Anaesthesia for JMOs Dr Ben Piper ICU and Anaesthetic Registrar Gas Monkey

Anaesthesia for JMOs

Dr Ben Piper

ICU and Anaesthetic Registrar

Gas Monkey

What we will cover today

1. Acute Pain on the wards-• Some “go-to” moves.

2. Special circumstances-• Problems after Spinal and Epidural anaesthesia

If we have time…

1. My patient needs surgery- • What does the anesthetist want to know?

Pain

• What is pain?– An unpleasant sensory and emotional experience

associated with actual or perceived tissue damage.

• Types of Pain- “the good, the bad and the ugly”– Somatic- good– Visceral- bad– Neuropathic– Psychogenic (careful now)

Ugly

Multi Modal Analgesia

Case Study

• 46yo 140kg lady 12hrs post ORIF of patella• 10/10 pain in anterior knee• Screaming, sweaty, tachycardic

– Currently on Paracetamol 1g QID, Endone 5-10mg Q4H,

• What sort of pain is this? • Why now?• What can you do? What do you do?

Options…. What would you do?

1. Endone: give double stat dose (20mg)

2. NSAIDs STAT and chart regular dose

3. Oxycontin 20mg BD

4. IM Morphine 0.1mg/kg

5. IV Morphine 0.05mg/kg

6. Say: “What did you expect, this is surgery- harden up princess”.

7. Page the Anaesthetic Registrar

Lean body mass!!!!!

Pain is like fire……

Get it before it gets you……

Case Study cont…

• Your plan:– Damage control- “put out the fire”

• IV morphine 5mg STAT• IV morphine 2mg increments every 10min• Patient will need supplemental Oxygen• Regular obs- Q15min for 1hr post IV morphine

– Planning ahead• Chart regular ibuprofen 400mg TDS• Increase Endone frequency to 10mg Q3H• If not controlled call APS for help

Case Study cont…

• Your excellent plan worked…1hr later

– Pain is now 1/10– RR 7– Sat 92% on 3L

• What is going on? What will/can you do?

Case Study cont…

• O/E: pupils 2mm R=L, drowsy.– You increase Oxygen to 100% NRBM

– Sats now 94%

• What is the problem?• How long does morphine “last”

• You decide on Naloxone– What about the pain?

– How much?

– How often?

Morphine and Naloxone• Morphine

– IV Peak 10-20min Duration 1-2hrs– IM Peak 30min Duration 2-3hrs

• Naloxone– IV Dose 100mcg at a time wait 1min- repeat.– (slow and steady, you can always give more!!)– Duration 30-60min HENCE need to remain monitored and

may need repeat dosing (it wears off before morphine!)– What are you aiming for?

– Here is an ampoule- draw it up as you would use it!

Much longer than most think!

Endone peak 30min duration 1-2 hrs

Fixed

• After two doses of 100mcg the patient is less drowsy, RR 14, sat 98%

• You keep her on Oxygen with 15min Obs for the next hour, 30min the hour after that.

• Pain is settling and she gets a good nights sleep! She thinks you are a hero!

Take home message

• All doctors need to have a plan for the patient with severe pain!

• All patients on IV/IM opiates need Oxygen!• Get to know your core drugs- discuss a plan

with a senior and try it in daylight hours! – (alone at night is not the time!)

• Know how to get: 1. Help when you are unsure

2. Yourself and the patient out of trouble!– Have a few “go to moves”

Special Circumstances

“Stuff that fancy pants Anaesthetic doctors do but don’t tell anyone about” – Anonymous JMO

Case study: “No sympathy”

• 64yo man returned to ward post TURP– Bkg: HTN, smoker, BPH

• Nurse calls for clinical review:– Obs: BP 90/40 HR 60– O/E: pain free, talking to you

• What do you do?

Choose your own adventure

1. Bolus IVF 500mL

2. Don’t worry his HR is not elevated (60)

3. Withhold tonight's perindopril dose

4. Panic

Case study: “No sympathy”

• You bolus 500mL and with hold his perindopril

• 15min later:– BP75/40, HR 52, nauseated– What do you do? What is going on?

– Why is this man not maintaining his BP?

