Aneasthesia Pearls June 2013

ANAESTHESIA PEARLS

A Guide To Drugs

A GUIDE TO DRUGS IN ANAESTHESIA
EMERGENCY DRUGS (IV)
Metaraminol 10mg in 20ml NS (bolus 10mcg/kg to 500mcg)
Ephedrine 30mg in 10ml NS (bolus 50mcg/kg to 6mg)
Atropine 20mcg/kg bolus (undiluted in 2ml syringe)
Adrenaline 1mg in 10ml (bolus 10mcg/kg)
PREMED
Paracetamol 15mg/kg (max 90mg/kg/day) PO
Midazolam 0.5mg/kg PO (max 20mg), 0.02mg/kg IV/IM
Temazepam 0.3mg/kg (max 40mg) PO
OPIOIDS (IV)
Fentanyl 1-2mcg/kg
Morphine 100mcg/kg
Alfentanil 10mcg/kg
Remifentanil 0.05-0.5mcg/kg/min
INDUCTION AGENTS (IV)
Thiopentone 2-5mg/kg
Propofol 1-2mg/kg
Ketamine 1-2mg/kg
MUSCLE BLOCKADE (IV)
Suxamethonium 1-1.5mg/kg (RSI)
Rocuronium 0.6-1.2mg/kg (RSI)
Vecuronium 0.1mg/kg
Cisatacuronium 0.1mg/kg
Atacuronium 0.5mg/kg
Pancuronium 0.1mg/kg
VOLATILE AGENTS
Desflurane MAC 6%
Sevoflurane MAC 2%
Nitrous Oxide MAC 105%
REVERSAL OF MUSCLE RELAXATION (IV)
Neostigmine 50mcg/kg (with Atropine/Gylcopyrrolate)
Atropine 20mcg/kg
Glycopyrrolate 5mcg/kg
Sugammadex 2 (weak), 4 (PTC 1) or 16mg/kg (immediate)
Kids 2.5 neo + 1.2 atropine in 5ml NS, give 1ml/10kg
ANTI EMETICS
Granisetron 40mcg/kg IV (Max 1mg q24h)
Droperidol 10mcg/kg IV (Max 625mcg q6h)
Dexamethasone 0.2mg/kg IV (Max 8mg)
Metoclopramide 0.3mg/kg q6h IV/IM/PO (Max 20mg)
LOCAL ANAESTHETIC TOXIC DOSES
Lignocaine max 5mg/kg, 7mg/kg + adr
Bupivicaine max 2.5mg/kg
Ropivacaine 2.5mg/kg (up to 250mg)
ANALGESICS
Naproxen 5mg/kg q8h PO (max 1250mg/day)
Diclofenac 1mg/kg q8h PO (max 150mg/day)
Oxycodone 0.1mg/kg q4h PO (max 50mg/day)
Tramadol 1-2mg/kg q4h PO/IV (max 600mg/day)
Ketorolac 0.2mg/kg q6h IV/IM (max 40mg/day)
Parecoxib 40mg IV daily
ET TUBES LMA
Female 7-8 > 30kg size 3
Male 8-9 > 50kg size 4
Kids Age/4 + 4 > 70kg size 5
NB:This is a guide only. Doses must be tailored to the patient. Check individual product information sheets for contraindications, interactions and cautions, and to be certain that information on this card is accurate and that changes have not been made.
Author:   G Doolan

