As a medical student, you must be competent to manage your patient's pain, there are multiple way to diminish your patient's pain such as the local anaesthetics to inhibit the neural conduction to perception in the spinal cord then pain pathway. You can employ oral medication as well, such as paracetamol in mild to moderate pain level, or you can give NSAIDS either oral or parenteral then if your patient pain is in the severe scale, you then have to order opioid analgesics.
You may observe that anaesthetist has to plan in advance once a patient is due to anaesthetise, what the technique to control the pain after the surgical procedure is done. Due to some side effects from opioid administration, the development of multimodal pain management is usually performed for reaching the early recovery goal as opioid may prolong this recovery.
Epidural analgesia is definitely a great alternative, because you can reduce the overall opioid consumption, your patient is likely to have a lower pain score, so that he/she will be ready to ambulate, have an effective cough so that the perioperative pulmonary complication is avoided. For that surgical patient underwent abdominal procedure especially colectomy, an epidural pain control is an essential part of the enhanced recovery scheme.
In a special case sometimes you may find a patient with the underlying chronic pain symptoms became a surgical patient so that the plan for severe pain control should be kept in mind because you do have to realise the he will be complicated with acute and chronic pain. It is prudent to ask for help or notify an anaesthetist consultant who is keen to take care the chronic pain so that the patient will receive an optimal pain control.
2012-04-20
Anaesthesia for the Aged patients
The society is getting older, and now we in thailand cannot escape this trend. According to the Nation Statistics Buereau, our kingdom is now an ageing society. Therefore, more ageing patients are expected to be the patients in the healthcare service all over the world, and anaesthetic considerations for these fragile population include many topics.
We can categorise the aged patient according to their chronological or their functional age, although some patients may look or appear to be healthy, however the organ function is less reserved in this healthy aged group.
First of all, the anatomical changes both the structure and function. These normal organ and overall function changes must be put together with planning anaethetics for them, although that is not considered as a disease or disorder. The skin is an obvious sign for all, the spines are osteoporotic, the vertebral column is collapsing making patient shorter than they were. Organ function, all decline after the age of 30, therefore, they cannot tolerate the tachycardia, the resting oxygen tension in blood is lower, the liver and kidney aggravate more pharmacokinetic changes, drug elimination is prolonged.
Secondly, they are likely to have pre-existing medical problems, especially diabetes and/or hypertension. That would make them receive preoperative medications; antihypertensives, hypoglycaemics, statins, etc. Some drugs would potentiate the anaesthetic drug effects making them prone to have perioperative complications.
Therefore when you have an aged patient in front of you, you do have to perform adequate preanaesthetic evaluation and preparation, choose the appropriate anaethetic technique, titrate the dose of planned given drugs to suit the patient's background, otherwise you would get mad after your patient develops a perioperative complication in the postanaesthesia care service area.
We can categorise the aged patient according to their chronological or their functional age, although some patients may look or appear to be healthy, however the organ function is less reserved in this healthy aged group.
First of all, the anatomical changes both the structure and function. These normal organ and overall function changes must be put together with planning anaethetics for them, although that is not considered as a disease or disorder. The skin is an obvious sign for all, the spines are osteoporotic, the vertebral column is collapsing making patient shorter than they were. Organ function, all decline after the age of 30, therefore, they cannot tolerate the tachycardia, the resting oxygen tension in blood is lower, the liver and kidney aggravate more pharmacokinetic changes, drug elimination is prolonged.
Secondly, they are likely to have pre-existing medical problems, especially diabetes and/or hypertension. That would make them receive preoperative medications; antihypertensives, hypoglycaemics, statins, etc. Some drugs would potentiate the anaesthetic drug effects making them prone to have perioperative complications.
Therefore when you have an aged patient in front of you, you do have to perform adequate preanaesthetic evaluation and preparation, choose the appropriate anaethetic technique, titrate the dose of planned given drugs to suit the patient's background, otherwise you would get mad after your patient develops a perioperative complication in the postanaesthesia care service area.
2012-04-15
Difficult airway management in the Surgical ICU
When it was the right time to intubate your patient's trachea, be sure that you can handle the problems arised after your induction of anaesthetics. The plan must include what your next step should be if you cannot pass the endotracheal tube into the correct position in the trachea. The problem of difficult airway management can be categorised to planned difficult or unexpected difficult airway.
