Electrocardiogram (ECG)

A help in Need!!

Clinical monitoring is an important ingredient of an anaesthetic care, the purposes of an ECG monitoring are for detection of abnormal cardiac rhythm during anaesthetics, early warning of abnormal physiologic changes that may follow especially the changes in haemodynamics, and also for the detection of problem of coronary circulation leading to a change in ST segment change.

Cardiac arrhythmias are considered as perioperative cardiac morbidities especially if it happens for the first time in your patient, you have to look for each algorithm one by one for appropriate management ranging from intravenous medication to cardioversion and then defibrillation. In a patient care you are also in need to learn more about the cardiac risk evaluation especially for patients scheduled for non-cardiac procedure, so that an appropriate management is delivered to them.

Have a look at our ABC page and see how competent you are in the reading of the ECG tracing by linking at the topic in the top part of this post, Enjoy !!

Updated on Sept 7th, 2555:

Another ECG tracing is waiting for you to enjoy right Here:
2nd ECG Tracing

All about Monitoring 2: Critical Care Conference in Thailand 3rd

The ideal or how good of the monitoring would not be useful, if it does not help initiate the action plan to correct your patient or solve your patient 's problems. So, when you have a chance to monitor your patients, don't forget to think beyond what you can see from the screen, start to do the most appropriate procedure to manage your patient, then monitor again to see how things progress, and finally re-evaluate the effects from the actions you have put in. That is the Monitoring Truth.

Cardiac output monitoring; it just tells you the low flow state, the threshold value, in high risk surgical patient you do have to try to increase your patient the Oxygen Delivery to gain the better patient outcome. It should be somewhere from 450 ml/min/sq.m. to not over 600 ml/min/sq.m. because beyond 600 it would not be more helpful like it has passed the maximal effects.

Fluid resuscitation and Dobutamine: you have to do your best to prevent more morbidity in your patient by start the fluid management at the sooner point to get the better outcome, because it has been demonstrated that it would not be beneficial if you have done it too late especially when there is an organ failure in your patient. If you do/ manage your patient at the right time, it would help lessen the risk of perioperative cardiac complications especially the most common cause of dying, the congestive heart failure.

Choose the Right patient: in order to gain the highest possible benefit in your patient, you have to decide which patient you should perform or proceed the right action. In the right patient, if you have a goal directed fluid therapy, it has shown that the life expectancy of your patient can be lengthened by three more years in a 15 year follow up study. Fluid resuscitation in haemodynamic unstable patient would not be helpful in every single patient, it would help approximately half of the critically ill patient with circulatory shock when you started the process of management with a delay.

Please Stay tuned, for more from the Crit Care Conf en Thailande.

Nutrition Support in Surgical Patients

Every physician has to care their patients in the holistic way, it means that you have to even think of what your patients' minds have but they do not shout it out. Nutrition support is one thing that you have to reconsider when you are looking after someone who is either be able to eat by themselves or they just cannot help themselves.

In surgical patients, some may tell you that they are so thirsty and would like to have something to moisten their dried mouth, but you cannot help them because they are not allowed to do so because it is in the middle of NPO period/ order, they are prone to have a high risk for aspiration because they are just recovered from anaesthetics or whatever the causes would be.

In another end of perioperative care, surgical patients may have a history of weight loss due to cancer of somewhere inside their body, they need a time period to feed them so that they are not too much thin, and their body functions in many organ system are harm, such as the wound healing process delayed, the risk for infection in postoperative course, the haemodynamics changes due to inability to pull water to stay within the vascular tree, and also their metabolic disturbances.

Nutrition also can be a harm to your patient if you do not realise how much your patient need energy/ food/ fluid in each day, if you feed them less than it should be, it should be still OK, because they can take most of what you give, but the other way round, if you load them too much energy than they can take, you are creating some problems in them. Fat can interfere the laboratory testing if you do not stop them long enough, protein can have bad particle to the kidney and the nitrogen waste products would harm them, and carbohydrate, Carbo = Carbon, if you give them too much energy, you have to realise how much carbon dioxide you are loading or doping to your patient, you may have your patient facing a weaning failure for ventilator discontinuation.

Feed them less, the Less is More, just make it right.

How we can feed our patients? Enteral or Parenteral nutrition can be your answers.

