ILCOR 2010 guidelines

DO NOT RECOMMEND the use of INTRATRACHEAL route for administration of drugs
IV Adrenaline is given in the protocol during compression after the 3rd shock

If IV route is not available INTRA-OSSEOUS route is recommended both in adults and children

However if no IV or IT access is available
then intratracheal may be used = Class 2B Level of Evidence C

regs

1% DRL
that is what they call it

intial studies have been very encouraging

AHA/ ECC 2010 guidelines on CPR
under ACLS
recommends
QUANTITATIVE CONTINUOUS WAVEFORM CAPNOGRAPHY is mandatory in ACLS
for
Confirming ETT placement - Class I recommendation ( Level of Evidence A)
For monitoring effectiveness of CPR - Class IIa
FOr monitoring return of ROSC - Class IIa
For monitoring post cardiac arrest intensive care - Class IIb

How many of you on this forum beleive that we can comply with this recommendation
How many of us use ETCO2 for all GA cases as is recommended in minimum mandatory monitoring protocol
In fact how many of us use it for high risk surgeries like Laprascopic surgery and pts with COPD

If we cannot follow a Class I recommendation are we liable to negligence
This is of great importance what with medical tourism increasing in our country and we have to anaesthetize more  and more of foreign nationals

Would like to hear your thoughts

regs

A 70 year old man with fracture Neck of Femur is scheduled for surgery

If the patient was on Aspirin 75 mg OD

1. Would you postpone the surgery
2. If no, why
3. If yes by how many days and why

If the patient is on Clopidogrel 75 mg OD

1. Would you postpone the surgery
2. If no, why
3. If yes by how many days and why


Remember that prolonged immobilization comes with its own set of problems

regs
jafo

Dear gasman
or who so ever is so diligently moderating this site
Looks like trouble out there
site is being bombarded by unsolicited spam
I wonder if this is going to screw up our comps
so who ever is incharge can this be taken care of
thanks in advance
regs

not significant
Just ignore
High Eosinophil count may indicate lingering infection
If at operative site, it can make tissues friable ( As in MS)
that is the surgeons problem
you just watch the bleeding carefully
regs

I do not think that epidural is absolutely contraindicated.
You probably feel that the after spinal, if you give epidural the drug placed in the epidural space will force itelf into the spinal space
yes it can,  but it does not cause any huge problems if you titrate slowly and carefully
that is the basis of COMBINED SPINAL EPIDURAL  which is indeed a safe technique
Yes there may be a role for blocks
If elective, postponing case is an option
regs

PRE-Op
Not a known HT
Did he receive any drugs that could increase BP
If not it must be anxiety
Can try a small dose of IV Midazolam
Usually you can take them up. Once under anaesthesia they settle down well
Books say that for elective surgery BP > 190 / 110 needs to be postponed

INTRA_OP HT
Check ETCO2 - if high
change soda lime
make sure unidirectional valves are working
If using any Mapleson circuits make sure FGF is adequate

Check analgesia - give a top up of analgeics that you are using

Check plane of  anaesthesia - Dial in some more inhalational if necessary
Check relxation  - Top up of relaxant if necessary

Check drugs given - can anything produce a rise in BP

After clearing all this
reconfirm he is not a hypertensive ( need to avoid overreduction of MAP in hypertensives)


Check heart rate

if > 70 give beta blockers
Metoprolol or Esmolol
Stop when HR < 70


IF BP still high - Switch to vasodilators - inhalational or intravenous

res

Text books say that a child who has URI continues to have reactive airway for 4 -6 weeks and hence surgery needs to be postponed.
These guidelines are hardly practiced by anaesthetists in private practice. They have a pretty good success rate.

Also any child not feed from morning and in anxiety can cry and can have a runny nose. This should not be wrongly interpreted as URTI
Child with cough, fever and sniffles needs to be carefully evaluated and elective surgery postponed ( I dont wait for 6 weeks. Maybe symptom free 1 week ).
But be prepared to avoid stimulating or instrumenting the airway in lighter plane

regs

Depends on the nature and extent of surgery which is not specified.
For elective procedures as per ASA guidelines
Hb less than 6 definitely needs transfusion of pRBC
Hb> 10 definitely does not need any
Hb between 6 and 10 decide based on patient condition esp his cardiorespiratory reserve. Best tested by taking history of EFFORT TOLERANCE and checking his ability to do BREATH HOLDING TEST and SHUTTLE WALKING

Fluids are managed as for any other case. Third space losses may exist because dry gas put into the abdominal cavity may enhance evaporation of water from exposed viscera. ALso gas insuffalation can obstruct venous return to right heart and produce hypotension. This may also need titrated boluses of fluids. Extensive surgeries with risk factors may need CVP monitoring. In other cases urine output can be an effective indicator of vital organ perfusion and hence fluid status.

