1. Anaesthesia/Periop Revision Dr Rob Stephens Consultant in Anaesthesia UCLH Hon Senior Lecturer UCL Thanks to Dr Roger Cordery

2. www.ucl.ac.uk/anaesthesia/people/stephens www.ucl.ac.uk/anaesthesia/people/stephens Google UCL Stephens Google UCL Anaesthesia Student

4. Only 50 minutes!! Search..‘department of anaesthesia’

5. Contents Physiology Anaesthesia Basics Analgesia Fluid Basics Airway /kit Basics Drugs / Perioperative Medicine

6. Physiology CO = SV x Hr MAP = CO x SVR O 2 delivery = CO x O 2 content (= Hb x SaO 2 ) Hypoxaemia = low O 2 in blood Deadspace = ventilation with no gas exchange = ventilation with no perfusion eg PE, Hemorrhage Shunt = perfusion with no ventilation eg Pneumonia, collapsed lung

7. Anaesthesia Basics Check out podcast Introduction to AnaesthesiaIntroduction to Anaesthesia At www.ucl.ac.uk/anaesthesia/StudentsandTrain ees/students

8. Anaesthesia Triad of Anaesthesia – Hypnosis – Analgesia – +/-Neuromuscular paralysis

9. Anaesthesia Triad of Anaesthesia – Hypnosis – Analgesia – +/-Neuromuscular paralysis

10. Anaesthesia- Hypnosis Hypnosis= reducing consciouness Either I/v or volatile I/V Thiopentone Propofol CVS RS NS Depressants Volatiles- gasses- Sevoflurane, Isoflurane Breathe in, then out CVS RS NS Depressants I/V Ketamine Different side effects

11. Anaesthesia Triad of Anaesthesia – Hypnosis – Analgesia – +/-Neuromuscular paralysis

13. Anaesthesia: Analgesia Other, psychology, local, regional, systemic Local/regional – Na + channel Lignocaine, Bupivicaine Systemic – ‘ladder’ plus adjvants (extras) – Simple –Paracetamol – NSAID – oral, I/v s/e GI/platelets/ asthma/renal – Opioids = any drug acting on opioid receptors s/e N+Vomit / constipation / RS /NS Dihydrocoedine, Morphine, Fentanyl I/m, PCA (cautious i/v) Oral,transdermal – Gabapentin, Amitriptyline, Nitrous oxide etc

14. Analgesia Other, psychology, local, regional, systemic Postop pain – depends on expected needs ?Intraop block/epidural + systemic Everyone gets Paracetamol regularly 1G QDS ?add NSAID regularly eg Ibuprofen 200mg-400mg TDS ?add Dihydrocoedine regular ?need stronger – oral PRN Oral Morphine ? need stronger – PCA – i/v

15. Analgesia- PCA Patient Controlled Analgesia Morphine IV 1mg/ml PCA Pictur1mg bolus No background 5 min lockout Nursing Obs

16. Anaesthesia Triad of Anaesthesia – Hypnosis – Analgesia – +/-Neuromuscular paralysis

17. Anaesthesia: Neuromuscular To allow intubation and easy ventilation No movement for surgery NMJ Nicotinic Cholinergic antagonists – Non-competitive/depolarising = Suxamethonium= 2 acetylcholine molecules – Competitive/non- depolarising = Others – Atracurium, Rocuronium, Vecuronium.. Reversal- inhibit the enzyme that breaks down Ach (Cholinesterase) with Neostigmine used in Myaesthenia Gravis

18. Anaesthesia: 3 classical phases Preoperative – v important Induction- going to sleep – Dangerous – Mostly Analgesia, Iv hypnosis, paralysis – O 2, Air, ABCD Maintenance –during surgery Emergence – once surgery has ended ?postop? and recovery

19. ‘Preoperative’ CVS SOBOE < 2 flights stairs? = Heart Failure Angina? = IHD Can’t assess exercise tolerance? Many other issues…. risk vs benefit of surgery ?postpone elective surgery to ’optimise’ ?