Sensor ResponseMemory scratcher

Case study: “Overly sympathetic”

• You check his sensation: • “He is numb to the nipples”

• “High Block”: – This is a medical emergency– Stop any intrathecal medications– Call a MET– Give IVF, elevate legs, ACLS

• Treatment: Hopefully the cavalry will arrive!• IVF- Starling may help a bit!• Vasopressor + chronotropy: Alpha and beta agonist!

– Don’t do this unless you know what you are doing!!– Get advise from someone who knows!– This is a registrar “go to move”

Case Study: “Morphology”

• 56yo man, 4hrs post TKR– PMHx: OA, OSA– Nurses ask for review b/c RR 6 sat 98%

• Initial thoughts?

• What do you need to know?

Case Study: “Morphology”

• On Exam:– Drowsy but can answer questions, Pupils

3mm reactive.– Pain free– No opiates have been given post operatively.– Block height to umbilicus starting to wear off.

Case Study: “Morphology”

• RR now 5• Sat 92%- bugger.• 100% NRBM/MET call

• The anaesthetic registrar gives naloxne in 100mcg increments- plan basically the same as before!

• Why??

Case Study: “Morphology”

• As it turns our morphine and Fentanyl in commonly used in spinal anaesthetics. – Here are some charts: these are the areas to look at on the

anaesthetic chart for this info.

• Was it the Morphine or the Fentanyl? Why the delay?? Any ideas?

Take home message

• Neuro-Axial blockade can cause major disruption in cardiovascular/Resp function- it can be delayed and present on the ward.– It must be recognised!!

• Management of Post Op patients needs an understanding of basic physiological principles that many of us forget after med school!

• Read the Anaesthetic sheet! Its full of goodies!• If in doubt ask!! We don’t bite!!

Quick: other pearls for the ward..• Beta Blockers: It is quiet rare that you need to withhold

these (bradycardia, heart block) – generally don’t do it, even if NBM!!

• Oxycontin: Do not withhold chronic opiates pre-operatively even if NBM!

Special patients:• The classic “possible opiate seeker”, give the patient the

benefit of the doubt initially- seek higher level input thereafter. Tramadol can be handy here- less “buz” but good analgesic.

• Palliative care: seek higher advise early!! They are lovely people to deal with!

• Any questions???

My MET call mantra- “ABC and…”• Have a basic plan for the nurses:• Identify the nurse looking after the patient, “Jane”:

• This: – Gives the impression that you are not panicking, – gives others confidence in you and themselves, – and gets things done

“Jane, can you please:1. Increase the oxygen to 100%”

“Jane, can you please get someone else to:1. Check a BSL2. Do an ECG3. Get me the notes

So that you can tell me about what has happened”.“Thankyou Jane-”

Thanks

“Have fun at work:– do Anaesthetics and/or

Intensive Care”

My patient needs Surgery…

My patient needs Surgery…

• What does the anaesthetic team need to know?

(A part from the basic PMHx and current problem)

• We want to know what degree of stress/trauma a person can withstand?– The surgeons are about to unleash their fury on them.

Key Question:• What is their physiological reserve?

A basic approach (there are many)

• Airway & Anaesthetic History:

• Breathing: Respiratory function/reserve

• Circualtion: Cardiovascular function/reserve

• Drugs: what, why and when?

• Eating: When, what

Airway & Anaesthetic History:

• Airway:– Can their mouth open?– Can their neck move?– Can you see their oropharynx? MP score– Are they obese?

• Have they had previous anaesthetics?– Were there any problems?

Breathing: Respiratory function/reserve

• Respiratory– Smoker?– SOB: when, why– WOB due to either

• Restriction from parenchyma (fibrosis/APO)• Obstruction to flow (asthma/COPD)

– Spirometry -if available-• FEV1• FVC

– Concurrent infection

Circualtion: Cardiovascular function/reserve

Cardiovascular: (more than just “patient has history of IHD”!! We all say it, but it means nothing!!)

– Exercise tolerance- the best test• Walking distance/stairs/what actually stops them

– Cardiac Failure: what type, symptomatic?– Angina: when, why, new?– Valve disease: Murmur, symptomatic?– Stents of surgery: what, when

Drugs: what, when and why?

• Special attention to:– Cardiac meds– Antiplatelets– Anticoagulants

– This will effect the type of anaesthesia that can be utilized.

• E.g. Spinal vs General