Ministry of Education and Science of Ukraine Ministry of Health of Ukraine Sumy State University V.D.Shyschuk, S.I.Redko, M.M.Ogienko GENERAL QUESTIONS OF ANAESTHESIOLOGY Study Guide Recommended by the Medical Institute Academic Council of Sumy State University Sumy – 2015 УДК 616-089.5 ББК 54.5 Ш 65 Recommended for publication by the Medicine Faculty Academic Council of Sumy State University (the Minutes N 3 of 23.11.2015 ) Authors: V.D.Shyschuk, Doctor of Medicine, Professor S.I.Redko, Assistant M.M.Ogienko, PhD, Assistant Reviewers: V.O. Litovchenko – Doctor of Medicine, Professor of Department Emergency Medicine, Ortopedics and Traumatology. Kharkiv Nacional Medical University. O. I. Smiyan – Doctor of Medicine, Professor. Head of the Department of Pediatrics postgraduate education of Sumy State University. O.L.Sytnik – PhD, Associate Professor of Surgery Department of Sumy State University. Shyschuk V.D. Ш 65 General questions of anaesthesiology: study guide / V.D.Shyschuk, S.I.Redko, M.M.Ogienko. – Суми: ТОВ «ВПП «Фабрика друку», 2015. – 168 с. ISBN 978-966-97423-4-6 This book covers information about basic principles and methods of the modern anesthesiology. For English-speaking students of higher educational institutions III-IV levels of accreditation, postgraduates. ISBN 978-966-97423-4-6 УДК 616-089.5 ББК 54.5 © V.D.Shyschuk, S.I.Redko, M.M.Ogienko, 2015 © ТОВ «Видавничо-поліграфічне підприємство «Фабрика друку», 2015 CONTENTS Topic 1. PREOPERATIV PREPARATION …………... 4 Topic 2. ANESTESIA……………………...…………… 39 Topic 3. POSTANESTESIA CARE………………….... 137 Referenses ……………………………………………… 167 3 Topic 1. PREOPERATIV PREPARATION The main aim: to be able to prepare the patient for surgery, to assess the risk of anesthesia, choose the appropriate type of anesthesia, premedication appoint, prepare equipment and instruments for anesthesia. The student must know: -The components of modern anesthesia. -Features of anesthesia preoperative history and physical. - The risk assessment. -Classification of modern anesthesia. -Principles of choice оf anesthesia technique. -Pharmacokinetics of drugs for premedication. -Mein components of the anaesthetic machine. -Preparation of the anaesthetic machine. - Mein components and preparation of monitors. The student must be able: -Collect anamnesis and examine of the patient in anestesiological aspect. -Prognosticate the difficult intubation. -Evaluate risk of anesthesia according ASA Physical Status Classification. - Select the appropriate for patient anesthesia technique. - Prepare the anestesiological equipment to operation. Short methodical instructions for practical study. The initial level of students knowledge-abilities performed at the beginning of the study, using the test tasks. Students examine patients which operative intervention coming, see the results of patients laboratory and instrumental investigations, study hospital charts, determine the degree of surgical risk and choose the optimal type of anaesthesia. If it possible they are in an operating-room, if not they decide 4 situational tasks. All students independent work and their answers controlled by a teacher. In an educational room students together with a teacher discuss the results of examination, produce the general tactic/pl of conduct of patients in a предоперационном period, optimal type of anaesthesia, general tactic/pl of conduct of patients and послеоперационном period. Students discuss with a teacher by them sufferet errors. After it students pass test control. In the end worked out the totals of work, and students get the estimations of the work on employment. Mein material Terminology Anesthesiology is the science of managing the life functions of the patients organism in connection with surgery or aggressive diagnostic procedure. Anesthesia, or anaesthesia (from Greek αν-, an-, "without"; and αἴσθησις, aisthēsis, "sensation". On October 16, 1846, in Boston, William T.G. Morton conducted the first publicized demonstration of general anesthesia using ether. The pre-existing word anesthesia was suggested by Oliver Wendell Holmes, Sr. in 1846 as a word to use to describe this state. Anesthesia is reversible, drug-induced condition of: Amnesia & unconsciousness – inhibition of psychic perception (narcosis, sleep); Analgesia – blockade of pain impulses; Neurovegetative blockade; Immobility (myorelaxation); Maintenance of adequate gas exchange; Maintenance of adequate blood circulation; Maintenance of normal metabolism. 