Manage a Patient Under Anesthesia
Transcript of Manage a Patient Under Anesthesia
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Manage a Patient UnderAnesthesia
Andi Salahuddin
SMF/Bag.Anestesiologi, Perawatan
Intensif dan Pengelolaan Nyeri FK-
UNHAS/ RSWS Makassar23 Pebruari 2011
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Components of Anesthesia
( Trias Anesthesia )
Muscle Relaxation
Unconsciousness
Analgesia
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REASON
1. Anesthetics have potent CNS, CV &
RESPIRATORY depressant in therapeutic
dose.
2. Severe depression is life threatening.
EMERGENCY STATE
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MONITORING
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Monitoring in the Past• Visual monitoring of
respiration and
overall clinical
appearance• Finger on pulse
• Blood pressure
(sometimes)
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Monitoring in the Present• Standardized basic monitoring requirements
(guidelines) from the ASA (American Society of
Anesthesiologists), CAS (Canadian
Anesthesiologists’ Society) and other national
societies
• Many integrated monitors available
• Many special purpose monitors available
• Many problems with existing monitors (e.g., cost,
complexity, reliability, artifacts)
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ASA Monitoring Guidelines
• STANDARD I
Qualified anesthesia personnel shall be
present in the room throughout theconduct of all general anesthetics,regional anesthetics and monitoredanesthesia care.
http://www.asahq.org/publicationsAndServices/standards/02.pdf
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ASA Monitoring Guidelines
• STANDARD II
During all anesthetics, the patient’s
oxygenation, ventilation, circulation andtemperature shall be continuallyevaluated.
http://www.asahq.org/publicationsAndServices/standards/02.pdf
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“The only indispensable monitor is the presence, at all
times, of a physician or an anesthesia assistant, under
the immediate supervision of an anesthesiologist, with
appropriate training and experience. Mechanical and
electronic monitors are, at best, aids to vigilance. Such
devices assist the anesthesiologist to ensure the
integrity of the vital organs and, in particular, the
adequacy of tissue perfusion and oxygenation.”
CAS Monitoring Guidelines
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• The following are required: – Pulse oximeter
– Apparatus to measure blood pressure, either
directly or noninvasively
– Electrocardiography
– Capnography, when endotracheal tubes or
laryngeal masks are inserted.
– Agent-specific anesthetic gas monitor, wheninhalation anesthetic agents are used.
CAS Monitoring Guidelines
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• The following shall be exclusivelyavailable for each patient:
– Apparatus to measure temperature
– Peripheral nerve stimulator, whenneuromuscular blocking drugs are used
– Stethoscope — either precordial, esophageal
or paratracheal
– Appropriate lighting to visualize an exposedportion of the patient.
CAS Monitoring Guidelines
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• The following shall be immediately
available:
– Spirometer for measurement of tidal volume.
CAS Monitoring Guidelines
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Detecting Mishaps Using Monitors
1. Disconnection2. Hypoventilation
3. Esophageal intubation
4. Bronchial intubation
5. Circuit hypoxia
6. Halocarbon overdose
7. Hypovolemia
8. Pneumothorax
9. Air Embolism
10. Hyperthermia
11. Aspiration
12. Acid-base imbalance
13. Cardiac dysrhythmias
14. IV drug overdose
Source: Barash Handboo k
These mishaps …
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Basic Monitoring • Cardiac: Blood Pressure, Heart Rate, ECG
• ECG: Rate, ST Segment (ischemia), Rhythm
• Respiratory: Airway Pressure, Capnogram, Pulse Oximeter,
Spirometry, Visual Cues
• Temperature [pharyngeal, axillary, esophageal, etc.]
• Urine output (if Foley catheter has been placed)
• Nerve stimulator [face, forearm] (if relaxants used)
• ETT cuff pressure (keep < 20 cm H2O)
• Auscultation (esophageal or precordial stethoscope)
• Visual surveillance of the anesthesia workspace and some
exposed portion of the patient
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Visual Surveillance
• Anesthesia machine / workspace checkout
• Patient monitor numbers and waveforms
• Bleeding/coagulation (e.g., are the su rgeons us ing a lo
of suct ion or sponges? )
• Diaphoresis / movements / grimaces
• Line quality (is my IV rel iable?)
• Positioning safety review
• Respiratory pattern (e.g. tracheal tug , accessory musc
use etc.)
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High Tech Patient Monitoring
Examples of Multiparameter Patient Monitors
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High Tech Patient Monitoring
Some Specialized Patient Monitors
Depth of Anesthesia Monitor
Evoked Potential Mon
Transesophageal
Echocardiography
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Special Monitoring
• Pulmonary artery lines (Swan Ganz)
• Transesophageal echocardiography
• Intracranial pressure (ICP) monitoring
• Electrophysiological CNS monitoring• Renal function monitoring (indices)
• Coagulation monitoring (e.g. ACT)
• Acid-base monitoring (ABGs)
• Monitoring depth of anesthesia
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PROCEDURES
• Review the principles of monitoring and
maintenance
• Review the components, clinical signs,
and depth of anesthesia
• Apply the principles of monitoring and
maintenance (Circle of Awareness)
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Review the Principles of
Monitoring and Maintenance
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Monitoring
Tasks
• Level of Anesthesia
• A• B
• C
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Monitoring
Level of Anesthesia
• Unresponsive to pain stimuli
• Eyes fixed and pupils constricted• Muscles relaxed
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Monitoring
Airway
• Must maintain positive control over the
patients airway (to include the tongue)
• Monitor the airway at all time while the patientis under general anesthesia.