21. Fluid Therapy Everyone gets confused! Think about why you’re called to see patient Hx, Exam, Ix, Management Ward Guidelines- NICE vs others How can you monitor fluid status? Colloids / Crystalloids / Blood products Colloids vs Crystalloids – no real evidence

22. Fluid: Crystalloids / Colloids CSL = Hartmann’s Saline 0.9% Gelofusin / Geloplamsa Picture of Fluids

23. NICE 2013- ward fluid Assess - usual ways Resuscitate – Hartmanns/ Saline 500ml 15ml Routine Maintenance Oral ideally, if i/v Glucose 50-100g /day 25-30ml / kg / day Na K Cl 1mmol/kg/day Replace + Redistribution

25. Fluid Therapy Crystalloid – Saline / Glucose / Hartmann’s – Saline – Na Cl, acidosis, renal dysfunction – Glucose = water, no electrolytes, hyponatraemia – Hartmann’s-less Na K+, Ca+ less Cl, has lactate, no acidosis Colloids – smaller volumes / artificial- allergy – Gelatin in saline/Hartmann’s-like ‘Gelofusin’ ‘geloplasma’

26. Blood PRC FFPPlateletsCryoprecipitateOther PRC Transfusion – Immune / Infection /Over-Underload PRC Massive transfusion – Blood = cold,  K,  Ca, Coagulopathy Usually aim for 70-80g/L Unless CVS/RS disease

27. Fluid Intravenous Cannulae / ‘Venflons’ 22 g 20 g18 g 16 g 14 g Awake Asleep / local

28. Fluid Preparation Chat / Gloves / Sterilize skin Correct dressing + documentation

29. Arterial blood gas Essentially like venous – apart from 0xygen. pH pCO 2 sBEx (sHCO 3 ) Oxygen- what’s the Fi0 2 Other stuff UCLH happen to have bought – Eg Na, K, lactate, CO, Hb, MetHb New way of thinking- ‘Stewart’ (gold medal)

30. Airway Airways obstruct Under Anaesthesia If consciousness reduced Likely if GCS <8

31. Oxygen Nasal Cannuale1-3L/min Variable Flow ‘Hudson Mask’ 1-15L/min ‘Venturi’ Masks:Coloured for different % Tight fitting mask or hood for CPAP / NiV Oxygen via Airway ie anaesthetised / sedated

32. Airway 0 Give Oxygen – different ways 1 Airway Manouvers – caution in head trauma Jaw thrust / Head tilt / chin lift / 2 Airway Adjuncts Guedel 3 Airway kit eg Laryngeal Mask Airway 4 ‘Definitive’ Airway Intubate- Cuffed Oral EndoTracheal Tube / Tracheostomy 5 Surgical Airway – Cricothyroid /Tracheostomy

33. Airway Equipment

34. Airway Use adjuncts Adult male Adult female

35. Airway Equipment

37. Equipment

38. Video of LMA

39. Airway Equipment Cuffed Oral (nasal) Endotracheal Tube ‘ET Tube’ Internal Diameter sized Need to be paralyzed Inserted under Laryngoscopy

40. Airway Equipment

41. Drugs before surgery Don’t stop CVS drugs except ACE ie continue B Blockers, Ca ++ antagonists, Nitrates etc Don’t stop Asprin/Clopidegril with Coronary Stents Type 2 DM: no food, no hypoglycaemics ‘NBM’ –sips of water ok for drugs

42. Fasting Food, milk, 6 hours Clear fluids 2 hours Water -30 ml hour until surgery

43. Summary Anaesthesia- triad Hypnosis – IV Gas Analgesia – local, regional systemic Preoperative / 3 phases / Postoperative Fluids Equipment Welcome in theatre anytime www.ucl.ac.uk/anaesthesia/people/stephens www.ucl.ac.uk/anaesthesia/people/stephens Google UCL Stephens Google UCL Anaesthesia Student