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How to set your room

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65 slides describing the every day practice in the OR.It is a helpful guide for all anesthesia residents

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How to set your room

  1. 1. The Practical guide for the everyday practices <br />Ahmad Mustapha Abou Leila<br />PGY5 -Anesthesiology <br />How to set your room<br />
  2. 2. The Must-Dos<br />
  3. 3. Check your Anesthesia Machine<br />Turn on<br />O2-Air-N2O attached(look at the pipes, the pressure monitor)<br />Turn On the Ventilator<br />Check for circuit leak<br />Check the Soda Lime(purple or grey)<br />The Scavenger is Open-the risk of pollution<br />The Vaporizer –The level of gas <br />
  4. 4. Check your Anesthesia Machine<br />The Ventilator is different <br />The Jet ventilator <br />Turn it ON<br />Check for the Pressure (keep the Pressure between 20-30)<br />RR between 18-20<br />
  5. 5. Always Prepare set for general anesthesia<br />You will need them<br />For the regular induction<br />For emergent intubation<br />For sedation<br />For regional anesthesia conversion into general anesthesia<br />
  6. 6. Always Prepare Vasopressor set<br />Specially <br />Elderly <br />Spinal anesthesia<br />Hypotensive patients <br />Pediatrics <br />
  7. 7. Always Prepare Vasopressor set<br />Neosynephrine (0.1mg/ml)-Hypotension+ Tachy<br />EPHEDRINE (6mg/ml)-Hypotension+ Brady<br />Atropine (0.1mg/ml)-symptomatic bradycardia<br />
  8. 8. Check for the SALT<br />S: Suction <br />A : Ambu Bag-Airway<br />L:Laryngoscope<br />T:Tubes<br />
  9. 9. check The monitors(the minimal monitoring) <br />ECG<br />Bp<br />ETCO2<br />SPO2<br />Temp<br />For every case …every case ..every case <br />
  10. 10. For PEDS casesask the RN to warm up the roomAsk the Anesthesia Assistant to prepare the bair hugger make a capAll of these to prevent hypothermia <br />
  11. 11. The OR Trip from Chart reading till extubation<br />
  12. 12. Read the chart thourghly<br />The patient Name<br />The peropDx<br />The planned surgery<br />The consultations<br />The anesthesia Preop note<br />
  13. 13. Quick re-assessment:<br />Air way<br />NPO hours<br />Anticoagulation<br />Allergies <br />
  14. 14. IV SITE<br />Check for previous mastectomy, axillary dissection ,AV fistula, site of surgery before IV prick<br />Otherwise choose the left hand (most patient are right handed and it is easier for us)<br />Avoid the positional IV (near joints )<br />
  15. 15. The Guage<br />Small gauge <br />(pedatrics,HF,Renal failure ,local case)<br />Big gauage<br />(work near big vessels,Trauma,spinal,Burn)<br />
  16. 16. The solution <br />LR most cases<br />NSS for (renal failure,Neuro cases)<br />Dextrose containing fluid in neonatal surgeries<br />Voluven for spinal cases, burn,risk of bleeding<br />Blood(call for blood units if risk of bleeding, preop anemia)<br />FFP(patient on warfarin,massive transfusion)<br />Platelets(platelets dysfunction,Plavix)<br />
  17. 17. IV fixation <br />(pediatrics-prone position)<br />Transparent (phelbitis)<br />Date<br />
  18. 18. Three way directly on the Angiocath<br />If you plan to give Precedex,Remifentanil,or post op PCA) <br />
  19. 19. Give some sedation before u go into the room….the patent in extreme anxiety <br />
  20. 20. Multivariable logistic regression analyses showed a significant increase in the odds of SSI when antimicrobial prophylaxis was administered less than 30 minutes<br />and 120 to 60 minutes <br />as compared with the reference interval of 59 to 30 minutes before incision <br />
  21. 21. Patient A M has infected arthritis ,he is admitted to OR for Knee Joint arthroscopy and lavage .<br />What is the optimal time for ABX administration ?<br />
  22. 22. To the room <br />
  23. 23. Always Baseline <br />
  24. 24. Aspiration Pneumonitis <br />
  25. 25. Patient positioning in case of regurgitation <br />
  26. 26. check the OR table ….not working<br />call the Orderly….fix it before u induce GA<br />
  27. 27. Machine checked<br />SALT checked <br />Chart checked<br />IV secured <br />Vitals checked <br />Table checked<br />
  28. 28. Take off--------------induction<br />
  29. 29. The sequence of regular induction <br />Fentanyl<br />Xylocaine<br />1-2µg/kg<br />Peaks after 5 min<br />This why we give it first<br />Abolish the pain reflex on intubation<br />More if high ICP<br />Less if RSI <br />Patient cough <br />Midazolam <br />2mg/kg<br />Abolish the laryngeal reflex<br />Vein anesthesia<br />Analgesic ??<br />Less if history of seizure <br />Propofol<br />1-2 mg <br />Anterograde Amnesia <br />Relaxants <br />1-2mg/kg<br />Real hypnosis<br />Loss of corneal reflex<br />Time to do Trial of ventilation <br />Easy vent-go to MR<br />Roc 0.6mg/kg<br />1.2 mg/kg RSI<br />Cis 0.15 mg/Kg<br />SUX 2mg/kg <br />
