ISAKanyakumari - Anaesthesia Practice in Kanyakumari District

ANAESTHESIA PEARLS

A Guide To drugs
Bag-Valve Mask Ventilation
How to set your room

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

'PROCEDURAL BASICS' ANAESTHESIOLOGISTS MAY OVERLOOK!

Focus On - Bag-Valve Mask Ventilation

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

a small thyromental distance (less than 6 cm)

airway obstruction caused by vomitus or blood and trauma to the face or neck

edentulous, obese, elderly, or pregnant patient

Triad of BVM

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

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.

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.

If a second person is available to provide ventilations by compressing the bag, a two-hand technique can be used.

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

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
	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)

Give some sedation before you go into the room….the patent in extreme anxiety

In Theatre:

Check the OR table ….not working

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

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:

	female tube 7-7.5
	Male tube 8-8.5
	pediatrics age/4+4

Surgery related

	ENT:preformed tube
	SML:MLT tube
	Thyroid: Reinforced tube
	Thoracic: DLT

Uncuffed till age of 8….. Contraversial?

Depth of insertion

	Adult :height/10 + 5
	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:

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

Maintenance phase:

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:

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
	4x4 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
		High sympathetic state: Pain, awarness, adrenaline injection Pheo, thyroid storm
		Hypovolemic, septic patient, carcinoid crisis, anaphylaxis
		High fentanyl dose, Neostigmine, B-blockers, spinal shock
		After phenylephrine , Cushing reflex

Tests to assess recovery: Tests to assess Depth

Ahmad M. Abou Leila

ISA KANYAKUMARI

Public Awareness

Search