Importance of Basic Sciences: Clinical Anatomy 2

If you did not have any basis in anatomy, you would not have any ideas the related manual skills you would do for this. The upper figure, you have put you patient prone, where you would put an intra-arterial catheter to monitor invasive blood pressure, this child underwent intracranial procedure, so it was an essential monitoring because you must have a quick decision to manage your patient. So, anyone who would answer where to monitor a BP if you have put him prone.

 The middle figure, can you give any comments or ideas what went wrong with this leg and foot >,<''

 Without the utilisation of an untrasound machine, how you can put a double lumen catheter in this great vein without the knowledge of very Important Anatomy.

Importance of the Basic Sciences; Clinical Anatomy

Anatomy is definitely an important subject for every single doctor with all specialties, in the anaesthesia world you do practise with anatomy every single day, from airway control from mask-assisted ventilation to airway device placement from an LMA to endotracheal tube or even to endobronchial tube placement. To get the proper position of the devices you placed in you do have to adjust to suit the anatomy of your patient.


Vascular access; both arterial and venous access you do have to know the anatomy of the vascular trees, where you can palpate the peripheral pulse so that you can take arterial blood samples, or you can see either anaesthesist or trainee put an cannular in the artery in order to monitor the invasive BP; yes, can be anywhere from brachial a., radial a., ulnar a., femoral a. and dorsalis pedis a. The venous system is so important when you need a great vein access for rapid fluid resuscitation or infusion of vasoactive agents. 


Neural blockade; the central neural blockade you have to know from skin to the subarachnoid space, the spinal cord and in the modern world the epidural anaesthesia/ analgesia is a superior route to manage the pain control from the intraoperative period to the early postoperative care. With the help of ultrasonography/ the ultrasound machine the peripheral nerve block can be easily performed such as the brachial plexus anaesthesia at the infraclavicular access, or for the abdomen TAP, transversus abdominis plain block can be performed with this ultrasound guide technique. For an ankle block, you do have to know where you can block the nerves in that area, that would apply to the wrist and nerve of the region as well.


The anaesthetist should be able to read the CT scan of wherever of your patient, although it may not be related to anaesthetic management, but it is important to anticipate the complications that may arise from the operation, you may have to know some surgeons' point of view what he/she may perform to get rid of this/that/those, so that you can make a plan for anaesthetic management for your patient in a much better way.


Hope that you would agree with me that Anatomy is so essential for all disciplines of medicine.

Hypertension vs Hypotension

Why? you might be wondered how this two situations happen alternately during operation. Why not! Imagine you are taking care of a hypertensive patient, because you have seen his/her high systolic BP, so you decided to administer more amount of anaesthetics to attenuate the stress response occurred from the operation, just a while your patient will end up with a hypotensive episode, as if he/she has not been seen by you before or you will not remember who this patient is, not the same as I have known. After the blood pressure is reduced from whatever the course would be, you then lighten the plane of anaesthetics, not so long the patient's blood pressure will shoot to where it was to the hypertensive level or much more than it had been in the early part of the anaesthetics management.

 You have to realise what pathophysiologic changes occur in a hypertensive patient, the high BP does not mean that your patient has adequate blood volume, when we measure blood pressure, we usually assume that pressure and volume should be moved in the same direction, or high pressure reflects high volume. However, this assumption is definitely not true, because high blood pressure does not have to result from high blood volume/ high cardiac output but it can arise from the vessel itself, the vascular resistance. The more resistance the vessel has, the higher blood pressure you will get from the reading.

 Therefore, the flip-flop of hypertension and hypotension is quite common during anaesthesia, and that would impose more complications to your patient as well, because the autoregulation of the cerebral blood flow, renal blood flow are used to be familiar with longstanding hypertensive level, when a hypotensive episode occurs, it would definitely harm your patient, and the perioperative complication can lead to mortality.

What an anaesthetist sees During a Typical day

If we are working outside the operating theatre environment, you can see familiar environment such as radiology equipment espcially when you are at the cardiac catheterisation unit or GI endoscope unit. Life will be much different if you are at the Surgical ICU or General ICU, and will be so dramatically changed if you are dealing with acute pain service or Pain clinic.

@ The Cardiac Centre

With a TOE for british or TEE for american english

We have time for education work with the Faculty meeting, so that we can keep up what has happened elsewhere outside the normal familiar environment.

