1. 1 2. 7 3. 14 4. 24 5. .... 49 6. -- 58 7. 64 8. 70 / 9. ... 74 /

10. 79 /

11. ... 85 / 12. 90 / 13. 96 14. 105 15. 113 16. 119 17. 126 18. 132 19. CVP 138

1

Pneumothorax

2

(Pneumothorax)

Air accumulation in the pleural space with secondary lung

collapse

Visceral pleura Ruptured esophagus Chest wall defect Gas-forming organisms

Diffusion properties of the gases Pressure gradients Area of contact Permeability of pleural surface

Page 1 of 143

3

COPD Infection Neoplasm Catamenial Miscellaneous

Blunt Penetrating

Inadvertent Diagnostic Therapeutic

4

Sudden onset chest pain Shortness of breathing Non-productive cough

Decrease in chest wall movement on inspection Chest cavity hyperesonant and tympanic on percussion Decrease breathing sound on auscultation

CXR

Skin fold Giant bulla

Page 2 of 143

5

6

7

(driver, airplane pilot)

Page 3 of 143

7

Resection of the blebs or

bulla Obliteration of the pleural

space

(Video-assisted thoracoscopic surgery)

(Thoracotomy)

Parietal pleurectomy Abration pleurodesis Laser pleurodesis

8

(%) Expectant 30 Aspiration 20-50 Chest tube drainage 20-30 Pleurodesis (tetracycline) 25 Pleurodesis (talc) 7 Surgery 2

Page 4 of 143

9

Tension pneumothorax Re-expansion pulmonary edema Persistent air leak Hemothorax (

11

Collection System

12

(Misplacement of chest tube): lung, liver, spleen, colon

(Pleural infection)

100 cc

Page 6 of 143

1

Hematuria

2

The Types of Hematuria

True hematuriaFalse hematuria

Dye in urineMedication inducedStrip test

Page 7 of 143

3

The Types of Hematuria

Gross hematuria vs. MicrohematuriaSediment under microscopy

RBC more than 0-2 /HPF

Cause of hematuriaDegree of hematuriaThe same importance of both

4

The Types of Hematuria

Painful hematuria vs. Painless hematuria

Obstruction or notStone, blood clot, tumor,

InflammationThe same importance of both

Painful hematuria not equal to benign causePainless hematuria not equal to malignant cause

Page 8 of 143

5

The Types of Hematuria

Initial hematuria, Terminal hematuria vs. Total hematuria

The location of the hematuria sourceInitial hematuria: anterior urethra

Urethritis, urethral foreign body, urethral stone,

Terminal hematuria: posterior urethra, prostateBPH, CaP, TCC of prostatic urethra,

Total hematuria: U-B, upper urinary tractTCC of U-B, ureter, renal pelvis, RCC,

6

The Studies for Hematuria

Urine analysisStrip test: pH, Sugar, SpGr, O.B., Nitrate, Sediment: WBC, RBC, Crystal,

IVP + PVSerum Creat < 1.8

SonographyLow abdominal sono: prostate, U-B, and bil kidney

Urine cytology3 sets in 3 different days

Cystoscopy

Page 9 of 143

7

The Treatments for Hematuria

Dependent on the cause of hematuria

8

Case Presentation

x ()77 y/o, maleChief complaint

Gross painless hematuria for 3 weeks

Present illnessGross painless hematuria 3 weeks before presentation at China.U-B tumor with left hydronephrosis was informed and radical cystectomy was arranged for him.

Page 10 of 143

9

Case Presentation

Present illness (cont.)Came back to Taiwan and visited our OPD

Diagnostic studiesUrine analysis:

RBC: 6-10 /HPF, WBC: 0-2 /HPF

IVP+PV:Poor opacification of left collecting systemLeft hydronephrosis and hydroureter, nature to be determinedModerate residual urine amount due to BPH

10

Case Presentation

Diagnostic studies (cont.)Urine cytology: (voiding urine)

Atypical cell present x 1 setInflammatory change x 1 setHigh grade TCC x 1 set

CT scan of pelvis:Thinning of left renal parenchymaLeft side hydronephrosis and hydroureter down to the UVJ levelSoft tissue mass about 13 mm over left UVJ junction, R/O neoplasm from left U-B wall with obstructive uropathy

Page 11 of 143

11

Case PresentationDiagnostic studies (cont.)