Convert to GA if block is acting but is patchy or of inadequate spread
IF totally failed, double confirm and then proceed to repeat spinal with all precautions in place
Would like to report this case history to drive home the point of safety first while repeating spinals

22 year old ASA 1 man with trauma lands for wound debriment and external fixator for tibia. Was sat up and spinal given by junior resident. Spinal taken up but extremely patchy and around L2 level. Patient uncomfrotable . So repeat spinal given patient went in for severe hypotension and bradycardia. Finally asystole. Revived with diffculty and put on ventilator. Lost on day3 to MOFS.

Cause probabaly very high level of block due to repeat spinal in a inadequately volume resuscitated patient.

So please be careful about repeating spinals. Choose patient carefully. Never repeat spinals in trauma and obstetrics. In such patients safer to give an uncomplicated GA if no absolute contraindications

regs

I think we already had a thread on this site regarding RA for laproscopic surgery.

You will find many case and series reports but no approved text book will back this as a primary preferred technique for lap surgeries.

So if you get into a medicolegal scenario you might be on a risky wicket.

Having said that there are a lot of things we seem to do in private practice that is equally risky like how many of us use all monitors esp temp, how many of us put all this monitors for a saddle block for a bottom surgery, how many of us actually use the recommended O2 analyser, O2 safety link on our machines and ETCO2 monitors in our private practice in these numerous small hospitals we render anesthesia in.

On a personnel note we attempted SAB for LAP appendicectomy as a study. We started the study 3 different times and all the times gave up this study due to extreme patient discomfort. Incidentally all these studies were attempted when I was teaching at one of the top medical schools in our country.

SO personally I cannot figure out a patient being comfortable unless you have used  plenty of sedation, narcotics and ketamine.
But all these durgs can depress respiration leading to CO2 retention and can also compromise the ability to protect airway.

In lap surgeries we need to increase ventilation to remove the increased absorbed CO2 and we also need to protect airways adequately because the increase in intra-abdominal pressure will increase the risk of regurgitation.
So I think using excess sedation seems to defy the logic of physiological changes that occur during lap surgery

T he one thing that RA may provide of benefit to the patient may be the ability to counter the increase in BP produced by CO2 insuffulation
Recently I saw a study where in Lap surgery SAB was done and CLonidine given at 30 mcg and then GA was given. Produced stable heamodynamics. But I think if clonidine was given IV or orally it would have the same effect. Need to check that out.


My final thoughts
Anaes technique should offer the best safety to the patient both theoretically and to save your skin medico legally
I would base on available scientific evidence strongly recommend GA with ET CO2 monitoring

regs

There are the following MAC values
MAC50
MAC 95
MAC BAR 50 & 95
MAC EI 50 & 95
MAC AGE
And
MAC  AWAKE

SO there is no recommended MAC value for extubation because MAC awake seems to meet this criteria

MAC AWAKE (if my memory serves right) is defined as the end tidal concentration of an inhalational agent at  1 atm at which 50% of patients will

Wake up
Respond to oral commands
Open eyes to oral commands
Indicating recovery from effect of inhalational agents.
MAC AWAKE = 0.6 of MAC 50 valueBut it has been found that even at MAC awake values the co-ordination of the fine muscles of the pharyngolarynx may not be fully restored. SO although the patient may be awake , the ability to swallow and protect airway adequately may not be 100% and hence the risk
In clinical practice and end tidal  concentration of 0.2 MAC is preferred before shifting the patient out of OT irrespective of at what value you prefer to extubate them at.