Bag-Valve Mask Ventilation

‘PROCEDURAL BASICS’ ANAESTHESIOLOGISTS MAY OVERLOOK!
Focus On – Bag-Valve Mask Ventilation
isa kanyakumari
BVM ventilation is a difficult skill to master. There are many impediments to successful mask ventilation. Kheterpal, et al2 described these factors that hinder BVM ventilation:
A body mass index of 30 kg/square meter or more
Presence of a beard
Mallampati score of three or four
Age of 57 or older
Severely limited jaw protrusion
Snoring
Others
isa a small thyromental distance (less than 6 cm)
isa airway obstruction caused by vomitus or blood and trauma to the face or neck
isa edentulous, obese, elderly, or pregnant patient
Triad of BVM
Isa Kanyakumari
Equipment
A pulse oximeter,
Oxygen source,
Bag-valve mask device,
Cushioned rim mask with variable sizes,
Nasopharyngeal and oropharyngeal airways,
Tongue blade,
Water-based lubricant, and
A Yankauer suction catheter with vacuum power source.
An appropriate mask is one that does not cover the patient’s eyes and does not extend beyond the chin.
Positioning
isa Kanyakumari
Copyright © 2011 International Anesthesia Research Society
The head in the sniffing position:
The neck should be flexed 35° on the torso and the head extended at the atlanto-occipital joint to produce a 15° angle between the facial plane and the horizontal. These angles should be used to define the proper sniffing position.
The optimal head position in the morbidly obese patient:
The optimal head position in the morbidly obese patient is achieved by supporting and elevating the shoulders and upper torso. Horizontal alignment of the external auditory meatus with the sternal notch should be used as an end point for correct positioning.
isa kanyakumari
The use of airway adjuncts may be an important component of successful BVM ventilation. There are two types of adjuncts: the oropharyngeal (OP) and nasopharyngeal (NP) airways. The NP airway size is measured from the naris to the angle of the mandible.
Seal:
BVM ventilation can be performed with one or two providers.
Traditionally, the ‘EC’ hand position is utilized to obtain a seal with the mask.
isa kanyakumari
If a second person is available to provide ventilations by compressing the bag, a two-hand technique can be used.
isa kanyakumari
Problems and Troubleshooting
Whenever encountering problems with ventilation, review the key steps of BVM ventilation: equipment, position, seal, and oxygenation/ventilation.
Review your equipment:
is your oxygen source on?
Is your bag functioning?
Do you have the appropriate airway adjunct?
Evaluate patient positioning:
is the ear-to-sternal notch position attained?
Repeat your chin lift and jaw thrust, if indicated.
Evaluate your seal:
Do you need to change your technique to a one- or two-person hold?
Does your mask fit properly or is there an air leak?
Consider other causes of poor oxygenation and ventilation, such as vomitus, secretions, or difficult anatomy.
Pearls
Lift the mandible up to the mask rather than pushing the mask down onto the face.
An adequate seal can more easily be made with a mask that is too big than one that is too small.
Leave dentures in place, when possible, to improve mask seal.
If the patient’s facial hair makes a seal difficult to obtain, apply a water-soluble lubricant over the beard to improve the contact between the face and the mask.
If the one-handed mask ventilation is not effective, switch to the two-handed technique.
Insert NPA devices bilaterally if necessary.
The best way to prevent aspiration is with good technique, including low-pressure, low-volume ventilation with slow insufflation. Newer bags have built-in pressure valves. The green zone includes pressures up to 20 cm of water and corresponds to the lowest risk of gastric distention.
Note the type of bag being used. Bags with one-way expiratory valves allow greater than 90% oxygen delivery during both positive pressure and spontaneous ventilation, while bags lacking this feature only deliver about 30% oxygen during spontaneous breaths.
Ref:
1. Focus On – Bag-Valve Mask Ventilation: ACEP News September 2008
2. Bag-Valve-Mask Ventilation : Author: Nichole Bosson, MD; Chief Editor: Zab Mosenifar, MD
3.Head and Neck Position for Direct Laryngoscopy Volume X, Number X: 2011