Cystoscopy: No U-B tumorExternal tumor compression over left U-B wall just above the left UVJ

TURBT:Necrostic tumor tissue over the intramural segment of left ureterR/O TCC of left L/3 ureter, intramural segment

Left side R.P. (retrograde pyelogram)5 Fr ureteral catheter through central part of tumorNo suspicious filling defect over upper collecting system

12

Case Presentation

Diagnostic studies (cont.)Urine cytology: (left renal pelvic urine)

High grade TCC x 1 set

Left side 6 Fr 24 cm D-J inserted for preserve left renal functionERPF (effective renal plasma flow / comprehensive renal function study)

Total: 217.6 ml/minLeft: 64.3 ml/minRight 153.3 ml/min

Page 12 of 143

13

Case Presentation

TreatmentLeft nephroureterectomy and partial cystectomy

Left flank incision and low midline incisionPartial cystectomy including the left UVJ

Pathology reportsKidney: chronic pyelonephritisLeft ureter: flat urothelial carcinoma in situ (3/M ureter)Bladder cuff: invasive non-papillary urothelial carcinoma, high grade, pT3a (tumor penetrates the muscularispropria to the adventitia)Cut margin: free of tumor

14

The EndThanks for Your Attentions!!

Page 13 of 143

1

2

Traumatic Brain Injury

35%

( IICP ) (cerebral perfusion)

Page 14 of 143

3

(Definition and Classification of MTBI)

Standard :

Level , Guideline

2 GCS score15

Options GCS score 15

GCS score 15

X X

GCS score 14 15

5

(Care of Hospitalized MTBI Patients)(Care of Hospitalized MTBI Patients) Options Options

Cranial CT Cranial CT Cranial CT Cranial CT GCS score GCS score 15 15 Cranial CT Cranial CT

Cranial CT Cranial CT

drug or alcohol intoxication drug or alcohol intoxication

extracranialextracranial injuries or shock injuries or shock suspected nonsuspected non--accidental injury accidental injury

GCS score 15 GCS score 15 1 1 1 1 12 12 GCS score 15 GCS score 15 4 4 1 1 12 12

6

(Post Concussion Syndrome) Standard :

Level , Guideline

(Patient Education)

Options

Page 16 of 143

7

(Management in ER)

Standard :

Level Guideline

Level Options A.

ABC(Airway)(Breathing)(Circulation) -

B.

C. Glasgow Coma Scale

8

D. (Sedation) ( ) ( ) ( )

E. X

F.

G.

H.

Page 17 of 143

9

(Cerebral perfusion pressure)

Standard :

Level

Guideline (CPP) 60 -70mmHg (Level )

(CPP) 60mmHg (Level )

(CPP) 70mmHg (ARDS) (Level )

10

(Cerebral perfusion pressure)

Options Lund concept EBIC(European brain injury

consortium) (Level ) CPP 60 -70mmHg Lund

(stress) (Capillary hydrostatic

pressure)

colloid (CPP) 70mmHg (ARDS) (CPP) 70mmHg 5 (Level )

Page 18 of 143

11

(Fluid Therapy)

Standard : Level

Guideline 0.9% (Saline) (Lactate Ringer's) (Level )

(Level )

12

(Fluid Therapy)

Options Rosner et al Lund concept

( colloid) (Level ) ( colloid) ( Colloid) ( colloid) (Level )

FFP ( Coagulopathy) ( volume expander) ( Level )

(Hypertonic saline) (Level )

Page 19 of 143

13

(ICP monitoring)

Standard : Level

Guideline IICP hyperventilation PCO2 30 -35mmHg mannitol sedation barbiturate coma CSF

14

(ICP monitoring)

level 1. (GCS score 3-8 )

hematomas contusions edema compressed basal cisterns

2. (GCS score 3-8 ) 40 (unilateral or bilateral

motor posturing) 90mmHg

3. GCS score 13~15 GCS score 9~12 Treatment Threshold

TBI 20~ 25 mmHg 20 mmHg Guideline

Page 20 of 143

15

(Sedation)