  30. 30. Special scenarios <br />Pediatrics …higher Propofol<br />Elderly …lower Propofol<br />Shock…ketamine,etomidate<br />Mediastinal mass…sevo induction<br />Neuro…thiopentone<br />High ICP..addβ-blockers<br />RSI…Propofol and SUX only<br />
  31. 31. Air way management <br />Tube selection and insertion <br />Patient related:<br /><ul><li>female tube 7-7.5
  32. 32. Male tube 8-8.5
  33. 33. pediatrics age/4+4</li></ul>Surgery related<br />ENT:preformed tube<br />SML:MLT tube<br />Thyroid: Reinforced tube<br />Thoracic: DLT<br />Uncuffed till age of 8…..what about our practice in AUB ?<br />Depth of insertion <br />Adult :height/10 + 5<br />Peds :age in years + 10<br />Nasal intubation<br />Smaller size tube<br />Depth of insertion: Oral depth + 3<br />
  34. 34. The surest sign of correct intubation<br />
  35. 35. Tube fixation <br />
  36. 36. The time of BP and hemodynamics fluctuation<br />Up and down<br />BP q 1min till stabilize<br />
  37. 37. Now u can put your invasive monitors if needed <br />
  38. 38. Baseline ABGS<br />Assess PaCo2-ETCO2 gradient<br />Oxygenation PaO2/fiO2..>200 it is OK<br />Hct<br />Electrolytes <br />
  39. 39. Patient Positioning <br />
  40. 40. What nerve at risk of injury?<br />
  41. 41. After prone positioning you noticed increase in Peak air way pressure and hypoventilation <br />What will you check? <br />
  42. 42. Patient placed in Trendelenburg position …<br />then you noticed desaturation and increase in the Peak airway pressure<br />What is the explanation? And what will you do?<br />
  43. 43. ENT surgeon extended the neck for Tonsillectomy <br />What are the risks? <br />
  44. 44. Extension<br />Exit<br />Flexion<br />Further <br />
  45. 45. Maintenance phase <br />
  46. 46. Q 5minutes <br />
  47. 47. UOP Q 1 hr<br />
  48. 48. Baseline kidney dysfunction<br />CHF<br />Age > 70<br />DM<br />Contrast injection <br />
  49. 49. Nerve stimulator<br />TOF=0 in Neuro,Eye<br />TOF =1 in other cases <br />Deep parlysis needed PTC 0<br />Face more resistant than thumb<br />(twitch in the face doesn’t mean twitch in the thumb)<br />
  50. 50. Apply FAWS as soon as possible<br />More effective intraop than Post op<br />
  51. 51. Hpothermia<br />Increase solubility of inhalation agents<br />Decrease metabolism<br />Increase risk of bleeding<br />Increase risk of wound infection<br />Acidosis<br />Post operative shivering<br />Arrythmias<br />
  52. 52.
  53. 53.
  54. 54.
  55. 55.
  56. 56. Watch for the blood loss<br />
  57. 57. The bleed that you hear is more serious from the bleed that you see<br />
  58. 58. Infection trasmission(viral,bacterial,parasitic,prions)<br />Fever(bacterial sepsis,AHTR,febrile non hemolytic transfusion reaction)<br />TRALI<br />TACO(transfusion associated circulatory overload)<br />Anaphylaxis<br />PTP<br />Transfusion –(GVHD) <br />Transfusion thrombocytopenia<br />Transfusion neutropenia<br />Citrate toxicity<br />Hyperkalmia<br />Adenine toxicity<br />Hypothermia<br />Dilutionalcoagulopathy<br />Decrease 2,3 DPG<br />Acid base Changes<br />Microaggregate delivery(ARDS)………………………<br />Immune supression<br />Allergic reactions<br />
  59. 59. Long list<br />Infectious and non infectious<br />Immunlogic and non imunologic<br />TRICC study:Liberal transfusion associated with longer hospital stay,and higher mortality and morbidity <br />
  60. 60. > 10 <br />inappropriate<br />Likely to be appropriate if signs <br />Of impaired O2 Delivery <br />7-10<br />appropriate<br /><7<br />Highly recommended<br /><6<br />
  61. 61. Transfusion triggers<br />Regardless these numbers if patient showed sign of inadequate oxygenation<br /><ul><li>Hemodynamic instability
  62. 62. SVO2<50%
  63. 63. Myocardial ischemia(new ST depression>0.1mV,new ST elevation >0.2 </li></ul>Transfuse <br />Antibiotics Re-dose after 4 hours<br />If bleeding after 3 hours<br />
  64. 64. High sympathetic state<br />Pain, awarness, adrenaline injection ,pheo,<br />thyroid storm<br />Hypovolemic, septic patient, carcinoid crisis,<br />anaphylaxis <br />High fentanyl dose,Neostigmine,B-blockers ,<br />spinal shock<br />After Neosynephrine,Cushing reflex<br />
  65. 65. Patient SD undergoing LAP gastric BYPASS ,MV settings TV 700 RR 14<br />After 1 hr u noticed desaturation?<br />
  66. 66. Check for Disconnection <br />NO disconnection<br />
  67. 67. Check for FiO2<br />FiO2 :40%<br />
  68. 68. Chest Auscultation <br />BIL equal breathing sounds<br />NO wheezes or crackles<br />
  69. 69. Check BP<br />BP:120/80<br />
  70. 70. u noticed high peak airway pressure<br />Delivered TV is 35o ml <br />
  71. 71. TOF 3/4<br />
  72. 72. 4 causes of hypoxemia <br />Hypoventilation <br />Impaired diffusion<br />Shunt<br />V/Q mismatch <br />

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