17 09 13

Prof. A. K.
SethisEORCAPS-2013
1
Prof.A. K. SethisEORCAPS-2013
BREATHING SYSTEMS
Dr. Pramod Kohli
Define a breathing system
A system - usually an assembly of components which
connects the patients airway to the anaesthesia
machine,
for to and fro delivery of a gas mixture of controlled
composition,
at physiological respiratory pressures.
What are the functions of a breathing
system ?
Delivery of gases
Conversion of plenum to intermittent flow
Assisted spontaneous respiration / IPPV
Conservation of heat and moisture
Gas sampling composition, volumes and pressures
Elimination of exhaled carbon dioxide
What is the ideal breathing circuit ?
Economy of gases
Low anatomical dead space
Low resistance
Efficient in both spont resp and IPPV
Conservation of heat
Humidification
Adaptable for adults / child / ventilator
Light weight
Convenient to use
Easy to sterilize
Re-breathing
What are the factors affecting re-breathing ?
- fresh gas flow
- mechanical dead space (minimum volume re-inhaled)
- design of the breathing system
What is re breathing good for ? What is re-breathing good for ?
- gas economy
- heat and moisture retention
What is re-breathing bad for ?
- maintenance of alveolar oxygen tension
- alveolar gas tensions (delayed induction and recovery)
Spont resp & re-breathing
Re-breathing PaCO
2
hyperventilation
EtCO
2
normal, but
work of breathing
Prof. A. K. SethisEORCAPS-2013
2
Dead Space
Space occupied by gases that are re-breathed
without change in composition
Classification of breathing systems
Dripps, Eckenhoff and Vandam
Insufflation no valves, no bag
Open no mixing of insp & exp gases
i/mittent flow machines / non-rebreathing valves
Semi-open mixing of insp and exp gases, no CO
2
removal
Semi closed partial re- breathing with CO
2
absorption
Closed total re-breathing with CO
2
absorption
. . . contd
Collins
Open insp & exp gases open to atmosphere, no reservoir
Semi-open insp & exp gases open to atmosphere,
i t & t t h reservoir present & open to atmosphere
Semi-closed only exp gases open to atmosphere,
reservoir present but closed to atmosphere
Closed both insp and exp gases closed to atmosphere with
total re-breathing
contd
McMohan
Open no re-breathing
Semi-closed partial re-breathing
Closed total re-breathing
Millers classification
Without CO
2
absorber
Uni-directional flow
- non-rebreathing valves
- circle system without
absorber
With CO
2
absorber
Uni-directional flow
- circle system
absorber
Bi-directional flow
- afferent reservoir
(Mapleson A, B and C)
- efferent reserboir
(Mapleson D, E and F)
Combined system
- Humphrey ADE
Bi- directional flow
- Waters to and fro system
Mapleson Breathing systems (1954)
General features
Flow controlled / CO
2
washout breathing circuits
No CO absorber No CO
2
absorber
No clear cut separation of insp & exp gases
Re-breathing possible if FGF < Insp flow
Many variables so ideal FGF best decided by EtCO
2
3
Maplesons classification
Relative position & presence / absence of :
Fresh gas entry Fresh gas entry
APL valve
Reservoir bag
contd
Mapleson A system
FGF farthest away from patient
APL closest to the patient
Reservoir bag in between but away from APL, close to FGF
Corrugated tubing separates bag and valve
Functional analysis : spont. resp.
During exhalation first the dead space gases, next the alveolar gases
emerge and move towards the bag. Pressure rises as the bag fills &
valve opens to vent out alveolar gases first. Dead space gases are
retained to be inhaled with the next breath.
If FGF > min ventilation, dead space gases will also be vented out.
If FGF < min ventilation, alveolar gases will be retained with re-breathing.
With FGF = min ventilation, system is best for spontaneous respiration.
More efficient for spont resp than for assisted spont resp.
Prof.A. K. SethisEORCAPS-2013 Prof.A. K. SethisEORCAPS-2013
Functional analysis : IPPV
During exhalation gases move as in spontaneous respiration, but since
th l i l d j t th b di t d With th i i ti (b the valve is closed, just the bag distends. With the inspiration (bag
compression), some alveolar gases that lie closest to the valve will be
re-inhaled. As the pressure , the valve opens and vents out the
rest of the alveolar gases. Dead space gas + FGF is directed to the lungs.
If FGF < min ventilation, pressure rises late with more re-breathing
If FGF > min ventilation, pressure rises early with venting of even FGF
Mapleson A not good for controlled ventilation
4
Flows for Mapleson A system
For spontaneous respiration:
FGF = 70 % of minute ventilation (42 88 %)
= 51 85 ml / kg / min
Not recommended for IPPV, but for a short term
low respiratory rate & high tidal volumes maintain gas economy
Not to be used with ventilators with inbuilt vents
Mapleson A - merits and demerits
Advantages:
- near ideal for spontaneous respiration
- maintains gas economy
- simple assembly
- easy to manage and maintain
Disadvantages:
- cannot be used for long term IPPV
- uncomfortable for mask ventilation
- limits mobility
- APL close to patient access, scavenging difficult
Lack system (modified Mapleson A)
Mapleson B system
APL valve closest to the patient
FGF close to the patient
Reservoir bag at patient end, but farthest from the patient
Corrugated tubing separates bag and FGF
During exhalation , dead space gases and alveolar gases move down the
corrugated tubing to the reservoir bag, along with fresh gases which push it
along. When bag is filled to capacity, pressure , APL valve opens
& gases in the corrugated tubing vented out, along with fresh gas.
During inspiration, pressure and APL valve closes, fresh gas inhaled.
If FGF PIFR (25 35 L/min), only fresh gas will be inhaled. No re-breathing
If FGF < PIFR fresh gas along with residual gas in tubing will be inhaled
IPPV
During exhalation, gases move as in spontaneous respiration, but since
APL valve is partially closed, it does not open and gases move into the
tubing and bag. During expiratory pause, FGF further pushes the gases
back to the bag. With bag compression fresh gas moves in to the lungs and
with further in pressure APL valve opens to vent out gases in the tubing,
including fresh gas & alveolar gas.
5
Flows for Mapleson B system
Spontaneous respiration : FGF > 2 X minute volume
IPPV / i t d til ti FGF 2 2 5 X i t l IPPV / assisted ventilation: FGF 2- 2.5 X minute volume
Ventilatory pattern defines fresh gas loss
Keep expiratory pause short
Mapleson C system
APL valve closest to the patient
FGF close to the patient
Reservoir bag at patient end, farthest from the patient
No corrugated tubing between the bag and FGF
Essentially same as Mapleson B MINUS the tubing
Mapleson C system
Functions almost same as Mapleson B
Almost as efficient as Mapleson A, if exp pause is minimum
Flows for Mapleson C system
Spontaneous respiration: FGF 2 X minute volume
IPPV / assisted ventilation: FGF 2 - 2.5 X minute volume
Mapleson D system
FGF closest to the patient
Reservoir bag farthest away from the patient
APL between the bag and FGF, close to the bag
Corrugated tubing between the valve and FGF
Mapleson D system
Classic Mapleson D circuit
Bains circuit
FGF
Exp gas
To patient
6
E h l d d d f ll d b l l t d Exhaled dead space gases followed by alveolar gases move towards
the bag. FGF pushes the gases to the bag. Pressure in bag rises to
open the valve through which alveolar gases (closest to valve) are
vented out.
During inspiration first the FGF in the tubing, then the gases from the
bag (dead space gas) are inhaled.
If FGF is high only fresh gas is inhaled.
If FGF is very low some expired alveolar gas is also inhaled.
contd
Re-breathing decreases with:
Long exp pause g p p
High I: E ratio
Slow rise in insp flow rate
Recommended flow rates for spont resp
100 300 ml / kg / min
FGF t t l i til ti FGF = total min ventilation
FGF 1.5 3 X min ventilation
4000 4700 ml / m
2
/min
The dead space gases followed by alveolar gases advance towards the
reservoir bag. During exp pause the FGF pushes them further into the bag.
With bag compression pressure . This delivers the FGF collected in the
tubing to the lungs and at the same time opens the APL valve to vent out
exhaled alveolar gases.
If FGF is high, some fresh gas also gets vented.
If FGF is low, pressure late, all alv. gases not vented causing re-breathing.
IPPV & re-breathing in Bains circuit
Decreased
FGF
Increased
Insp time
Long exp pause Resp rate
Insp plateau
contd
If FGF > min ventilation, EtCO
2
determined by
MIN VENTILATION MIN VENTILATION
If FGF < min ventilation, EtCO
2
determined by
FGF
7
contd
FGF + min ventilation recommended for
Patients with poor cardiac reserve
Patients with stiff lungs ( compliance)
Hypovolaemic states
Bains circuit
Outer tube 22 mm Inner tube 7 mm Length 110 cm
The advantages of Bains circuit ?
Low dead space
Resistance (< 0.7 cmH
2
O)
Light weight
Easy for scavenging
Long tubing better
mobility
Heat and moisture
retention
Disposable
Compliance volume loss
< circle system
Min vol variations affect
EtCO
2
less than others
No CO
2
absorber no
toxic gas inhalation
Disadvantages of Bains circuit
High fresh gas flow needed
Prone to kinks and damage
Prone to disconnection
Separate tests for inner & outer tube integrity
Incorrect assembly entire system becomes V
D
Mapleson E system
Simple T- piece with 3 open ports
No reservoir bag
No APL valve
contd
8
contd
Inner diameter :
1cm (paed), 1.5 cm (adults)
No valve : minimal resistance
Small volume : minimum dead space
no turbulent flow
No reservoir bag : not needed in neonates
Expiratory port open to atmosphere
Functional analysis (T- piece)
spontaneous respiration
expiration
Pt Exp port
inspiration
FGF
Functions like Mapleson D system for IPPV
contd
Length of expiratory limb
If too long re-breathing
If too short air dilution
contd
Air dilution will not occur if:
Volume of exp limb > V
t
p
t
FGF > PIFR
FGF = 2 X min vol with exp reservoir of 1/3 V
t
Controlled ventilation
contd
What should be the ideal FGF ?
15 X wt X resp rate 15 X wt X resp rate
2 3 X minute volume
3.5 4.0 L / min
What are the merits of Ayres T piece ?
Least resistance
Minimal dead space
Compact Compact
Economical to use
Easily cleaned and sterilized
Inexpensive
9
What are the demerits of Ayres T piece ?
IPPV difficult
Barotrauma common Barotrauma common
CPAP and PEEP not possible
Heat and moisture lost
Scavenging difficult
Mapleson F system
J R modification of Ayres T - piece
Advantages of Mapleson F system
All advantages of T- piece PLUS
Visual monitoring of volume & resp rate
Assisted spont resp & IPPV possible
CPAP and PEEP possible
Which is the best system for spont resp ?
In decreasing order
Mapleson A
Mapleson D
Mapleson F
Mapleson E
Mapleson C
Mapleson B
Which is the best system for IPPV ?
In decreasing order
Mapleson D
Mapleson F Mapleson F
Mapleson E
Mapleson B
Mapleson C
Mapleson A
1
Benign Prostatic Benign Prostatic
Hyperplasia Hyperplasia
Dr Dr. . Sujata Sujata Chaudhary Chaudhary
CASE CASE
Difficulty in initiation of micturition Difficulty in initiation of micturition
70 Yr Old Male Patient
Progressive increase in frequency of micturition Progressive increase in frequency of micturition
Progressive difficulty in micturition Progressive difficulty in micturition
History of Present Illness History of Present Illness
Asymptomatic 6 months back Asymptomatic 6 months back
Developed progressive urinary complaints: Developed progressive urinary complaints:
Increased frequency Increased frequency
Nocturnal awakenings Nocturnal awakenings
Difficulty in initiation Difficulty in initiation
Sense of incomplete evacuation Sense of incomplete evacuation
Dribbling/Incontinence Dribbling/Incontinence
No H/O: Pelvic Trauma / Hematuria / Pyuria / No H/O: Pelvic Trauma / Hematuria / Pyuria /
Burning micturition / Weight loss / Anorexia Burning micturition / Weight loss / Anorexia
History contd History contd
Past history Past history-- no h/o no h/o DM, HT, CAD, COPD and TB DM, HT, CAD, COPD and TB
Personal history Personal history-- non non- -smoker, non smoker, non- -alcoholic , alcoholic , yy ,, ,,
vegetarian vegetarian
No h/o No h/o-- any drug therapy and operative intervention any drug therapy and operative intervention
General General Physical Examination Physical Examination
Average built Average built
No pallor / icterus / edema / lymphadenopathy No pallor / icterus / edema / lymphadenopathy
PR PR--62/min, regular 62/min, regular , g , g
BP BP--140/80 mm Hg 140/80 mm Hg
RR RR--18/min 18/min
Afebrile Afebrile
Systemic Examination Systemic Examination
Resp: Resp: B/L Air entry equal, no added sounds B/L Air entry equal, no added sounds
CVS CVS: S : S
11
SS
22
audible , No murmur present audible , No murmur present
CNS CNS: Normal : Normal
P/A P/A: Soft, BS + : Soft, BS +
Local Local (P/R) examination (P/R) examination
Upper margin not reached & Median sulcus exaggerated , Upper margin not reached & Median sulcus exaggerated ,
Uniformly firm with no discrete nodule Uniformly firm with no discrete nodule
Rectal mucosa mobile Rectal mucosa mobile
2
Differential diagnosis Differential diagnosis
BPH BPH
Ca. Prostate Ca. Prostate
Urethral stricture Urethral stricture Urethral stricture Urethral stricture
Bladder neck hypertrophy Bladder neck hypertrophy
Neurogenic bladder Neurogenic bladder
UTI UTI
Positive findings Positive findings
Progressive Progressive in frequency in frequency
Frequent nocturnal Frequent nocturnal
awakenings awakenings
Progressive Progressive in difficulty in difficulty
Negative findings Negative findings
No wt loss / anorexia No wt loss / anorexia
No hematuria / pyuria No hematuria / pyuria
No h/o trauma No h/o trauma
No palpable nodules No palpable nodules
in initiation & micturition in initiation & micturition
Sense of incomplete Sense of incomplete
evacuation evacuation
Dribbling incontinence Dribbling incontinence
Median sulcus palpable Median sulcus palpable
Ability to feel upper margin Ability to feel upper margin
No palpable nodules No palpable nodules
Benign
Prostatic
Hyperplasia
Investigations Investigations
Hb, TLC, DLC, platelet count Hb, TLC, DLC, platelet count
Blood sugar Blood sugar
Blood urea, S. Electrolytes, S. Creatinine, and Blood urea, S. Electrolytes, S. Creatinine, and
C ti i l C ti i l Creatinine clearance Creatinine clearance
Urine R/M Urine R/M
Chest x Chest x- -ray and EKG ray and EKG
Blood grouping and cross matching Blood grouping and cross matching
Uroflowmetry, PSA and S. Alk. PO4 Uroflowmetry, PSA and S. Alk. PO4
Anatomy of Prostate Anatomy of Prostate
Composed of glandular Composed of glandular
tissue in tissue in fibromuscular fibromuscular
stroma stroma
Shape Shape: chestnut : chestnut
Size Size: 4X3X2 cm : 4X3X2 cm
Weight Weight: 10 : 10 - -20 gm 20 gm
BPH: BPH:
Median Lobe Median Lobe
Anterior Anterior
Two lateral lobes Two lateral lobes
Ca prostate: Ca prostate:
Posterior lobe Posterior lobe
True /anatomical True /anatomical
capsule capsule
Formed by the visceral layers Formed by the visceral layers
of pelvic fascia of pelvic fascia
F l /S i l l F l /S i l l False/Surgical capsule False/Surgical capsule
Formed by condensation of Formed by condensation of
Prostatic tissue Prostatic tissue
Tissue inside this capsule can Tissue inside this capsule can
be scooped out during surgery be scooped out during surgery
Prostatic venous plexus lies Prostatic venous plexus lies
b/w the two capsules b/w the two capsules
Nerve supply Nerve supply
Sympathetic supply Sympathetic supply Parasympathetic supply Parasympathetic supply
T11 T11--L2 S 2,3,4 L2 S 2,3,4- -prostate,urethra prostate,urethra
Bladder neck Bladder neck
S 4,5 sympathetic chain S 4,5 sympathetic chain
Inferior Inferior hypogastric hypogastric plexus plexus Inferior Inferior hypogastric hypogastric plexus plexus
Blood supply Blood supply
Arterial supply Arterial supply Venous plexus Venous plexus
Inferior Inferior vesical vesical artery artery Vesical Vesical plexus, plexus,
Middle rectal artery Middle rectal artery Internal Internal pudendal pudendal veins veins
Internal Internal pudendal pudendal artery Vertebral venous plexus artery Vertebral venous plexus
3
Pathophysiology Pathophysiology
Prostate growth governed by: Prostate growth governed by:
Testosterone Testosterone
Local peptide growth Local peptide growth
factors factors
Testosterone Testosterone 55- -DHT DHT by 5 by 5--
reductase reductase
Imbalance b/w DHT & local Imbalance b/w DHT & local
peptide growth factors peptide growth factors
Estrogenic steroids from Estrogenic steroids from
adrenal cortex may have a adrenal cortex may have a
role role
Affects sub Affects sub--mucosal glands of mucosal glands of
the transitional zone the transitional zone
Problems Due To BPH Problems Due To BPH
Obstructive Symptoms Obstructive Symptoms
Hesitancy Hesitancy
Poor flow Poor flow
Intermittent flow Intermittent flow
Dribbling Dribbling
Sensation of incomplete Sensation of incomplete Sensation of incomplete Sensation of incomplete
evacuation evacuation
Episodes of near retention Episodes of near retention
Irritative Symptoms Irritative Symptoms
Frequency Frequency
Nocturia Nocturia
Urgency Urgency
Urge incontinence Urge incontinence
Nocturnal incontinence Nocturnal incontinence
NON-SURGICAL SURGICAL
MEDICAL
Nonsurgical Management Nonsurgical Management
Fluid intake & Anticholinergic drugs Fluid intake & Anticholinergic drugs
Drug therapy Drug therapy Drug therapy Drug therapy
Prostatic stents Prostatic stents
Permanent indwelling catheters Permanent indwelling catheters
Balloon dilatation Balloon dilatation
Medical Management Medical Management
--adrenergic antagonist adrenergic antagonist 55- - reductase inhibitors reductase inhibitors
Agents Agents Tamsulosin , Terazocin Tamsulosin , Terazocin
Selective alpha 1A/1D Selective alpha 1A/1D
receptor antagonist receptor antagonist
Relaxes smooth muscles of Relaxes smooth muscles of
Finasteride Finasteride
Competitive inhibition of Competitive inhibition of
55- -alpha reductase alpha reductase
DD i f l d d i f l d d
MOA MOA
Action Action
Relaxes smooth muscles of Relaxes smooth muscles of
bladder, prostate and its bladder, prostate and its
urethra urethra
0.4mg OD 0.4mg OD
Headache, Dizziness Headache, Dizziness
Orthostatic hypotension Orthostatic hypotension
Decreases Decreases size of gland and size of gland and
resistance to flow resistance to flow
5 mg OD 5 mg OD
Decreased libido,impotence Decreased libido,impotence
Gynaecomastia Gynaecomastia
on on
gland gland
Dose Dose
Side Side
effects effects
Surgical Approaches to Surgical Approaches to
Prostatectomy Prostatectomy
Endoscopic TUR procedures Endoscopic TUR procedures
Transurethral resection (TURP) Transurethral resection (TURP)
Bipolar TURP Bipolar TURP
Mi th (TUMT) Mi th (TUMT) Microwave therapy (TUMT) Microwave therapy (TUMT)
Laser prostatectomy (VLAP) Laser prostatectomy (VLAP)
Vaporization (TUVP) Vaporization (TUVP)
Radiofrequency needle ablation (TUNA) Radiofrequency needle ablation (TUNA)
Open Open
Retropubic Retropubic
Suprapubic / Transvesical Suprapubic / Transvesical
Transperineal Transperineal
4
Instruments for TURP Instruments for TURP
Anesthetic Considerations Anesthetic Considerations
Patient related problems Patient related problems
Geriatric age group Geriatric age group
Associated co Associated co--morbid morbid
conditions conditions
Problems due to disease Problems due to disease
Back pressure changes in Back pressure changes in
kidneys kidneys
U.T.I U.T.I
Problems due to Problems due to
surgical procedure surgical procedure
Preoperative Preparation Preoperative Preparation
Optimization of preexisting co Optimization of preexisting co- -morbid conditions morbid conditions
