Anesthesia and Pain Management Lukáš Dadák, ARK, FNUSA Podzim2018/aVLAL091 My goal:   understand basic concepts of general and regional anesthesia learn basic skills of airway management anatomy of regional anesthesia (SA, EPI) anesthesia of children   .. and if you would like, more … How to get credit?? Lectures Literature : Larsen, Miller, Barash Anesthesia Short test Simulation (Airway management drill) OR – voluntary intership Oral Exam Anesthesia&Pain Management; pondělí 13:30 (knihovna ARK) 3 4 5 6 7 8 9 10 11 12 13 14 15 Mon 1 Oct 18 Mon 8 Oct 18 Mon 15 Oct 18 Mon 22 Oct 18 Mon 29 Oct 18 Mon 5 Nov 18 Mon 12 Nov 18 Mon 19 Nov 18 Mon 26 Nov 18 Mon 3 Dec 18 Mon 10 Dec 18 Mon 17 Dec 18 Mon 24 Dec 18 Introduction, investigation, premedication Anesthesia Machine, Monitoring Pharmacology of Anaesthetic Airway Management Regional Anesthesia Acute and chronic pain Children and anesthesia Simulation Simulation Simulation Simulation Simulation Simulation Dadák Dadák Vach Dadák Vach doc.Štourač doc.Štourač Topics for oral exam • • • • • • • • • Anatomy of airways + physiology of breathing Physiology of circulation (cardiac output) Monitoring Pharmacology ASA I patient and GA, premedication; Airway management – – Rapid sequence of induction = technique, indications Difficult ventilation / intubation Malignant hyperthermia Acute, chronic pain Anatomy of spinal column – SA, EPI History Opium (Egypt, Syria) – Hippokrates 400 BC ease pain 1555 Andreas Vesalius - arteficial ventilation through tube between vocal cords, ventricular fibrilation (animals) 1546 Valerius Cordus - ether – oleum vitreolum dulce 1547 Paracelsus - analgetic effect of ether 1646 Severino - cryoanaesthesia – Napoleon's wars - Larey 1773 N2O Joseph Priestley (1733-1804) 1774 oxygen 1779 Humphry Davy - anaesthetic effect of N2O Surgery before modern Anesthesia Surgical procedures were carried out prior to the introduction of anesthetics. The key to success was the speed of the procedure, with successful amputations lasting 30 seconds. Strong assistants and restraints were frequently required. Alternatively, decreased cerebral perfusion via bilateral carotid compression was used to decrease sensation during the procedure. Importantly, surgical procedures were associated with significant risk of death and, at a minimum, severe pain. The development of anesthesia was heralded as one of the great advances of modern medicine, in that it allowed surgery to advance. Beginning of GA October 16th 1846 ether general anaesthesia Boston dentist William Thomas Green Morton to Gilbert Abbott (tumor of mandibule) February 6th 1847 Prague - first Czech ether anaesthesia - Celestýn Opitz 1895 direct laryngoscopy Alfred Kirstein in Berlin. – 1920 direct laryngoskopy to clinical praxis Magill and Rowbotham Ether After ether    1847 – chloroform – obstetrics anesth. 1884 – cocaine – eye, .. mucosa 1885-99 – cocaine “spinaly” 1950's – halothan 1960's – enflurane, isoflurane 1994 – sevoflurane    Ideal anesthetic    temporary disable function of neurons no influence on breathing, circulation safe, cheap, non-toxic,... Does not exist.  Anesthesiology is a jung discipline (162y) dealing with • The preoperative, intraoperative and postoperative evaluation and treatment of patients who are rendered unconscious and/or insensible to pain and emotional stress during surgical, obstetrical, therapeutic and diagnostic medical procedures; • The protection of life functions and vital organs (brain, heart, lungs, kidneys, liver, endocrine, skin integrity, nerve) under the stress of surgical and other medical procedures; Anesthesiology • • • • • • • Monitoring and maintenance of normal physiology during the perioperative period; Diagnosis and treatment of acute, chronic and cancer-related pain; Clinical management of CPR; Evaluation of respiratory function and application of respiratory therapy; Management of critically ill patients; Conduct of clinical research; Teaching personnel involved in perioperative care GUIDELINES FOR PATIENT CARE IN ANESTHESIOLOGY, ASA 1967 General Anesthesia - Definition arteficial intoxication, controled coma reversible drug-induced loss of consciousness, felling, pain. „No reaction“ to stimuli allow therapy (surgery, electroshock) allow diagnostic method (CT, MRI) General anaesthesia Hypnotics, volatile anaesthetics Analgetics -opioids -N2O Muscle relaxants Patient + GA preoperative anaest. visit, premedication venous line monitoring informed consent induction (airway protection) maintenance (extubation) treatment of postoperative pain record of GA ASA Physical Status = risk I Healthy patient II Mild systemic disease, no functional limitations hypertension, smoker, mild asthma 0,06% 0,47% 4,39% III Severe systemic disease- definite functional limitation coronary disease, COPD, DM, CHF, renal failure IV Severe systemic disease that is a constant threat to life unstable angina, burn with septic shock 23,48% V Moribund patient not expected to survive 24 hours with or without operation patient with extensive bowel infarction, polytrauma 50,8% Preoperative tests as a component of the preanesthesia evaluation, may be indicated to: 1) discovery a disease / disorder which may affect perioperative anesthetic care, 2) verification of an already known disease, disorder, medical or alternative therapy which may affect perioperative anesthetic care, 3) formulation of specific anesth. plans Will I change something if the resust is ...? Preoperative examination history (GA, RA, complications) physical examination (neck, back) laboratory: blood cells, ions, urea, creatinin, glucose, AST, ALT, GMT, bilirubin, AB0. ECG (older 45). Xray of chest (older 60 let). function exam – cardiological, lung, nephro, hemato Why to do PreOP exam?  decrease RISKs what is the benefit of surgery Airway exam GA // regional? premedication     History of Airway Management  History − − any difficulty, teeth? TS scar [narrower trachea]? !!! Tell the truth about troubles in anesthesia !!!  Examination: − − − − − − − − Mouth Opening(3 fingers) free teeth gotic palatum big tongue, small mouth hypoplastic mandibula anteposition of larynx = mandibula-os hyoideum <3 fing. fletion, extension of head Mallanpati Difficul airway * Obesity - body weight > 110kg * Mouth opening - inter-incisor distance < 4cm in an adult * Ability to prognath - a large overbite, or the inability to shift the lower incisors in front of the upper incisors * Thyromental distance - The distance from the thyroid cartilage to the mentum (tip of the chin) should be > 6.5-7 cm. * Mentum-Hyoid distance - Similar to thyromental distance, and should be at least 3-4 finger-breadths. Mouth opening Should be adequate (3 cm or more) to easily • allow a laryngoscope plus endotracheal tube (ETT). • Patients with temporomandibular joint (TMJ) disease or trismus may not be able to open widely, and may require fiberoptic intubation by the nasal route Teeth Edentulous patients are always easier to intubate, but are often more difficult to ventilate with a face mask. Patients with teeth in poor condition or with very prominent teeth may be more difficult to intubate. Thyromental distance Distance from the mentum of the mandible to the thyroid, with neck fully extended. If distance is less than 6 cm there is less space for the tongue to be displaced with laryngoscopy Mallanpati OTI easy 95% OTI difficult 50% Your easy patient? Predicted difficult airway        epiglotitis abscesus (submandibular, retropharyngeal) tetanus trauma of the neck, mouth tumor of the larynx, faryngx temporomandibular joint disease obezity Respiratory risk  spirometry, Blood gases COPD Astma chronic bronchitis acute inflamation of lunx     Cardiovaskular risks   ECG (load) ECHO, (coronarography) hypertension ( cardiac work, failure)  ischemia (AP, IM, rhythm)  Cor pulmonale  Valvular abnormalities (Ao stenosis) Prophylaxis:  Beta blockers, ? antihypertenzive drugs  … other risks   Diabetes mellitus Hepatic – – porphyry failure, cirhosis   Renal CNS − − epilepsy mm. (Myastenia gr., ) Conversation before GA or RA empty stomach - last food, fluid tooth (artificial, free) weight allergy complication of CA in his/family history check-up questionnaire agreement with anaesthesia PreOP starving    24 h no smoking 6-8 h no eating 4h breast milk 2 h last clear liquid Premedication usually p.os - evening + morning sedation/anxiolysis (Benzodiazepines) analgesia only if pain (opioids) reduce airway secretions + heart