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.

Anaesthesia plan for a healthy patient

Some patients are transferred to you with their good history of their health, no underlying diseases, as a sport representative for their colleges, either elective or emergency, they should be evaluated as a chronic patient is performed. History taking process can be simultaneously performed with clinical evaluation, any problem with their cardiovascular and respiratory systems. Confirm or verify that the history as a previously healthy is genuine, because as the first or the highest priority for anaesthesia service is safety.

Preoperative evaluation in this patient group may be on the day of surgery especially when we consider the cost of hospital admission for a healthy ASA 1 has to wait at the surgical ward without necessary preoperative preparation or procedure prior their operative plan. Not only the cost, the extensive evaluation or laboratory testing are rarely required in this patient before their uncomplicated procedures.

Basic non-invasive monitoring is usually enough for their anaesthetic care, it is uncommon for the need of more invasive monitoring in this patient group.

Of course, a very successful anaesthetic care has to be a joining hand of both anaesthetic team member and the surgical team member, so that the needs from both team are not overlooked and taken into account.

Certificate of the Resident Class 2552 Academic year

A long farewell, Auf wiedersehen, Good bye ^^.  It is always the happiest moment whenever the graduation ceremony is organised. Today marks the ceremony for the third year Residents who have spent their time with us, after the final board examination, they will have their own ways to work for the patient kingdom-wide, wish them well and thank you for being with us.

Another Education Videos

UC Irvine Anaesthesia Resource

I ran across another web site from the University of California Irvine, it has many education video clips on various anaesthesia topic, for me an airway procedure and IV catheter placement are beneficial for the medical students.

I hope you enjoy this web page as well as I actually did. Hope that it is valueable for the medical students.

Holidays away from home

The undergraduate education team of the Department of Anesthesiology has been away, two with the department head joined the World Congress of Anesthesiology in Baunos ires, one more also had finished her latin american trip. My turn I went to Europe for a Family get away.

Some foto are here, naschte halt/ prochain arret/ prossima fermata Home!!

Management of Acute postoperative Pain

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.