Back to Cardiac Cath again >.<

On a duty at the GI centre

On Non-invasive ventilation in the SICU

Manual in-line cervical stabilisation; the video

This is the full video clip on the day of my working at the orthopaedic theatre, the quality is not quite good in the sound may be the problem of my notebook web camera. The other problem would be some OR personnel moving around during the clip, therefore do not be annoyed by that, otherwise the main part is quite all right.

Be happy and enjoy the show.

1000 Hit Today

Since this blog has been founded, it has reached total visit of 1000 today. I would try to update the blog and try to mention anything that would be helpful for the medical students not only in the Kingdom of Thailand but  hopefully be beneficial to all global medical students.

Thank you so much for your kind visit to this blog.

Manual in-line cervical Stablilisation

Once in a while, very uncommon, that I had a chance to work at the orthopaedic theatre, on that special day I had two patients with difficult endotracheal intubation, one was unexpected, while the other one was known to have the problem of her cervical spine and that was the course brought her to our hospital.

One thing when you face with the patient with cervical spine problem is how you may intervene when the endotracheal tube are planned, because you may extend the cervical spine too much and it would induce more injury to your patient, the thing that you can do can be the hard Philadelphia collar to support the patient during intubation, but my patient did not have one, so we just performed manual in-line cervical stabilisation to limit some degree of cervical movement during laryngoscope.

Position yourself not to obstruct the team member who is in-charge of airway control, you have to grasp the neck and shoulder in your hands, after that you can sit down to let your team member a chance to manipulate the airway.

With the new era of video-assisted endotracheal intubation, it would be easier to take care of your patient. On that day we utilised the brand of King-Fisher.

You have to maintain the head and neck of your patient at all time, when the tracheal tube was in placed, don't forget to auscultate the chest wall.

Monitoring of the neuromuscular function

When you have to care the patient with abnormal neuromuscular function, you have to consider about the fate of your patient when he/she is allowed to breathe by him/herself whether or not your patient can tolerate this test because this would mean safety of him.

On Friday 15 June 2555, we encountered a lady with the problem of muscle weakness for a decade, she has been treated with Pyridostigmine 180 mg/day, her presenting symptom at that time was the problem with the eyelids, however, she had never been hospitalised before, never been admitted due to respiratory failure.

With the application of neuromuscular monitoring we can attenuate the total dose of neuromuscular blocking agent (muscle relaxant) to nearly 15% of the total dose required by her based on her body weight and assumed that she would have normal muscle power. Therefore, she can have an uneventful perioperative course in the immediate postoperative period.

TOF is a mode commonly used to monitor the response of a muscle relaxant, normally it is quite all right to have a TOF count of 2 for an anaesthetic with administered relaxant. One thing to be kept in mind is the neuromuscular blocking agents are not anaesthetics, they would not help you with the analgesic or amnesic effects, not help deepen the anaesthetic depth, it is just an agent that makes your patient flaccid, cannot scream, cannot move, and fully awake.

Positioning your patients

You have to deal with varieties of position when you anaesthesised your patients, it is mainly dependent on where the major organ involved would be. Patient positioning is important because your patient cannot complain of their discomfort during the procedure under anaesthetics, that discomfort may occur because of the entrapment of peripheral nerves in the weight bearing point, or even pain from the pressure after the position is secured. For examples, your patient can become blind because you have not appropriately protected their eyes in prone position. Even in supine position pressure sore due to inappropriate pillow may cause baldness >.<

The more important thing would be cardiopulmonary physiologic changes from patient positioning, cardiovascular and haemodynamic changes would be your major concern when you turn your patient's  position to prone, because if your have not protected the compression of both the chest and the abdomen, you will definitely get your patient hypotensive and load of bleeding because you have impeded the venous return to the heart especially the IVC. Not only the prone, but also the head up position or even the sitting position is the major cause of hypotension, because the patient's heart is higher than the legs and abdomen therefore you have to throughoutly look for any cause that might prevent venous drainage back to the heart.

You have to consider the change in lung compliance when you prepare your patient in the position suitable for surgical procedure, in supine, sitting the lung expansion would be improved, while in lateral position you have to think of mismatching of the perfusion and ventilation, because the upper lung (independent lung) would get more ventilation but less blood, while the other way round applies to dependent lung, because blood will behave like waterfall effect. In prone position the ventilation would be attenuated most if your have not supported the chest wall well enough. 