Need your help, Please!! (Respiratory Crisis video)

need your help 1

need your help 2

We have put two respiratory crisis videos on our Facebook page, hope that both of them can encourage your learning on the self-motivated way. These clips have some differences, one occurs in the operating theatre environment, while the help 1 happens in the Surgical ICU. However, both of them can happen at anywhere such as the emergency rooms, post-anaesthesia care unit or even the in-patient wards.

You should formulate your idea about the diagnosis for early or immediate management first, after that process, you can have time for details or more investigations for the definite diagnosis, re-evaluate your patients about the treatment given whether or not it helps your patient, and plan for further care afterwards.

Have a look and enjoy!!

ARDS; Acute Respiratory Distress Syndrome

ARDS is a syndrome of severe hypoxaemia and may be a challenge for every physician who has a chance to take care of this poor patient. The criteria for diagnosis of this syndrome are usually composed of bilateral pulmonary oedema, the cause is not cardiac in origin, and it is usually refractory to oxygen therapy.

In the world of Surgical ICU these poor patients may have risk factors for ARDS from aspiration pneumonitis, sepsis or septic shock, pancreatitis, massive blood transfusion or TRALI (transfusion related acute lung injury). These patients usually have a very high risk of morbidity and mortality.

The treatment option is mainly the ventilation support to correct the patient to have an acceptable of oxygenation, the main part is PEEP titration since they are usually severe hypoxia from flooded alveoli, the PEEP setting helps open the collapsed alveoli and prevent the recruited alveoli derecruited again. Since the pulmonary mechanics especially compliance (that is physiology the basic science) is so poor meaning that it is more difficult to ventilate your patient and the very high pressure to open the alveoli required.

If you are more interested in this syndrome, please check at the ARDS net for the table of FiO2 and PEEP level, and also the principles of lung protective strategy in order to attenuate the complications of barotrauma or volutrauma from the application of IPPV in this poor patient group.

Some people may turn the patient prone, because with the blood flow is dependent on the gravity which means that blood flow is more likely to be in the dorsal region when the patient lies supine, but the ventilation is more on the front. However, when you turn your patient prone, unexpectedly the blood flow is still on the back region of the thoracic cage which is now on the independent part of the thorax, but the ventilation still goes to the independent part, therefore, ventilation/perfusion (V/Q) are more matched than it was in the supine position.

One more thing that you have to consider when you have to care for the patients with the ARDS is the fluid balance, with the concept of "Less is More" should be applied to this patient group. When you give more fluids to the patients with organ dysfunction especially the kidney, fluid cannot go anywhere but the lung and other body tissues. Therefore, this overloaded fluid would definitely affect the oxygen exchange in the poor and dysfunction alveoli.

All about Monitoring; The 3rd Critical Care Conference in Thailand

From July 12th until tomorrow July 14th 2012 The Thai Society of Critical Care Medicine has organised the critical care conference in Thailand, the third time but first ever in Bangkok. On Saturday I will have a chance to participate the conference after working in the operating theatres in my hospital.

Clinical monitoring is also an important part of basic sciences especially Physiology, you do have to understand both physiology and pathophysiology so that you can make  the very best decision suitable to manage your patient. And those who enjoy your time in Anaesthetics they must love physiology and pharmacology, otherwise their lives will have a very long terrible time.

Promise to update some new interesting topics here later on. For next year the theme has been settled as "All about Shock" the time would be around the end of June next year.

Intravenous Sedation for short Procedures

Although medical student does not need a competent skill to perform general and regional anaesthesia to his/her patients, but they should be able to administer intravenous anaesthetics for a short procedure by themselves. According to the skill required by Thai Medical Council a sedation skill is a must for everyone, it means that you are expected to do it yourself when you are a new graduate physician.

When you are facing an uncooperative patient, you have to assess whether or not he can have an acceptable level of ventilation without need of help to assist the breathing, that would be A and B from ABC, so an acceptable of spontaneous respiration together with a good patent airway is a must. Then you have to evaluate the haemodynamics of your patient, for example a risk of hypovolaemia or dehydration in an urgent or emergent patient, or in an elective patient about the effects of NPO or prior diuretic treatment.

