This document discusses the propofol-ketamine (P-K) anesthesia technique for rapid turnover outpatient procedures. P-K anesthesia uses propofol and ketamine to attain deep sedation with brief periods of general anesthesia, relying on surgeon-administered local anesthesia for analgesia. Appropriate procedures include cosmetic, minor GYN, urology, and interventional radiology cases. The document outlines the pre-operative, intra-operative, and post-operative processes, including NPO guidelines, pre-medication, IV setup, anesthesia administration and maintenance, surgical analgesia, recovery and discharge goals. It emphasizes managing expectations, developing routines, timely turnover, communicating with surgeons, and measuring outcomes to
Scalp block is simple and easy to perform. It has the advantages of minimizing cardiovascular effects and decreasing intraoperative analgesia requirements.
New GCS, the GCS-P was adopted in 2018 by the same person who proposed GCS. It gives better prognosticate outcomes compared to GCS.
Scalp block is simple and easy to perform. It has the advantages of minimizing cardiovascular effects and decreasing intraoperative analgesia requirements.
New GCS, the GCS-P was adopted in 2018 by the same person who proposed GCS. It gives better prognosticate outcomes compared to GCS.
TIVA is a technique of anesthesia involving the induction and maintenance of anesthetic state with IV drugs alone. Shorter context sensitivity half time anesthetic agents like propofol is the universally accepted induction agent of choice widely used as a component of TIVA.
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
Intravenous Anaesthetics are a group of fast-acting
compounds that are used to induce a state of impaired
awareness of complete sedation.
These are drugs that, when given intravenously in an
appropriate dose, cause a rapid loss of consciousness.
TIVA is a technique of anesthesia involving the induction and maintenance of anesthetic state with IV drugs alone. Shorter context sensitivity half time anesthetic agents like propofol is the universally accepted induction agent of choice widely used as a component of TIVA.
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
Intravenous Anaesthetics are a group of fast-acting
compounds that are used to induce a state of impaired
awareness of complete sedation.
These are drugs that, when given intravenously in an
appropriate dose, cause a rapid loss of consciousness.
Pre and post operative care for patients undergoing general anesthesiaJewel George Thomas
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Management Of Patient Undergoing Surgerykalyan kumar
Preoperative care refers to health care provided before a surgical operation. The aim of preoperative care is to do whatever is right to increase the success of the surgery.
At some point before the operation the health care provider will assess the fitness of the person to have surgery.
During the perioperative period, specialised nursing care is needed during each phase of treatment. For nurses to give effective and competent care, they need to understand the full perioperative experience for the patient.
Perioperative refers to the three phases of surgery.
Preoperative stage
Intraoperative stage
Postoperative stage
Within these stages there are many different roles for nurses and different care needed for the patient dependent on which stage they are in.
As with any nursing care, the goal during these stages is to provide holistic and evidence based care as well as support to the individual.
There are different nursing roles throughout the perioperative process including: admissions nurse, anaesthetic nurse, circulating nurse or scout nurse, instrument or scrub nurse, post anaesthesia care unit (PACU) nurse and the surgical ward nurse. Other nurses may be included in the perioperative process such as pain management specialist nurses, diabetes educators.
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Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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3. What is P-K Anesthesia?
P-K anesthesia is the use of a propofol and
ketamine based technique to attain a level of deep
sedation. This is a sedation/MAC technique with
brief intermittent periods of general anesthesia.
P-K anesthesia relies heavily on surgeon
participation. The majority of analgesia provided is
done so by the surgeon with liberal and strategic
application of an appropriate LA
4. Types of Procedures Appropriate
for P-K Technique
Cosmetic procedures (breast augmentation,
abdominoplasty, facelift/neck lift/brow lift,
brachioplasty, liposuction, otoplasty, rhinoplasty)
Minor GYN procedures (hysteroscopy,
colposcopy, LEEP, Novasure, Essure)
Minor urology procedures (bladder scope, prostate
biopsy, lithotripsy, circumcision, stone extraction,
vasectomy and reversal
Interventional radiology procedures (arteriograms,
fibroid embolizations, varicose vein procedures,
AV fistula placements
6. Serving Two Masters: Goals for
Patients/Goals for Facilities
Patient Goals
-feel confident in the
surgeon, anesthesia
provider, facility and
process
-patient who understands
the pre-op, operative,
discharge and post
anesthesia process
-relative comfort during
and after procedure
-meeting discharge criteria
30-45 minutes post
procedure
Facility Goals
-patient safety
-patient satisfaction and
referrals
-surgeon satisfaction
-provide high quality care
at a max profit
-quiet surgical field
-efficient turnover allowing
for more cases
7. The Pre-Anesthesia Process:
Setting the Stage for Success
Set admission criteria, surgery types and lengths
(policy created in conjunction with facility)
Pre-anesthesia phone call
-health history
-NPO/medication instructions
-describe day or procedure process
Day of surgery pre-anesthesia interview
-review health history
-ensure NPO status
-manage post operative pain expectations
-family member/driver education
8. NPO Guidelines
Clear liquids 2hrs
Dry toast 6hrs
Regular meal 8hrs
(no dairy on surgery day)
Adhere to these
guidelines and
administer routine
fluids.
