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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