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Anaesthesia…….In Space

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Anaesthesia…….In Space Anaesthesia…….in Space Sqn Ldr Bonnie Posselt BSc MB ChB (E) MRCP ARAeS DAvMed RAF ST5 Aviation and Space Medicine RAF Centre of Aviation Medicine @bonposselt BACKGROUND • Joined RAF as undergraduate ’06 • Manchester medical school ‘09 • Intercalated BSc aerospace physiology ’08 • FYs Birmingham • Officer training – RAF Cranwell • General duties – RAF Akrotiri and Benson • ACCS-Acute medicine, London ® MRCP • Aeromed physician • Aviation and space medicine registrar ‘15 • Diploma in aviation medicine ‘16 SCOPE • Space environment • Anticipated medical risks • Patient population & Case example • Anaesthetic challenges • Medications • Regional vs. General • Advanced Life Support • Surgical considerations • Evacuation Space Environment • Suborbital – minutes to hours • Low Earth Orbit – months to a year • Exploration class missions – years • Space habitats • Extra Vehicular Activity (Spacewalk) • Analogue space missions • Combat • Humanitarian • Microgravity SPACE ENVIRONMENTS Common anticipated Occasional incidences Medical conditions expected to manage Not addressed Space motion sickness Renal stones Radiation sickness Cellulitis Cardiogenic shock Nasal/sinus congestion Acute urinary retention Severe decompression Dental: Malignancy sickness cavity/pulpitis/avulsion Constipation UTIs Barotrauma Eye penetration Acute glaucoma Headache Gastroenteritis Osteoporosis Limb amputation Compartment 0.06 per person- year of flight syndrome Back pain Prostatitis Seizure Chest trauma Head injury Upper respiratory tract Otitiscrew of 6 on 900 day mission = ONE Anaphylaxis Obstructed airway Hypovolaemic shock infection medical emergency Minor abrasion Contact dermatitis Anxiety Haemorrhage Lumbar spine # MSK trauma Decompression Depression Burns sickness Corneal irritation Aspiration of a foreign Medication Smoke inhalation body overdose/misuse insomnia Near drowning Palliative Cardiac dysrhythmias Sepsis PATIENT POPULATION • Screening for professional astronauts • Lower standards for space passengers • 57 Male 1. COPD – moderate severity • FVC 4.76L (92% predicted) • FEV1, 2.13 L (53%) • FEV1/FVC, 0.45 (57%) – 0.54 (63%) after bronchodilator • ABG: pH, 7.420; PaCO2; 5.06 KPa (38 mmHg); PaO2; 11.46 KPa (86 mmHg) • SpO2 93.8% RA, Hb 14.2 2. Bilateral lung parenchymal bullae 3. Previous pneumothorax treated with talc pleurodesis 4. Left posterior lung mass 5. Substernal mass, possibly substernal thyroid, thymic tissue, talcoma, or neoplasm 6. Ventricular and atrial ectopy 7. Renal cyst OUTCOME • Optimise resp function • VATs pleurodesis • Hypobaric challenge • Hypoxia simulation • Centrifuge (+Gz) assessment • Pleural mass biopsy • FIT to FLY Jennings RT, Murphy DM, Ware DL, et al. Medical qualification of a commercial spaceflight participant: not your average astronaut. Aviat Space Environ Med 2006; 77: 475-84 ANAESTHETICS CHALLENGES • Closed environment – vapour contaminant, fire risk • Alterations in physiological response, autonomic dysfunction • Gastric motility reduced • Skeletal muscle atrophy - K+ • Impaired renal and hepatic function • Can’t measure weight - mass • Limited equipment – 1kg = US$ 22,000 MEDICATIONS • Chemically stable • Thermally robust • Adequate shelf life • Rapid degradation from radiation • Powdered? Norfleet WT. Anesthetic concerns of spaceflight. Anesthesiology 2000; 92: 1219-22 REGIONAL ANAESTHESIA Pros Cons Safe Difficult to train All limbs No spinal Less equipment Skill fade Longer induction time Compartment syndrome Toxicity Komorowski M, Watkins SD, Lebuffe G, Clark JB. Potential anesthesia protocols for space exploration missions. Aviat Space Environ Med 2013; 84: 226-33 Komorowski M, Fleming, S, Kirkpatrick, A. Fundamentals of Anaesthology for Space flight. Journal Cardiothoracic and Vascular Anaesthesia 2016; 30 (3) 781-90 GENERAL ANAESTHESIA • Hypoxia i. Pre-Oxy ii. Video laryngoscope Pros Cons • Cardiovascular collapse Easy to perform Dangerous i. Hypovolaemic 10-15% Can do all surgery Equipment ii. Altered baroreflex + SVR Assess fluid state Preventative low dose Ketamine + Rocuronium vasopressor AIRWAY MANAGEMENT Norfleet WT. Anesthetic concerns of spaceflight. Anesthesiology 2000; 92: 1219-22 CHOICE OF ANAESTHETIC OTHER CONSIDERATIONS • Skill set of operator • Telecommunications • 3D printing SURGICAL CONSIDERATIONS • Restraint • Sterile techniques • Haemostasis • Post-op care • Wound healing • Endothelial leak Campbell MR, Williams DR, Buckey JC, Jr., Kirkpatrick AW. Animal surgery during spaceflight on the Neurolab Shuttle mission. Aviat Space Environ Med 2005; 76: 589-93 https://www.airspacemag.com/space/space-station-er-180956246/ ADVANCED LIFE SUPPORT Rehnberg L, Ashcroft A, Baers JH, et al. Three methods of manual external chest compressions during microgravity simulation. Aviat Space Environ Med 2014; 85: 687-93 Rehnberg L, Russomano T, Falcao F, Campos F, Everts SN. Evaluation of a novel basic life support method in simulated microgravity. Aviat Space Environ Med 2011; 82: 104-10 MEDICAL EVACUATION • Cramped Soyuz • All or none • Dependent on flight profile SPACE MEDICINE SURGICAL SIEVE Hodkinson, P. Anderton, R, Posselt, B. Fong, K. “An Overview of Space Medicine” 2017 Submitted, awaiting publication to British Journal of Anesthesia. Typical medical kits • Type of mission • Population • Allergy • Antibiotics • Analgesics • Antiemetics • Stimulants • Cardiovascular • Ophthalmic • Otic • Laxatives • Hypnotics THANK YOU Any questions? Twitter: @bonposselt Email: [email protected].
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