Anesthesia Review Dwi
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Transcript of Anesthesia Review Dwi
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Anesthesia Review
M. Dwi Satriyanto
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The Anesthesiologist
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Initial Assessment
ASA classification is part of the physical
examination of the patient.
Is graded classes 1- in order of increasingris! of mortality.
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ASA "lassification
"lass 1 #ealthy
"lass $ Mild systemic disease% no f&nc limitations
"lass ' Moderate to severe systemic disease%f&nctional limitations
"lass ( Severe systemic disease% constantly lifethreatening% f&nctionally incapacitating
"lass ) *ot expected to s&rvive with or witho&ts&rgery $(h
"lass +rgan Donor
"lass , ,mergency
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Monitoring
*oninvasive monitoring with
appropriate c&ff si/e.
Invasive monitoring 0A-line for electivehypotension% anticipation of wide variations
in % need for fre2&ent 3lood sampling.
"ommon sites are femoral and radial sites.Don4t &se rachial artery.
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Monitoring
,56 for detection of dysrhythmias% myocardialischemia% electrolyte a3normalities.
7eads 8$ and 8) together detect 9): of
intraoperative ischemia% allowing for earlyintervention.
&lse oximetry estimates level of oxygen 3inding3y hemoglo3in
Sa+$ of ;
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Monitoring
Temperat&re- Axilla% esophag&s% pharynx% 3ladder%tympani.
>rine o&tp&t- a meas&re of end-organ perf&sion?
@oley for all cases over $ hrs% to decompress3ladder 0lap proced&res.
Swan-6an/- for 78,D% "+% S8R.
"apnography- confirms ade2&acy of ventilation%,TT placement% estimates a"+$.
>nexpected rise in "+$ Malignant hyperthermia.
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Ind&ction of Anesthesia
I8 or mas! ind&ction of general anesthesia.
"om3ination of agents 3ased on patient
characteristics% and proced&re.
Incl&des an amnestic% analgesic% hypnotic% m&scle
relaxant% and a volatile agent.
Rapid se2&ence ind&ction.
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Rapid Se2&ence Ind&ction
re-oxygenate with 1
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Analgesic Agents
In 3ol&ses at ind&ction and 3efore incision% thenmaintenance as needed.
Additional doses 3ased &pon sympathetic response to
pain% li!e increased #R% .Fentanyl% a synthetic narcotic% onset $min% pea!)min. Meta3oli/ed 3y liver.
6ag is 3l&nted% minimal cardiac depression% can
ind&ce respiratory arrest.(< times potency of morphine% no cross allergytho&gh.
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Analgesics
Morphine- )min onset% pea! at $
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Analgesics
Ketamineincreases #R% %3ronchodilator% maintains spontaneo&sventilation. Increased "@.
Ill&sions% dysphoria.
*ot a respiratory depressant% can 3e soleanesthetic agent.
+ne of several ind&ction agents% good forchildren% contraindicated in head inC&ry.
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Sedative-#ypnotic Agents
Sodium thiopental% a 3ar3it&rate% ind&ces&nconscio&sness within '< seconds witho&tanalgesia.
,xcellent anticonv&lsant.
After single dose dr&g redistri3&tion into m&scle mayres< in rapid awa!ening.
Side effects hypotension 0in hypovolemia%heartfail&re% 3eta 3loc!ade% resp. arrest% decreases "@%meta3olic rate.
PentotalB
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Sedative-#ypnotic Agents
Propofol% fast acting% no hangover 0great for
o&tpatients% antiemetic.
Rapid meta3olism 3y liver.
Side effects hypotension% 3l&nting of airway
reflexes helping in int&3ation% resp. arrest.
>sed for maintaining anesthesia% sedation in I">.1.1!"alm7E
1
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Sedative-#ypnotic Agents
Etomidate% fast acting% minimal hypotension% great
for ind&ction.
Rapid meta3olism 3y liver% avoid contin&o&s
inf&sions as can ca&se adrenocortical s&ppression.
"an ca&se myoclon&s.
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Sedative-#ypnotic Agents
Benzodiazapines% provide anxiolysis% hypnosis%amnesia% anticonv&lsant% s!eletal m&scle relaxant
properties.
*o analgesic properties here.
Versed most common% short acting% liver meta3%so watch itF.crosses placenta.
Ativan0lora/epam long acting.Flumazenil is a 3en/odia/apine antagonistFassociated with sei/&resE
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M&scle Relaxants
>sed to facilitate int&3ation.
D&ring a3dominal s&rgery.
Ghen movement can 3e devastating.Paralyzed but still feel and remember
everythingE
*o analgesia% hypnosis% or amnesia.
Diaphragm last to go down% first to recover.
*ec! M&scles first to go down% last to recover.
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M&scle Relaxants
Depolarizingand non-depolarizing.