rate control + hemodynamic stability prevent bronchospasm prevent and/or minimize the impact of aspiration decrease post-op nausea/vomiting Premedication goal: cooperating patient anxiolysis  easer induction of A.  lower consumption of drugs Risk of Aspiration • • • • • Severe obesity Symptoms of gastroesophageal reflux Advanced pregnancy Severe ascites Opioid administration or other condition resulting in delayed gastric emptying • History of gastroparesis or other motility disorder • Bowel ileus or bowel obstruction ((Metoclopramid, sodium citrate with citric acid)) → RSI Rapid Sequence of Induction Induction of Anesthesia 1 – 3 drugs i.v. =  lethal dose  the most effective way => no self-controle, unable call for help, suppress of vital autoregulating mechanisms  unmask compensated disturbances (hypovolemia, relative respiratory insuf, ...) Induction  30 - 60s from fully conscious to vitally dependent on anaesthetist Moment with big influence on the rest of the life.  P.S. Did you ever sign “Informed Consend“ Airways Indication for intubation: full stomach (Rapid Sequence of Induction) artificial ventilation after procedure Laryngeal mask Face mask Orotracheal intubation, nasotracheal intubation with direct laryngoscopy Tracheotomy Cricothyreotomy In the End of Anesthesia Stable ABCD: extubation, pain, temperature control, PostAnest.CareUnit Unstable: analgosedation + arteficial ventilation - transport to ICU Extubation    pay now or pay later - if in doubt, leave it in. always awake if - difficult mask airway or intubation, full stomach, surgical considerations, sux contraindicated awake means awake - if in doubt, leave it in Postoperative care ICU or standard department monitoring according to the type of OP + health control laboratory treatment of acute pain infusion therapy, blood loss OR checklist Test A.Machine = does it inflate O2 [before anesthesia]        Identity Procedure, side Allergy Documentation (fill in, Informed Consend) i.v. access Monitoring ORoom • „Dobry den“ fellowship anesthetist ~ A.nurse • confidence, respect • hygiene – wash your hands before every case, use gloves Mortality of anaesthesia (ASA I) 0,008-0,009% primary connected with A 0,01-0,02% partially connected with A 0,6% 6 day mortality after operation 3 times danger than flying [1: 775 000] Complications of GA !!! No risk = no anaesthesia !!! difficult intubation, ventilation … asfyxia aspiration of stomach fluid … pneumonia overdose anaesthetic … cardiovascular, respiratory colaps malfunction of the monitor, ventilator organ failure (MI, COPD, hepatitis, ...) malignant hyperthermia allergic reaction / shock Risk of anesthesia - mortality  Trend to improve safety => low tolerance to complications of anesthesia Mortality and Anesthesia:  1952 1 : 2 000 (Beecher, 1954)  1982 1 : 10 000 (NCEPOD 1987)  2001 1 : 50 000 – 220 000 (Brown, 2002) Risk of death in aviation 1: 755 000 (1997)  Death and Anesthesia      hypoxia / UPV / intubation of oesophagus aspiration / regurgitation of gastric fluid to lung circulatory instability (ischaemia) overdose anaphylaxy, interaction of drugs !!! Death was preventable (30-60%) !!! Phraseology   analgesia = elimination of pain sedation = elimination of stress, impatience, fear – Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. – Phraseology – Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. General Anesthesia is … loss of consciousness during which patients are not arousable, even by painful stimulation. • inability to maintain ventilatory function = often require assistance in maintaining a patent airway, and positive pressure ventilation may be required. – Continuum of depth of sedation ASA 2004/2009 Anesthesia  General – – – – – inhal., TIVA central block (SA, EPI) periferal blocks (brachial, nervous) local anesthesia (eye – cornea + conjunctiva, infiltration)  Regional Combined = GA + EPI-line Useful web http://www.virtual-anaesthesia-textbook.com/ www.asahq.org www.akutne.cz www.cobatrice.org http://airwaymicrotext.homestead.com Virtual Anesthesia Machine:  http://www.anest.ufl.edu/vam/  www.simanest.org Preoperative evaluation and premedication     Risk of A PreOp evaluation Premedication Safety in OR Next week:  Anesthesia Machine  Monitoring