Consideration of ongoing drug therapy Consideration of ongoing drug therapy
Advice regarding fasting status Advice regarding fasting status
Arrangement of blood Arrangement of blood gg
Preoperative sedation Preoperative sedation: :
Short acting Benzodiazepines as Alprazolam Short acting Benzodiazepines as Alprazolam
Preoperative antibiotics Preoperative antibiotics specifically indicated in: specifically indicated in:
Preexisting urine retention Preexisting urine retention
Patients with prosthetic materials in situ Patients with prosthetic materials in situ
Choice of Anaesthesia for Prostatectomy Choice of Anaesthesia for Prostatectomy::
Regional anesthesia is preferred Regional anesthesia is preferred
GA when regional anesthesia is contraindicated GA when regional anesthesia is contraindicated
Advantages of regional over general anesthesia Advantages of regional over general anesthesia
1. 1. Allows monitoring of mentation and early signs of TUR Allows monitoring of mentation and early signs of TUR
syndrome & bladder perforation syndrome & bladder perforation
2. 2. Promotes peripheral vasodilatation, reducing circulatory Promotes peripheral vasodilatation, reducing circulatory
overload overload
3. 3. Reduces bleeding by reducing BP Reduces bleeding by reducing BP
4. 4. Low incidence of perioperative MI in patients at risk Low incidence of perioperative MI in patients at risk
5. 5. Low incidence of post Low incidence of post- -op DVT op DVT
6. 6. Post Post--op analgesia op analgesia
Anesthesia for Prostatectomy Anesthesia for Prostatectomy
Level of regional anesthesia: Level of regional anesthesia:
TT- -10 dermatome level: 10 dermatome level: To eliminate discomfort due to bladder To eliminate discomfort due to bladder
distention distention
TT- -9 dermatome level: 9 dermatome level: To eliminate the pain on perforation of To eliminate the pain on perforation of
prostatic capsule (capsular sign) prostatic capsule (capsular sign)
Technique of regional anesthesia: Technique of regional anesthesia:
SAB SAB
Epidural block Epidural block
Caudal block Caudal block
Saddle block Saddle block
Advantages of SAB Advantages of SAB
Technically easier to perform Technically easier to perform
Lower incidence of PDPH in elderly Lower incidence of PDPH in elderly
Better pelvic floor muscle relaxation Better pelvic floor muscle relaxation
No Sacral sparing as with epidural block No Sacral sparing as with epidural block
Continuous epidural anesthesia has no role Continuous epidural anesthesia has no role
because of short duration of surgery because of short duration of surgery
5
Monitoring Monitoring
ECG ECG
Blood pressure Blood pressure
Pulse Pulse oximetry oximetry
Temperature Temperature
Blood loss Blood loss
S. Electrolytes S. Electrolytes
ET CO ET CO
22
if GA is used if GA is used
Orientation Orientation
Problems Due to Surgical Problems Due to Surgical
Procedure Procedure
Lithotomy position Lithotomy position
TURP s ndrome TURP s ndrome TURP syndrome TURP syndrome
Bladder perforation Bladder perforation
Bleeding and coagulation abnormalities Bleeding and coagulation abnormalities
Hypothermia Hypothermia
Transient bacterial septicemia Transient bacterial septicemia
Positioning: Lithotomy Positioning: Lithotomy
Supine; lower limbs flexed Supine; lower limbs flexed
at hip & knee; legs hanging at hip & knee; legs hanging
freely freely
Both limbs simultaneously Both limbs simultaneously
elevated or lowered elevated or lowered
Ensure proper padding at Ensure proper padding at
angulations and edges angulations and edges
While lowering legs should While lowering legs should
be brought together at the be brought together at the
knees and then lowered knees and then lowered
slowly to prevent injury, slowly to prevent injury,
stress on lumbar spine and stress on lumbar spine and
sudden sudden in BP in BP
Problems of Lithotomy Position Problems of Lithotomy Position
Injury to nerves Injury to nerves- - common common
Peroneal, Saphenous, Peroneal, Saphenous,
Sciatic, femoral & obturator Sciatic, femoral & obturator
Injury to fingers Injury to fingers
Compression of major Compression of major
vessels at the joints vessels at the joints vessels at the joints vessels at the joints
Compartment syndrome Compartment syndrome
Hypotension if legs are Hypotension if legs are
rapidly lowered rapidly lowered
Precipitation of CHF Precipitation of CHF
Breathing difficulty in Breathing difficulty in
patients with already patients with already
diseased lungs diseased lungs
Physiologic Alterations in Physiologic Alterations in
Lithotomy Lithotomy
FRC / VC : Atelectasis & hypoxia FRC / VC : Atelectasis & hypoxia
Trendelenberg position and old age Trendelenberg position and old age
Elevation of legs Elevation of legs increase increase venous return venous return
Circulatory overload Circulatory overload mean BP mean BP
( risk for patients with preexisting heart disease ) ( risk for patients with preexisting heart disease )
Venous return following lowering of legs Venous return following lowering of legs BP BP
Exaggeration Exaggeration of hypotension with SAB of hypotension with SAB
Irrigation Fluids Irrigation Fluids
Purpose of Irrigation: Purpose of Irrigation:
Distends bladder and prostatic urethra Distends bladder and prostatic urethra
Improving visibility Improving visibility
Flushes out blood and tissue debris Flushes out blood and tissue debris Flushes out blood and tissue debris Flushes out blood and tissue debris
Decreases bleeding Decreases bleeding
Characteristics of ideal Irrigating fluid: Characteristics of ideal Irrigating fluid:
1. Clear 1. Clear 2. Isotonic/ nearly isotonic 2. Isotonic/ nearly isotonic
3. Cheap 3. Cheap 4. Non hemolytic 4. Non hemolytic
5. Electrically inert 5. Electrically inert 6. Rapidly excreted 6. Rapidly excreted
7. No metabolism 7. No metabolism 8. Non toxic 8. Non toxic
6
Irrigation fluids Irrigation fluids
Solution Solution Osmolality Osmolality
Osm/kg Osm/kg
Advantage Advantage Disadvantage Disadvantage
Distilled water Distilled water 0 (hypo) 0 (hypo) Clear view Clear view
Electrically Electrically
inert inert
Hemolysis Hemolysis
Hemoglobinema Hemoglobinema
Hyponatremia Hyponatremia
Glucose (2 5 Glucose (2 5 139(hypo) 139(hypo) Sticky Sticky Glucose (2.5 Glucose (2.5--
4%) 4%)
139(hypo) 139(hypo) Sticky Sticky
Ringers Ringers
lactate lactate
139(hypo) 139(hypo) Ionized, cannot be used Ionized, cannot be used
with cautery with cautery
Normal Saline Normal Saline 308 (iso) 308 (iso) Ionized, cannot be used Ionized, cannot be used
with cautery with cautery
Urea (1%) Urea (1%) 167(hypo) 167(hypo) Free passage into extra Free passage into extra- -
vascular space, vascular space, Blood Blood
urea urea
Irrigating Fluids (contd) Irrigating Fluids (contd)
Sorbitol (3.5%) Sorbitol (3.5%) 165 165
(hypo) (hypo)
Less chances Less chances
of TURP of TURP
Syndrome Syndrome
Hyperglycemia Hyperglycemia
Lactic acidosis Lactic acidosis
Osmotic diuresis Osmotic diuresis
Mannitol Mannitol
( 5%) ( 5%)
275 (Iso) 275 (Iso) Iso Iso- -osmolar osmolar
solution solution
No metabolism No metabolism
Osmotic diuresis Osmotic diuresis
Ac intravascular Ac intravascular
volume expansion volume expansion
Cytal Cytal
((2.7%sorbitol ((2.7%sorbitol
+Mannitol +Mannitol
0.54%) 0.54%)
178 (Iso) 178 (Iso) Expensive Expensive
Not easily available Not easily available
Glycine (1.2%) Glycine (1.2%)
Glycine (1.5%) Glycine (1.5%)
175 (Iso) 175 (Iso)
220 (Iso) 220 (Iso)
Less likelihood Less likelihood
of TURP of TURP
syndrome syndrome
Transient visual Transient visual
impairment impairment
Hyperammonemia Hyperammonemia
Hyperoxaluria Hyperoxaluria
Factors Affecting Amount and Factors Affecting Amount and
Rate of Fluid Absorption Rate of Fluid Absorption
Size of gland Size of gland
Hydrostatic pressure of irrigating fluid Hydrostatic pressure of irrigating fluid ( Ht 60 cm) ( Ht 60 cm)
Duration of procedure Duration of procedure (max 90 min) (max 90 min) @20 @20 30ml/min 30ml/min Duration of procedure Duration of procedure (max 90 min) (max 90 min)-- @ 20 @ 20-- 30ml/min 30ml/min
Integrity of capsule Integrity of capsule
Number of open sinuses Number of open sinuses
Skills of the operating surgeon Skills of the operating surgeon
Congestion of the gland Congestion of the gland
Intravesical Intravesical pressure pressure (max 15cm of H (max 15cm of H
22
O) O)
TURP Syndrome TURP Syndrome
Incidence is 1 Incidence is 1- -8% 8%
15 15- -20 min after start of surgery 20 min after start of surgery- - 24 hrs after surgery 24 hrs after surgery
Rapid & excessive absorption of fluid leads to : Rapid & excessive absorption of fluid leads to :
Water intoxication Water intoxication
Pulmonary edema Pulmonary edema Pulmonary edema Pulmonary edema
Glycine toxicity Glycine toxicity
Visual disturbances Visual disturbances
Hemolysis Hemolysis
TURP SYNDROME
TURP Syndrome TURP Syndrome
Absorption of fluid Absorption of fluid - - mild fluid overload and diuresis mild fluid overload and diuresis
Absorption of large amount Absorption of large amount -- hypervolemia, hypo hypervolemia, hypo- -
osmolality and hyponatremia osmolality and hyponatremia osmolality and hyponatremia osmolality and hyponatremia
Since BPH occurs in elderly patients with high Since BPH occurs in elderly patients with high
incidence of cardiac decompensation and impaired incidence of cardiac decompensation and impaired
organ function, the concomitant pathology can organ function, the concomitant pathology can
contribute to development of TURP syndrome contribute to development of TURP syndrome
Mechanism of TURP Syndrome Mechanism of TURP Syndrome
BPH Algo.J PG
BPH Algo.J PG BPH Algo.J PG BPH Algo.J PG BPH Algo.J PG
7
Signs / Symptoms of TURP syndrome Signs / Symptoms of TURP syndrome
Cardiopulmonary Cardiopulmonary Hematologic/ Renal Hematologic/ Renal CNS CNS
1. 1. Hypertension Hypertension
2. 2. Bradycardia Bradycardia
3. 3. Hypotension Hypotension
4. 4. CHF CHF
55 Dysrhythmias Dysrhythmias
1. 1. Hyponatremia Hyponatremia
2. 2. Hypoosmolality Hypoosmolality
3. 3. Metabolic acidosis Metabolic acidosis
4. 4. Hyperammonemia Hyperammonemia
55 Hyperglycemia Hyperglycemia
1. 1. Nausea Nausea
2. 2. Vomiting Vomiting
3. 3. Confusion Confusion
4. 4. Agitation Agitation
55 Seizures Seizures 5. 5. Dysrhythmias Dysrhythmias
6. 6. Pulmonary Pulmonary
edema edema
7. 7. Arterial Arterial
hypoxemia hypoxemia
8. 8. MI MI
9. 9. Shock Shock
5. 5. Hyperglycemia Hyperglycemia
6. 6. Hemolysis Hemolysis
5. 5. Seizures Seizures
6. 6. Coma Coma
7. 7. Transient blindness Transient blindness
Presentation Presentation - - TURP Syndrome TURP Syndrome
Dizziness, nausea, tightness Dizziness, nausea, tightness
in chest or throat , in chest or throat ,
breathlessness, lethargy breathlessness, lethargy
Rise followed by fall in BP Rise followed by fall in BP
ST changes, nodal rhythm, ST changes, nodal rhythm,
U waves, widening of U waves, widening of
QRS l ECG QRS l ECG
Regional GA
Restlessness, retching, Restlessness, retching,
confusion,agitation confusion,agitation
// BP, BP, HR, cyanosis, HR, cyanosis,
unconsciousness, dilated unconsciousness, dilated
pupil with sluggish reaction pupil with sluggish reaction
Tonic Tonic- - clonic seizures, coma, clonic seizures, coma,
cardiac arrest cardiac arrest
QRS complex on ECG QRS complex on ECG
Respiratory arrest Respiratory arrest
Delayed recovery Delayed recovery
Water Intoxication Water Intoxication
Cause Cause
Hypervolemia , hypo Hypervolemia , hypo- -osmolality osmolality- - cerebral edema cerebral edema
Manifestations Manifestations
Decerebrate posture Clonus Positive Babinskis Decerebrate posture Clonus Positive Babinskis Decerebrate posture, Clonus, Positive Babinski s Decerebrate posture, Clonus, Positive Babinski s
sign, Convulsions and Coma sign, Convulsions and Coma
Features of raised ICT: bradycardia, hypertension Features of raised ICT: bradycardia, hypertension
and papilledema (Cushings triad) and papilledema (Cushings triad)
Under GA Under GA- - pulmonary edema, excessive oozing, pulmonary edema, excessive oozing,
muscle twitchings muscle twitchings
Absorption of Na free fluid Absorption of Na free fluid - - with S. Na levels fall with S. Na levels fall
by 3 by 3- -10 10 meq meq /l /l
Rate of fall of S. Na, instead of total fall, determines Rate of fall of S. Na, instead of total fall, determines
Cause
, , , ,
development of neurological symptoms development of neurological symptoms
Signs and symptoms Signs and symptoms
Agitation and or confusion Agitation and or confusion
Visual disturbances Visual disturbances
Pulmonary edema Pulmonary edema
CV collapse CV collapse
Seizures Seizures
S. Na conc. S. Na conc.
(meq/l) (meq/l)
ECG ECG
manifestation manifestation
CVS CVS
manifestatio manifestatio
nn
CNS signs CNS signs
120 120 Wide QRS Wide QRS
complex complex
Hypotension Hypotension
Bradycardia Bradycardia
Restlessness Restlessness
Confusion Confusion
Manifestations of Hyponatremia
complex complex
Bradycardia Bradycardia Confusion Confusion
115 115 Wide QRS Wide QRS
ST segment ST segment
VPC VPC
Cardiac Cardiac
depression depression
Nausea Nausea
Somnolence Somnolence
110 110 VT, VF VT, VF CHF CHF Seizures Seizures
Coma Coma
Hypoosmolality Hypoosmolality
IMPORTANT FACTOR IMPORTANT FACTOR -- CNS manifestations CNS manifestations
Differential permeability of Na and water Differential permeability of Na and water Differential permeability of Na and water Differential permeability of Na and water
Diuretics given to treat Diuretics given to treat hypervolemia hypervolemia accentuate accentuate
Na and Na and osmolality osmolality
Causes cerebral edema Causes cerebral edemaHypertension and Hypertension and
bradycardia bradycardia
8
Glycine Glycine
Non Non--essential amino acid, inhibitory neurotransmitter essential amino acid, inhibitory neurotransmitter
Better optical visibility, low electrical conductivity Better optical visibility, low electrical conductivity
Normal plasma Glycine level Normal plasma Glycine level-- 0.3mmol/l,13 0.3mmol/l,13--17mg/dl 17mg/dl
Distribution half life: 6 min Distribution half life: 6 min Distribution half life: 6 min Distribution half life: 6 min
Termination half life: 40min Termination half life: 40min several hrs, dose several hrs, dose
dependent dependent
Causes osmotic diuresis Causes osmotic diuresis
Direct toxic effect on heart and retina Direct toxic effect on heart and retina
Systemic effects of Glycine Systemic effects of Glycine
Volume of Glycine Volume of Glycine
absorbed absorbed
Signs and symptoms Signs and symptoms
>500 ml >500 ml Visual disturbances Visual disturbances
>1000 ml >1000 ml Depressed consciousness, Depressed consciousness,
Pain abdomen Pain abdomen
>3000 ml >3000 ml Diarrhea Diarrhea
Plasma conc. of Glycine Plasma conc. of Glycine Signs and symptoms Signs and symptoms
55- -8 mmol/l 8 mmol/l Visual disturbances Visual disturbances
>10 mmol/l >10 mmol/l Transient blindness,N&V Transient blindness,N&V
>20 mmol/l >20 mmol/l Fatal Fatal
TURP Blindness TURP Blindness
Transient blindness seen in OT/ PACU Transient blindness seen in OT/ PACU
Due to retinal dysfunction consequent to Due to retinal dysfunction consequent to
Hyperglycinemia Hyperglycinemia Hyperglycinemia Hyperglycinemia
Signs/Symptoms Signs/Symptoms
Blurred vision, haloes around light, pupillary Blurred vision, haloes around light, pupillary
dilatation, unresponsive pupils dilatation, unresponsive pupils
Recovers within 8 Recovers within 8- -48 hrs following surgery 48 hrs following surgery
Cause Cause
Glycine containing fluids Glycine containing fluids
Glycine Glycine - - Glyoxylic acid + Ammonia (oxidative deamination) Glyoxylic acid + Ammonia (oxidative deamination)
Ammonia Ammonia - - Urea (facilitated by Arginine in liver) Urea (facilitated by Arginine in liver)
Arginine is depleted in patients fasting for >12 hrs & liver Arginine is depleted in patients fasting for >12 hrs & liver
disease disease
Signs and Symptoms: Signs and Symptoms:
Nausea, vomiting followed by coma Nausea, vomiting followed by coma within 1 hr post operatively within 1 hr post operatively
CV effects: Myocardial depression, T wave ,non specific ECG CV effects: Myocardial depression, T wave ,non specific ECG
changes changes
Due to S. ammonia levels > 500mmol/l Due to S. ammonia levels > 500mmol/l
Reversed once S.ammonia levels come down to < 150mmol/l Reversed once S.ammonia levels come down to < 150mmol/l
Hyperglycinemia Hyperglycinemia
Glycine may cause encephalopathy and Glycine may cause encephalopathy and
seizures by potentiating the effect of NMDA seizures by potentiating the effect of NMDA
Hypomagnesemia resulting from dilution by Hypomagnesemia resulting from dilution by
irrigant solution and diuretics increase irrigant solution and diuretics increase irrigant solution and diuretics increase irrigant solution and diuretics increase
susceptibility to seizures susceptibility to seizures
Magnesium therapy may have a role in such Magnesium therapy may have a role in such
patients patients
Prevention of TURP Syndrome Prevention of TURP Syndrome
Correct fluid and electrolyte imbalances Correct fluid and electrolyte imbalances
Cautious administration of IV fluids Cautious administration of IV fluids
Reduce surgical time to <60 min Reduce surgical time to <60 min
Max height of fluid bag 60cm Max height of fluid bag 60cm
Max intravesical pressure 15cm of water Max intravesical pressure 15cm of water
Use bipolar resectoscope Use bipolar resectoscope
Vaporisation technique Vaporisation technique
Vasoconstrictors at the operative site Vasoconstrictors at the operative site
9
Measuring Fluid Absorption in Measuring Fluid Absorption in
TURP TURP
Volume of fluid absorbed Volume of fluid absorbed= =
Pre Pre--op Na conc. / post op Na conc. / post--op Na conc. X ECF op Na conc. X ECF -- ECF ECF
Volumetric fluid balance (difference between amount Volumetric fluid balance (difference between amount
f i i i d i fl id) f i i i d i fl id) of irrigating and returning fluid) of irrigating and returning fluid)
Gravimetry (measuring weight gain during surgery) Gravimetry (measuring weight gain during surgery)
CVP measurement CVP measurement
Isotopes Isotopes
Measurement of ethanol concentration in exhaled Measurement of ethanol concentration in exhaled
breath breath
Management of TURP Management of TURP
Syndrome Syndrome
Terminate surgery Terminate surgery
Oxygen supplementation Oxygen supplementation
Pulmonary edema: Pulmonary edema: Oxygenation,Ventilation Oxygenation,Ventilation
Restrict I/V fluids Restrict I/V fluids -- If pulmonary edema If pulmonary edema
--frusemide frusemide to induce to induce diuresis diuresis when it does not occur when it does not occur
spontaneously spontaneously
ABG, S. Na and ABG, S. Na and osmolality osmolality
Invasive monitoring in pulmonary edema, Invasive monitoring in pulmonary edema,
hypotension hypotension
Management of TURP Management of TURP
Syndrome Syndrome
Seizures: BZD, Seizures: BZD, Thiopentone Thiopentone, , Phenytoin Phenytoin, Muscle , Muscle
relaxants relaxants
Bradycardia Bradycardia & hypotension: Atropine adrenergic & hypotension: Atropine adrenergic Bradycardia Bradycardia & hypotension: Atropine, adrenergic & hypotension: Atropine, adrenergic
agonists and iv calcium agonists and iv calcium
Significant blood loss, transfuse Packed Cells Significant blood loss, transfuse Packed Cells
Visual disturbances resolve spontaneously within Visual disturbances resolve spontaneously within
24 hrs 24 hrs
Hypertonic Saline Hypertonic Saline
Indications: Indications:
Overt signs of Overt signs of hyponatremia hyponatremia