If you encounter with a planned difficult airway, you can prepare ahead which equipment you would employ to get access to your patient airway. However, it doesn't mean that it would quarantee its success., so you need plan B for the next step if the first step does not work.
When you are facing the unexpected difficult airway control, one thing to keep in mind is a "Call for Help" because you would become fatigue after a couple of laryngoscope attempts. The other important thing to remember is don't forget to ventilate and oxygenate your patient!
In this patient, although we can intubate the trachea after another attempt, but it led us to another problem, unstable haemodynamics; hypotension, bradycardia, finally cardiac arrest. Oh my God >.<
2012-04-10
The Class of 2554/ 2011 Evaluation
When each medical student finished their anaethetics rotation, we invited them to give/ answer the survey to feedback themselves (a kind of self-reflection) on the technical skill competency whether or not they can improve those skills after they are on the last day of their rotation.
We ask them about the skills of the first and second class category which means that they must be able to perform those skills by themselves (first cl.) or after their finished their intensive skill practise after the first graduate year; they must be able to demonstrate those competencies (the 2nd cl.). Those skills include oxygen therapy, airway control, preoperative evaluation & preparation, preoperative medication order and lab order, acute and chronic pain control, acute cardiac and respiratory emergency management. We also ask about the link of anaesthetics with the basic preclinical sciences, how important of the anaesthetic team service, the pride of anaesthetist compared with their surgeon counterpart, and their interest in further education in anaesthetics.
The overall survey results show that every skill is far better than the time they entered the rotation, therefore we will not show the details of the score of their results, the score here is based on each student feedback (approx. 230 students, 209 responded) on a scale of 1 to 10.
We ask them about the skills of the first and second class category which means that they must be able to perform those skills by themselves (first cl.) or after their finished their intensive skill practise after the first graduate year; they must be able to demonstrate those competencies (the 2nd cl.). Those skills include oxygen therapy, airway control, preoperative evaluation & preparation, preoperative medication order and lab order, acute and chronic pain control, acute cardiac and respiratory emergency management. We also ask about the link of anaesthetics with the basic preclinical sciences, how important of the anaesthetic team service, the pride of anaesthetist compared with their surgeon counterpart, and their interest in further education in anaesthetics.
The overall survey results show that every skill is far better than the time they entered the rotation, therefore we will not show the details of the score of their results, the score here is based on each student feedback (approx. 230 students, 209 responded) on a scale of 1 to 10.
2012-04-09
Clinical Skill Teaching: venepuncture
Another academic year has started, so we participated with new 4th year medical students prior to their clinical learning to practise venepuncture. On April 2nd and April 3rd we joined other medical faculties to teach them hand-washing, venepuncture, and insertion of an IV catheter.
Here are some climate of learning on that day in the venepuncture stations.
Although it is a very basic skill, but for a very inexperienced learning, doing is much harder than expected, so there are some learners that cannot perform this task by the end of the day. The main mistake is the fixation of the needle when it is at the right position, in the vein, because during the blood drawing if the needle is not fixed (standstill) it will be moved backwards and you will not be able to draw the blood, and there would be some blood leakage around the puncture site.
So, education requires some training to get successful.
Here are some climate of learning on that day in the venepuncture stations.
So, education requires some training to get successful.
2012-04-07
Postoperative care and Surgical ICU
There are several issues to be considered when we think about the plan for postoperative care of noncardiac surgical patients whether or not that patient should be cared in the Surgical ICU (SICU).
First of all, the bed allocation, the SICU bed during the workday are usually not enough for the increasing demand, therefore there are some patients that they would not get the bed access, while the others who receive a permission for SICU care cancel their postoperative care plan, because the surgical procedures may be much better than the provisional plan, the bleeding was so imminent, or the surgical plan cannot be performed as plan due to the change of staging. The surgeon and anaesthetist should plan and discuss the patient care pathway together, and anaesthetist in charge of patient care in the operating theatre should have some important role in decision making about the care plan where to send the patient to depending on intraoperative course.