5 The main aim of anesthesiology is to protect the organism from the operative injury. According to Rene Lerish, "the operation saves the patient by ways which may kill him". General Anesthesia consist from 3 main parts: – preoperative evaluation; – intraoperative management; – postoperative management Preoperative Evaluation Unlike the standard internal medicine H&P, ours is much more focused, with specific attention being paid to the airway and to organ systems at potential risk for anesthetic complications. The type of operation, and the type of anesthetic will also help to focus the evaluation. The overall goal of the preoperative evaluation is to reduce perioperative morbidity and mortality and alleviate patient anxiety. The preoperative visit should include the following steps: I. Problem Identification II. Risk Assessment III. Plan of Anaesthetic Technique IV. Preoperative Preparation. Problem Identification Anesthesia preoperative history and physical A. Note the date and time of the interview, the planned procedure, and a description of any extraordinary circumstances regarding the anesthesia. B. Current medications and allergies: history of steroids, chemotherapy and herb and dietary supplements . C. Cigarette, alcohol, and illicit drug history, including most recent use. D. Anesthetic history, including specific details of any problems. E. Prior surgical procedures and hospitalizations. F. Family history, especially anesthetic problems. 6 Birth and development history (pediatric cases). G. Obstetrical history: last menstrual period (females). H. Medical history; evaluation, current treatment, and degree of control. I. Review of systems, including general, cardiac, pulmonary, neurologic, liver, renal, gastrointestinal, endocrine, hematologic, psychiatric. J. History of airway problems (difficult intubation or airway disease, symptoms of temporomandibular joint disease, loose teeth, etc). K. Last oral intake. L. Physical exam, including airway evaluation (see below), current vital signs, height and body weight, baseline mental status, evaluation of heart and lungs, vascular access. M.Overall impression of the complexity of the patient’s medical condition, with assignment of ASA Physical Status Class (see below). N. Anesthetic plan (general anesthesia, regional, spinal, MAC). The anesthetic plan is based on the patient's medical status, the planned operation, and the patient’s wishes. O. Documentation that risks and benefits were explained to the patient. 3. Preoperative laboratory evaluation A. Hemoglobin: menstruating females, children less than 6 months or with suspected sickle cell disease, history of anemia, blood dyscrasia or malignancy, congenital heart disease, chronic disease states, age greater than 50 years (65 years for males), patients likely to experience large blood loss. B. WBC count: suspected infection or immunosuppression. C. Platelet count: history of abnormal bleeding or bruising, liver disease, blood dyscrasias, chemotherapy, hypersplenism. D. Coagulation studies: history of abnormal bleeding, anticoagulant drug therapy, liver disease, malabsorption, poor nutrition, vascular procedure. 7 E. Electrolytes, blood glucose, BUN/creatinine: renal disease, adrenal or thyroid disorders, diabetes mellitus, diuretic therapy, chemotherapy. F. Liver function tests: patients with liver disease, history of or exposure to hepatitis, history of alcohol or drug abuse, drug therapy with agents that may affect liver function. G. Pregnancy test: patients for whom pregnancy might complicate the surgery, patients of uncertain status by history and/or examination. H. Electrocardiogram: age 50 or older, hypertension, current or past significant cardiac disease or circulatory disease, diabetes mellitus in a person age 40 or older. An EKG showing normal results that was performed within 6 months of surgery can be used if there has been no intervening clinical event. I. Chest x–ray: asthma or chronic obstructive pulmonary disease with change of symptoms or acute episode within the past 6 months, cardiothoracic procedures. J. Urinalysis: genito–urologic procedures; surgeon may request to rule out infection before certain surgical procedures. K. Cervical spine flexion/extension x–rays: patients with rheumatoid arthritis or Down’s syndrome. Routine screening in asymptomatic patients is generally not required. L. Preoperative pulmonary function tests (PFTs). There is no evidence to suggest that pulmonary function tests are useful for purposes of risk assessment or modification in patients with cigarette smoking or adequately treated brochospastic disease. Identification of the problems a patient brings to the operating room is one of the most vital, yet easily neglected, components of the perioperative management of the surgical patient. A system–oriented approach to the patient is helpful in completing a thorough preoperative assessment. As is the case elsewhere in medicine, the preoperative evaluation should progress through history (including a review of the 8 patient's chart), physical examination,