When you plan to put your patient in Lithotomy position, you can have better haemodynamics parameters because you promote venous return at first and then maintain a higher SVR by the raising legs, however, that is the start of the problem because you can have hypotensive episode by the end of the surgical procedure when you put your patient's legs back to supine position. Be careful of this.

Best Practice in medical education

The Faculty of Medicine Siriraj Hospital has a monthly committee meeting on education of the undergraduate  students, the vice-dean for undergraduate education has proposed a new forum for us, the medical teachers, to share experience, to show good things hidden in each department to the outsiders.

The first department on stage was Department of Anatomy, the chief of medical education staff has shown many things from the movement of the Lab Gross to the new building, moved of all specimens, how the medical students involved in those activities, she even showed the department of anatomy facebook page, at that time our department has not yet launched the facebook page for medical student.

Today after the meeting session ended, the vice-dean asked us to present the best practices form our department in next month meeting, he mentioned our Chairwoman has done so well in the Faculty Board meeting chaired by the Dean on LeapFrog in education. We really do not know what she had mentioned about undergraduate education to the board, but it would definitely include the curriculum changes to put a simulation teaching in it, and also the boundary of the Department of Anesthesiology is now without wall, we do not have to work in the operating theatre any more, we have expertise in preoperative evaluation and preparation and have set up a pre-anaesthetic clinic, we can give an appropriate acute pain service as well as  care for the patients suffered with chronic pain, and also we can take care critic patients in the surgical ICU.

Looking forwards to giving a 10 minute talk, a little bit nervous though >.<

Education video for med students

Our ABC video

Although we have an hour self-directed learning about what sequences of anaesthesia conduct would happen in the operating theatre, but in our opinion it is too new and it is not quite good enough, we do know that the quality of our homemade video is not so good, but anyhow it is our work. Therefore, we are now trying to make things better for the medical students who are always with us for a year-round, we have just launched our new release an update version of the video about the anaesthesia conduct.

Have a look and visit us on our facebook page by have a click on the link above, and then just Enjoy the show ^^.

Formative evaluation

The above photo is from the University of Wisconsin, at the medical school there when each medical student reaches their mid-rotation in every department they will have an evaluation form to evaluate themselves and will be countersigned by their supervisor.

We really think that this evaluation form is worth trying and completing the form, it is very helpful for a self-reflection because when the mid-point of the rotation arrives, you should have some ideas which domain you are not satisfied with from your rotation in the department of anesthesiology.

This evaluation form also helps you what you should get and gain for your knowledge so that you will not lose your short and valuable time within the department when the end of the rotation approaches.

A shared airway

You may wonder what the airway control would happen in  for the surgical patients underwent the surgical procedures involving the patient's airway. These patients may be a child who has swallowed a foreign body; beed, toy, food especially nut, or an ageing man who had a lump in throat with a hoarseness of voice requiring an examination with possible biopsies in the pharynx and/or larynx.

Because the anaesthetist and the surgeon would like to control the airway during surgical procedure, therefore, we have to share our patient's airway. It can be either an apnoea during the surgeon's turn to manipulate and have any procedure within the airway and hyperventilate by the anaesthetist when patient's oxygen saturation starts to alarm because of its downfall or this can be like an endotracheal tube but actually the rigid bronchoscope, the surgeon can perform their procedure while the anaesthetist can simultaneously ventilate the patient via a side-arm port. Besides these two ventilation technique, there is another option to ventilate the patient by using either a small calibre endotracheal tube called microlaryngeal tube which is smaller than the standard one so that the surgeon can perform some microexcision around the larynx or you can ventilate your patient using a jet ventilation which is applied by the physics principles, Bernoullie's principle, about the conservation of energy, the energy can be interchangeable in the form but overall energy is still comparable.

About the anaesthetic management it can be business as usual which is comparable to other surgical procedures  when you can ventilate your patient via a small microlaryngeal tube or rigid bronchoscope, or you can employ the total intravenous anaesthesia technique to your patient. One thing to be kept in mind in airway surgery is the airway fire because sometimes the surgeon using electrocauterisation or Laser surgery which the oxygen fraction of inspired gas has to be reduced.