The diagnosis or priority setting for the patient going to SICU can be categorised as priority model; the most appropriate group means that the patient requires IPPV support, vasopressors or inotropes infusion, suitable for the care in SICU, while the least appropriate group can mean either the patient is too good or too bad to benefit for a care from SICU. The diagnosis model is grouped by the diagnosis of each organ system, such as cardiac arrest, perioperative AMI, malignant arrhythmias for cardiac diagnosis model, while pulmonary embolism with unstable haemodynamics belongs to respiratory diagnosis, and surgical diagnosis can include patient requiring haemodynamics monitoring, ruptured viscera with haemodynamics changes. While the last model is objective parameter model; such as ECG shows complete heart block, ABG shows severe metabolic disturbances suchas pH <7.1 or >7.7, hypercalcaemia from blood chemistry. These three models can be combined to consider the patient selection for SICU bed access.
In 2004 we studied the patients who stay in SICU longer than 4 days, overall the average LOS was 2.7 days, this patient subgroup was approximate 20% of the overall patients during the six-month period, the mean LOS for this group was 12 days, and overall mortality in the group was 12.1 %. The associated factors with longer stay in SICU is shown in the table here.
The SICU patients are at risk of postoperative pulmonary complications : aspiration, ventilator associated pneumonia, acute lung injury, therefore, care should include how the predisposing factors in this patient group can be attenuated.
New approaches to acute postoperative pain control is much improved means that patient pain control is much better than the past, therefore the surgical procedures such as thoracic and vascular patients can have a good postoperative pain control resulting in a reducing care intensity in SICU.
First of all, the bed allocation, the SICU bed during the workday are usually not enough for the increasing demand, therefore there are some patients that they would not get the bed access, while the others who receive a permission for SICU care cancel their postoperative care plan, because the surgical procedures may be much better than the provisional plan, the bleeding was so imminent, or the surgical plan cannot be performed as plan due to the change of staging. The surgeon and anaesthetist should plan and discuss the patient care pathway together, and anaesthetist in charge of patient care in the operating theatre should have some important role in decision making about the care plan where to send the patient to depending on intraoperative course.
The diagnosis or priority setting for the patient going to SICU can be categorised as priority model; the most appropriate group means that the patient requires IPPV support, vasopressors or inotropes infusion, suitable for the care in SICU, while the least appropriate group can mean either the patient is too good or too bad to benefit for a care from SICU. The diagnosis model is grouped by the diagnosis of each organ system, such as cardiac arrest, perioperative AMI, malignant arrhythmias for cardiac diagnosis model, while pulmonary embolism with unstable haemodynamics belongs to respiratory diagnosis, and surgical diagnosis can include patient requiring haemodynamics monitoring, ruptured viscera with haemodynamics changes. While the last model is objective parameter model; such as ECG shows complete heart block, ABG shows severe metabolic disturbances suchas pH <7.1 or >7.7, hypercalcaemia from blood chemistry. These three models can be combined to consider the patient selection for SICU bed access.
In 2004 we studied the patients who stay in SICU longer than 4 days, overall the average LOS was 2.7 days, this patient subgroup was approximate 20% of the overall patients during the six-month period, the mean LOS for this group was 12 days, and overall mortality in the group was 12.1 %. The associated factors with longer stay in SICU is shown in the table here.
Factors
|
Odds ratio
|
95% CI
|
p value
|
Periop cardiac complications
|
12.77
|
4.5-36.1
|
<0.01
|
Periop RS complications
|
2.77
|
1.1-7.0
|
0.03
|
IPPV support
|
6.95
|
3.1-15.4
|
<0.01
|
Bleeding in SICU
|
4.85
|
1.3-17.6
|
0.02
|
Emergency service
|
2.47
|
1.3-4.5
|
<0.01
|
Active monitoring
|
2.28
|
1.3-4.1
|
<0.01
|
Oliguria
|
1.82
|
1.03-3.2
|
0.04
|
hypotension
|
2.27
|
1.2-4.5
|
0.02
|
2012-04-05
What would you do?
As we have mentioned the simulation teaching for medical students, so think about what you would do if some of these situation arise.
The skills for crisis management is put as Class I which means that everyone should be able to perform that task/ procedure by themselves, not under supervision, therefore you have to formulate some clues to manage the priority problems then you have time for more details for investigation or history review after your patients have been stabilised.
The Thai Medical Council recommends that all new graduate doctors should be qualified to perform crisis management of some cardiac (cardiovascular) and respiratory situations.
The skills for crisis management is put as Class I which means that everyone should be able to perform that task/ procedure by themselves, not under supervision, therefore you have to formulate some clues to manage the priority problems then you have time for more details for investigation or history review after your patients have been stabilised.
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