Depolari/ing agents ca&se an initial
transient m&scle fi3er activation 3eforerelaxation occ&rs.
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M&scle Relaxants 0Depolari/ing
Suinylholine% provides rapid depolari/ing
3loc!ade. Mimics acetylcholine% '< seconds%
short d&ration )-1< min.
Rapidly meta3oli/ed 3y plasma
pse&docholinesterase.
The only oneE
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M&scle Relaxants 0Depolari/ing
1 in '
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Malignant #yperthermia
"om3o of volatile anesthetic pl&s s&ccs.
@irst Sign is Increased end-tidal "+$.
Acidosis% m&scle spasm.
#ypertension% arrhythmias.
#ypoxemia% hyper!alemia
Tachycardia% pyrexia.
Myoglo3in&ria.Tx I8!antrolene "#mg$%g% cool% Dc volatileagent.
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*on-Depolari/ing
Mivac&ri&m
Roc&roni&m
8ec&roni&mAtrac&ri&m
anc&roni&m
All inhi3it acetylcholine at *MH.
*o fascic&lation% or increase in potassi&m.
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*on-Depolari/ing
Mivauriumdependent on pse&docholinesterase.
&ouronium% fast% &sed when s&ccscontraindicated.
Panuronium% inexpensive% &sed for prolongedparalysis% tachy% prolonged in renal.
All potentiated 3y hypo!alemia% calcemia%hypermagnesemia.
Monitored 3y peripheral nerve stim&lation.
To reverse% &se 'eostigmine 03loc!s acetylcholinesterase pl&s anticholinergic agent 0to
co&nteract 3rady at end of s&rgery.
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Airway
Mas%ventilation &sed at time of ind&ction.
"an 3e sole means of airway in patients withminimal ris! of aspiration.
8entilation also facilitated 3y oral or nasalair(ay0tong&e% awa!e patient.
)MAlodges in hypopharynx s&perior to larynxpreventing soft tiss&e o3str&ction of airway."ontraindicated in aspirators% paraly/ed% need forcontrolled ventilation.
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7MA
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Airway
Endotraheal *ntubationallows for vents&pport% oxygenation% relative protection ofairway.
"onfirm position 3y chec!ing 3ilateralchest rising% condensation in ,TT% ,nd-tidal"+$% 3ilateral 3reath so&nds.
@i3eroptic laryngoscopy in diffic<int&3ations.
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Inhalation Anesthetic
Afterind&ction anesthesia is maintained
with a volatile anesthetic.
rovides hypnosis% amnesia% some degree ofanalgesia and m&scle relaxation.
Differ in 3lood sol&3ility% potency% side
effect profiles.
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Inhalation Anesthetic
Minim&m Alveolar "onc. 0MA" is the
smallest concentration at which )
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Inhalation Anesthetic Agents
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8olatile Agents
#alothane
,nfl&ran
Isofl&raneSevofl&rane
Desfl&rane
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Side ,ffects of 8olatile Agents
#ypotension via cardiac depression 0halothane
or vasodilitation.
Arrythmogenic 0halothane potentiated 3y
epinephrine.
Enfluran contraindication for epilepsi
*sofluraneleast cardiac depressant% most coronary
artery dilation.
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Side ,ffects of 8olatile Agents
Rapid% shallow 3reathing res<ing in decreased
min&te ventilation% 3ronchodilation.
l&nts hypoxic drive
Impair cere3ral a&to reg&lation% or a3ility of 3rain
to maintain cere3ral 3lood flow over a wide range
of s.
*soflurane&sed in I" patients+alothanerarely ca&ses #epatitis.
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*itro&s +xide
*ot potent% re2&ires large inhalation
concentrations.
Insol&3le in 3lood
Minimal cardiac depression% changes little. *o
m&scle relaxant properties li!e volatile agents.
*ot 3ronchodilator% increases 8R.
May expand air cavities 3y diff&sing in faster thandiff&ses o&tF.. Avoid in middle ear occl&sion.
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Regional Anesthesia
Spinal Anesthesia% 7'-7( interspace. @ree flow of"S@ confirms s&3arachnoid placement where local isinCected.
Anesthesia occ&rs in min&tes% lasting &p to $ hrsdepending on agent and dose.
7evel of sympathetic 3loc! higher than sensory 3loc!%this in t&rn a3ove level of motor 3loc!.
Sympathetic 3loc! res<s in hypotension.#igh spinal res<s in respiratory depression.
Motor recovers 3efore sensory.
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Spinal
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Regional Anesthesia
In Epiduralanesthesia% a catheter is placed
in epid&ral space allowing for contin&o&s
inf&sion to relieve postoperative pain.@inal level of sensory 3loc!ade depends on
volume in,etednot dose.
+nset slower than spinal.
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,pid&ral
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