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Monitoring
Airway
• Oxygenation
pre-oxygenate for Intubation100% O2 - 6 L/minresuscitation 100% O2 - 15+ L/min
• Ventilation
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Monitoring
Breathing
• The lungs and breathing must be
continuously monitored.
• Rate and depth of respirations
• Dry versus wet lungs? ( humidifier )
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Monitoring
Breathing
• I Inspection
• A Auscultation
• P Palpation
• P Percussion
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Monitoring
Circulation• Heart rate, character, and rhythm = 68
strong and regular
• Tissue perfusion
• Body temperature• Renal Function
Output = >25 to 50cc/hr
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Components of General
AnesthesiaMuscle Relaxation
Amount of skeletal muscle relaxationrequirements depend on the type of
operation.
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Components of General
AnesthesiaAnalgesia/ Areflexia
Pain reflexes are subdued.
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Components of General
AnesthesiaUnconsciousness/Hypnosis
The patient is oblivious to all sensationbut pain reflexes can occur.
Depth of Anesthesia
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Depth of Anesthesia
• Stages and Planes of Ether Anesthesia
Stage I AmnesiaStage II Excitement
Stage III Surgical Anesthesia
Plane 1 Plane 2 The Surgical Plane
Plane 3
Plane 4
Stage IV Impending Death
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Stages and Planes of Ether
Anesthesia
• STAGE I Amnesia
From the onset of drowsiness to the loss of
the eyelash reflex.
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Stages and Planes of Ether
Anesthesia
• STAGE II Excitatory Stage
Agitation, delirium, irregular respiration and
breath holding .
Pupils dilate, eyes diverge.
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Stages and Planes of Ether
Anesthesia
• STAGE III Surgical Anesthesia
Plane 1
From the return of regular respirations to the
cessation of REM.
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Stages and Planes of Ether
Anesthesia
• STAGE III
Plane 2 The Surgical Plane
From the cessation of REM to the onset of
paresis of the intercostal muscles.
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Stages and Planes of Ether
Anesthesia
• STAGE III
Plane 3
From the onset to the complete paralysis of
the intercostal muscles.
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Stages and Planes of Ether
Anesthesia
• STAGE III
Plane 4
From the paralysis of the intercostal muscles
to the paralysis of the diaphragm - at the end
of this plane the patient will be apneic.
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Stages and Planes of Ether
Anesthesia
• STAGE IV Impending Death
From the onset of apnea to circulatory failure.
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Why we need monitors?
1. Our sense is limited.
2. Free up the anesthetist hand.
3. Monitor many parameters simultaneously
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The Circle of Awareness is the
anesthetist monitoring
management tool.
Th i l h l th th ti t
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The circle helps the anesthetist
to monitor and manage:
• Vital signs
• Stage of general anesthesia
• Airway, respiratory and cardiac systems
• Input and output of all fluids and drugs
• Time
• Recording
• Communications
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The circle of awareness shouldbegin a few moments after the
patient is placed on anesthesia
maintenance.
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PATIENT
• Patient should be unresponsive to painful stimuli
• Eye’s should be: Fixed, pupils constricted (dilated =
caprine specific) and non-reactive to light
• Mandible and tongue: Relaxed
• Limbs: Relaxed, non-withdrawal to pain
• If being assisted by personnel within the OR,
request a temperature and blood pressure be takenat this time
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AIRWAY
• Inspect Oxygen Tubing: From the wall to the
patient
• Inspect Endotracheal Tube: Secured, bulb
inflated, bite block present, and suction PRN• Inspect Patients Respiratory Effort: Note rate
and rhythm, one deep ventilation
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BREATHING
• Inspect Trachea: Look for Tracheal deviation
or jugular vein distention (JVD)
• Inspect Chest: Rise and fall
• Auscultate Chest: Clear breath sounds, noterate and rhythm (again)
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CIRCULATION
• Auscultate Heart: Note rate and rhythm
• Inspect All IV’s : Read labels and check fluid
levels, check drip rate, inspect tubing tocatheter, inspect IV site for infiltration
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RECORD
• Record on the SF 517: Time, drug input,
suction, oxygenation, ventilation, level of
consciousness, vitals signs, fluid input/output,
all complications throughout surgery in otherremarks
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REPORT
• Communicate: Communication the patients
status and vitals to surgical team.
• Insure you receive a response from the
surgeon• At this point, make improvements,
adjustments and corrections to any
deficiencies that you discovered during the
circle
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SUMMARY OF
PROCEDURES• Review the principles of monitoring and
maintenance
• Review the components, clinical signs,and depth of anesthesia
• Apply the principles of monitoring and
maintenance (Circle of Awareness)