Standard : Level ,

Guideline Level ,

Options GCS score 3-8

GCS Score 3-8

16

(Nutrition)

Standard Level

Guideline

15%

(resting metabolic expenditure) 100% 140%

Options Level

Page 21 of 143

17

(Intracranial Hypertension)

Standard : Level

Guideline

(Level )

(Level ~ ) Options

20 mmHg

18

(Seizure Prophylaxis)

Standard : ( Phenytoin )

( carbamazepine ) ( phenobarbital ) ( valproate )

Guideline Level

Options

GCS score 10 24

Page 22 of 143

19

(Second Tier Therapy)

Standard : Level Guideline Level Options Hypertonic saline

Barbiturate coma

Hyperventilation

autoregulation

PaCO2 30 mmHg Hypothermia

Steroid

Page 23 of 143

1

Basic concept and technique in surgical wound management

2

Introduction

Langers line Choice of incision Anatomic sites Age Type of skin

Page 24 of 143

3

4Page 25 of 143

5

6Page 26 of 143

7

Choice of method of repair

Age Sex Camouflage vs anatomical restoration Color and texture match The Barters Principles Shifting the defect Autogenous vs alloplastic

8Page 27 of 143

9

10

Suturing technique (I)

Precision of skin approximation No undue tension Correct choice of suture materioal Eversion or inversion Suture marks

Page 28 of 143

11

12Page 29 of 143

13

14

Suture technique (II)

Eversion or invertion ? Simple or mattress ? Continuous or interrupted ? Vertical or horizontal ? Locked or unlocked Making knots

Page 30 of 143

15

Suturing technique (III)

Anatomic restoration Dead space Drainage Dressings

16Page 31 of 143

17

18Page 32 of 143

19

20Page 33 of 143

21

22

Interrupted subcuticular sutures Interrupted Vertical mattress Continous locking suture

Page 34 of 143

23

24Page 35 of 143

25

26

Depuckering the puckers

Dog ear deformity

Page 36 of 143

27

28

Three enemies of plastic surgeonThree enemies of plastic surgeon

Full thickness defectFull thickness defect TensionTension StreightStreight lineline

Z Z plastyplasty W W plastyplasty V V Y advancement flap Y advancement flap

Page 37 of 143

29

30Page 38 of 143

31

Wound healing:Wound healing:

Inflammatory phaseInflammatory phase FibroplasticFibroplastic ( ( proliferativeproliferative) ) phase:aboutphase:about 48 48

hrshrs Maturation (remodeling) phase: as long as Maturation (remodeling) phase: as long as

one yearone year

32

Wound healing:

Primary healingPrimary healing DelyedDelyed primary healinghealing Secondary healingSecondary healing

Page 39 of 143

33

34

Recnstructin ladder

Page 40 of 143

35

Skin graft Skin graft vsvs skin flapskin flap

36

Full thickness skin graft vs Splittedthickness skin graft

Page 41 of 143

37

38Page 42 of 143

39

40Page 43 of 143

41

Flap

Angiosome (Taylor) Classification of

Muscle flap Pedicle flap vs

Random flap Distant flap vs Free

flap

42Page 44 of 143

43

44Page 45 of 143

45

46Page 46 of 143

47

48Page 47 of 143

49

Thanks a lot!Thanks a lot!

Rome is not built in a day.Rome is not built in a day. Practice makes perfect.Practice makes perfect.

Page 48 of 143

1

2

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Page 64 of 143

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Page 65 of 143

5

Burn Management Burn Management Airway & BreathingAirway & Breathing

Assess for injuryAssess for injury

Establish and maintain airway earlyEstablish and maintain airway early

Assume CO exposureAssume CO exposure

Inhalation of toxic fumes, carbon particlesInhalation of toxic fumes, carbon particles

Direct thermal injuryDirect thermal injury

Oxygenate/ventilateOxygenate/ventilate

EndotrachealEndotracheal intubationintubation

ABGsABGs and CO levelsand CO levels

6

bcbc defdghdefdghijklmnnijklmnn

opop defdghdefdghmnnmnn

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Page 66 of 143

7

Estimate Fluid NeedsEstimate Fluid Needs

22--4 4 mLmL warmed LR/Kg/%BSA inwarmed LR/Kg/%BSA infirst 24 hoursfirst 24 hours in first 8 hoursin first 8 hours in next 16 hoursin next 16 hours