Serum Na < 120mmol/l Serum Na < 120mmol/l
Safe rate of administration: 0.5 Safe rate of administration: 0.5- -1meq/l (not 1meq/l (not
th 100 l/h S N h ld t i b th 100 l/h S N h ld t i b
II
more than100ml/hr, S. Na should not rise by more than100ml/hr, S. Na should not rise by
more than 1mmol/l/hr) more than 1mmol/l/hr)
Rapid correction may cause cerebral edema, Rapid correction may cause cerebral edema,
hypervolemia hypervolemia & CPM & CPM
Correction to normal is not indicated Correction to normal is not indicated clinical clinical
improvement improvement
Should be given into a large vein Should be given into a large vein
Hyponatremia Hyponatremia & hypertonic & hypertonic
saline saline
Mechanism of action Mechanism of action
Corrects Corrects hyponatremia hyponatremia
Expands plasma volume Expands plasma volume
Combats cerebral edema Combats cerebral edema
Reduces cellular edema Reduces cellular edema
Increases urinary excretion Increases urinary excretion
without loss of solutes without loss of solutes
Bladder Perforation Bladder Perforation
Incidence 1% Incidence 1%
Causes: Causes:
Trauma by surgical intervention Trauma by surgical intervention
Over distention of the bladder Over distention of the bladder Over distention of the bladder Over distention of the bladder
Explosion of traces of hydrogen gas inside the bladder Explosion of traces of hydrogen gas inside the bladder
In conscious patient early sign is In conscious patient early sign is in return of in return of
irrigating fluid and pain abdomen irrigating fluid and pain abdomen
Under GA Under GA- - Bradycardia Bradycardia, hypotension followed by , hypotension followed by
hypertension , reflex type movement of limbs hypertension , reflex type movement of limbs
10
Types of Bladder Perforation Types of Bladder Perforation
Intraperitoneal Intraperitoneal
Symptoms develop faster Symptoms develop faster
Shoulder pain is typical Shoulder pain is typical
Rapid Rapid in returning fluid with abdominal distention in returning fluid with abdominal distention
E t it l E t it l Extraperitoneal Extraperitoneal
Due to bladder neck rupture Due to bladder neck rupture
Pain abdomen ( periumbilical, inguinal) Pain abdomen ( periumbilical, inguinal)
Irregular return of fluid Irregular return of fluid
Periprostatic Periprostatic
Due to rupture of anatomical capsule Due to rupture of anatomical capsule
Suprapubic pain Suprapubic pain
Profuse bleeding Profuse bleeding
Bladder Perforation: Management Bladder Perforation: Management
OO
22
inhalation inhalation
If shock develops: fluids, vasopressors, If shock develops: fluids, vasopressors,
i t i t i t i t inotropic agents inotropic agents
Intubation & ventilation if required Intubation & ventilation if required
Laparotomy and bladder repair over SPC Laparotomy and bladder repair over SPC
Blood Loss Blood Loss
Depends on: Depends on:
Wt of resected tissue:15 Wt of resected tissue:15- -50ml/ gm resected tissue 50ml/ gm resected tissue
Surgical time : 2 Surgical time : 2- -5 ml/min of resection time 5 ml/min of resection time
No of open Prostatic sinuses No of open Prostatic sinuses
Bl d Bl d Blood pressure Blood pressure
Infection & inflammation Infection & inflammation
Visual estimation is grossly inaccurate & difficult Visual estimation is grossly inaccurate & difficult
Classical signs of hypotension and tachycardia are not Classical signs of hypotension and tachycardia are not
seen immediately due to increased blood volume seen immediately due to increased blood volume
Hemorrhage and Coagulopathy Hemorrhage and Coagulopathy
Causes Causes
Dilutional Dilutional thrombocytopenia & thrombocytopenia &
hypofibrinogenemia hypofibrinogenemia
Release of Release of fibrinolytic fibrinolytic agents ( agents (urokinase urokinase)) Release of Release of fibrinolytic fibrinolytic agents ( agents (urokinase urokinase))
plasminogen plasminogen activator from prostatic tissue activator from prostatic tissue
DIC consequent to release of prostatic DIC consequent to release of prostatic
particles rich in particles rich in thromboplastin thromboplastin into the blood into the blood
Treatment Treatment
BT, Platelets, cryoprecipitate and FFP BT, Platelets, cryoprecipitate and FFP
EACA for DIC(4 EACA for DIC(4- -5g in 1st hr&1g/hr) 5g in 1st hr&1g/hr)
Hypothermia Hypothermia
Caused by prolonged and continuous irrigation Caused by prolonged and continuous irrigation
with large amount of cold irrigant with large amount of cold irrigant
Monitor body temperature of patient Monitor body temperature of patient
Important to maintain normothermia in the Important to maintain normothermia in the
perioperative period using warm irrigant & perioperative period using warm irrigant &
intravenous fluids intravenous fluids
Use of systemic & intrathecal opiods to Use of systemic & intrathecal opiods to
decrease postoperative shivering decrease postoperative shivering
Transient Transient
Bacteremia & Septicemia Bacteremia & Septicemia
Causes Causes
Release of bacteria from prostate Release of bacteria from prostate
Preoperative indwelling catheter Preoperative indwelling catheter
Preoperative UTI Preoperative UTI
Si d S t Si d S t Signs and Symptoms Signs and Symptoms
Asymptomatic Asymptomatic
Fever, chills, tachycardia, hypotension, CV collapse Fever, chills, tachycardia, hypotension, CV collapse
Management Management
Preoperative antibiotics Preoperative antibiotics
If sepsis develops, broad spectrum antibiotics If sepsis develops, broad spectrum antibiotics
CV support CV support
11
Open Prostatectomy Open Prostatectomy
Indication Indication: prostate weight >80 gm : prostate weight >80 gm
Routes: Routes:
T i l bi i i iti T i l bi i i iti Transvesical suprapubic, using supine position Transvesical suprapubic, using supine position
Retropubic, using supine position Retropubic, using supine position
Transperineal, using lithotomy position Transperineal, using lithotomy position
Type of anesthesia: GA, regional or combined Type of anesthesia: GA, regional or combined
For regional: dermatomal level T For regional: dermatomal level T
88--10 10
Associated with moderate to severe blood loss Associated with moderate to severe blood loss
Postoperative Postoperative Care Care
Advisable to monitor patient in PACU Advisable to monitor patient in PACU
Monitor vitals and, in particular, CNS Monitor vitals and, in particular, CNS
Continue irrigation Continue irrigation
As the postoperative pain following TURP is As the postoperative pain following TURP is As the postoperative pain following TURP is As the postoperative pain following TURP is
moderate, routine analgesia using moderate, routine analgesia using
NSAIDS NSAIDS
Opioids such as tramadol, fentanyl, Opioids such as tramadol, fentanyl,
morphine morphine
Butorphanol if not contraindicated Butorphanol if not contraindicated
Suggested Reading Suggested Reading
Bailey and Loves Short Practice of Surgery: 24 Bailey and Loves Short Practice of Surgery: 24
th th
edition edition
Anesthesiologists Manual of Surgical Procedures. Jaffe and Samuel: 3 Anesthesiologists Manual of Surgical Procedures. Jaffe and Samuel: 3
rd rd
ed ed
Millers Anesthesia, by R D Miller: 6 Millers Anesthesia, by R D Miller: 6
th th
edition edition
Stoelting Stoelting ,s Anesthesia and coexisting disease 5 ,s Anesthesia and coexisting disease 5
th th
edition 2010 edition 2010
Anesthesia for laparoscopic urological surgery BJA2004;93(6)859 Anesthesia for laparoscopic urological surgery BJA2004;93(6)859- -64 64
Hahn RG. Fluid absorption in endoscopic surgery. BJA 2005; 96: 8 Hahn RG. Fluid absorption in endoscopic surgery. BJA 2005; 96: 8- -20 20
Clinical Anesthesia by Clinical Anesthesia by Barash Barash, Cullen, , Cullen, Stoelting Stoelting: 5 : 5
th th
edition edition
Clinical Anesthesiology by Morgan, Mikhail: 4 Clinical Anesthesiology by Morgan, Mikhail: 4
th th
edition edition
Anesthesiology Problem Oriented Patient Management, by Yao, Anesthesiology Problem Oriented Patient Management, by Yao, Artusio Artusio: 7 : 7
th th
edition edition
Complications of transurethral surgery. In complications in anaesthesia.2 Complications of transurethral surgery. In complications in anaesthesia.2
nd nd
edition. edition. Malhotra Malhotra VV
Serum electrolytes in TURP syndrome. IJA. 2002:46(6) 441 Serum electrolytes in TURP syndrome. IJA. 2002:46(6) 441--444 444
1
Case Discussion
Prof. Anjan Trikha
Session Details:
70 yr old with Ca Larynx
Specific problems
D/L biopsy
Laryngectomy
Laser treatment for laryngeal
lesions
Tracheostomy
90 minutes
Geriatric cases
Theory long question
Short notes
Drug aging, Pulmonary aging
L n s Long case
Short case
Main Viva
X ray, Pace maker, Dementia,
Parkinsonism drugs, Alzheimer's.
Case Scenario
70 year old patient with Ca larynx
D/l and biopsy
Tracheostomy
Laryngectomy Laryngectomy
Incidental surgery
TURP, Hernia, orthopedics.
All surgical procedures
Intensive care unit COPD, Asthma.
70 year old & carcinoma larynx
History 70 year old, male patient
P/C - Change of voice, hoarseness, bad breath.
No H/o choking, dysphagia, weight loss, difficulty in breathing,
hemoptysis, otalgia. .
P t hi t Past history:
Hypertensive on calcium blockers, ACE inhibitors
Diabetic on glibenclamide, metformin.
CAD on nitrates, aspirin, anti platelets
Prostatism on prazosin
COPD off & on antibiotics & bronchodilators.
.
No H/O jaundice/ BA / blood transfusions/ TB.
Personal history: Chronic smoker & Pan
chewer, social alcohol intake, vegetarian.
Treatment history: Radiotherapy neck
A th i hi t B/L t t i Anesthesia history: B/L cataract in a
hospital & throat biopsy under LA.
Past, surgical, treatment and anesthesia history provide insight
about patients general health
Social history: risk factors & functional status.
2
GPE: Old man, 55 kg, right handed, bad
breath, pallor, cyanosis, edema.
Clinically well nourished & hydrated.
Airway: Edentulous 3 fingers MP II Airway: Edentulous, 3 fingers, MP II.
Chest, CVS, No neck bruits
Neck: Pigmented, thick, Less mobility.
PR/ BP/ all peripheral pulses felt, Allens.
Investigations
Hematological
Blood biochemistry
EKG / ECHO / Stress ECHO/ MUGA
LFT & KFT & urine examination
Viral markers
Radiology X ray Chest, CT / MRI.
Dehydration, malnourishment, electrolyte imbalance,
major surgery, blood loss, hemodynamic instability
VIVA
History & examination
Stridor at rest: Airway diameter <4.5cm.
Inspiratory stridor: Supraglottic lesions. n p rat ry tr r uprag tt c n .
Expiratory stridor: Airway narrowing
below glottis.
Both: Subglottic lesions
VIVA - Stridor: Causes
Supralaryngeal : Choanal atresia, thyroglossal cysts.
Laryngeal : Laryngomalacia , VC paralysis.
Subglottic stenosis: congenital or acquired.
Tracheal: Extrinsic compression . p
Bronchogenic cysts, Trachomalacia.
Non anatomic causes of stridor
Compression of the recurrent laryngeal nerve.
Foreign body, Gastro esophageal reflux
Infections: Epiglottitis, retrophrayngeal abscess,
croup
Stridor
Wheezing vs Stridor
Ascertain intubation necessary or not.
O
2
face mask, head up 45
- 90
.
D h 0 15 / k IV / 8 h Dexamethasone 0.15mg / kg IV / 8 hrs.
Nebulized racemic adrenalin.
Heliox
Viva could go to - Other racemic medications , Steroids
& difficult airway.
Racemic epinephrine
1:1 mixture mixture dextrorotatory &
levorotatory isomers
L form is the active component. p
Stimulates & receptors in airway
Mucosal vasoconstriction
Decreases sub glottic edema
Relaxation of the bronchial smooth
muscle
3
Heliox
79 % helium + 21% O
2
Respiratory airflow laminar - Gas
viscosity.
Setting of Airway Obstruction Setting of Airway Obstruction
Airflow turbulent - Gas density.
Heliox density 1/3 of air & O
2
Leads to decrease in airway resistance
Improvement in Ventilation.
Heliox
Cylinders: white with brown shoulders
Pressure: 137 bar
H l 100 % B l d Helium: 100 %, Brown cylinders.
Reduces WOB in upper airway obstruction
Severe asthma & lower airway diseases
Further direction of viva
Radiotherapy, Chemotherapy,
Depression
Airway: MP classification 3 / 4 /
zero airway.
Allens test: time, positive / negative /
modified.
Invasive monitoring - IBP, CVP
Anesthesia implications
Compromised airway
Difficult airway: Alarming signs
Positioning
Patients on opioids, anesthesia implications
Shared operative field
Circuits used
Appropriate timing for extubation.
Airway: MP classification zero.
Ability to see any part of the
epiglottis upon mouth opening and
tongue protrusion, with out phonation.
d l f l l h ld Adults, females, males, children.
Easy & difficult intubation.
Difficult mask ventilation, airway cart.
Difficult BM Ventilation
(BONES)
Beard
Obesity
No teeth
(Elderly)
(Snores)
Severe facial burns / angioedema /
trauma
Unstable midface and/or mandible
4
Risk factors: laryngeal cancer
Smoking
Excessive ethanol
Male sex
Larngopharyngeal
reflux.
Diets rich in spicy food
Infection with
HPV
Increasing age
Chewing betel
leaf
Low intake of veggies
Exposure to sulfuric
acid
Exposure to radiation
Diets low in vitamin A
Direction of viva
Drugs & co morbid conditions.
Hypertensive on
Calcium blockers, ACE inhibitors
Diabetic on glibenclamide metformin Diabetic on glibenclamide, metformin.
Prostatism on prazosin
CAD on
Nitrates, aspirin, anti platelets, statins
COPD off & on antibiotics & bronchodilators.
Calcium Blockers: Over dose
Treatment
IV calcium
High doses catecholamines
Insulin
Glucagon.
Levosimendan
Inotrope, calcium sensitizer & improves contraction
without increasing intracytosolic calcium concentration.
D/L under GA viva could go to
Xylocaine dose: 4 mg / kg
Anesthesia technique
Hypertensive surges
Bleeding at extubation
Laryngospasm
PONV
Hoarseness
Arytenoid Dislocation
Arytenoid subluxation: cricoarytenoid joint
Incidence: 0.023%, Left side more common.
Associated anomalies: CRF, RHD, Acromegaly
laryngomalacia, Diabetes, long corticosteroid laryngomalacia, Diabetes, long corticosteroid
use
Lighted stylet, LMA, McCoy laryngoscope
Difficult / Uneventful intubation, DLT
Symptoms: Hoarseness, Sore throat,
Dysphagia, Stridor
Arytenoid Dislocation
D/D: Recurrent Laryngeal palsy.
Pressure on nerve , ETT cuff.
External laryngeal trauma.
Differentiation : difficult
Diagnosis: Fibreoptic laryngoscopy, Laryngeal electro
myography, Computed tomography.
Early treatment / High suspicion
Treatment: Voice therapy / Chemical splinting
Closed reduction
5
Laryngectomy - VIVA
AIRWAY ;
RT, fixed neck structures, adjuncts & tracheostomy
If NO stridor
Normal airway
Standard induction Standard induction
If moderate stridor: (Tumor not too large, absence of gross
anatomical distortion, absence of fixed hemilarynx)
Intubation possible
Inhalational induction, Mask ventilation
2- 3 attempts, Asleep FOI
Tracheostomy.
Laryngectomy - VIVA
Obstruction: (stridor, difficult breathing, sleeping
upright).
Likely to be difficult MV & intubation.
Anesthesiologists expertise g p
Inhalational induction
Awake intubation FOB or otherwise
Ask for tracheostomy.
All patients would have a tracheostomy any
way
Laryngectomy - VIVA
CVS problems
Vagal reflexes / carotid sinus HR & BP.
Trauma to stellate ganglion
I t ti f i l th ti tfl Interruption of cervical sympathetic outflow
Prolonged QT interval & ventricular
arrhythmias.
Treatment: stop surgery, atropine, local LA.
VAE: ETCO
2
, ETN
2
, hypotension, ST - T
elevation, Mill wheel murmur, unexplained
hypotension.
Laryngectomy - VIVA
Measures: inform, 100 % O
2
, stop
inhalational, prevent awareness, compress
neck veins, flood field, left lateral, head
down for air aspiration iv fluids and down, for air aspiration, iv fluids and
inotropes.
Durant maneuver and Trendelenburg .
If CPR : supine and head-down position.
Other surgeries.
Laryngectomy - VIVA
Monitoring
Post operative problems:
HTN, Tachycardia.
N i j i f i l RLN & h i Nerve injuries; facial, RLN & phrenic.
Agitation: PaO
2
, PaCO
2
, HR.
Check neck dressing
Establish airway, NMJ,CAS
Direction of viva
Central Anticholinergic Syndrome
Central signs (somnolence, confusion, amnesia,
agitation, hallucinations, dysarthria, ataxia,
delirium, stupor, coma) p
Peripheral signs (dry mouth, dry skin, tachy,
visual disturbances and difficulty in
micturition).
Occurs when central cholinergic sites are
occupied by specific drugs and also as a result
of an insufficient release of acetylcholine.
6
Direction of viva
Incidence : 10% GA, 4% RA +sedation.
D/d:
A h i d Anaesthetic overdose,
Altered electrolyte or acid-base state
Hypoglycaemia, hypoxia, hypercapnia
Hypocapnia, hyperthermia, hypothermia
Hormonal disorders, embolism.
Direction of viva
Caused by
Atropine sulphate,
Hyoscine (scopolamine),
Promethazine,
Benz di zepines Benzodiazepines,
Opioids, halothane, enflurane
Ketamine
Diagnosis: Process of exclusion
Therapeutic response to centrally active
anticholinesterase agent - Physostigmine.
Laryngeal speech
Esophageal Speech
Tracheo esophageal Speech Tracheo-esophageal Speech
Electronic speech.
Viva can go to blood loss
ABL = EBV x (Hi - Hf)
Hi
EBV = weight (kg) x average blood volume
Adult Men 75 mL/kg. Women 65 mL/kg Adult Men 75 mL/kg. Women 65 mL/kg
Hct Values Men 42-52%. Women37-47%
Normovolemic hemodilutional
Autologus blood transfusion
Estimation of blood loss.
Viva can go to -
Day Care surgery
Criteria for accepting, Pre & intraoperative
medications, Discharge score : Aldrete,PADS
(Vit l A b l ti N P i Bl di (Vitals, Ambulation, Nausea, Pain, Bleeding
(0,1,2, At least 9.
Drinking & voiding.
Trans tracheal jet ventilation
LASERS LASERS
Light Amplification by Stimulated Emission of
Radiation
7
Advantages
Precise focus, enormous heat, on a small
area of tissue
Instantaneous sealing
S ll bl d l Small blood vessels
Lymphatics
With minimal damage to surrounding
tissues
Anesthetic Goals: Laser Surgery
Safe environment
Both patient and OT staff
C l t i bilit f i l fi ld Complete immobility of surgical field
Adequate analgesia and anesthesia
Prevent complications
Laser for laryngeal lesions
Papilloma
Polyp
Hyperkaratosis
Vocal Nodule
Carcinoma in situ
Laryngeal amylodosis
LASER: viva
CO
2
laser: Radiation with 10,600 nm wavelength.
Absorbed by H
2
O, effects tissue 0.2 mm
depth.
Suitable for lesions on VC, larynx.
Nd-Yag laser: Radiation, 1064 nm wavelength.
Can be transmitted thru fiberoptics.
Energy absorbed preferably by
Hemoglobin,Pigmented tissue
Deep penetrating effects 4 - 5 mm
Useful in treating detached retina.
LASER: Further viva
CO
2
or Nd-Yag both used.
Problems with LASER
Operating room hazards
Patient risks
Special ETT
Anesthesia: ETT, JV, TIVA. Thru LMA Nd-Yag.
Airway fires.
Anesthetic Techniques
Non-intubation techniques
Apneic Oxygenation
Spontaneous Ventilation
Jet Ventilation
Intubation Techniques
8
LASER: Further viva
Intubation:
Cuffed ETT, deep anesthesia &
relaxation
PVC HC R d R bb CO ETT PVC HCI - , Red Rubber CO - ETT
Silastic tube, Laser shield tube
Bivona foam cuff tube,
Norton steel tube
Laser-Flex tube
Aluminum foil wrap
LASER: Further viva
With out intubation
Airway is unprotected
Hyperinflation: Esophagus and stomach
The vocal cords vibrate in the jet stream
Periglottic tumor location: Prevents adequate ventilation
Jet ventilation
Superaglottic, Subglottic, , Intratracheal,
Transtracheal
Intermittent apneic technique
TIVA
LASER - Still further
Laser Plume
30% O
2
in nitrogen, helium
N
2
O supports combustion.
What to do if fire?
Laser Plume
Debris produced
Contents
Carcinogens, mutagens, irritants, fine dusts
Bioaerosols, viruses (HPV, HIV), hydrocarbons, Toxic , ( , ), y ,
gases.
Chemicals : Formaldehyde, hydrogen cyanide, benzene.
Health hazard
Control
Ventilation, Safe work practices, Personal protective
equipment.