For the monitoring during your sedation it should be comparable to the anaesthetic standard, all basic non-invasive monitoring should be ready and function before you initiate medical titration of your sedative medications. The ingredients of your medications should be consisted of induction or sedative agents plus analgesics plus a supplement drug; such as antiemetics.

You can begin with any induction agents; thiopental- ok for in-patient, cheap and safe old drug, propofol- a drug that involves in Michael Jackson's death, good recovery for out-patient but more likely to have a hypotensive episode, ketamine- a good old drug with analgesic effect but delayed awakening and bad vivid dreams, or you can choose benzodiazepines as an inducing agent. The next or even first drug group is an analgesic, any choice would do, it really depends on your patient's plan of recovery, this drug class is quite safe however do not forget to monitor the respiratory effect and prophylaxis of vomiting this drug group might cause and that is the reason why you may need antiemetics as an extra!

Learning from Failure; Morbidity and Mortality Conference

The department of Anesthesiology used to have a Motto for M&M conference long ago as "No-one is Perfect, Everyone has defect." It seems so true that working or doing everything has some errors, it does not have to be 100% perfect, whoever does more than somebody else would  have  more feedback of complications. However, the positive side of complications is a lesson so that you would never do it in the same way again so that it would not happen again.

The M&M conference is an important moment for not only every anaesthesia trainees, but also to the consultants to discuss the way out for each crisis or scenario that may unexpectedly happen and the management to attenuate the effects in your patient. Now we have some representatives to present the patient case, they are not belonged to the anaesthetic management team, they just ask for more details and consult the consultant who would lead the conference in the most appropriate way. This way would definitely lessen the traumatic effects on the anaesthetic management team.

Relax and Enjoy, Listen and Discuss, Participate the education moment of your life.

Feedback about Simulation Learning session

Student Feedback is an important part of every single education curriculum, the response help make the better teaching plan, improve the learning objectives, and also affect the learners themselves.

Self reflection can help the students to know what their weak points are, know where they are among the group of friends working together and facilitate their learning needs in order to attenuate their weakest points. Although the department has very short rotation for 5th year medical student rotation, but the two-week period is quite applicable worldwide From Ottawa to Melbourne, and here in Bangkok. The response from our medical students regarding the utilisation of simulation learning methods are available at the end of this post. The last figure is a verbal rating scale on the means of simulation teaching.

Med Student Feedback

Importance of basic Sciences; Pharmacology

Pharmacology is an essential part of an anaesthesist ' s life, we administer many drugs to ensure our patients' safe journey during their operation. We not only give anaesthetics agents, but we are also responsible for antibiotics/ chemotherapeutic agent to prevent perioperative infection complication, even the anticoagulant is sometimes we do have to put to our patients' vein to allow the surgical team to perform some procedures involving the vascular trees to prevent thrombosis.

Oh! we can administer insulin when we are resuscitating a patient with high risk for hyperkalaemia or we are titrating insulin for glycaemic control. What's about vasoactive agents, either vasoconstrictor or vasodilator, we can manage it with our competence and it also includes the inotropic agents to help promote the myocardial contractility. Antiemetic is also an integral part of anaesthetic care because severe postoperative nausea and vomiting can cause an unplanned hospital admission. Exogenous steroid to minimise the risk of anaphylaxis or help stabilise the cardiovascular function when our patient is a steroid user.

We are also experienced in pulmonary route of drug adminstration, not only the volatile anaesthetics for our patients, with the nebuliser we can give the drugs just to the upper airway such as local anaesthetics to facilitate endotracheal intubation or epinephrine to decrease the laryngeal oedema, we also nabulised the bronchodilators to the distal airway.

You may feel that we can give our patients too many drugs during their surgical procedure, we have to understand and know well nearly all classes of the scope of Pharmacology with just one exception that we normally do not use it; the chemotherapy for cancer.

Best Practise; Leapfrog revolution

Best Practise document

Today we presented to the Undergraduate Education committee of the Faculty about the major change in our department. With a major support from the Chairwoman of the department, otherwise we would not have been this far especially the medical student education with the utilisation of a simulation based technique.

We have employed the simulation teaching to our student for nearly a year now, we know that it is just the beginning step, however, with our determination we would produce a new breed of medical students which should be better and ready for the 21st century.

The presentation slide can be viewed by click at the uppermost of the post.