? Y / N any problems encountered
___________________________________________________________________________________
Importants Do's & Don't's
1) Please be, 'Nil by mouth' 6 hours before surgery
2) Know your Anaesthetist & Anaesthesia before the surgery.
3) Remove all lipstick, nail polish, ornaments before surgery.
4) Keep mobiles, keys, valuables with responsible relatives.
5) Do not consume alcohol, tobacco & do not smoke before or after the surgery.
6) Do not take anything by mouth without doctors permission after surgery.
7) Do not go home alone after surgery.
8) Do not drive vehicle, cooking or use equipment on day of surgery.
9) Please contact the doctor for any problem.
43. COMPLICATIONS AND PROVISION OF CARE
Anaesthesia Care: Your anaesthetist is a qualified post graduate & is well versed with dealing with all types of
situations that can occur during any life threatening situation one may see in the ICU.
Complications: Anaesthesia has become safer and safer; however, there remains the risk of complications
with any anaesthetic rendered.
There remains a risk of death or organ injury; however, this risk is extremely low for the vast majority of
patients. Below we list some of the more common side effects or complications of specific anaesthetic
techniques. It is always possible that a general anaesthetic may be employed if another technique is not
satisfactory.
Spinal or epidural block
•Headache: if your headache is severe, contact your anaesthesia team for further evaluation l
•Pain in one or both legs: this is usually self-limited, improving within 1-2 days; contact your anaesthesia for
concerns
•Team Temporary difficulty with emptying your bladderl
Nausea and/or itching when opioids are added for postoperative pain relief
Complications such as neurologic injury or complications secondary to bleeding or infections are very rare. It
is important for your anaesthesia team to be aware of any coexisting infections or the use of any blood
thinners, including aspirin, Coumadin (Warfarin),Plavix (Clopidogrex), and related drugs.
Occasionally self limiting Backache .
General Anaesthesia
Nausea : your anaesthesia team tries to recognize those at highest risk for nausea in order to minimize this
risk. Alert us if you have a history of postoperative nausea.
Dental trauma: teeth, especially when in poor repair or when there is dental work or dental prostheses, can be
injured during or after anaesthesia. A sore throat is common after general anaesthesia because of placement
of a breathing tube.
Nerve injury : we make every effort to prevent injury to nerves while in the operating room; however, there
remains a small risk of nerve injury with surgery and anesthesia, though most of these injuries improve
within days. Incidence of nerve injury may be increased with certain surgical positions, duration of
procedure, and body habitus.
44. INFORMED CONSENT AND AUTHORIZATION FOR ANAESTHESIA.
I, _________________________________________, for______________________________________________ as
Parent,/Guardian/ Representative acting on his/her or my behalf, am seeking to receive anaesthesia during his/her
or my pending procedure/operation/treatment. I want to have anaesthesia in order to lessen the pain I would
therwise experience.
I understand that regardless of the type of anaesthesia used there may be some unforseen risks and
consequences which may occur. The following are some but not all of the common foreseeable risks and
consequences which I have been told can occur: sore throat and hoarseness, nausea and vomiting, muscle
soreness. Further, I understand instrumentation in the mouth to maintain an open airway during anesthesia might
unavoidably result in dental damage including fracture or loss of teeth, bridgework, dentures, crowns and fillings,
laceration of the gums or lips.
I understand that medications that I am taking may cause complications with anaesthesia or surgery. I
understand that it is in my best interest to inform my doctors about the nature of any medications Allopathic /
Homoeopathic / Ayurvedic / Unani.
I understand the more serious risks and consequences of anaesthesia include but are not limited to changes
in blood pressure, allergic/drug reaction, awareness of the surgery, injury to my baby if pregnant, excessive
bleeding, cardiac arrest, brain damage ,embolism, paralysis or death.
I acknowledge that Dr. has told me that in his/her medical judgment the type(s) of anaesthesia I could receive
is/are General Anaesthesia /Spinal / Epidural Anaesthesia /MAC (Monitored Anaesthesia Care) / Sedation /
Regional anaesthetic block. I have listened to the doctor's explanation of the type(s) of anaesthesia I may receive,
its benefits and common foreseeable risks and consequences as well as those of its alternatives and now accept
his/her recommendation .
I understand that during my procedure/operation/treatment invasive monitoring may be necessary. I
understand the risks and benefits associated with this type of monitoring which have been fully explained to me.
I understand that while I am receiving anaesthesia, conditions may develop which require modifying or
extending this consent. I therefore authorize modifications or extension of this consent that professional
judgment indicates to be necessary under the circumstances.
I understand that I must not eat or drink anything 6 hours prior to surgery unless directly permitted by the
anesthesia-staff.