Airway Fires
Remove burning ETT, Re intubate
Flush pharynx with cold saline
Check damage, presence of FB.
Ventilatory support, Fluid resuscitation, y pp , ,
intensive pulmonary toilet
Steroids, antibiotics, NSAIDS controversial
Tracheostomy.
Routine monitoring, X Ray Chest.
Inhalational burn injury- G
1
, G
2,
G
3
according to
depth of mucosal damage
1
CATARACT
Case presentation
Dr. Mahendra Kumar (Prof)
Dr. Kritika Agrawal (P.G. II Yr)
History
Patient : Mrs Kalawati
Age : 80 Year
R/O : Gazipur, Delhi
CR. No. : 05184591
History of present illness
B/L Diminution of vision X 5years
Gradual
Progressive
Painless
No H/O redness, discharge , watering,
double vision, flashes, headache
Past history
No history of
Eye Trauma
Previous ocular surgery
Diabetes mellitus Diabetes mellitus
Hypertension
No H/O any other Resp. or Cardiac illness
Treatment history
No H/O
- any drug intake
- any treatment for chronic illness
2
Personal History
Belongs to low socioeconomic status
Illiterate
Non smoker, not addict to any intoxicant
V t i Vegetarian
House wife
Physical Examination
General Examination
Average built female, Wt. 50 kg
Conscious, oriented
Sitting comfortably.
Vitals- Vitals-
PR-76/min, regular
BP-110/70 mmHg
RR-13/min
Afebrile to touch
pale
no icterus or cyanosis
Physical Examination - General
Airway Examination
Mouth opening
Adequate,
Edentulous, Edentulous,
MPG - II
Neck movement
normal & adequate
Chest examination
B/L air entry adequate and equal
No added sounds
CVS Examination
S1 - S2 heart sounds normal
No added sounds
Examination of Eyes
EYEBROWS- Normal B/L
LIDS
Normal - B/L
No redness, swelling OR Inflam
No ptosis or retraction
No inversion or eversion
Able to close eyes completely
EYE LASHES
No discharge / inflammation
No loss of eyelashes B/L
3
Examination of Eyes
CONJUNCTIVA
Both conjunctiva Normal
No redness or inflamm.
No tearing or discharge
CORNEA
Contour - Normal Contour Normal
No opacity, haziness.
SCLERA
White coloured
No redness or inflamm
ANTERIOR CHAMBER
Clear in both eyes
Examination of Eyes
IRIS
Dark brown colour
Circular, normal size
PUPIL
Normal size and equal B/L
Reaction to light Direct and
. Consensual
LENS
Grayish white in both eyes
Iris shadow - present
Examination of Eyes
VISION
Poor - B/L
MOVEMENTS OF EYES MOVEMENTS OF EYES
Normal and adequate
OCULAR TENSION
Normal.
Summary
80 yrs F
H/o gradually diminution of vision x 5 yrs
Painless
No other associated illness
Lens - grayish white with iris shadow
in both eyes.
What is your diagnosis?
B/L Immature Senile Cataract
What are the other types of cataract?
Congenital
Traumatic (eye trauma/surgery)
Di b ti Diabetic
Drugs induced steroid
Hereditary disease - Myotonic dystrophy
Treatment?
Which Anaesthesia technique will you prefer for her?
Local Anaesthesia
Peribulbar Block
4
Which is most important anatomical landmark
for peribulbar block?
Inferior Border of Orbit
What is the normal anatomy of Orbital cavity?
Pyramid shaped
Base & apex
Four borders
Four walls Four walls
Two fissures
Optic foramen
Depth 33-35mm
What are the contents of the orbit ?
It contains Eye
globe, orbital fat,
extra ocular muscles,
nerves, blood
l d l i l vessels, and lacrimal
apparatus.
Two compartment
-Central / retrobulbar
-Peripheral / peribulbar
What are the Extra-ocular muscles?
Four rectus muscles
(lat, med, sup and inf)
Two oblique
(superior & inferior)
Levator palpebrae
superioris
Orbicularis oculi
What are the nerves supplying these
muscles?
Lat. Rectus Abducent - 6
th
cranial N.
Sup. Oblique Trochlear - 4
th
cranial N.
Other all muscles Oculomotor- 3
rd
cranial N
Orbicularis oculi Facial - 7
th
cranial N.
LR6(SO4)3-O-O-7
What are the sensory and autonomic
nerve supply to the orbital contents?
Sensory-by branches of ophthalmic division of
Trigeminal 5
th
cranial N
Lacrimal branch conjuctiva
Ciliary branches cornea, sclera, iris, cilliary body.
Vision Optic Nerve 2
nd
cranial N
Sympathetic - from 1
st
thoracic symp. out flow
through short and long ciliary nerves.
Para sympathetic Afferent via ciliary
ganglion trigeminal N gasserion ganglion
Efferent through Vagus N
5
What is the blood supply to orbit?
Ophthalmic artery a branch of internal
carotid artery.
V d i i i di f i Venous drainage via superior and inferior
ophthalmic veins.
Intra-ocular pressure
normal 10 20 mmHg
Factors affecting the IOP
Factors which increase the IOP
High venous pressure - coughing sneezing High venous pressure - coughing, sneezing,
vomiting, straining
High arterial pressure
Hypoxia and hypercarbia (vasodilation)
External pressure by face mask
Retrobulbar haematoma, SOL
Drugs- suxamethonium, ketamine
Inadequate depth of anaesthesia
Intra-ocular pressure
Factors which decrease the IOP
Reduced venous pressure- head up tilt
Low arterial pressure e.g. 90mmHg
H til ti H bi Hyperventilation, Hypocarbia
I.V. induction agents( except ketamine)
Inhalational anaesthetic agents
Drugs e.g. acetazolamide, mannitol.
Local anaesthestic block.
What are the requirements of the Patient, Surgeon
and Anaesthetist during cataract surgery ?
Requirement of
patient
No sensation, No pain
No vision
Complete analgesia
Without vision
Requirement of
Anaesthetist
No reflex at all
Complete Areflexia
No Oculocardiac
reflex
Requirement of
surgeon
No movement at all
No rise in IOP
Complete Akinesia
Low IOP
All requirements of
patient, surgeon and
anaesthetist
Regional Block
Which drugs will you use for ophthalmic Block?
Quick onset of effect
Long duration of
effect
Fast spread of drug
Lignocaine +
Adrenaline+(1: 200,000)
Hyaluronidase 150 units
OR
Fast spread of drug
Lignocaine +
Bupivacaine (1:1) +
Hyaluronidase
150 units
How will you take care of the patient for eye surgery?
Position- comfortable (pillow and pads)
Drapes- keep away from the pts face
Oxygen 6-8L/min under drapes.
A good IV line to be secured. g
Sedation - minimum in incremental doses.
Midazolam 1mg IV. Avoid over sedation.
Communicate with pt for any problem
Monitoring for: Cont. ECG, HR, NIBP, SpO
2
.
6
Position of the Patient
What are the various blocks used for cataract surgery ?
Topical Anaesthesia / block
Facial N blocks -
- Van Lint block,
- OBrien block, ,
- Nadbath-Rehman block (NR Block)
Bulbar blocks
- Peribulbar block + Superionasal.
- Retrobulbar block +Van Lint block
- Sub-tenons block
- Parabulbar block
Topical Anaesthesia / block
Instill 1-2 drops of 4% lignocaine in
conjuctival sac. Wait for few min.
Uses Uses
Phacoemulsification (cataract)
To measure IOP with Tonometer
To supplement the bulbar block
As a part of the bulbar block
Facial N block technique
(To block orbicularis oculi)
1. Nadbath-Rehman
block (NR Block)
(Ant. to Mastoid Process
stylomastoid foramen)
2. OBrien block
(Condyloid process of mandible)
3. Van Lint block
Facial N block -- Van Lint block - technique
Site - 2cm lateral to the
lateral border of the orbit, at
the level of inferior border.
Infiltrate the LA in upper and
lower lid along orbital border
3mL in each 3mL in each.
Same skin puncture is used
for injection in both lids in
order to make a V.
It produces akinesia of
orbicularis oculi. (both lids)
Bulbar blocks -- techniques
Peribulbar Block Retrobulbar Block
7
Bulbar blocks - techniques
Position supine, looking
upward or straight ahead
Approach -
1. Transcutaneous
2. Conjuctival
Site
At the junction of lat and j
middle 1/3
rd
of inferior
border of orbit.
Needle
35mm-retrobulbar
25mm-peribulbar
25 G
Syringe - 10 mL
Bulbar blocks -techniques Peribulbar Block
Introduce a needle at the junction of
lateral and middle 1/3
rd
of inferior
border of orbit perpendicularly,
Advance backward, parallel to the
floor of the orbit.
After crossing the equator of eye ball After crossing the equator of eye ball
perform aspiration test
Inject the drug in orbital fat 6 8mL,
slowly.
Remove the needle
Apply pressure over eye ball.
Assess the block after 10 min.
Requires superionasal block.
Bulbar blocks -techniques Superionasal Block
Site: J ust medial to supra-
trochlear notch at superior
border
Insert needle parallel to roof
of orbit for 12-15 mm
Beyond the equator of eye
ball - perform aspiration test
deposit 2-3 mL drug.
Remove the needle
Assess the block after 10min.
Bulbar blocks -- techniques Retrobulbar block
After crossing the equator of the eye
ball redirect the needle.
Push the hub at 10 downward
Rotate laterally to make an angle of
45 with sagittal plane
Advance backward, medially and y
upward to enter in the cone.
Never advance beyond the 31mm to
avoid complications
After aspiration test inject the drug
1.5 - 2mL slowly in orbital fat.
Remove the needle
Assess the block after 5min.
Requires facial N block
Complications --
Retrobulbar Block
Intravascular injection
Retrobulbar haemorrage, haematoma formation, and
raised IOP proptosis
Retinal artery occlusion
Brain stem anaesthesia / central spread of L A
Optic nerve damage Optic nerve damage
Oculocardiac reflex
Perforation of eye ball
Peribulbar Block
Subconjuctival haemorrhage
Chemosis or subconjuctival oedema
Toxicity of epinephrine
Allergic reaction to local anaesth agent
Bulbar blocks - comparison of two blocks
Difference
Retrobulbar
Block
Peribulbar
Block
Site inside the cone outside the cone
Needle 35mm 25mm
Effect Quick @ 5 min Slow effect 10-12min
Facial N block generally required generally not required
(superionasal)
Complications More complications less complications.
Volume of LA
required
1.5- 2 mL 6-8mL
8
How will you assess the effect of block ?
Signs of successful block
Ptosis
Loss of sensation (Analgesia)
Loss of movement (Akinesia) Loss of movement (Akinesia)
Loss of vision
Inability to close the eyes once opened.
What will be your postoperative
management?
Analgesia NSAIDS, Paracetamol / Diclo
Antiemetic - Ondansetron
Observe for vitals andcomplications. Observe for vitals and complications.
Allow orally after few hours.
Peribulbar block
Superionasal Block
Assessment of block
1
Circle Absorbers Circle Absorbers
Dr. Chhavi S. Sharma Dr. Chhavi S. Sharma
Learning Objectives Learning Objectives
What is circle system What is circle system
Component of circle breathing system Component of circle breathing system
Objectives, how they are achieved Objectives, how they are achieved
Classical circle system and some variants Classical circle system and some variants
Advantages, Disadvantages Advantages, Disadvantages
Gas flow in a circular pathway through 2 separate channels Gas flow in a circular pathway through 2 separate channels
Inspiratory Inspiratory Expiratory Expiratory Inspiratory Inspiratory Expiratory Expiratory
Gas exhaled by the patient removed by absorbent. Gas exhaled by the patient removed by absorbent.
Components of circle system Components of circle system
Absorber Absorber
Unidirectional valves Unidirectional valves
Inspiratory and expiratory ports Inspiratory and expiratory ports
APL APL
Pressure guage Pressure guage
Breathing tubes Breathing tubes Inspiratory and expiratory ports Inspiratory and expiratory ports
YY- -piece piece
Fresh gas inlet Fresh gas inlet
Breathing tubes Breathing tubes
Reservoir bag/ventilator Reservoir bag/ventilator
Bag/ventilator switch Bag/ventilator switch
Diagram of classical circle system Diagram of classical circle system
2
Canisters & Absorber Canisters & Absorber
Size Size
Large (long interval change but causes desiccation) Large (long interval change but causes desiccation)
Small (Fresh absorbent with proper water content, less comp A Small (Fresh absorbent with proper water content, less comp A
OR CO formation, internal volume of breathing system OR CO formation, internal volume of breathing system
maintained) maintained)
Transparent Transparent
Perforated screen at bottom Perforated screen at bottom vertical vertical
Mounting Mounting
Single/Double canister in series Single/Double canister in series
Pre Pre--packed canister packed canister obstruction reported as foil was not obstruction reported as foil was not
removed before mounting in the machine removed before mounting in the machine gg
Head and base of absorber Head and base of absorber
Metal Metal Plastic Plastic
Older canister Older canister
Metal body Metal body waters canister (To and Fro system) waters canister (To and Fro system)
Disadvantages Disadvantages
W i ht W i ht Weight Weight
Metal body Metal body heat could produce face burns heat could produce face burns
Increase in dead space Increase in dead space exhaust exhaust
Horizontal position Horizontal position channeling of gases channeling of gases
Inability to see color change of absorber Inability to see color change of absorber
Baffles Rings Baffles Rings
Increase gas flow to center part Increase gas flow to center part
Increase travel path of gases Increase travel path of gases
B l B l Bypass valve Bypass valve
Allows exhaled gases to completely or partially bypass the Allows exhaled gases to completely or partially bypass the
absorber absorber
3
Absorption pattern Absorption pattern
Absorbent Absorbent
CO CO
22
absorption employs the principal of a base neutralizing absorption employs the principal of a base neutralizing
acid. acid.
Reaction Reaction- -
CO CO
22
+H +H
22
OO HH
22
CO CO
33
(Carbonic acid) (Carbonic acid) CO CO
22
+H +H
22
OO HH
22
CO CO
33
(Carbonic acid) (Carbonic acid)
HH
22
CO CO
33
HH
++
+HCO +HCO
--
33
NaOH NaOH OH OH
--
+Na +Na
++
Ca(OH) Ca(OH)
22
20H 20H
--
+Ca +Ca
2+ 2+
NaOH +H NaOH +H
22
CO CO
33
+Ca(0H) +Ca(0H)
22
CaCO CaCO
33
+Na +Na
22
CO CO
33
+4H +4H
22
OO
Heat is liberated at 13,700 calories per mole of water Heat is liberated at 13,700 calories per mole of water
Soda lime (Sodasorb) Soda lime (Sodasorb)
Constituents Constituents
Ca(OH) Ca(OH)
22
80% 80%
Moisture Moisture 12 12--19%(typical 16%) 19%(typical 16%)
NaOH NaOH 4% 4%
KOH KOH Removed Removed
Silica Silica Hardness Hardness
Indicator dye Indicator dye Fractional amount Fractional amount
Types Types
Absorbents can be Absorbents can be
High alkali High alkali
Low alkali Low alkali
Alkali free Alkali free Alkali free Alkali free
Lithium Hydroxide Lithium Hydroxide
Low alkali absorbent Low alkali absorbent
Contain less amount of Na Contain less amount of Na
++
/K /K
++
hydroxide hydroxide
Lower amounts of CO & Comp A. Lower amounts of CO & Comp A.
Alkali free absorbents: Alkali free absorbents:
Mainly Ca(OH) Mainly Ca(OH)
22
with small quantity of other agents as catalyst with small quantity of other agents as catalyst
No comp A/CO seen even with desiccation. No comp A/CO seen even with desiccation.
Color indicator works well even when dry Color indicator works well even when dry
CO CO
22
absorption capacity is significantly less absorption capacity is significantly less CO CO
22
absorption capacity is significantly less absorption capacity is significantly less
High alkali High alkali Aborbent Aborbent
High content of K High content of K
++
/Na /Na
++
(e.g. (e.g. sodalime sodalime))
Desiccated high alkali absorber Desiccated high alkali absorber
Reacts with volatile Reacts with volatile anaesthetic anaesthetic CO formation CO formation
Has reduced efficiency Has reduced efficiency
Forms comp A with Forms comp A with sevoflurane sevoflurane
Does not change color on exhaustion Does not change color on exhaustion
Lithium hydroxide Lithium hydroxide
Expensive Expensive
Absorbs CO Absorbs CO
22
Does not react with volatile Anaesthetic Does not react with volatile Anaesthetic Does not react with volatile Anaesthetic Does not react with volatile Anaesthetic
Handling & usage problem (can cause burn to eye, skin Handling & usage problem (can cause burn to eye, skin
and respiratory tract) and respiratory tract)
4
Component Component Sodalime Sodalime Medisorb Medisorb Dragersorb Dragersorb
800+ 800+
Amsorb Amsorb
Ca(OH)2 % Ca(OH)2 % 94 94 70 70--80 80 80 80 83 83
NaOH% NaOH% 2 2- -44 11--22 22 --
KOH% KOH% -- - - - - 11
CaSO4 (hardener) CaSO4 (hardener) -- - - - - 11
Polyvinylpyrrolidine % Polyvinylpyrrolidine %
(hardener) (hardener)
-- - - -- 11
Water content % Water content % 14 14--19 19 16 16--20 20 ~14 ~14 14.5 14.5
Ba(OH)2 Ba(OH)2--8H 8H
22
O% O% -- - - - - --
Size (mesh) Size (mesh) 44--8 8 44--88 44- -88 44--88
Indicator Indicator Yes Yes Yes Yes Yes Yes Yes Yes
Indicators Indicators
pH Indicators pH Indicators
Phenolpthalein Phenolpthaleinwhite to purple white to purple
Ethyl violet Ethyl violet white to purple white to purple
Many others like ethyl orange, Many others like ethyl orange, clayton claytonyellow and yellow and y y g , y y g , yy yy
mimosa mimosa--Z have been used Z have been used
Supplied in granules/pellets. Supplied in granules/pellets.
Mesh number 4 Mesh number 4--8 mesh 8 mesh
4 opening per square inch 4 opening per square inch
8 opening per square inch 8 opening per square inch
Hardness Hardness
Soft granules Soft granules
Dust inhalation Dust inhalation
Caking, channeling of gases Caking, channeling of gases
Malfunction of valves Malfunction of valves Malfunction of valves Malfunction of valves
Hardening agent added or film coating of granules Hardening agent added or film coating of granules
Breathing filters in circuits (Inspiratory side) of breathing Breathing filters in circuits (Inspiratory side) of breathing
system system Prevent inhalation of dust Prevent inhalation of dust
Interaction of absorbent and anaesthetic Interaction of absorbent and anaesthetic
agents agents
Halothane degradation Halothane degradation haloalkene2 haloalkene2 bromo bromo-- 2 2 bromo bromo--
2 chloro 2 chloro--1,1 1,1 difluroethane difluroethane(BCDEF) (BCDEF)
Sevoflurane SevofluraneCompound A (vinyl ether) Compound A (vinyl ether)
Dependent on Dependent on Dependent on Dependent on
FGF FGF Increases with low FGF Increases with low FGF
Absorbent composition Absorbent composition increases with increases with NaOH NaOH& KOH & KOH
Temperature Temperature Temp Temp CompA CompA
Duration Duration duration duration CompA CompA
Water content Water content
Carbon monoxide formation (CO) Carbon monoxide formation (CO)
Desflurane Desflurane, , Enflurane Enflurane, or , or Isoflurane Isoflurane(containing CHF (containing CHF
22
))
React with dry absorbent containing strong alkalis React with dry absorbent containing strong alkalis form form
CO CO
Sevoflurane Sevofluranedegrades to form CO at >80 degrades to form CO at >80
oo
CC
CO conc. in breathing system varies with time, leading to CO conc. in breathing system varies with time, leading to
peak in first 60 minutes peak in first 60 minutes
RGMs used in routine do not detect CO RGMs used in routine do not detect CO
Symptoms like confusion, headache and nausea Symptoms like confusion, headache and nausea
Slight fall in SpO Slight fall in SpO
22
seen with very high levels of CO seen with very high levels of CO
Abnormal display could point to CO build up Abnormal display could point to CO build up
Wrong agent/mixed agent Wrong agent/mixed agent
Unexpected fall in volatile Unexpected fall in volatile anaesthetic anaesthetic concentration concentration
Failed inhalation induction Failed inhalation induction
Co Co--oximetry oximetrycombines CO and SpO combines CO and SpO
22
display display
5
Factors associated with CO formation Factors associated with CO formation
Alkali base Alkali base
Absorbent desiccation Absorbent desiccation
HME HME humidity humidity
Anaesthesia AnaesthesiaPatient Safety Foundation Patient Safety Foundation
Guidelines Guidelines
Alkali free absorber Alkali free absorber
Switch gases between cases Switch gases between cases
Flush breathing system with gas free of volatile Flush breathing system with gas free of volatile anaesthetic anaesthetic
at end of each case at end of each case
Disconnect pipeline Disconnect pipeline Disconnect pipeline Disconnect pipeline
Change absorber at least once a week Change absorber at least once a week
Absorbent containers should be closed tight Absorbent containers should be closed tight
Checking working of AGSS negative pressure relief valve Checking working of AGSS negative pressure relief valve
Canister temp >50 Canister temp >50
oo
C indicate volatile C indicate volatile anaesthetic anaesthetic
breakdown breakdown change absorber change absorber
Humidification Humidification
ABSORBANT STORAGE AND HANDLING ABSORBANT STORAGE AND HANDLING
Open containers should be resealed Open containers should be resealed
High ambient temp High ambient temp no effect no effect
Very low ambient temp Very low ambient temp expand the moisture and break expand the moisture and break
the granules the granules
Handling absorber Handling absorber
Caustic effect on contact with eye, skin Caustic effect on contact with eye, skin more with more with
wet/moist absorber wet/moist absorber
Remove dust over edges Remove dust over edges air tight seal air tight seal
Do not overfill Do not overfill
Remove foil over prefilled canister Remove foil over prefilled canister
When and how to change the When and how to change the
absorbent? absorbent?
