Anesthetics introduction – teaching day

(very rough edit of the knowledge gained from this teaching day – will edit by tonight.)

Introduction given by first speaker – (I missed out the first 10-15 minutes of it, maybe longer, was searching for parking) Gave a few pearls of wisdom, in particular, the Royal College of Anesthetics e-learning website link

2nd speaker – Difficult Airway
objective is to oxygenate – help with ventilation
can be by mask, tube through nose or through mouth, or through trachea
airway assessment — HISTORY -check for pathology – burns etc, identify previous anaesthetic history, charts etc, visualisation of laryngoscope views – grades
clear is grade 1, partial block is grade 2 (take home message was that 1+2 easier) EXAMINATION – multiple airway assessment tests – none accurate enough – 5 things most important to be done – 1)-how likely to face mask ventilate, tight seal etc, facial trauma, elderly, dentures, sunken face, high BMI, snorers/sleep apnea – /2)-mouth opening – 3 cm magic number, estimation usually, LMA/laryngoscope fit, foreign objects, tumors, masses – 3) – neck movement ‘sniffing morning air position ‘ flex neck, extend head trying to align the axes for optimum visualisation, 4)-malampatti score (4 classes – first gen reassuring. upright,mouth maximum open and tongue protrusion max, visualise tongue, posterior, uvula, tonsillar pillars
DAS difficult intubation guidelines – 4 plans need to be aware of
(5)-cricothyroidotomy explained theoretical but not practically ever used – worth knowing in case ever required – explained cartilages etc and neck surface anatomy – I noticed everyone palpated their neck involuntarily, including me!)
priority is ventilation not intubation – whichever way that may be achieved

3rd speaker – PRE-ASSESSMENT
HISTORY (what surgery, elective/emergency, major/minor, PMH, systemic review, medications, allergies, anticoagulants, any prior problems with anetshetics/personal or familial – any surgery to same site, starvation time, risk of reflux, dentition, how they have been in last few weeks, assessment of fitness (climb upstairs) , less than 4 mins exercise tolerance is not good for anaesthesia/ EXAMINATION (gpe, murmurs, chest, vascular access, airway, the back, high BMI, positioning)/INVESTIGATIONS (confirm, assess or alter risk – depends on patient)/MAKE A PLAN (think about conditions cvs -heart failure,aortic, mitral stenosis, ACS/MI within 3 months; fracture NOF)
Preassessment is your own personal way to do things, no perfect way: “there are many ways to skin a cat” (!!!)
patients risk of undergoing surgery/undergoing anaesthesia (?high risk patient, ?high risk surgery, ? high risk anaesthetic) for each problem identified, has it been optimised as much as possible, or how can the risk be reduced/optimized, and do you need to change your plan.
PLANNING
– pre-operative – optimisation any more investigations, treatments, fluids/inhalers etc, ask for help if needed.
intra-operative – technique, induction, maintenance, wakeup
post op

CONSENTING THE PATIENT – Royal college website (anesthetics rcoa pils) details consent information for any medical condition/procedure
complications – sore throat, dental damage, cuts to lips etc, pain, nausea, anaphylaxis, death, loss of airway, awareness and regional complications – low bp, particularly with obstetrics, itching, urinary retention, headache, failure of procedure, infection, bleeding, nerve damage (1/50000 spinal, 1/13000 epidural)

4th speaker(s) – scenario enacted by actual anaesthetic consultants and fellows from the department – to give an idea about how things go in theaters. walking though an actual scenario – from introduction, consent, explanation of steps to patient, end tidal co2, patient under, putting tube in under vision – grade 1 view – inflating cough, good chest rise – end tidal trace, fix tube. looking at the monitor —–smooth induction

5th speaker – anaesthetic drugs
induction agents – 1)propofol -lipophillic, stings a bit, onset 20-30 seconds, 2-3mg/kg generally 300mg given, bradycardia, propofol infusion syndrome 2)thiopental -4-5mg/kg onset 10-20 seconds, tachycardia
muscle relaxants – neuromuscuar blocking agents – depolarising (suxamethonium, succinylcholine) and non depolarising (atracurium, rocuronium, pancuronium, vecuronium)
inhalation – no2 (not very common), sevoflurane, isoflurane, desflurane
reversal – anticholinesterases (neostigmine usually, sugamamadex – newer drug)
other drugs
MAC – minimum alveolar concentration of anaesthetic agent which is required to prevent movement in 50 percent of patients.