45. I consent to appropriate tests and treatments which may better evaluate my risk and prepare me for surgery as
part of my medical care associated with this procedure/operation/treatment.
I understand that my anaesthesia care will be given under the supervision of Dr __________________a member
of KAKINADA SOCIETY OF ANAESTHESIOLOGIST'S Affliated to ISA. I also understand that medical center
personnel such as anaesthesia technicians may be involved in my anaesthesia care.
I, the undersigned patient, give my consent to discuss my personal health information with any person that
accompanies me or is present with me that I have identified in advance of any procedure as active in my mental,
physical, emotional, or spiritual care, including, but not limited to family, close personal friends, and patient
advocates.
I am aware of the facilities which are available and not available in this hospital. I may have to be shifted to
another hospital for treatment of complications and I am bound to pay the bill of that hospital.
46. PATIENT AFFIRMATION
By signing this document, I am indicating that I understand the contents of this document and its
attachments, agree to its provisions and consent to the administration of anaesthesia during my
procedure/operation/treatment. I know that if I have concerns or wou ld like more detailed information, I can ask
more questions and get more information from my attending anaesthetist. I am also acknowledging that I know
that the practice of anaesthesiology, medicine and surgery is not an exact science and that no one has given me
any promises or guarantees about the administration of anaesthesia or its results. I fully understand what I am
now signing of my own free will and the above 13 questions & 12 points in the consent form have been explained
to me thoroughly in my own language.
__________________________________________ SIGNATURE OF RELATIVE / WITNESS
__________________________________________ SIGNATURE OF PATIENT
DATE & TIME___________________
ANAESTHESIOLOGIST'S ATTESTATION
I attest that this patient or the representative named above has been informed about the common
foreseeable risks and benefits of undergoing the anaesthetic and related problems as well as its reasonable
alternative(s), if any. Further questions with regard to this anaesthetic and related procedure have been answered
to his/her apparent satisfaction in the patients own language
ANAESTHESIOLOGIST'S SIGNATURE
____________________________________
____________________________________
48. Specialty Median salary (USD)[6] Average hours
work/week[7]
Average salary/hour
(USD)[8]
Orthopedic surgery 397,879 to $600,000 58
Radiology (diagnostic) 377,300 to $478,000 58
Neurological surgery 350,000 to $705,000 132
Urology 331,192 to $443,518 60.5
Anesthesiology 331,000 to $423,507 61
Dermatology 313,100 to $480,088 45.5 103
Surgery (general) 284,642 to $383,333 60
Plastic surgery 265,000 to $500,000 114
Obstetrics and Gynecology 251,500 to $326,924 61 83
Gastroenterology 251,026 to $396,450 93
Pathology 239,000 to $331,842 45.5
Emergency medicine 239,000 to $316,296 46 87
Cardiac Surgery 218,684 to $500,000 55
Neurology 213,000 to $301,327 55.5 93
Otolaryngology 191,000 to $393,000 53.5
Internal medicine 184,200 to $231,691 57 58
Family medicine 175,000 to $220,196 52.5 58
Psychiatry 173,800 to $248,198 48 72
Pulmonology 165,000 to $365,875 72
Pediatrics 160,111 to $228,750 54 69
Ophthalmology 150,000 to $351,000 47
49.
50.
51. Proposed Charges Of ANESTHESIOLOGIST’S In KAKINADA
Obstetrics & Gynaecology
M.T.P/D&C /CERVICAL Stitch 1200-1500/-
Tubectomy- Open 1500-2000/-
Tubectomy- Lap 2500-3000/-
L.S.C.S 2000-2500/-
T.A.H/ V.H 3000-3500/-
T.L.H/ L.A.V.H/ Myomectomy 4000-5000/-
Ectopic- Open 3000-3500/-
Ectopic- lap 4000-4500/-
Wertheim’s Hysterectomy 5000-6000/-
Labour Analgesia
Basic charges 3000/-
Per hour after that 1000/-
52. General Surgery
Appendectomy- open 2500-3000/-
Appendecectomy- lap 3000-3500/-
Inguinal Hernia- open (unilateral) 2000-2500/-
Inguinal Hernia- open-bilateral 3000-4000/-
Inguinal Hernia- lap 4000-4500/-
Cholecystectomy- open 3000-3500/-
Cholecystectomy- lap 4000-4500/-
Thyroid 3500-4000/-
M.R.M 3000-3500/-
Explorative Laporotomy 3000-4000/-
Haemorrhoids/ Fistulectomy/ Hydrocoele -2000/-
Endoscopy
Sedation in Upper G.I Endoscopy 1500/-
Colonoscopy 2000/-
ERCP 2500-3000/-
Oesophgeal Dilatation 2000-2500/-
Variceal banding 2500-3000/-