Indicator color guidance Indicator color guidance not reliable not reliable
Change both canisters even if one shows color change Change both canisters even if one shows color change
FiCO FiCO
22
most reliable most reliable
Peaking or regeneration is seen with absorber containing Peaking or regeneration is seen with absorber containing
strong base strong base
Unidirectional Valves
Two valves used in circle system
Transparent dome
Valve discs are light weight
Guide / cage over the seating
Both horizontal and vertical valves are
used
Disc should be hydrophobic
6
Tubings and Y Connectors
Inner inspiratory and outer expiratory tubes
Plastic, disposable and non-conductive
Dead space extends from Y piece patient
Co-axial breathing system Co-axial breathing system
APL Valve and Pressure Gauge
Release pressure variable from
0-70 cm H
2
O
During mechanical ventilation
the valve is disconnected from the valve is disconnected from
circle system
Pressure gauge attached to the
exhalation pathway (diaphragm
type)
Bag and Ventilator Switch
Selector switch is essentially a three
way stop cock
One port connects to breathing system
Second attached to bag mount
Third attach to ventilator hose
Absorption of other agents Absorption of other agents
Nitric oxide and nitrogen dioxide, monitor it downstream Nitric oxide and nitrogen dioxide, monitor it downstream
from the absorber from the absorber
If nitric oxide, monitor it downstream from the absorber If nitric oxide, monitor it downstream from the absorber
Objectives Objectives
To determine best arrangement of components To determine best arrangement of components
Minimizing absorbent desiccation Minimizing absorbent desiccation
Maximum inclusion of FG in the inspired mixture and Maximum inclusion of FG in the inspired mixture and
maximum venting of alveolar gas maximum venting of alveolar gas -- results faster induction results faster induction
and emergence and emergence
Minimal consumption of absorbents Minimal consumption of absorbents
Accurate reading from a Accurate reading from a respirometer respirometer placed in the system placed in the system
Minimal dead space Minimal dead space
Low resistance Low resistance
Minimal pull on tracheal tubes Minimal pull on tracheal tubes
Convenience Convenience
Gas flows through the breathing system Gas flows through the breathing system
7
8
Anestar breathing system
Fabius GS and Apollo Breathing Systems
Fabius GS and Apollo Breathing Systems
Consideration of individual components Consideration of individual components
Fresh Gas Inlet Fresh Gas Inlet
9
Reservoir Bag Reservoir Bag
A
P
L

V
a
l
v
e
Classical position of individual components Classical position of individual components
FGI FGI -- Upstream of the Upstream of the inspiratory inspiratoryunidirectional valve and unidirectional valve and
downstream of the absorber downstream of the absorber
Resevoir Resevoir Bag Bag Expiratory unidirectional valve and Expiratory unidirectional valve and
upstream of the absorber upstream of the absorber upstream of the absorber upstream of the absorber
APL Valve APL Valve Near reservoir bag, downstream of the Near reservoir bag, downstream of the
expiratory unidirectional valve and upstream of the expiratory unidirectional valve and upstream of the
absorber absorber
Filters, O Filters, O22 sensor, sensor, Respirometer Respirometer , RGMs , RGMs Between the Y Between the Y--
piece and the Patient piece and the Patient
Monitors in circle system Monitors in circle system
Oxygen sensor Oxygen sensor
Capnometry Capnometry
Agent monitor Agent monitor
Respirometer Respirometer
Airway pressure monitor Airway pressure monitor
Dead space of circle system Dead space of circle system
Extends from patient port Extends from patient port Y piece Y piece
partition decreases dead space partition decreases dead space
Backlash before valve closure Backlash before valve closure Backlash before valve closure Backlash before valve closure
Unidirectional valve Unidirectional valve
Competent valve Competent valve minimal dead space minimal dead space
Incompetent valve Incompetent valve greatly increases dead space greatly increases dead space
Heat and humidity Heat and humidity
Moisture from Moisture from
Exhaled gases Exhaled gases
Absorbent Absorbent
Water liberated from Neutralization of carbon Water liberated from Neutralization of carbon dioxide dioxide Water liberated from Neutralization of carbon Water liberated from Neutralization of carbon--dioxide dioxide
A fresh gas flow of 0.5 A fresh gas flow of 0.5--2 l/min 2 l/min will result in humidity will result in humidity
between 20 and 25mg H between 20 and 25mg H
22
O/l at 60 minutes O/l at 60 minutes
10
Relationship between inspired and Relationship between inspired and
delivered concentration delivered concentration
The larger the breathing system internal volume the greater The larger the breathing system internal volume the greater
will be the difference between inspired and delivered will be the difference between inspired and delivered
concentration concentration
Canister size is most important determinant Canister size is most important determinant internal internal
volume in circle system volume in circle system
Denitrogenation Denitrogenation
Nitrogen in breathing system is 80% Nitrogen in breathing system is 80%
More is added from expired gases More is added from expired gases
High initial FGF for few minutes washes it out High initial FGF for few minutes washes it out
There is no set time as variable are too many There is no set time as variable are too manyyy
Even after complete Even after complete denitrogenation denitrogenationNitrogen in closed Nitrogen in closed
system will rise system will rise gradually.Sources gradually.Sourcesof Nitrogen include of Nitrogen include
Air used by analyzers as reference for calibration Air used by analyzers as reference for calibration
Leak in sampling line can entrain air Leak in sampling line can entrain air
Maximum Nitrogen accumulation is usually under 18% Maximum Nitrogen accumulation is usually under 18%
Advantages of Advantages of circle system circle system
Reduced consumption of anaesthetic gases Reduced consumption of anaesthetic gases
Reduced cost Reduced cost
R d d i t l ll ti R d d i t l ll ti Reduced environmental pollution Reduced environmental pollution
Temperature of inspired gas is maintained Temperature of inspired gas is maintained
Better humidity maintained with low fresh gas flow Better humidity maintained with low fresh gas flow
Disadvantage Disadvantage
Circle system is composed of many parts that can be Circle system is composed of many parts that can be
arranged incorrectly or may malfunction arranged incorrectly or may malfunction
Large number of connections that can become Large number of connections that can become
disconnected or leak disconnected or leak disconnected or leak disconnected or leak
Some components are difficult to clean Some components are difficult to clean
The system is relatively bulky and not easily moved The system is relatively bulky and not easily moved
The compliance of the circle system is high compared with The compliance of the circle system is high compared with
other system other system
The trend toward smaller absorbent canister will reduce the The trend toward smaller absorbent canister will reduce the
i t l l f b thi t d d i t l l f b thi t d d internal volume of breathing system and decrease internal volume of breathing system and decrease
compliance compliance
The use of an absorbent may result in formation of CO & The use of an absorbent may result in formation of CO &
Compound A Compound A
Pediatric circle system Pediatric circle system
Smaller lumen tubes, bag and Y Smaller lumen tubes, bag and Y--connectors replace adult connectors replace adult
system system
Absorber and valves etc. remain same Absorber and valves etc. remain same
Adult system can be used in small infants, provided Adult system can be used in small infants, provided
HME/filters not used beyond Y HME/filters not used beyond Y--connector connector
Compression volume poses difficulty in measuring minute Compression volume poses difficulty in measuring minute
volume volume
1
D VP K
GENERAL PRINCIPLES IN
GERIATRIC ANAESTHESIA
Prof.A. K. Prof.A. K. Sethis SethisEORCAPS EORCAPS- -2013 2013
Dr. V.P. Kumra
Geriatric Anaesthesia Geriatric Anaesthesia
Ageing is universal Impact on the demand of Healthcare
Progressive Physiological phenomenon,
Characterized by degenerative changes in structural and
functional capacity
Ageing is universal Impact on the demand of Healthcare
Progressive Physiological phenomenon,
Characterized by degenerative changes in structural and
functional capacity functional capacity
Elderly population > 65 yrs is fast growing globally
Delhi Electoral ROLL 2014:
Aged over 100 Years : 154
Aged between 80 yrs 100 yrs : over 68,000
functional capacity
Elderly population > 65 yrs is fast growing globally
Delhi Electoral ROLL 2014:
Aged over 100 Years : 154
Aged between 80 yrs 100 yrs : over 68,000
Why the aged need special perioperative care ?
>85 yrs age carries Increased surgical load
Physiological / chronological variability
Steady & unpredictable decline of organs reserve
function with Progressive loss of functional capacity
Why the aged need special perioperative care ?
>85 yrs age carries Increased surgical load
Physiological / chronological variability
Steady & unpredictable decline of organs reserve
function with Progressive loss of functional capacity
Geriatric Anaesthesia
g p y
Potential diminished mental acuity
Associated comorbidities Polymedications
Frailty syndrome & Metabolic syndrome with age
Age related changes in organ system relevant to
the anaesthetist
g p y
Potential diminished mental acuity
Associated comorbidities Polymedications
Frailty syndrome & Metabolic syndrome with age
Age related changes in organ system relevant to
the anaesthetist
Predictive factors / risk factors for PO morbidity & mortality
Reduced functional capacity
Reduced exercise tolerance in ADL: MET levels (1-4)
Major clinical predictors: cardiac, pulmonary, DM ,hepato-renal
Predictive factors / risk factors for PO morbidity & mortality
Reduced functional capacity
Reduced exercise tolerance in ADL: MET levels (1-4)
Major clinical predictors: cardiac, pulmonary, DM ,hepato-renal
Ageing Ageing
reserve and ability to endure stress
ASA physical status III / IV
Surgical specific risk factors & emergency procedure
Nutritional status albumin level, Hb concentration
Age related changes in organ systems
reserve and ability to endure stress
ASA physical status III / IV
Surgical specific risk factors & emergency procedure
Nutritional status albumin level, Hb concentration
Age related changes in organ systems
Cardiovascular & autonomic ageing makes BP unstable
during anaesthesia
Impaired baroreflex responsiveness: decreased response to
B receptor stimulation
Linear systolic BP widened pulse pressure 30 -80yrs
Cardiovascular & autonomic ageing makes BP unstable
during anaesthesia
Impaired baroreflex responsiveness: decreased response to
B receptor stimulation
Linear systolic BP widened pulse pressure 30 -80yrs
Age Related Cardiovascular Changes
Linear systolic BP, widened pulse pressure 30 -80yrs
Arterial stiffness (50 75%), SVR (25%)
Sympathetic nervous system activity
Ejection fraction shows initial rise only

1
stimulation, failure of
2
vasodilatation
epinephrine release
Linear systolic BP, widened pulse pressure 30 -80yrs
Arterial stiffness (50 75%), SVR (25%)
Sympathetic nervous system activity
Ejection fraction shows initial rise only

1
stimulation, failure of
2
vasodilatation
epinephrine release
Stratton JR et al. Circulation, 1994
Physiology of Ageing Cardiovascular System (Contd.) Physiology of Ageing Cardiovascular System (Contd.)
Connective tissue stiffening
Progressive loss of elasticity: Free Radical Attack, glycoselation
Arterial stiffness (aorta) - afterload
Ventricular hypertrophy : increasing wall stress, myocardial 0
2
demand,
Connective tissue stiffening
Progressive loss of elasticity: Free Radical Attack, glycoselation
Arterial stiffness (aorta) - afterload
Ventricular hypertrophy : increasing wall stress, myocardial 0
2
demand,
susceptibility to myocardial ischaemia
Gradual myocyte death without replacement : slow relaxation
Venous stiffening
75% capacity, maintain central blood volume
Reduce venous return, PL - orthostatic hypotension
Conduction defects (SSS, AF, BBB)
susceptibility to myocardial ischaemia
Gradual myocyte death without replacement : slow relaxation
Venous stiffening
75% capacity, maintain central blood volume
Reduce venous return, PL - orthostatic hypotension
Conduction defects (SSS, AF, BBB) Rooke GA et al. Anesth Cl N Am 2000
2
Diastolic Dysfunction Diastolic Dysfunction
Cardiac Stiffening
Impaired ventricular ability to accept blood
Early active relaxation ( 1/3 ) or entire
diastolic phase (atrial kick)
S ll h LVEDV / LVEDP
Cardiac Stiffening
Impaired ventricular ability to accept blood
Early active relaxation ( 1/3 ) or entire
diastolic phase (atrial kick)
S ll h LVEDV / LVEDP
Small changes LVEDV / LVEDP,
leftward shift of PV curve
Symptoms of pulmonary congestion +++
LAP, tachycardia, increased blood volume
accentuated by exercise exercise intolerance
Small changes LVEDV / LVEDP,
leftward shift of PV curve
Symptoms of pulmonary congestion +++
LAP, tachycardia, increased blood volume
accentuated by exercise exercise intolerance
Aurigemma et al. N Engl J Med 2004
Diastolic Dysfunction Diastolic Dysfunction
Diagnosis:
Clinical: LVF with normal systolic function
Doppler echocardiography & ECG.
Diagnosis:
Clinical: LVF with normal systolic function
Doppler echocardiography & ECG. Doppler echocardiography & ECG.
Indication of LA enlargement & LVH ( strong predictors )
Radionucleotide ventriculography
Cardiac catheterization: LAP, PVP, LVEDP >16 mmHg
Mild increased BNP (N =100 -700 pg/ml)
Monitored fluid infusion is mandatory.
Doppler echocardiography & ECG.
Indication of LA enlargement & LVH ( strong predictors )
Radionucleotide ventriculography
Cardiac catheterization: LAP, PVP, LVEDP >16 mmHg
Mild increased BNP (N =100 -700 pg/ml)
Monitored fluid infusion is mandatory.
Preoperative maintenance of haemodynamic stability:
Continue all antihypertensive drugs till the day of operation
Identify & optimise potentially reversible causes ( accelerated HT, IHD, DD )
Integrate Clinical CVS risk factors, Exercise capacity & surgical risk
Avoid hypotension: ( underfilling ). Measure CVP with LARGE FLUID SHIFTS
Blunting of sympathetic response to laryngoscopy
LMA i l th i d
Preoperative maintenance of haemodynamic stability:
Continue all antihypertensive drugs till the day of operation
Identify & optimise potentially reversible causes ( accelerated HT, IHD, DD )
Integrate Clinical CVS risk factors, Exercise capacity & surgical risk
Avoid hypotension: ( underfilling ). Measure CVP with LARGE FLUID SHIFTS
Blunting of sympathetic response to laryngoscopy
LMA i l th i d
Anaesthetic Considerations Anaesthetic Considerations
LMA, regional anaesthesia, drugs
Avoid perioperative hypoxaemia EDV, pulmonary congestion
Treat stage II HT & Diastolic dysfunction: ( Stage II HT is NO contraindication )
Diuretics ( central blood volume, CVP); CCB ( AL, slow HR, vent. Relaxation,
ischaemia relaxation); ACEI (AL, vent. relaxation)
Beta blockers RCRI gr. III, IV or those already on blockers
Myocardial regression of hypertrophy : Livosemindan, Pimobendan
LMA, regional anaesthesia, drugs
Avoid perioperative hypoxaemia EDV, pulmonary congestion
Treat stage II HT & Diastolic dysfunction: ( Stage II HT is NO contraindication )
Diuretics ( central blood volume, CVP); CCB ( AL, slow HR, vent. Relaxation,
ischaemia relaxation); ACEI (AL, vent. relaxation)
Beta blockers RCRI gr. III, IV or those already on blockers
Myocardial regression of hypertrophy : Livosemindan, Pimobendan
Rosenthal RA, Kavic SM. Crit Care Med 2004
Structural changes in airway
Loss of pharyngeal muscle support / dentition
upper airway obstruction
respiratory effort to airway obstruction (OSA)
Structural changes in airway
Loss of pharyngeal muscle support / dentition
upper airway obstruction
respiratory effort to airway obstruction (OSA)
Respiratory System Respiratory System
p y y ( )
Loss of protective reflexes ( silent regurgitation )
age related pharyngeal deafferentation
diminished cough reflex: age, muscular weakness exaggerated by residual
effects of anaesthetics & relaxants
COPD, Pneumonia and Sleep Apnoea are very common
p y y ( )
Loss of protective reflexes ( silent regurgitation )
age related pharyngeal deafferentation
diminished cough reflex: age, muscular weakness exaggerated by residual
effects of anaesthetics & relaxants
COPD, Pneumonia and Sleep Apnoea are very common
Changes in lung volumes
TLC, Vital capacity, tidal volume & IRV
RV (5-10%), FRC (1-3%) graduall y increase / decade
Closing Capacity (RV+CV) : progressivel y encroaches on FRC
at 60/40 yrs posture dependent
Changes in lung volumes
TLC, Vital capacity, tidal volume & IRV
RV (5-10%), FRC (1-3%) graduall y increase / decade
Closing Capacity (RV+CV) : progressivel y encroaches on FRC
at 60/40 yrs posture dependent
Respiratory System
y p p
Airway closure, V/Q mismatch & hypoxaemia
FEV
1
decreases 6 8 % per year ( reduced Pulm compliance )
Elastin: collagen ratio--Tracheo-broncheal instability
Small airway obstruction, ( resistance ) Difficult to reopen
Increased WOB, Diffcult to wean off ventilator
y p p
Airway closure, V/Q mismatch & hypoxaemia
FEV
1
decreases 6 8 % per year ( reduced Pulm compliance )
Elastin: collagen ratio--Tracheo-broncheal instability
Small airway obstruction, ( resistance ) Difficult to reopen
Increased WOB, Diffcult to wean off ventilator
N Am Cl Anesth 2000
Jurag Sprung. Can J Anesth 2006
Changes in respiratory mechanics
Barrel shaped chest with Chest wall rigidity, muscle power, flatter diaphragm
Balance between altered compliances & elastic recoil of lungs
intrapleural pressure by 2-4 cms H
2
O
Laplace equation; in diaphragm radius = equal TDP
energy to develop transdiaphragmatic pressure
Changes in respiratory mechanics
Barrel shaped chest with Chest wall rigidity, muscle power, flatter diaphragm
Balance between altered compliances & elastic recoil of lungs
intrapleural pressure by 2-4 cms H
2
O
Laplace equation; in diaphragm radius = equal TDP
Respiratory System
WOB, diaphragm gets easily fatigued - difficult to wean
Maximal inspiratory / expiratory air flow (50%)
Little ventilatory reserves to accommodate
ventilatory demand
Compensated by respiratory rate
exp. flow rate further constraints on RR
WOB, diaphragm gets easily fatigued - difficult to wean
Maximal inspiratory / expiratory air flow (50%)
Little ventilatory reserves to accommodate
ventilatory demand
Compensated by respiratory rate
exp. flow rate further constraints on RR
Jurag Sprung. Can J Anesth 2006
3
Progressive arterial diffusion capacity
Alveolar gas exchange surface area 75 m
2
to 30-50 m
2
VD physiological; VD anatomical (ductectasia)
- impaired oxygenation ( A-a O
2
); PaO
2
4 mm Hg / decade ; 83 mm Hg at 73 yrs
Uneven distribution of inspired gases
Progressive arterial diffusion capacity
Alveolar gas exchange surface area 75 m
2
to 30-50 m
2
VD physiological; VD anatomical (ductectasia)
- impaired oxygenation ( A-a O
2
); PaO
2
4 mm Hg / decade ; 83 mm Hg at 73 yrs
Uneven distribution of inspired gases
Impaired Efficiency of Gas Exchange
early closure of airways
attenuation of HPV, hypocapnoeic bronchoconstriction under GA
Ventilatory response to hypoxaemia, hypercapnia (reduced by 50%)
response to chemical ( opioids,BZD, VA ) & mechanical stress ( airway resist )
Elderly work harder during quiet respiration -- inability to reopen collapsed airways
struggle to adapt to hypoxia -- limited capacity to meet additional needs
early closure of airways
attenuation of HPV, hypocapnoeic bronchoconstriction under GA
Ventilatory response to hypoxaemia, hypercapnia (reduced by 50%)
response to chemical ( opioids,BZD, VA ) & mechanical stress ( airway resist )
Elderly work harder during quiet respiration -- inability to reopen collapsed airways
struggle to adapt to hypoxia -- limited capacity to meet additional needs
Zuagg M et al. Anesth Cl N Am 2000
Anaesthetic management Anaesthetic management
Preoperative: Optimize Respiratory functions
Cessation of smoking: 6 - 8 weeks preoperatively
Pulse oximetry on air / history of snoring SaO
2
< 96%
ABG
Decide if additional testing is required ( PFT X ray )
Preoperative: Optimize Respiratory functions
Cessation of smoking: 6 - 8 weeks preoperatively
Pulse oximetry on air / history of snoring SaO
2
< 96%
ABG
Decide if additional testing is required ( PFT X ray )
Decide if additional testing is required ( PFT, X ray ),
pulmonologist consultation
Optimise markers for PPC ( patient / surgery related),
functional reserves
Structural pulmonary rehabilitation programme /
Forced cough, lung expansion techniques
Decide if additional testing is required ( PFT, X ray ),
pulmonologist consultation
Optimise markers for PPC ( patient / surgery related),
functional reserves
Structural pulmonary rehabilitation programme /
Forced cough, lung expansion techniques
Arozullah AM, Conde MV. Med Clinics N Am 2003
Anaesthetic management Anaesthetic management
Perioperative period
Prevention of perioperative hypoxemia ( FRC VC)
Preoxygenate: 8 VC breaths with 10 L / minute O
2
flow in 60
seconds.