6th speaker – anaesthetic equipment

LMA – must have absent airway reflexes, cuff deflated, muscle relaxant not required – but is not a definite airway (vomit, aspirate)
i-gel – preferable
ETT – SIZE – 8 FOR MEN, 7 FOR WOMEN, AGE/4 +4 PAEDS – definitive airway
uncuffed for smaller children; RAE tube – out of the way of head neck surgeries.
bougies – angle tipped rubber tube, aid intubation
laryngoscopes (under direct visualisation)- mac (size 3 adult, size 4 for large adults), mccoy (lever to lift epiglottis), miller (paeds)
indirect laryngoscopy -in cases where visualisation is not optimum. e.g. airtraq, mcgrath (video laryngoscope)

breathing circuits –
APL VALVE
Bain circuit – most commonly used
BMV – AMBU BAG
WATERS CIRCUIT

Anesthetic machines
PENLON NUFFIELD 200
draeger primus – main anaesthetic machine
explained the charts etc – lots f abbreviations lots of number, lost of values and waveforms and colours – confusing but will become second nature to us! reassuring? not really!

7th speaker – chat with an ODP who tells us about his experience and his duties and what is required of them and of us – they check the instruments, the machines prepare trolleys, the tubes, the drugs etc for each interaction – make sure everything is clean or new or usable, batteries etc, lights of the laryngoscopes etc, and going through the checklist, who’s checklist – (something that he asks the whole room if they know about and they all say yes, but I have never heard of. yikes.) they also offer suggestions, ideas, but the final responsibility of what is happening is the anaesthetists. they won’t draw the medication, they won’t give meds (unless emergency situation) here to help you, work with you and make sure your training opportunities are met and are fulfilling – someone asked what pisses you off – lots of laughter – nervous, me thinks?

8th speaker was just the first speaker again – qualified the previous talk with “know your ODP, they will be your best friend”

BREAK FOR LUNCH (not provided *frown*)

Coming back in from lunch to another scenario that started off as a smooth induction but then went on to become a critical incident (penicillin administered to a patient with no known allergies – while undergoing surgery) – some hilariousness ensued as the “surgeon” put her hands up when the patient became critical and watched as the “anesthetist” dealt with it all, even exclaiming “oh is that what is done?” when the anesthetist administered epinephrine as part of the anaphylaxis treatment. *titters of laughter*

9th speaker – vasopressors/pharmacology
background – vasoconstriction, inotropic effect, sympathomimetic – alpha 1 blood vessels, beta 1 in lungs, beta 2 are in lungs, blood vessels
indications – hypotension due to whatever reason – treat if >30mm hg drop from baseline systolic BP or MAP <60, or any evidence of hypo perfusion/end organ damage – always fluid resuscitate before chronotropy.
most commonly used agents – ephedrine (synthetic sympathomimetic), metaraminol (mainly alpha effect, can be given peripherally, reflex bradycardia) and noradrenaline (usually for very sick patients in profound circulatory failure, both alpha/beta actions, needs to be given via central lines)
others – adrenaline (all adrenergic receptors, asystole, anaphylaxis), dobutamine (beta 1 agonist – cardiac effect, should be given through central line), dopamine (central neurotransmitter)
Points to consider -access : peripheral vs central ? arterial line if needed, boluses, side effects, tachyphylaxis (with long term treatment, receptors become desensitised), arrhythmias

another qualification from speaker 1 who I feel might be the head of the department or atleast leading this day. “These drugs are your best friend!”

10th speaker – one of our peers from an ACCS program currently rotating in aesthetics/itu somewhere : hemodynamic monitoring
NIBP, HR, pulses, mental status, etc do the basics
Invasive – ARTERIAL LINES (continuous BP monitoring, trends etc with drug administration, ABGs, posy-major surgery) commonly put in the radial artery (always do the allens test) discussion of types of art lines followed by a discussion of how to put up and put in an art line (OFF TO PATIENT OPEN TO AIR), complications (air emboli), can stay in for a week; CENTRAL LINES (cvp measurements, medications that can’t be given in peripheral lines), goes in a big vessel, should all be usg guided, patient positioning important, aseptic non touch technique, explanation of the technique (excellent explanation and demonstration, including usg) followed by blood gas, transduction image and a car – also discussed complications, how to measure cvp (normal cvp 0-8) – web links provided – frca
session in the middle about us being able to handle the instruments and ask questions

11th speaker – introduced himself as the last speaker of the day (thankfully!) with 9 slides to his presentation and the first slide was his name and he reported the last slide is thank you and any questions.
analgesia – definition – unpleasant sensation associated with emotional connotation related to tissue damage
types/managements/etc etc This part was particularly vague for me as I was just checking the clock by this time, looking forward to the long drive home.

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