Safe anesthesia for sterilization Dr. S. Parthasarathy MD, DA, DNB, Dip Diab.MD ,DCA, Dip software based statistics, PhD (physiology) Associate professor Dept of anaesthesiology and critical care , MGMCRI puducherry

Prof. Ravishankar !!

Why was this topic given ?? Thinking ??

Subramaniya bharathiyar முப்பது கோடி முகமுடையாள் ,உயிர் மொய்ம்புற வொன்றுடையாள் – இவள் செப்பு மொழி பதினெட்டு உடையாள் எனிற்  சிந்தனை ஒன்றுடையாள் .  Safe conduct is essential Population of India in 2013 ! -1,270,272,105 (1.27 billion)

We have to put a full stop some where !!

safety

There was one question ?? Which is the greatest risk in anesthesia ?? Safety margin is its maximal risk !! What is that ?? Thio 3 or 6 Ketamine 1- 3 Spinal 2 or 3 ml ??

Preanaesthetic checkup Is it there ?? Akin to God ?? Harakiri Briyani served Missed !!

Preanaesthetic check up ?? Previous surgical history Previous anaesthetic history Snoring Fasting – means what ?? Systemic illness Why should I tell my fits to this doctor for PS ??

Clinical examination Fever Sub involution Previous laparotomy Systemic diseases Dental, polio , etc.. PV findings Baby fine ??

Investigations Hb. Concentrate on Hb targets and not on PS targets !! Urine complete Pus cell cast – ECG ???

Sterilization is an elective case

Systemic illness Better to do it in medical colleges or tertiary care institutions

Examples Bronchial asthma Nebulized drugs , regional anesthesia Diagnosis !!!

Anemia Hb 9 gm % -- possible borderline Can we give blood – improve Hb and operate ?? NO

Cardiovascular disease Possible with minimal risks Cardiac grid Idealize Talk with physician Convince for a Vasectomy

Preanaesthetic concerns Jewels, dentures, glasses. Removed Consent form Beware = empty the bladder Ovarian cyst ??

Equipments Anaesthesia machine Suction Laryngoscope Drugs ET tubes Pulse oximetry BP apparatus How many are working ?? Drugs LMA

All are available – nearby

Anaesthetic options

Dhoni has lost in Ranchi Is it possible !! Activate an epidural 12 to 14 ml of 1.5 to 2 % ligno with adrenaline. If facilities permit, fentanyl 25 mic. gm. Level of T6 Upto 36 hours similar doses

Intrathecal prior intravenous access and adequate preloading hyperbaric bupivacaine (1.8 to 2.2 ml) Relaxation but head down in lap No urgency and monitoring No polypharmacy Back preparation

General anaesthesia Controlled GA Spontaneous LMA TIVA – drugs Technique is changing but the narcotic is mostly pentazocine 20 – 30 mg. IV

General anesthesia – continued Preoxygenation and RSI Scoline one more dose With or without ET tube Or rare atracurium relaxants with ?? Post op care centres LMA is available in some centers and used as emergency equipment Aspiration ??

Lot of studies Propofol fentanyl Propofol remifentanyl Propofol isoflurane are described – similar results Rarely propofol and ketamine is used .

But what is common A masala of 1.Inj. Atropine 0.6 mg 2.Inj. Diazepam 5 mg 3. Inj Pentazocine 30 mg 4. . Inj ketamine 40 – 70 mg ( 1.5 mg / kg ) Mask oxygen – few puffs – Scoline= 0.5 mg / kg SOS

Have we seen this book ??

The Govt of India says ?? Pethidine + promethazine IM followed by pethidine IV shots and local Obese and uncooperative patients controlled GA No ketamine No mention about spinal Continuously talk with patient

It is safe But is it anesthesia ??

Monitoring Pulse oximetry , ECG, NIBP !! ETCO2 ??

Complications Difficult identification and mobilization of the tubes Local skin infections bladder inj. Intraoperative bleeding perforation Delayed hemorrhage diffi. Pneumo Bowel laceration Vascular injury Failure

If urgent sterilization(disinfection) is needed

Postoperative pain Incision Pneumo peritoneum Tubal ischemia NSAIDs Narcotics are reserved – not for pain but for the night Day care ??

Some other options

Post op period Some nurse Medical officer Trained in picking up complications

Stick to basics and expect the unexpected To summarize No routine working Preop – no systemic illness , fasting -baby ?? Anaesthetic options -- but TIVA with ketamine The Govt. stops Monitoring Complications Post op pain Trained personnel Stick to basics and expect the unexpected

Hiccups, problems, defects Yet surgeries are successful Experience - surgeon, anaesthesiologist , staff BMI of patients

I may not have told something new I emphasize that practice old things foolproof

Long live ISA

Thank you all