P i di i d i l i i i
Perioperative period
Prevention of perioperative hypoxemia ( FRC VC)
Preoxygenate: 8 VC breaths with 10 L / minute O
2
flow in 60
seconds.
P i di i d i l i i i
Periodic sustained maximal inspiration
Titrate dosages of opioids, anaesthetics and muscle relaxants
Oxygen supply during transportation to PACU & 5 post operative
nights
Incentive spirometry, early ambulation, hydration, normothermia
Bronchodilators, nebulization perioperatively
PO effective multimodal analgesia
IMPROVE LUNG FUNCTIONS, EARLY RECOVERY
Periodic sustained maximal inspiration
Titrate dosages of opioids, anaesthetics and muscle relaxants
Oxygen supply during transportation to PACU & 5 post operative
nights
Incentive spirometry, early ambulation, hydration, normothermia
Bronchodilators, nebulization perioperatively
PO effective multimodal analgesia
IMPROVE LUNG FUNCTIONS, EARLY RECOVERY
Central Nervous System Central Nervous System
CNS dysfunction: Affects cognitive, motor, sensory, autonomic functions
Ageing process & all anaesthetics TARGET brain
Brain size 18% < volume 92 87%
Cortical Gray matter middle age Cerebral Atrophy
Gray : White matter 1:28 (20 yrs); 1:13 (50yrs); 1:55 (100yrs)
CBF 20% parallel selective attrition of neurons
Perioperative risk factors
CNS dysfunction: Affects cognitive, motor, sensory, autonomic functions
Ageing process & all anaesthetics TARGET brain
Brain size 18% < volume 92 87%
Cortical Gray matter middle age Cerebral Atrophy
Gray : White matter 1:28 (20 yrs); 1:13 (50yrs); 1:55 (100yrs)
CBF 20% parallel selective attrition of neurons
Patient: Ageing process, preoperative dementia, increased comorbidities
Surgery: stress, major high risk emergent procedures, sepsis
Cardiac: cerebral perfusion, less pulsatile flow, micro emboli
Orthopedic: fat emboli
Ophthalmology: vision loss
Anaesthesia: hypotension, hypoventilation, hypoxia, high central neural block
Drugs: slowly metabolized (BZD)
Metabolic : hyperglycaemia, hyponatraemia, BUN / Cr >18
Patient: Ageing process, preoperative dementia, increased comorbidities
Surgery: stress, major high risk emergent procedures, sepsis
Cardiac: cerebral perfusion, less pulsatile flow, micro emboli
Orthopedic: fat emboli
Ophthalmology: vision loss
Anaesthesia: hypotension, hypoventilation, hypoxia, high central neural block
Drugs: slowly metabolized (BZD)
Metabolic : hyperglycaemia, hyponatraemia, BUN / Cr >18
Moller JT et al. Lancet 1998
Neubaver et al. J Am Physicians, Surg Con 2005
Postoperative Cognitive Disorders Postoperative Cognitive Disorders
All Anaesthetics target brain
Normal
ageing
MCI Delirium POCD Dementia
Continuum from normal ageing through MCI to Dementia
Delirium: 10-15% of elderly patients after GA
Mild neurocognitive disorder - POCD
Dementia (rare):Multiple cognitive deficits,
Impairment in occupational and social function
Continuum from normal ageing through MCI to Dementia
Delirium: 10-15% of elderly patients after GA
Mild neurocognitive disorder - POCD
Dementia (rare):Multiple cognitive deficits,
Impairment in occupational and social function
Schnider. Anesthesiology 1999
Assessment of cognitive deficit Assessment of cognitive deficit
Diagnosis : Cognitive decline or MCI
Three item recall & draw a clock, AMT, MMSE, SLUMS
14 days before operation, at discharge, at 1- month postoperatively.
Serial testing useful: abrupt decline of 2 or more points
Sensitivity & specificity indicative of Delirium
ABBREVIATED MENTAL TEST:
Age Time to nearest hour
Diagnosis : Cognitive decline or MCI
Three item recall & draw a clock, AMT, MMSE, SLUMS
14 days before operation, at discharge, at 1- month postoperatively.
Serial testing useful: abrupt decline of 2 or more points
Sensitivity & specificity indicative of Delirium
ABBREVIATED MENTAL TEST:
Age Time to nearest hour
Age, Time to nearest hour
Address: to recall at the end of the test
Year, Date of birth
Name of the hospital
Recognise two persons - doctor, nurse, relative
Some event in the history - world war, independence year
Name your President, Prime minister
Count downwards from 20 to 1
Age, Time to nearest hour
Address: to recall at the end of the test
Year, Date of birth
Name of the hospital
Recognise two persons - doctor, nurse, relative
Some event in the history - world war, independence year
Name your President, Prime minister
Count downwards from 20 to 1
Woodford MJ & George J. 2007
4
Pharmacology of Ageing Pharmacology of Ageing
Drug Metabolism
Hepatic mass, blood flow, intrinsic hepatic capacity
Microsomal oxidizing sensitivity activity (Phase I , Phase II spared)
Protein binding (Serum albumin ,
1
acid glycoprotein )
Renal function & blood flow ( GFR parallels Tubular functions )
Reduced renal clearance prolonged drug effects
S tibilit t h l i / h d ti l t l t i b l (N )
Drug Metabolism
Hepatic mass, blood flow, intrinsic hepatic capacity
Microsomal oxidizing sensitivity activity (Phase I , Phase II spared)
Protein binding (Serum albumin ,
1
acid glycoprotein )
Renal function & blood flow ( GFR parallels Tubular functions )
Reduced renal clearance prolonged drug effects
S tibilit t h l i / h d ti l t l t i b l (N ) Susceptibility to hypovolemia / over hydration, electrolyte imbalance (Na)
Creatinine clearance index of renal functions
Altered body composition
Lean body mass - O
2
consumption drug dose
Total body water high peak conc. with bolus /IV infusion
Total body fat - volume of distribution, prolonged effect
Prolonged arm brain circulation time
Duration of drug effect prolonged - dose, frequency
Susceptibility to hypovolemia / over hydration, electrolyte imbalance (Na)
Creatinine clearance index of renal functions
Altered body composition
Lean body mass - O
2
consumption drug dose
Total body water high peak conc. with bolus /IV infusion
Total body fat - volume of distribution, prolonged effect
Prolonged arm brain circulation time
Duration of drug effect prolonged - dose, frequency
More vulnerable to toxic effects of hypnotics & sedatives
Induction agents Instant peak level (V1), slow redistribution
Thiopental : less haemodynamic stability, myocardial contractility
Ketamine : negative lusitropic action
Propofol safe, no adverse effects on diastolic dysfunction
Induction time : Young = old = 40 seconds
More vulnerable to toxic effects of hypnotics & sedatives
Induction agents Instant peak level (V1), slow redistribution
Thiopental : less haemodynamic stability, myocardial contractility
Ketamine : negative lusitropic action
Propofol safe, no adverse effects on diastolic dysfunction
Induction time : Young = old = 40 seconds
g
Dose : young 2-3mg / kg vs old 1mg / kg
Emergence: < 6 min vs > 10 min MAC at 70 yrs
BP: , 100 mm Hg (50%; <80 mm Hg (10%)
Nadir (1/2 time): 5-7 min vs 10 min
Opioids, benzodiazepines : Reduced dosages
fat sol (V3), brain sensitivity
hepatic clearance, protein binding
Remifintanil > fentanyl ( twice potent in elderl y )
BZD safe no adverse effect on diastolic dysfunction
g
Dose : young 2-3mg / kg vs old 1mg / kg
Emergence: < 6 min vs > 10 min MAC at 70 yrs
BP: , 100 mm Hg (50%; <80 mm Hg (10%)
Nadir (1/2 time): 5-7 min vs 10 min
Opioids, benzodiazepines : Reduced dosages
fat sol (V3), brain sensitivity
hepatic clearance, protein binding
Remifintanil > fentanyl ( twice potent in elderl y )
BZD safe no adverse effect on diastolic dysfunction Habib. Br J Anaesthe2002;88:430
Schnider: Anaesthesiology1999;90:1502
6
8
10
1 yr
Inhalational Agents: MAC 4% - 6% per decade
Halo, Iso, Sevo, Des 15-20% in O2; 20-30% in 60% N2O
Neuromuscular blocking agent
Longer duration of action (no change in effect)
Advanced age, drug metabolism
0
2
4
6
Isofl urane Sevofl urane Desflurane
1 yr
40 yr
80 yr
Nicholis et al. Br J Anaesth 2003; 91:170
Intraop hypothermia, DM, obesity
Succinyl choline - dose (pseudocholinesterase)
Atracurium - alternate pathway of metabolism
Rocuronium > Vecuronium >> Pancuronium
reduced receptor sensitivity, altered pharmacokinetics & excretion
Cis atracurium ester hydrolysis, [Cisatracurium > rocuronium if renal insufficiency]
Glycoryrrolate ( BBB) > Atropine
Preoperative Evaluation Stratification Preoperative Evaluation Stratification
Informed consent
Comprehensive Geriatric Assessment (CGA):
Preoperative assessment to identify adverse PO cardiac outcome
AHA task force / ACC guidelines (eight stepwise analysis - 2006)
Preoperative evaluation for PPCs: multifactorial risk index
Informed consent
Comprehensive Geriatric Assessment (CGA):
Preoperative assessment to identify adverse PO cardiac outcome
AHA task force / ACC guidelines (eight stepwise analysis - 2006)
Preoperative evaluation for PPCs: multifactorial risk index
Arozullah AM. Med Clin N Am 2003
Functional status 1-4 METs, Barthel index for ADL, BMI < 20 kg/m
2
Nutritional assessment S. albumin, Hb conc, S cholesterol
Cognitive status assessment MMSE, SLUMS, MCI, dementia
RED FLAGS to Reschedule elective surgery: to modify CVS risk: New symptoms;
Physical findings or New abnormalities in ECG, BNP levels; Increased Sr Creatinine levels
Preoperative testing if alteration in surgical plan is indicated or for invasive monitoring .
Arozullah AM. Med Clin N Am 2003
Functional status 1-4 METs, Barthel index for ADL, BMI < 20 kg/m
2
Nutritional assessment S. albumin, Hb conc, S cholesterol
Cognitive status assessment MMSE, SLUMS, MCI, dementia
RED FLAGS to Reschedule elective surgery: to modify CVS risk: New symptoms;
Physical findings or New abnormalities in ECG, BNP levels; Increased Sr Creatinine levels
Preoperative testing if alteration in surgical plan is indicated or for invasive monitoring .
General Anaesthesia General Anaesthesia
Reduced anaesthetic consumption:
Depletion in neurotransmitters, reduced neuronal density,
reduced innervation of skeletal muscles
Increased risk for IV anaesthetic agents:
Reduced Cardiac Index ( increased induction time) &
Reduced baroreflex response ( reduced compensatory tachycardia)
Reduced anaesthetic consumption:
Depletion in neurotransmitters, reduced neuronal density,
reduced innervation of skeletal muscles
Increased risk for IV anaesthetic agents:
Reduced Cardiac Index ( increased induction time) &
Reduced baroreflex response ( reduced compensatory tachycardia)
Overdosing of inhaled anaesthetics:
Discrepency between tele-expiratory & plasma concentration due to reduced alveolar
exchange & alteration of MAC values
Final action & increased side effects: Changes in
Pharmacokinetics ( reduced HBF,RBF, TB water) &
Pharmacodynamics ( increased sensitivity to CNS depressant agents),
Reduction in MAC with age by 4-6% per decade )
General anaesthesia better in severe CV disease if tight BP control is required
Overdosing of inhaled anaesthetics:
Discrepency between tele-expiratory & plasma concentration due to reduced alveolar
exchange & alteration of MAC values
Final action & increased side effects: Changes in
Pharmacokinetics ( reduced HBF,RBF, TB water) &
Pharmacodynamics ( increased sensitivity to CNS depressant agents),
Reduction in MAC with age by 4-6% per decade )
General anaesthesia better in severe CV disease if tight BP control is required
Regional Vs General Anaesthesia Regional Vs General Anaesthesia
Regional anaesthesia : (Anticipate increased sensitivity ). Reduce dosages by 40%
Wider block extension with greater diffusion of LAs:
Hyperbaric solution becomes less hyberbaric : Reduced latency time & CSF volume with
increased density
Demyelinization of nervous fibres
Hypotension & bradycardia: Age-related CVS alterations, Impaired Autonomic function,
Reduced compliance of arterial tree.
Regional anaesthesia : (Anticipate increased sensitivity ). Reduce dosages by 40%
Wider block extension with greater diffusion of LAs:
Hyperbaric solution becomes less hyberbaric : Reduced latency time & CSF volume with
increased density
Demyelinization of nervous fibres
Hypotension & bradycardia: Age-related CVS alterations, Impaired Autonomic function,
Reduced compliance of arterial tree.
p
Advantages
Deep vein thrombosis, stress of surgery & Decreased 1month mortality
the odds of pulmonary thrombo-embolism
Pulmonary (aspiration), Cardiac ( ischaemia ),improved GI outcome
Early detection of any mental status changes
Need for PO sedation and / or analgesics
Combination of regional analgesia & general anaesthesia preferred - PPCs
Roy RC ASA, 2006; Vol 34
p
Advantages
Deep vein thrombosis, stress of surgery & Decreased 1month mortality
the odds of pulmonary thrombo-embolism
Pulmonary (aspiration), Cardiac ( ischaemia ),improved GI outcome
Early detection of any mental status changes
Need for PO sedation and / or analgesics
Combination of regional analgesia & general anaesthesia preferred - PPCs
Roy RC ASA, 2006; Vol 34
5
Elderly Patient & Daycare Surgery Elderly Patient & Daycare Surgery
Benefits
Surgical procedures: Minimum Invasive Surgery and Fast-track Anaesthesia
Decreased impact on the patient and family / Reduced cost of healthcare
Benefits
Surgical procedures: Minimum Invasive Surgery and Fast-track Anaesthesia
Decreased impact on the patient and family / Reduced cost of healthcare
Decreased risk of hospital infection in patients with decreased or compromised
immune defense
Brevity of hospital stay- early re-assumption of active mobility
Decreased risk of postoperative disorders
Availability of bed for more needy serious patients
Decreased risk of hospital infection in patients with decreased or compromised
immune defense
Brevity of hospital stay- early re-assumption of active mobility
Decreased risk of postoperative disorders
Availability of bed for more needy serious patients
Elderly Patient & Daycare Surgery Elderly Patient & Daycare Surgery
Challenges: Comprehensive Geriatric assessment to evaluate degree of Frailty
Biological age more important: chronological age in fitness for Daycare
procedures Heterogeneity mandates individualised & thoughtful approach
Pre-operative assessment should focus on: Surgical risk for Cardiac events,
Functional status as judged by ADL (METs), Risk indices
Challenges: Comprehensive Geriatric assessment to evaluate degree of Frailty
Biological age more important: chronological age in fitness for Daycare
procedures Heterogeneity mandates individualised & thoughtful approach
Pre-operative assessment should focus on: Surgical risk for Cardiac events,
Functional status as judged by ADL (METs), Risk indices
Systemic diseases ( Cardiac insufficiency, COPD, Uncontrolled DM)
Pre-operative laboratory testing is of little value: do not predict outcome
Monitored Anaesthesia Care: Risk of unintentional GA & Cognitive disorders
under Propofol-based sedation due to limited physiologic reserves & reduced
ventilatory response to hypoxia and hypercarbia
Patient selection criteria: ASA Gr III or IV
Systemic diseases ( Cardiac insufficiency, COPD, Uncontrolled DM)
Pre-operative laboratory testing is of little value: do not predict outcome
Monitored Anaesthesia Care: Risk of unintentional GA & Cognitive disorders
under Propofol-based sedation due to limited physiologic reserves & reduced
ventilatory response to hypoxia and hypercarbia
Patient selection criteria: ASA Gr III or IV
Recommendations for anaesthetic management
of elderly patients undergoing major surgery
Identify high risk patients
Clinical examination, functional status, MET value, nutrition, cognitive dysfunction
Twelve lead ECG, urine analysis, X- Ray chest, random blood sugar
Cardio-Pulmonary exercise testing & Preoperative resting echocardiography
Preoperative optimization
Identify high risk patients
Clinical examination, functional status, MET value, nutrition, cognitive dysfunction
Twelve lead ECG, urine analysis, X- Ray chest, random blood sugar
Cardio-Pulmonary exercise testing & Preoperative resting echocardiography
Preoperative optimization
p p
Effective control of co-existing diseases: CVS, Respiratory, Diabetes Mellitus
Haemodynamic stability : -blockers, antihypertensives, fluid balance,
Anti aspiration prophylaxis, anti DVT prophylaxis, antibiotic therapy
Air way assessment & preparedness, care during Positioning
Correct nutritional status
Minimise intraoperative sympathetic stimulation
-blockers, opioids lignocaine, dexmeditomidine
Supraglottic devices, regional anaesthesia techniques
p p
Effective control of co-existing diseases: CVS, Respiratory, Diabetes Mellitus
Haemodynamic stability : -blockers, antihypertensives, fluid balance,
Anti aspiration prophylaxis, anti DVT prophylaxis, antibiotic therapy
Air way assessment & preparedness, care during Positioning
Correct nutritional status
Minimise intraoperative sympathetic stimulation
-blockers, opioids lignocaine, dexmeditomidine
Supraglottic devices, regional anaesthesia techniques
Plan quick emergence
Prefer short acting anaesthetics agents
Combine neuraxial blocks with GA (abdomino- thoracic surgery)
Titrate dosages of induction agents and muscle relaxants
Measures to reduce post operative delirium
Consider Pharmacokinetics, Pharmacodynamics & MAC values
Monitoring
Plan quick emergence
Prefer short acting anaesthetics agents
Combine neuraxial blocks with GA (abdomino- thoracic surgery)
Titrate dosages of induction agents and muscle relaxants
Measures to reduce post operative delirium
Consider Pharmacokinetics, Pharmacodynamics & MAC values
Monitoring
Monitoring
SaO
2
, EtCO2, NIBP / IBP, CVP, ECG, temperature, BIS monitor,
NM monitoring
Fluid balance ( Urine output )
Postoperative period
Avoid hypoxaemia supplement oxygen
During transportation to PACU & for 3-5 postoperative nights
Prevent hypothermia & shivering
Plan early ambulation, incentive spirometry
Effective multimodal analgesia: Improve lung functions, Early recovery
Monitoring
SaO
2
, EtCO2, NIBP / IBP, CVP, ECG, temperature, BIS monitor,
NM monitoring
Fluid balance ( Urine output )
Postoperative period
Avoid hypoxaemia supplement oxygen
During transportation to PACU & for 3-5 postoperative nights
Prevent hypothermia & shivering
Plan early ambulation, incentive spirometry
Effective multimodal analgesia: Improve lung functions, Early recovery
Postoperative Complications Postoperative Complications
Delayed Arousal
Postoperative Delirium - self limiting
Dexmeditomidine sedation ; pain management
Post operative myocardial infarction
Early : Vulnerable plaque / Late : prolonged ischaemia
Delayed Arousal
Postoperative Delirium - self limiting
Dexmeditomidine sedation ; pain management
Post operative myocardial infarction
Early : Vulnerable plaque / Late : prolonged ischaemia
y p q p g
Diagnosis: ST segment changes / cTnl serial monitoring
Postoperative Hypothermia
Frequent and prolonged, poikilothermic
Avoid shivering ( O
2
demand 300-800%)
Postoperative pain with cardio respiratory dysfunctions
Hypoxia, Hypoxaemia sp. In major thoraco-abdominal surgery.
Postoperative cognitive dysfunction
y p q p g
Diagnosis: ST segment changes / cTnl serial monitoring
Postoperative Hypothermia
Frequent and prolonged, poikilothermic
Avoid shivering ( O
2
demand 300-800%)
Postoperative pain with cardio respiratory dysfunctions
Hypoxia, Hypoxaemia sp. In major thoraco-abdominal surgery.