Regs

Let me see how we can make you understand this concept better
If you have read neuromuscular transmission , you would have come across 2 theories
The older- QUANTAL THEORY
The newer – SNARE CONCEPT

The QUANTAL CONCEPT will help understand the tachyphylaxis best

At the alpha and beta receptors let us assume there are 100 molecules of neurotransmitter, of this
50 mols are available for immediate release – lets call them "A"
30 mols, although not immediately available can be mobilized with a little bit of difficulty, using more stimulus – lets call them "B"
20 mols usually cannot be mobilized or may require super supramaximal stimulus to make a few of them available – lets call them "C". These C mols are immature or are not completely functional as say A or B

Now after SAB, hypotension (<90mm) occurs
You give 6 mg ephedrine
It mobilizes 30 mols of "A" and produces the desired effect (> 100 mm.)
BP again drops (<90 mm)
You give 6  mg ephedrine
It can now only mobilize 20 mols of "A"
Hence you have a decreased effect (92 mm) for the same drug dose
"B" molecules are difficult to mobilize
But we can mobilize them with larger dose of ephedrine say 12 mg
It now mobilizes 20 mols of "A" + 10 mols of "B"
So the desired effect (> 100 mm)

It kind of works like this
Not the exact numbers though

After about 60 mg of ephedrine
"A" are depleted
"B" are depleted
"C" 5 – 10 mols left

Now ephedrine stops working
You can no longer use an indirect acting vasopressor because all the neurotransmitters are depleted.
We should now switch to a direct acting vasopressor to get the desired effect like phenylephrine or adrenaline or noradrenaline



Elimination of a drug involves conversion of the lipid soluble ionic form to a water soluble ionic form in the liver and elimination by the kidney.

Elimination half life is after an initial bolus ( eg 100 mg)
Drug gets eliminated by  the kidney at a particular rate controlled by certain factors
When 50% of the drug has been eliminated by the kidney
Only 50% of the original bolus (50 mg) is present in the body

This is the ELIMINATION HALF LIFE for that drug


regs

PRE- ECLAMPTICS usually improve on termination of pregnancy
Seizures are possible but not common after termination.

If you are planning to terminate the pregnancy
Then seizure control can be done with
MgSO4 – is alone enough to control seizures
Phenytoin bolus + Infusion
Benzodiazepine ( Keep Flumenazil and ventilatory support) ready for baby
Thiopentone infusion
Controversy about Propofol – although it has been used
NDP relaxants are also part of management protocol

Once pregnancy is terminated seizures usually stop

Benzodiazepines and Thiopentone raise seizure threshold


How do you ensure adequate CMRO2
You could monitor jugular venous saturation or do a TCD.
All high sounding stuff that I have no idea how to use

So what do I do
Ensure
1.   CPP is > 90 mmHg by maintaining MAP around 100 mmHG and controlling ICP if any
2.   Ensure SaO2 and PaO2 are well within normal limits
If you do this basic things , even without advanced monitoring we can ensure adequate O2  to the brain

Intubation would be a "on the spot" decision looking at the possible edema of tongue and laryngopharynx
Call for senior help
Adequate pre-O2
Keep 5.5 mm ETT ready
Cricoid pressure, RSI
If you anticipate difficulty
FOB awake may be agood choice
Just remember that all awake intubation produce more stress response and can push the BP out of the roof.
Thankfully MgSO4 infusion can decrease the stress response
SO INTUBATE according to your expertise, experience and equipment available

It is prudent to definitely continue MgSO4 infusion through the intra-operative & post-operative period. IT will reduce seizures and stress response.
With MgSO4 one will be more worried about delayed neuromuscular recovery rather than water retention
Also most eclamptics deserve CVP Monitoring because the can be hypovolemic and at the same time prone to LVF
SO it is recommended to  manage fluids with CVP monitoring and  aim to keep the CVP a little low between 3 to 5 mm HG.

Post-operatively, the patient will benefit with elective post-op ventilation to allow seizures, cerebral edema and heamodynamic instability to settle down.
Continue with MgSO4 infusion.
After 12 hours, let them wake up and assess them
All criteria met, you can proceed to wean and extubate
Best to have a 12 hour seizure free period form the last seizure


With regard to possible residual laryngeal edema, one could try any of the following
"BREATHE AROUND THE TUBE" test
Awake look prior to extubation
Extubation over FOB or AEC

Those are my 2 bits on this topic

People,   learning can never be one sided
So lets here views of other people too

Jean, you have all of us on the site working up our grey cells as we return to basic topics in anaesthesia
That's the way anaes goes

regs