The airway procedure under rigid bronchoscope is shown in the above one, we employed the total intravenous anaesthesia using a new generation syringe pump called "TCI, target control infusion" in the lower photo.

Practical Aspect of Perioperative Mechanical Ventilation: A workshop for Professor Vorakitpokatorn Retirement

That is the full workshop name, and today is quite a good and funny day, because the two guest speakers from Mayo Clinic, Rochester MN have arranged an interactive educational sessions. We really think that lectures in our department should follow this pattern of the interactive activities, so that the participants have their times to analyse as well as think what next to make up their minds before the time is running out.

There are some photographs of the staffs working behind the scene, as well as the slide of the conference, and as promised some interactive sessions of the lecture by two Drs Daniel, Dr Daniel R Brown, and Dr Daniel Diedrich.

A postponed surgical procedure :((

When an elective surgical patient has been planned for colon surgery, many things would come up for the preparation process. Begin with bowel preparation either an enema or induced with luxatives, oral intake from solid food to clear liquid diet, both procedures can be performed on the day before surgery and can induce a chain reaction by making your patient to dehydration, fatigue, and disturbances in electrolytes. Some medical centres especially in northern europe have abandoned the bowel preparation, but in our hospital it is still working and included in the procedure required for colonic procedure.

Yesterday we encountered an elective colonic patient with a plan for laparoscopic assisted procedure, after an w opioid premedication, an induction agent, and an intubating dose of non-depolarising muscle relaxant were given, a pulse oximetry had showed an unstable wave form showing low output state, then the ECG monitoring showed the atrial fibrillation with the ventricular response of 160/min, so the emergency cart was called, the trachea was intubated at that point the blood pressure was 70/50 mmHg. After the patient was stabilised, a discussion with the surgeon was performed, the conclusion was to call off the surgery. An arterial sample had shown the potassium level of 2.8.

Rapid sequence induction with cricoid pressure

When you encounter an emergent/ urgent patient requiring an emergency operation, the anaesthetic management has to be modified to reduce perioperative complications. If you require an airway control with an endotracheal tube placement, the airway management technique should be shortened so that you required a shorter time to intubate your patient. In an elective surgical patient, you can administer an induction agent after adequate premedication, check whether or not you can assist a manual ventilation via a facemask, then you become sure that it is safe for him/ her if you cannot put the tube in, finally you can administer an intubating dose of a non-depolarising muscle relaxant to facilitate an intubation, you have to ventilate and oxygenate your patient until the muscle relaxant has its full effect which is normally more than three minutes.

This manual assisted ventilation is not safe for your emergent surgical patient, because it does not ensure you that you have a 100 % pulmonary ventilation without gastric ventilation. Therefore, an airway control in this patient group, you start with a pre-oxygenation with a facemask, you can encourage your patient to hyperventilate or denitogenate by telling him to have a big tidal volume reaching a forced vital capacity, this process requires approximately three minutes, so that your patient can tolerate an apnoea without a need of positive pressure ventilation like an induction of elective patient. Then you induce your patient after premedication with a calcuated induction dose of Thiopental, immediately after an induction dose you administer an intubating dose of suxamethonium/ succinyl choline, and then wait for 60 seconds before putting an endotracheal tube in. While an assistant is giving your patient the drugs, your need another assistant to compress the cricoid cartilage against the vertebral column immediately after beginning the pharmacologic administration. This technique is called "rapid sequence induction with cricoid pressure".

I have a problem downloading the video clip of an RSI with cricoid pressure "Sellick's manuvoure" for a pregnant scheduled for an elective caesarean section to this blog, however, if you are interested in viewing the clip, please have a look at our facebook page, Here.

http://www.facebook.com/photo.php?v=417572734949103&set=o.323333441056624&type=2&theater

Updated on 29 Aug 2012
The cricoid pressure application for Rapid sequence induction is usually asked by our team to the medical students in the last summative evaluation hour, because when you are a new graduate doctor, you might be asked to perform this especially here in Thailand where nurse anaesthetists are the main working force in the Kingdom, and anaesthetists are not available at every hospital.

One thing to be kept in mind is that compressing the cricoid would make a flexion move in the next which make a more difficult endotracheal intubation, in order to minimise this, you do have to have a cricoid pressure with a bi-manual technique, meaning that one hand is in front of the neck to compress the cartilage while the other is behind to increase the neck extension to facilitate an intubation.