Postoperative cognitive dysfunction
Conclusion Conclusion
Geriatric population globally increasing
Exposure to various surgical interventions
Role as Geriatric Anaesthesiologists
Age per se is not a barrier to surgery. Ageing changes alters the bodys capacity to
Geriatric population globally increasing
Exposure to various surgical interventions
Role as Geriatric Anaesthesiologists
Age per se is not a barrier to surgery. Ageing changes alters the bodys capacity to
cope with the stress of surgery / anaesthesia
Preoperative assessment, optimization & judicious use of drugs is essential
No single anaesthetic technique recommended,
Peri- operative care, minimise postoperative complications sp cognitive deficit
Precision monitoring needed
cope with the stress of surgery / anaesthesia
Preoperative assessment, optimization & judicious use of drugs is essential
No single anaesthetic technique recommended,
Peri- operative care, minimise postoperative complications sp cognitive deficit
Precision monitoring needed
6
MILD COGNITIVE IMPAIRMENT TO DEMENTIA
Postoperative Effects on CNS
Prof.A. K. Prof.A. K. Sethis SethisEORCAPS EORCAPS- -2013 2013 Prof.A. K. Prof.A. K. Sethis SethisEORCAPS EORCAPS- -2013 2013
Superman in his later years
1
Anaesthetic Considerations
&
Case Management
Prof. A. K. Sethi, Dr. Mona Lisa
The Patient
Nitish, 19 yr, Male, Maujpur
Deviation of right eye for 16 yr
Loss of vision - right eye x 16 yr
Trauma by wooden object profuse lacrimation, redness
Gradual loss of vision, Deviation
Advised surgery after 18 years of age
Relevant Present History
Headache and eye-ache after prolonged working on computer
No H/O - Diplopia
- Confusion or blurring of words
- Photophobia
- Head tilt
- Refractive error or use of glasses
- Alternating or intermittent squint
No H/O - Motion sickness or vertigo
- Weakness or drooping of eyelids by evening
Direct head trauma
CNS infection (meningitis, encephalitis)
CNS Surgery (ICSOL)
Past History
No H/O
Influenza or Measles in childhood
Prematurity or respiratory distress at birth
Muscle weakness or myopathy
Endocrine disorder
Past history
N H/ TB Di b t llit Ht A th J di S i
Increase predisposition to OCR
(Rogers Principles &Practice of Anesthesiology)
Anaesthetic exposure in the past
Black outs, Sudden Unconsciousness s/o AV block,
Vaso-vagal episodes
-blocker therapy
MH
No H/o TB, Diabetes mellitus, Ht, Asthma, Jaundice, Seizures
Pain chest, Palpitations, Dyspnoea, Cough or expectoration
Smoking, Alcohol intake, Allergy, Bleeding disorder
Family history
No H/o similar complaint in the family
No H/o anaestheticexposure in the past and anything
suggestive of development of MH
General Examination
Average built young man, oriented to TPP
Afebrile. HR 72 / min. Right Radial, regular good volume
BP 110 / 70 mmHg, Right Brachial, Supine
RR 14 / min
No pallor, icterus, cyanosis, pedal edema, lymphadenopathy
JVP not raised
S i E i i Systemic Examination
Chest - Clear, Equal B/L air entry, Normal BS, No added sounds
CVS - S1 S2 Normal, No accompaniments
P/A - Soft, No Organomegaly, Non tender
CNS - Spine normal,
2
Specific Examination of Airway
There is no obvious cause for difficult airway.
General and Rapid assessment of airway revealed no difficulties
1. Cooperation by patient
2. Natural airway
3. Bag Mask ventilation
4 Laryngoscopy
7. Use of alternate airway
devices like supraglottic
devices , esophageal
tracheal devices
4. Laryngoscopy
5. Endotracheal intubation
6. Emergency surgical
airway
8. Risk of pulmonary
aspiration
9. During/after removal of
airway maintenance device
10. Institution of L.A. in upper
airway & trachea
Ophthalmic examination
Head position - No head tilt, abnormal posturing of head
Eyebrows, Eyelids, Sclera, Cornea - Normal
Inspection - Outward deviation of Right Globe
Pupils : B/L NSNR (Direct and Consensual reaction)
Lens : No Lenticular opacity Lens : No Lenticular opacity
Bedside examination for Squint
Hirschberg Corneal reflex test :
-Centre of pupil : (L) Eye
-Pupillary margin : (R) Eye
Cover test :
- (R) Inward deviation ( )
- (L) No deviation
Alternate Cover test :
- No evidence of latent squint
Cover Uncover test :
- No evidence of intermittent or
alternating squint
Hirschberg Corneal Reflex Test
0
15
30
45
Bedside examination for Squint
Hirschberg Corneal reflex test :
-Centre of pupil : (L) Eye
-Pupillary margin : (R) Eye
Cover test :
- (R) Inward deviation
(L) No deviation - (L) No deviation
Alternate Cover test :
- No evidence of latent squint
Cover Uncover test :
- No evidence of intermittent or
alternating squint
Visual acuity
Perception of light
(R) Eye - 3 m
(L) Eye - (6/18)
Squint/Strabismus with Right Amblyopia
with Right Concomitant Exotropiawith 15 degree deviation in
a 19 r old male
Presumptive Diagnosis
a 19 yr old male.
Amisalignment of visual axes of the two eyes
that cannot be voluntarily corrected
3
Achieve good cosmetic correction
Improve visual acuity
Maintain binocular single vision
Spectacles with full correction of refractive error
Occlusion therapy
Preoperative orthoptic exercises
Strabismus surgery
Strengthening the weak muscle :
Resection
Tucking or plication
Advancement
To correct ocular misalignment by :
Advancement
Weakening the strong muscle :
Recession
Marginal myotomy
Myectomy
Transposing the muscles
Oculo-cardiac reflex
Oculo-respiratory reflex
Postoperative nausea and vomitingOculoemetic reflex ?
Systemic effects of ophthalmic drugs (Squint)
Malignant hyperthermia
Association with syndromes - Aperts, Crouzons, Pfeiffer
Systemic effects of Ophthalmic drugs
Phospholineiodide
Used for Intermittent & Fluctuating Squint
Inhibits pseudocholinesterase
Prolongs action of drugs e.g., Succinylcholine
Phenylephrine
Mydriasis, Haemostasis
Hypertension, Tachycardia
Cyclopentolate, Tropicamide
Mydriasiswithout above S/E
Acetylcholine
Miosisafter lens extraction
Bradycardia, bronchospasm, bronchial secretions
Cocaine
Vasoconstriction nasal packing in DCR p g
Sympathetic system activation
Timolol, Betaxolol
Glaucoma
Sinus bradycardia, Asthma crisis
General and Regional
GAusing Muscle Relaxants RA
Akinesia & Anesthesia Good Good
Surgical conditions Excellent Excellent Surgical conditions Excellent Excellent
Oculo-respiratory reflex IPPV obtunds this problem Reported
Oculo-cardiac reflex Less (Normocapnia) Reported
Better control Airway, CVS -
4
1. Forced Duction Test difficult to perform and interpret
2. Precipitate Malignant Hyperthermia
Di ti i h l ti i t d h i l t i ti f Distinguish paralytic squint and mechanical restriction of
movements (Graves disease)
Surgeon grasps sclera near limbusand tests for full range of
movements in all quadrants
FDT under General anesthesia
Wait 15-20 minutes following administration of succinylcholine
Non depolarising muscle relaxants
Intubate and maintain on deep inhalational anaesthetic till FDT.
Then institute NM blockade
Preoperative orders
Consent
NPO after midnight
Tab Diazepam 5 mg orally HS & 5 mg orally in morning
Tab Ranitidine 150 mg orally HS & 150 mg orally in morning
Anaesthetic plan Anaesthetic plan
Checking Anesthesia machine with pre-checkprotocol
Peripheral intravenous access - 20 G IVcannula, Ringer Lactate
Routine Monitors - ECG, Pulse oximeter, NIBP
Special Monitors - Temperature, End tidal CO2
Induction and Maintenance
Inj. Ketorolac 30 mg, IV, Slow
Inj. Propofol 110 mg IV (2-2.5 mg/kg)
Inj. Atropine
Inj. Lignocaine 80 mg IV (1.5-2.0 mg/kg)
Miller 7
th
ed Miller 6
th
ed Barash6
th
ed
j g g ( g g)
Inj. Rocuronium 50 mg IV (0.6-1.0 mg/kg)
1 min gentle IPPV, 02 + Isoflurane, Bain Circuit, Mask,
RAE Chin directed ETT, 7.5 ID
Securing ETT firmly using Double Adhesive tape
All connectors tightened properly
Trigeminal-Vagal reflex responsethat is manifested as cardiac
arrhythmias & hypotension
and
Bernard Aschner & Giuseppe Dagnini, 1908
may be elicited by
pain, pressure or manipulation of eyeballs
Miller 7
th
ed
Afferent Limb
Long and short Ciliarynerves (Trigeminal nerve, V
th
)
CiliaryGanglion
GasserianGanglion
Efferent limb
Impulses from Brain Stem via Vagusnerve
Miller 7
th
ed
Heart
5
1. Pressure on the globe
2. Traction - EO muscles, Conjunctiva or other orbital structures
3. Ocular trauma or Retrobulbar haematoma
4. Performing Retrobulbar block - LA- injection in or around eye
5. Ocular manipulations including Stretching of eyelids
6. Ocular pain
7. Manipulation of tissue in the orbital apex after enucleation
Medial Rectus
Manipulated most often
Less accessible and requires more force for exposure
Attachment : Pain sensitive Meninges around Optic nerve Attachment : Pain-sensitive Meninges around Optic nerve
Manifestations
Arrhythmias
Sinus bradycardia
Junctional rhythm
E t i t i l h th
Multi-focal PVCs
Wandering pacemaker
Idi t i l h th Ectopic atrial rhythm
AV block
Ventricular bigeminy
Idioventricular rhythm
Ventricular tachycardia
Asystole
Prevention of OCR
1. Gentle surgical manipulation
2. Maintenance of adequate depth of anesthesia
3. Maintenance of Normocapnia, Normoxemia, Normal pH
4 I t ti h li i At i 002 /k 4. Intravenous anticholinergics: Atropine 0.02 mg/kg
Glycopyrrolate 0.01 mg/kg
(Single dose protects against OCR for about 30 minutes)
5. Retrobulbar block ?
6. Prompt detection - Continuous ECG monitoring
Treatment of OCR
1. Stop surgical manipulation immediately
2. Assess ventilatory status normocapnia& no hypoxemia
3. Optimize depth of anesthesia
Returns to (N) within 20 s ( )
If arrhythmia is serious or persists :
Inj Atropine 0.007 mg/kg incremental dose
Inj Lignocaine1.5-2.0 mg/kg (ventricular arrhythmia)
Oculo-Respiratory Reflex
Oculo-Emetic Reflex Oculo Emetic Reflex
Van den Berg et al, Anaesthesia44, 1989
(Oculo Kinetic Reflex)
British Ophthalmic AnaesthesiaSociety, News Letter 5, Oct 2001
6
Afferent Limb
Long and Short Ciliary nerves
Oculo-Respiratory Reflex
Petzetakis 1915
Shallow breathing, Bradypnoea, Respiratory arrest
Efferent limb
Pneumotaxic Centre in Pons & Medullary Respiratory Centre
Ciliary Ganglion
Trigeminal Sensory Nucleus
Oculo Kinetic Reflex
British Ophthalmic Anaesthesia Society, News Letter 5, Oct 2001
Positional
information from
vestibular
apparatus
Sensory input
from visual
apparatus
Nausea & Vomiting
apparatus pp
Conflict in CNS
processing
Impulses from Extra-Ocular muscles
Vestibular nuclei III, IV, V
MLF in brainstem reticular formation
OculoKinetic Reflex
Close proximity to vomiting centre
EO traction stimulates & causes Nausea & Vomiting
PONV x 2.6
Aspirate gastric contents with Ryles tube
Ringer Lactate - 4 : 2 : 1 formula
Hourly requirement = 95 ml/hr (40+20+35 = 95)
Deficit = 95 x 9 hr (fasting) = 855 ml (Say 860)
of 860 ml in1
st
hour = 430 ml + 95 ml + 275 ml = 800 ml
Anaesthesia Contd.
of 860 ml in1 hour 430 ml 95 ml 275 ml 800 ml
(Incidence : 40 88 %)
PONV prophylaxis - 30 min before end of the surgery
Inj. Ondansetron 5.0 mg (0.1 mg/kg), IV
Inj. Dexamethasone 6.0 mg (0.15 mg/kg)
Inj. Droperidol : 75 g/kg
Extra pyramidal signs
Tremors
Restlessness
Drowsiness in post operative period
Inj. Metoclopramide : 0.15 mg/kg
Extra pyramidal signs
Drowsiness, Dystonia, Nausea
Hypertension, Hypotension
Arrhythmias
PONV prophylaxis
Minimal use of opioids in Peri-operative period
Induction with Propofol
Low dose Propofol (1020 mg) with potent volatile anaesthetic
Decrease or avoid use of nitrous oxide, Use of TIVA
Oro-gastric tube aspiration after induction
Gentle surgical manipulation of eye muscles
Maintenance of adequate hydration with IV crystalloids
Sub-Tenons block before closure of Conjunctiva
7
Limbal incision
Post operative analgesia
Pain score 2-4
Inj. Ketorolac(0.5 mg/kg)
Limbal incision
More painful, uncomfortable for patient
Fornix incision
More comfortable Patient
Post operative recovery area
Reversal
Neostigmine, Glycopyrrolate/Atropine
Oxygen
Watch out for OCR, ORR, PONV
Monitor for 3 hrs
In very cooperative patients,
Temporary positioning of muscle using adjustable sutures
Measurements retaken
Muscles placed in optimum position to properly align eyes
Th l ti d d
Adjustable or Variable Suture technique
Then securely tied down
Reduces the frequency of Re-operations
by eliminating post operative under correction or over correction
thus increasing the rate of surgical success
Intra-operative Manifestations of MH
Unexplained Tachycardia
Rapid rise in temperature > 2 C / hr
Muscle rigidity, Masseter spasm
Dysrrhythmias
Rhabdomyolysis
Metabolic Acidosis
Hypercarbia, Hyperkalemia
Thiopentone - Divergence of eyeballs
(Exotropicbecome moreoutward, Esotropicstraighter)
Effect of Anaesthetic Agents on Position of Eye Ball
NDMR - Divergence of eyeballs
Succinylcholine - Convergence
Twitch and Tonic contraction Neuromuscular
systems (Katz & Eakins, 1967)
Twitch system
Small regular & well defined fibrils produce twitches &
fast propagated muscle potentials when stimulated
Tonic system
Large irregular & poorly defined fibrils
Slow and graded muscle contractions when stimulated
Succinylcholinedepresses twitch & activates tonic system
- contracture of extrinsic muscles
Thiopentone& NDMRs depress both the twitch & tonic system
8
(1) Regional Anaesthesia
Methods, Advantages, Disadvantage, Complications etc.
Retrobulbar block
Peribulbar block
Sub-Tenons block
Other related Questions that can also be asked
(2) Ketamine
Suitability
Controversies
(3) Open globe, Anaesthesiaand IOP
Whats new ?
DTFNBA - Deep Topical Fornix Nerve Block Anaesthesia -
excellent resultsespeciallyfor adjustablesuturesurgery(BJA2002)
Sevoflurane reduces the incidence of OCR and ORR by 60%
whencomparedtoHalothane.
FlexibleLMAshavealsobeenusedfor squint surgeries.
1
TestingAnaesthesiaMachines
Prof.AnjaliKochhar
Aims
Todecreaseequipmentrelatedmorbidityand
mortality
Improvepreventivemaintenance
b i Knowmoreaboutequipment
AnaesthesiaMachinesTesting
Whentodo
Completecheckout
Eachdaybeforeadministratinganaesthesiatothefirst
patient
Wheneveranaesthesiamachineismovedtonew
location(EveninthesameOR)
Wheneverachangeismadeinthesysteme.g.