How to set your room

How to set your room
The Practical guide for the everyday practices
Ahmad Mustapha Abou Leila
The Must-Dos
Check your Anesthesia Machine
Turn on
O2-Air-N2O attached(look at the pipes, the pressure monitor)
Turn On the Ventilator
Check for circuit leak
Check the Soda Lime(purple or grey)
The Scavenger is Open-the risk of pollution
The Vaporizer –The level of gas
Always Prepare set for general anesthesia
You will need them
For the regular induction
For emergent intubation
For sedation
For regional anesthesia conversion into general anesthesia
Always Prepare Vasopressor set isa
Phenylephrine (0.1mg/ml) -Hypotension+ Tachycardia
Ephedrine (6mg/ml) -Hypotension+ Bradycardia
Atropine (0.1mg/ml) -symptomatic bradycardia
Check for the SALT
S: Suction
A : Ambu Bag-Airway
L:Laryngoscope
T:Tubes
Check the monitors Preoperatively:
Read the chart thoroughly
The patient Name
The peroperative Drugs
The planned surgery
The consultations
The anesthesia Preoperative notes
Quick re-assessment:
Air way
NPO hours
Anticoagulation
Allergies
IV SITE :
Check for previous mastectomy, axillary dissection ,AV fistula, site of surgery before IV prick
Otherwise choose the left hand (most patient are right handed and it is easier for us)
Avoid the positional IV (near joints )
The Gauge:
Small gauge (paedatrics, HF, Renal failure ,local case)
Big gauge (work near big vessels, Trauma, spinal, Burn)
The solution:
LR most cases
NSS for (renal failure, Neuro cases)
Dextrose containing fluid in neonatal surgeries
Voluven for spinal cases, burn, risk of bleeding
Blood (call for blood units if risk of bleeding, preop anemia)
FFP (patient on warfarin, massive transfusion)
Platelets (platelets dysfunction)
isa
Give some sedation before you go into the room….the patent in extreme anxiety
In Theatre:
isa
Check the OR table ….not working isa
Call the Orderly….fix it before u induce GA
Machine checked
SALT checked
Chart checked
IV secured
Vitals checked
Table checked
Induction:
The sequence of regular induction
isa
Special scenarios:
Pediatrics …higher Propofol
Elderly …lower Propofol
Shock…ketamine,etomidate
Mediastinal mass…sevoflurane induction
Neuro…thiopentone
High ICP… add β-blockers
RSI…Propofol and SUX only
Tube selection and insertion:
Patient related: isa
isa female tube 7-7.5
isa Male tube 8-8.5
isa pediatrics age/4+4
Surgery related
isa ENT:preformed tube
isa SML:MLT tube
isa Thyroid: Reinforced tube
isa Thoracic: DLT
Uncuffed till age of 8….. Contraversial?
Depth of insertion
isa Adult :height/10 + 5
isa Peds :age in years + 10
Nasal intubation – Smaller size tube
Depth of insertion: Oral depth + 3
Now you can put your invasive monitors if needed:
isa isa
Monitoring:
 Pulse Oximetry/ ECG/Temp
 Capnography
 Invasive/Non invasive BP
 CVP/ CWP
CVP 0-5mmHg Liver Resection
CVP 5-9mmHg Semi sitting Craniotomy
CVP 8-12mmHg Septic patient
CVP>15mmHg Fontane patient
 Urine Output
 Nerve Stimulator
TOF=0 in Neuro,Eye
TOF =1 in other cases
Deep parlysis needed PTC 0
Face more resistant than thumb
(twitch in the face doesn’t mean twitch in the thumb)
 Lab:
Baseline ABGS
Assess PaCo2-ETCO2 gradient
Oxygenation PaO2/fiO2..>200 it is OK
Hct
Electrolytes
Patient Positioning:
Watch for Nerve injury
Watch for Haemodynamic changes
Watch for ETT position
Remember
isa
Maintenance phase:
isa
Avoid Hypothermia:
Increase solubility of inhalation agents
Decrease metabolism
Increase risk of bleeding
Increase risk of wound infection
Acidosis
Post operative shivering
Arrhythmias
Watch for the blood loss:
isa
Allowable Blood Loss (ABL):
EBV x (Hi – Hf) = ABL
Hi
Hi = initial Hct
Hf = final lowest acceptable Hct
Estimated Blood Volume (EBV):
EBV = weight (kg) x average blood volume
Average blood volumes
Age Blood volume
Premature Neonates 95 mL/kg
Full Term Neonates 85 mL/kg
Infants 80 mL/kg
Adult Men 75 mL/kg
Adult Women 65 mL/kg
Normal Hct Values
Men 42-52%
Women 37-47%
Example:
Question: Before surgery is to take place, what is the estimated blood volume (EBV) of a female patient weighing 50 kg? Also, what is the allowable blood loss (ABL) of this patient if her Hct is 45?
In the example above, EBV = 50kg x 65 (adult woman’s blood volume) = 3250
The initial Hct (Hi) = 45%, her current Hct
The final lowest acceptable Hct (Hf) = 30% (What ever cut off is used clinically to decide how low the individual’s Hct will be allowed to drop. Thirty percent is used in this calculator but in reality this will vary from case to case.)
So the example would look like this:
Using this rough estimate, the patient in this example could lose 1083 mL of blood without needing a transfusion.
Estimating blood loss:
Dry sponges
4×4 hold ~ 10 mL blood
Ray-techs ~ 10-20 mL blood
Lap sponges ~ 100 mL blood
Pediatric cases should have sponges & gauze weighed for blood loss( 1GM = 1ML of blood)
Blood loss replacement:
Replace 1 mL blood with:
3 mL crystalloid (i.e. NS, Dextrose, LR)
1 mL colloid (i.e. albumin, Dextran)
1 mL whole blood
1 mL PRBC
Blood Transfusion:
Hb level Recommendation
> 10 inappropriate
7-10 Likely to be appropriate if signs of impaired O2 Delivery
< 7 appropriate
< 6 Highly recommended
Watch out:
BP HR Explanation
isa isa High sympathetic state: Pain, awarness, adrenaline injection Pheo, thyroid storm
isa isa Hypovolemic, septic patient, carcinoid crisis, anaphylaxis
isa isa High fentanyl dose, Neostigmine, B-blockers, spinal shock
isa isa After phenylephrine , Cushing reflex
Tests to assess recovery: Tests to assess Depth
isa
Ahmad M. Abou Leila
Posted in ANAESTHESIA PEARLS 2013

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