QuickTime™ and a
decompressor
are needed to see this picture.
9. Pre-Meds
Tylenol 1000mg po
Clonidine 0.1-0.2mg po**
Have patient take all routine meds am of
procedure (consider restricting lisinopril)
14. Anesthesia Administration
Routine (maintenance)
Titrate Propofol to sedation, ventilation & BP
Give ketamine 25-50mg q45-60min or before stimulating
portions of any procedure.
Generally the maintenance infusion of Propofol is in the
range of 140-180mcg/kg/min
Begin to decrease Propofol infusion 20 minutes prior to end
of procedure
Rules for Ketamine:
- no ketamine within 30 minutes of end of procedure
- do not exceed 200mg total dose for ketamine
15. Surgical Analgesia
The majority of analgesia is supplied by the surgeon
through LA injection, field coverage and tumescent fluid
(plastics).
Anesthesia provider/operating physician partnership
requires encouragement, education and communication.
Encourage maximum amounts of LA, give surgeon a
ballpark figure at the beginning of the case.
Plane of anesthesia can effect surgical administration of
adequate LA
Surgeon understanding of LA injection importance is vital
to quick recovery, discharge and patient satisfaction.
Exparel, adequately administered, is AWESOME!!
16. Recovery Process
Expected time to discharge is 30-45 minutes.
Assess pain on awakening, at 15 minute intervals,
treat early with IV fentanyl.
Encourage assisted ambulation to restroom at 15
minutes.
Instruct driver to have patient eat substantial solid
foods ASAP after d/c and begin oral pain
medication with first meal.
Treat PONV with fluid bolus, additonal IV Zofran or
PO Zofran. Alcohol sniff is effective as well.
17. Discharge Goals
Pain score 4 out of 10 or less.
Minimal to absence of nausea and vomiting
Stable vital signs
Ambulation with assistance
18. Keys to Achieving D/C Goals
Manage expectations
- describe expected level and quality of pain
- explain discharge goals
- set expectation of time to discharge post
procedure
- include family member/driver in discussion of
discharge goals
- explain the process for alleviating hindrances to
achieving discharge goals
19. Measuring Patient Outcomes
Measure post op analgesia scores
- emergence and discharge (average 3/10)
Measure rate of PONV (roughly 10%)
- separate PONV related to anesthesia from
PONV related to oral pain medications
Ask:
- when the nausea occurred
- what was oral intake prior to oral meds
Measure time from end of procedure to d/c home
20. Time Management
On to the next case:
- set staff expectations for
timely turnover
- measure and document
turnover times
- review at regular intervals
reasons for delays (patient
arrival, staff arrival,
equipment not ready,
surgeon not ready)
- routinely discuss turnover
times and any reasons for
trends in delay
21. Special Scenarios:
- Starting cases in prone position**
- Turning during cases
- IV’s for upper extremity procedures
- Surgical fire prevention
23. Managing Facility Profitability
Continuous review of process as it relates to
profitability
Continuous consideration of medications and
supplies used on a routine basis
Discover the costs of your anesthetic
- breast augmentation - roughly $22.00
- abdominoplasty - roughly $32.00
- AVF - roughly $28.00
Don’t be shy about advertising your attention to
detail and profitability.
24. Review of Pearls
Manage patient expectations throughout the
process.
Develop a repeatable routine that works with your
procedure type and facility
Keep everyone on the same page with time
management.
Frequently communicate with your surgeons
regarding LA administration. Let them know that
better LA coverage = less Propofol used which =
more profit!!
Set your metrics and measure your outcomes at
regular intervals.