Ventilatorbellows
Anaesthesiacircuits
Changingabsorbent
Briefcheckout
Beforeeachcase
Whowilldo
Anaesthesiaprovider
AnaesthesiaproviderorTechnician
AnaesthesiaproviderandTechnician
Howtodo
FDAAnaesthesiaapparatuscheckout
recommendations,1986 24Steps
ModifiedFDAAnaesthesiaapparatuscheckout
recommendations 1993 18 Steps recommendations,1993 18Steps
Moreuserfriendly
ASA2008Guidelinesforpreanaesthesia
checkoutprocedures 15Steps
Principlebased
Safedeliveryofanaesthesiacare
Reliabledeliveryofoxygen
Reliablemeansofpositivepressureventilation
Backupventilationequipment
Controlled release of Positive pressure from ControlledreleaseofPositivepressurefrom
thebreathingcircuit
Anaesthesiavapourdelivery
Adequatesuction
Meansforstandardpatientmonitoring
2
Tobecompleteddaily
Itemstobecompleted Responsible
party
Item#1:VerifyAuxillary oxygencylinderandselfinflating
Manualventilationdeviceareavailableandfunctioning
Providerand
Technician
Item#2:Verifypatientsuctionisadequatetocleartheairway Providerand
Technician
Item#3:TurnonanaesthesiadeliverysystemandconfirmAC
power
Provideror
Technician
Item#4:Verifyavailabilityofrequiredmonitorsandcheckalarms Provideror
Technician
Item#5:VerifyadequatepressureonthespareOxygencylinder
mountedonanaesthesiamachine
Providerand
Technician
Item#6:Verifypipedgaspressures Providerand
Technician
Item#7:Verifyadequatelyfilledvaporizers Provideror
Technician
party
Item#8:Verifynogasleaksbetweentheflowmetersandthe
commongasoutlet(LPC)
Provideror
Technician
Item#9:TestScavanging systemfunction Provideror
Technician
Item#10:CalibrateorverifycalibrationoftheOxygenmonitorand
checkthelowOxygenalarm
Provideror
Technician
Item#11:VerifyCarbonDioxideabsorbentisnotexhausted Provideror
Technician
Item#12:Breathingsystempressureandleaktesting Providerand
Technician
Item#13:Verifythatgasflowsproperlythroughthebreathing
circuitduringbothinspirationandexhalation
Providerand
Technician
Item#14:Documentcompletionofcheckoutprocedures Providerand
Technician
Item#15:Confirmventilatorsettingsandevaluatereadinessto
deliveranesthesia care
Provider
Beforeeachuse
party
Item#2:Verifypatientsuctionisadequatetocleartheairway Providerand
Technician
Item#4:Verifyavailabilityofrequiredmonitorsincludingalarms Provideror
Technician
Item#7:Verify thatVaporizersareadequatelyfilledandif
applicablethatthefillerportsaretightlyclosed
Provideror
Techician pp p g y
Item#11:VerifyCarbonDioxideabsorbentisnotexhausted Provideror
Technician
Item#12:Breathingsystempressureandleaktesting Providerand
Technician
Item#13:Verifythatgasflowsproperlythroughthebreathing
circuitduringbothinspirationandexhalation
Providerand
Technician
Item#14:Documentcompletionofcheckoutprocedures Providerand
Technician
Item#15:Confirmventilatorsettingsandevaluatereadinessto
deliveranesthesia care
Provider
PreAnaesthesiaCheckout(PAC)
Item1Verifyauxiliaryoxygencylinderandself
inflatingmanualventilationdeviceare
availableandfunctioning
Cylinder regulator Cylinderregulator
Keys
Resuscitationbag
Inspection
Testinspiratoryandexpiratorypaths
Placeareservoirbagtopt port,
b i b h ld fill squeezebagreservoirbagshouldfill
onreleasing reservoirbagshoulddeflate
Resuscitationbag
Inspiration Expiration
3
Resuscitationbag
Checkingclosedreservoir
Performseveralcompressionsandreleasecycles
withoutO2 intoreservoir
Reservoir should deflate but resuscitation bag Reservoirshoulddeflatebutresuscitationbag
shouldcontinuetoinflate
Resuscitationbag
Oxygenflow ON Oxygenflow OFF
PAC
Item2 Verifypatientsuctionisadequateto
cleartheairway
Adequatepressure
Ensure availability of a rigid suction catheter Ensureavailabilityofarigidsuctioncatheter
(Yankauer)
Suctioncatheters
PAC
Item3 Turnon
anaesthesiadelivery
systemandconfirmAC
power
Visualindicators
PAC
Item3 Turnon
anaesthesiadelivery
systemandconfirmAC
power
Visualindicators
4
PAC
Item4 Verifyavailabilityofrequiredmonitors
andcheckalarms
Standardsformonitoring
Capnography Capnography
Pulseoximetry
NIBP
ECG
Temperature
PAC
Monitors
Availability
Selftests
Audible and visual alarms Audibleandvisualalarms
Settingofalarmlimits
Verifyproperfunctioningofpulseoximetry and
capnography beforeinduction
PulseOximetry
Capnography
PAC
Item5 Verifyadequatepressureonthespare
Oxygencylindermountedonanaesthesia
machine
at least 1000 psi atleast1000psi
properlymounted
Closethevalve
Checkothercylinders(N2O,Air,CO2,Heliox) if
required
CylinderPressure
5
PAC
Item6 Verifypipedgaspressures
50psi
PAC
Item7 Verify
adequatelyfilled
vaporizers
Ensuretightlyclosefiller
ports
Highandlow
anaestheticagentalarms
Beforeeachuse
PAC
Item8 Verifynogasleaksbetweentheflow
metersandthecommongasoutlet(LPC)
Commonsourceofleaks
Positive pressure leak test Positivepressureleaktest
Negativepressureleaktest
Turnoneachvaporizerandrepeat
LPCLeakTests
Oxygenflushtest
Pressuregaugetest
CGOocclusiontest
Traditional positive pressure leak test Traditionalpositivepressureleaktest
Drager positivepressureleaktest
DatexOhmeda
internalpositivepressureleaktest
1993FDAUniversalnegativepressureleaktests
6
Check valve closes Checkvalvecloses
O2Flush
IPPV
Positivepressure
leaktest
GEDatex Ohmeda machines
ModulusI
ModulusII
Excel
OutletCheckvalvepresent
Aestiva
Drager Narkomed 2
Narkomed 3
Narkomed 4
Narkomed GS
Out et C ec a e p ese t
Nooutletcheckvalve
Universalleaktest
Turnoffmasterswitch,flowcontrolvalves&
vaporizers
AttachsuctionbulbtoCGOandsqueeze
repeatedlytillitcollapses
Itshouldremaincollapsedforatleast10secs
Ifbulbreinflates within10secs leakispresent
TurnONeachVAPORIZERindividuallyand
REPEAT
CGO
7
Advantages
Quickandsimpletoperform
Applicabletoallmachines(Universal)
Differentiates leaks in the LPC and breathing DifferentiatesleaksintheLPCandbreathing
circuit
Mostsensitiveofallleaktests(<30ml/min)
Positivepressureleaktests
Pressuregaugetest
AttachmanometertoCGO
TurnonO2 ,Mercurycolumnrises
Decrease flow to maintain 22 mmHg (30 cmH2O ) Decreaseflowtomaintain22mmHg(30cmH2O)
pressure
AtthispressureminimumpermissibleleakinLPC
=50ml/min
SwitchoffO2
Pressuredecreasesto15mminnot<10secs
Pressuregaugetest
Pressuregaugetest
Limitations
Cannotbeperformed
inmachineshaving
minimum mandatory minimummandatory
flow(Basalflow)
PAC
Item9 TestScavenging
system
Connections
Vacuumlevel
Pressurereliefvalves
8
Scavengingsystem
Negativepressurerelief
Withminimum/noflow
OpenAPLvalveand
occludept port
TurnONscavenging
suction
Breathingsystempressure
0to2cmH2O
Positivepressurerelief
Activateoxygenflush
Breathingsystempressure
<10cmH2O
PAC
Item10 Calibrateor
verifycalibrationofthe
Oxygenmonitorand
checkthelowOxygen
alarm alarm
Lastlineofdefence
ChecksintegrityofLPCin
ongoingfashion
21%onroomair
>90%onOxygen
Selftest/oncedaily
Oxygenmonitor
PAC
Item11 VerifyCO2absorbentisnotexhausted
Beforeeachuse
Colourchange
Capnography Capnography
Item12 Breathingsystempressureandleak
testing
Beforeeachuse
Leaktest
Flowtest
Circlesystemtests
Leaktest(Highpressuretest)
Closepopoffvalve
OccludeYpiece
OxygenflushON
Pressurizingthecircuitto30cmH2O
Pressurewillnotdeclineifsystemisleakfree
Highpressureleaktest
Photo
9
Combinedleaktests
(LPCandCirclesystem)
Squeezebulbtest
Turnallgasesandvaporizersoff
AttachmanometertoPts endofcircuit
Replacebagwithbulbandpressurizesystem
tillgaugereads37mmHgandstop
Pressuredecreasesto22mmHgin<30secs
significantleakpresent
Squeezebulbtest
Pt End
Bulbinplace
ofbag
PAC
Item13 Verifypropergasflowthroughthe
breathingcircuit
Bothmanualandmechanicalventilation
Uni directional valves Unidirectionalvalves
Mechanicalventilation
AttachsecondbreathingbagtoYpiece(Test
lung)
TurnONventilator,setventilatory parameters
Fill the bellows and breathing bag with O2 flush FillthebellowsandbreathingbagwithO2flush
SetO2 flowtominimumandothergasflowzero
Verifythatduringinspirationbellowsdeliver
appropriatetidalvolumeandduringexpiration
thebellowsfillcompletely
Inspiration
Expiration
10
Mechanicalventilation
SetFGF 5L/min
Verifythatventilatorbellowsandtestlungfill
andemptywithoutsustainedpressureatend
expiration expiration
Checkforproperactionofunidirectional
valves
Manualventilation
TurntheventilatorOFFandswitchtomanual
ventilation
Ventilatemanuallyandensureinflationand
deflation of the test lung and appropriate feel deflationofthetestlungandappropriatefeel
ofsystemresistanceandcompliance
RemovethesecondbreathingbagfromtheY
piece
Uni directionalValves
Visualobservation
Flowtest checksintegrityofthe
unidirectionalvalvesanddetectsobstruction
in the circle system inthecirclesystem
Breathethroughcorrugatedtubesindividually
Valvesshouldmoveappropriately
Abletoinhalenotexhalethroughinspiratorylimb
Abletoexhalenotinhalethroughexpiratorylimb
Disconnectcorrugated
inspiratoryhoseand
coverwithyourpalm
Trytoinhale
11
Disconnectcorrugated
expiratoryhoseand
coverwithyourpalm
Trytoexhale
Spirometry attheexpiratorylimb
Forexpiratoryvalvemalfunction
Spirometerwithreverseflowwillalarm
ForInspiratoryvalvemalfunction
M d h l d TV l h d MeasuredexhaledTVlessthanexpected
Capnography
Forexpiratoryvalvemalfunction
ElevatedCO2 baseline
ForInspiratoryvalvemalfunction
Gradualdownstroke
PAC
Item14 Documentation
Beforeeachuse
Audit
Item15 Confirmventilatorsettingsand
evaluatereadinesstodeliveranaesthesiacare
(ANAESTHESIATIMEOUT)
Beforeeachuse
ANAESTHESIATIMEOUT
Itemstocheck
Monitorsfunctional
Capnogram present
Oxygen saturation by Pulse Oximeter OxygensaturationbyPulseOximeter
measured
Flowmeterandventilatorsettingsproper
Manual/Ventilatorswitchsettomanual
Vaporizer(s)adequatelyfilled
Beforeeachuse
Suction
Requiredmonitors
Vaporizers
CO2 absorbent CO2 absorbent
Breathingsystempressureandleaktesting
Gasflow
Document
Ventilatorsettingsandreadiness
Anaesthesiaworkstations
GEADU
Drager Fabius GS
Drager Primus
Drager Apollo g p
Datex Ohmeda Avance
12
TestingAnaesthesiaworkstations
Electronicandautomatedselftests
Takes36mins
Automaticrecording
Selftesting Theoperatorfollowsthe
instructionswhentestingisinprogress
Assemblethebreathingcircuit
OccludeYpiece p
Componentsthatareselftested
Gassupplysystem
Flowcontrolvalves
Circlesystem
Ventilator
Eachvaporizerstobeusedshouldbechecked
byturningitONandrepeatingleaktest
portionofselftesting
Manual check Manualcheck
EmergencyO2cylinders
Backupventilationequipment
Suction
MustEnsure
AdequateOxygensupply
Propergasflowthroughthebreathingcircuit
BoylesMachine
BoylesMachine
Highpressure(pipeline,
cylinders,pressure
gaugesandregulators)
Lowpressure
(flowmeters,vaporisers,
andcommongasoutlet)
Breathingsystem
13
TestingBoylesMachine
1. Emergencybackupventilationequipment
2. Suction
3. Highpressuresystem
Highpressuresystem
Cylindersupply With
pipelinedisconnected
andflowmeterand
vaporizersoffOpen
cylinder fully cylinderfully
Audibleleak
Pressuredecrease>50
psiin5mins (significant
leak)
1000psi
Pipelinesupply
2. Suction
4. Lowpressuresystem
Lowpressuresystem
Testingflowmeters
Withallpipelineand
Cylinderoff,noflow
metershouldfunction
B t i O ByturningOnonegas
flow,onlythatflow
metershouldbe
operational
Checkforsmooth
operationfloatsand
undamagedflowtubes
Lowpressuresystem
Vaporizers
Checkfillleveland
tightenfillercaps
Leaktests
Negativepressureleak
test
Positivepressureleak
test
Categoriesofcheck
4. Breathingsystem
14
Breathingsystem
Checkthatbreathing
systemiscomplete,
undamagedand
unobstructed
Doahighpressureleak
test
CheckCO2 absorbent
4. Breathingsystem
5. Ventilationsystem(IfPresent)
6. Monitors
7. Finalposition
TestingDatex Ohmeda (Aestiva)
Dailychecklist
1. Inspectthesystem
2. Dothepipelineandcylindertests
3. Dotheflowcontroltests
4. Dothevaporizerbackpressuretests
5. Powerfailuretest
6. Dothealarmtests
7. Lowpressureleaktest
8. Breathingsystemtests
9. Monitorandventilatortests
15
1. Inspectthesystem
Checkconnectionsforpipelineandcylinder
supply
Check the breathing circuit Checkthebreathingcircuit
Emergencyventilationequipment
Suction
Connectpower
TurnMasterswitchON
Dailychecklist
1. Inspectthesystem
5. Powerfailuretest
6. Dothealarmtests
Datex Ohmeda (Aestiva ) Checklist
3. Flowcontroltests:
Minimumflows:O2 2575
mL/min,allothergasesno
flow.
Link system: Linksystem:
IncreaseN2Oflowtodriveup
O2flow
DecreaseO2 flowtodrive
downN2Oflow.
TheO2 flowisnominal25%.
O2 supplyfailurealarm
4. Vaporizerback
pressuretests
SetO2 flowto6L/min
TurnONvaporizer
O2 flowmustnot
decreasemorethan1
L/min
5. Powerfailuretest
UnplugthepowercordwiththesystemturnedOn.
Makesurethatthepowerfailurealarmcomeson.
Connectthepowercableagain.
Makesurethealarmcancels.
6. Dothealarmtests
Ventilatoralarms
Lowairwaypressure
High airway pressure Highairwaypressure
Lowminutevolume
Apnea alarm
O2 Monitor
16
Dailychecklist
1. Inspectthesystem
5. Powerfailuretest
6. Dothealarmtests
7. Lowpressureleaktest Negativepressureleaktest
Scavengingsystem
CO2 absorbent
Checkvalves
Ventilatorcircuit
Bagcircuit
APLvalve
Dailychecklist
1. Inspectthesystem
5. Powerfailuretest
6. Dothealarmtests
Everytimeadifferentclinicianusesthesystem
Doalowpressureleaktest.
Beforeeverypatient
Inspectthesystem
Checkvaporizerinstallation
Dothebreathingsystemtests
Monitorandventilatortests
Anaesthesiaworkstations Drager
Apollo
ApolloChecklist
Manualprocedureperformedbytheuser,
followedbyanautomatedselftest.
Thepipelinesupplyandthepowersupply
must be connected mustbeconnected.
17
ApolloChecklist(Manual)
Checkthepipelinegassupply
Checkthecylindergassupply
TesttheO2 flush
TesttheauxiliaryO2flowmeter
Testthefunctionofthefreshgasflowcontrol
knobs
APLvalve
O2 Flush
AuxiliaryO2flowmeter
APLValve
Flowcontrolknobs
(Virtualflowmeters)
18
ApolloChecklist(Manual)
Verifythatthevaporizersareinstalledandready
foruse
Checkthebreathingcircuit assembledand
connected
Verifythatthescavengingsystemisreadyforuse
CO2 absorbentOK
Watertrapfilllevel
Suction
Emergencyresuscitator
ApolloChecklist
PreparetheApollofor
theselftest
1.Ensurethatallflow
controlsareclosed.
2 Occlude the Ypiece by 2.OccludetheY pieceby
insertingitontotheplug
onthebagarmassembly.
3.Ensurethatthesample
lineisconnectedbetween
thewatertrapandtheY
piece.
ApolloChecklist(Self)
SelfCheck
Gasdelivery
Ventilator
Monitor Monitor
Systemcompliancetest
LeakTests Individuallycheckeachvaporizer
InEmergencySituations
Ensuresuctionisavailableandready
Highpressuretestofthebreathingcircuit
Observeand/orpalpatebreathingbagduringpre
oxygenation. yg
Adequateflowofoxygen
Thecircuitisunobstructed
TheBag/Ventswitchison"Bag"not"Vent"(older
machines)
Withallnewmachines,theelectronicchecklist
canbebypassedinemergencies.
19
Ancillaryequipment
Appropriatesizedmasks,airways,tracheal
tubes,connectors
Functionallaryngoscope,Accessoryintubation
equipment equipment
CheckPt trolley,OTtableforsmooth
movement
Thank
You
APLvalve
CloseAPLvalvefully
FGF 3L/min
Pressure<82cmH2O
OpenAPLvalve
Pressure 0cmH2O
Preparethesystem:
Turnallvaporizersoff
OpentheAPLvalve
h / h SettheBag/VentswitchtoBag
Setallflowcontrolstominimum
Setsufficientpatientsuction
Makesurethatthebreathingsystemis
correctlyconnectedandnotdamaged
1
Tracheostomy
Patient with T Tube in situ
Short case / Usually adult / rarely child.
History: Carcinoma Larynx, pre / postop / Injury /
Homicidal / Suicidal / Indication / Elective / Emergency /
PCDT / Papilloma.
Examination: Nothing significant.
Note co morbid conditions.
Risk factors
Treatment & surgical procedure planned
Radiotherapy.
Direction of viva
Anatomy / Nerve supply of larynx
Number of cartilages paired / unpaired
Definitions.
Pr cedure / Indic ti ns / C mplic ti ns Procedure / Indications / Complications.
Acute problems: loss of airway ?
Dislodgement ?
Advantages over ETT oral vs nasal
Types of tracheostomy tubes
Anatomy: Cartilages & Muscles
3 unpaired & 3 paired cartilages.
Un paired - Thyroid, cricoid & epiglottis.
Paired - arytenoid, cuneiform & corniculate.
8 extrinsic muscles; Suprahyoid group: 8 extrinsic muscles; Suprahyoid group:
Stylohyoid, Mylohyoid
Geniohyoid, Digastric.
Infrahyoid group:
Sternothyroid, Sternohyoid
Thyrohyoid, Omohyoid
Suprahyoid raise the larynx.
Infrahyoid lower the hyoid bone and larynx.
Anatomy: Intrinsic muscles
Interarytenoid, lateral cricoarytenoid,
posterior cricoarytenoid, cricothyroid &
thyroarytenoid (true vocal cord). y y
All paired (Rt & Lt) except Tr. interarytenoid.
All intrinsic muscles adductors of vocal cords
except posterior cricoarytenoid.
Arytenoids dislocated / sublaxation
Cricoarytenoid joint; RA & acromagaly.
Tracheal stenosis
Tracheomalacia
Speaking tubes valves
Pediatric tracheostomy
Decannulation
Timing - Early vs Late
Types open Vs PCDT
2
Definitions -Tracheostomy
Tracheotomy
Tracheostomy
h d
Mini tracheostomy
Open tracheostomy
P D Cricothyroid puncture. PCDT
Direction of viva
Anatomy / Nerve supply of larynx
Number of cartilages paired / unpaired
Definitions.
Indications / Procedure / Complications.
Acute problems: loss of airway ?
Dislodgement ?
Advantages over ETT oral vs nasal
Types of tracheostomy tubes
Indications
Upper Airway Obstruction
Trauma, congenital, edema, foreign body, infections,
growths.
Prolonged pulmonary ventilation
Pulmonary toilet
Poor cough, debilitated, aspiration prevention.
Elective head & neck procedures.
Procedure
Under local anesthesia : elective /
emergency
Sudden apnea
El ti d l th i Elective under general anesthesia.
Positioning
Spontaneous/ Controlled breathing
Patient on massive inotropes
Coagulation profile
Switching over from ETT
Projected time: need of artificial airway
Tolerance of ETT
d E h Continued ETI vs Tracheostomy
Over all condition (nutrition & infection)
Ability to tolerate a surgical procedure
Size: 2/3
rd
3/4
th
ID of trachea.
Advantages of tracheostomy
Easy secretion removal
Less obstruction
Swallowing possible.
Oral nutrition
Avoids ET complications
Decrease in
Dead space
Airway resistance
Work of breathing
Auto-PEEP
Avoids ET complications
Better tolerated
Avoids sedation.
Allows speech.
More stable
Enhanced mobility
Nursing outside ICU
Reduced laryngeal
ulceration
Incidence
Sinusitis
Tracheal stenosis
VC injury
3
Tracheostomy
Disadvantages.
Surgical procedure
Poor acceptance
Stomal complications
Contraindications
NONE
Coagulopathy
Local infection Stomal complications
Decannulation
Local infection
Distorted or
difficult anatomy
Difficult surgical
approach
Complications
Immediate
Apnea: loss of
hypoxic stimulation.
Hemorrhage
Intermediate
Tracheitis
Tracheobronchitis
Erosion /
Surgical injury to
structures.
Pneumothorax
Pneumomedistinum
Cricoid injury
hemorrhage
Displacement
Obstruction
S/C emphysema
Aspiration
Lung abscess
Late Complications
Persistent tracheo-cutaneous fistula
Stenosis of larynx / trachea
Tracheal granulomas
Tracheomalacia
Tracheo esophageal / inominate fistula
Difficult decannulation
Scar complications
Tracheostomy & Anesthesiologist
Difficult airway algorithm.
Elective tracheostomy for ICU patients. y p
Before or after Head & neck surgery.
GA / LA for tracheostomized patients.
Types of Tracheostomies
Emergency & elective
Permanent
B/L l d l L l t i OSA B/L vocal cord palsy, Laryngeal stenosis, OSA
Temporary
Surgical, PDT, cricothyrodotomy
High, mid & low
High, Mid & Low Tracheostomies
High tracheostomy
Above thyroid isthmus
Violates 1
st
tracheal
ring
Indication: ca-larynx
Complications:
Low tracheostomy
Below isthmus
Trachea is deep & close
to several large vessels
T T may impinge on
l h
Complications:
Perichondritis -
cricoid
Subglottic stenosis
y p g
supra sternal notch
Mid tracheostomy
Preferred
Done through the 2nd & 3rd rings
Division or retraction of thyroid isthmus to
expose trachea.
4
Pediatric Tracheostomy
Avoided / nasal tube preferred .
Technically difficult.
Changing tube hazardous.
V i l i i i b/ 2
d
d 3
d
i Vertical incision b/w 2
nd
and 3
rd
ring.
No excision of anterior wall of trachea.
High incidence of difficult de cannulation.
High incidence of stenosis.
P C D T
ICU Bed SideTracheostomy
Use of guide wire and Dilators
Blind
Under vision by Bronchoscope thru ETT Under vision by Bronchoscope thru ETT.
LMA
Less time, Less Expensive
Contraindications.
Types. Ciaglia, Rapitrach, Guide-wire dilating forceps (Griggs),
Blue Rhino (modified Ciaglia technique), Fantoni, Percu twist, White
Rhino, T Dagger.
Metallic Tracheostomy Tubes
Silver / Steel alloy/ 3 components: Inner &
Outer tube, Obturator.
Adult Sizes - 28-36 FG.(circumference inner tube in
mm. FG size is 4 times the portex size)
Advantages
Metallic, can be cleaned and boiled.
Disadvantages :
No standard connectors /Injury, Un cuffed,Cost
Synthetic Tracheostomy
Tubes
PVC / silicone, Cuffed / Uncuffed ,
Great Ormond street, Portex, Shiley.
Disposable Disposable
Thermolabile material.
Extra proximal / distal length.
Adjustable Flange
Double lumen tubes
Miscellaneous issues
Tube obstruction: Kinking, Herniation.
Mucus plug, Orifice against the wall.
Cuff leak, bigger size
Accidental extubation
Routine change in ICU
5
Difficult decannulation
Persistence of the condition
Granulation tissue around stoma
Anterior tracheal wall dislocation
Tracheal mucosal edema Tracheal mucosal edema.
Poor general condition
Inability to tolerate upper airway resistance.
Subglottic stenosis
Tracheomalacia.
Mini Tracheostomy
Cricothyroidotomy
Prevention of sputum retention
Alternative to naso-laryngeal y g
suction
Regular flexible bronchoscopy.
Tube internal diameter 4 mm.
Patient able to breathe normally
Mini Tracheostomy
Patient can talk, eat / drink
The tube does not prevent expectoration
Small size suction catheters
Suction takes longer time Suction takes longer time
Frequent Blockage
Good Tracheostomy care
Humidification essential
Tracheal stenosis
Tracheomalacia
Speaking tubes valves
Pediatric tracheostomyy
De cannulation
Timing of tracheostomy ICU
Types open Vs PCDT

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