Based on time from injuryBased on time from injury

Monitor heart rate and urinary output Monitor heart rate and urinary output

8

Develop Treatment PlanDevelop Treatment Plan

Estimate burn size/depthEstimate burn size/depth

Identify associated injuriesIdentify associated injuries

Weigh patientWeigh patient

Baseline blood analysis and CXRBaseline blood analysis and CXR

Document on flow sheet Document on flow sheet

Page 67 of 143

9

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Chemical BurnsChemical Burns

Type, duration, concentration,Type, duration, concentration,and amountand amount

Brush away dry chemicalsBrush away dry chemicals

Special consideration for specific Special consideration for specific chemicalschemicals

Flush with copious amounts of water for Flush with copious amounts of water for 2020--30 minutes30 minutes

Page 68 of 143

11

Electrical BurnsElectrical Burns

Result in damage to fascia and muscle, and Result in damage to fascia and muscle, and may spare the overlying skinmay spare the overlying skin

ABCDEsABCDEs MyoglobinuriaMyoglobinuria

Fluid: 100mL urine/hourFluid: 100mL urine/hourManitolManitol: 25g IV: 25g IV

Metabolic acidosisMetabolic acidosisMaintain adequate perfusionMaintain adequate perfusionSodium bicarbonateSodium bicarbonate

FasciotomyFasciotomy

12

Burn Transfer ProcedureBurn Transfer Procedure

Coordinate with burn center doctorCoordinate with burn center doctor

Transfer withTransfer withDocumentation/informationDocumentation/informationLaboratory resultsLaboratory results

Page 69 of 143

1

2

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Page 73 of 143

1

2

Gall bladder stone

Indications Symptomatic Gall stone Previous biliary colic/ cholangitis Previous pancreatitis Previous cholecystitis Gall bladder polyp ( >1cm)

Page 74 of 143

3

Peptic ulcer

Medical intractable Poor drug compliance Suspicious with malignant change Bleeding Perforation Gastric outlet obstruction

4

GERD

LA Grade C,D Poor drug compliance Typical symptom Barrett's esophagitis Complicated with hiatal hernia

Page 75 of 143

5

Adhesion ileus

Persistent abdominal pain unrelieved with narcotics

Progressive abdominal fullness under close followed up

Fixed dilated bowel looped on plain film Clear transition zone Image evidence of volvulus

6

pancreatitis

Documented infected pancreatic necrosis Ongoing organ failure despite intensive

medical care and treatment Disease over 2 weeks Surgical expertise

Page 76 of 143

7

UGI bleeding

PES attempted and documented bleeder Failed PES hemostasis Differential varices or non varices bleeding Aggressive fluid/ blood / PPI failed Repeat PES not allowed

8

peritonitis

R/O medical disease, ex SBP, CAPD related peritonitis

Autmoimmune disease Gyn problems, ex PID, TOA Consider chronicity, ex mesenteric venous

thrombosis, chonic mesentery ischemia Tenderness location, relive by nacrotics

easily ?

Page 77 of 143

9

Diverticulitis

Repeat attack Suspicious malignancy Bleeding Obstruction Free perforation with fecal peritonitis Poor compliance for followed up High risk ( ex. Heart failure ) for repeat

attack

10

Inguinal hernia

R/O inguinal lymphadenopathy or iliac aneurym

Correct diagnosis without underlie severe co-morbidity

Indication: without contraindication

Page 78 of 143

1

2

Three Mechanisms of wound healing

Epithelization Wound contracture Extracellular matrix synthesis

Page 79 of 143

3

Types of Wound Healing

Primary Healing: wound is closed within hours of its creation.

Delay Primary Healing: contaminated or poorly delineated wound.

Secondary Healing: close by both wound contraction and epithelialization.

Healing of Partial Thickness Wounds: heal mainly by epithelialization.

4

Overview of Wound Healing

Tissue Injury Coagulation Early inflammation Late inflammation Fibroblast Migration/Collagen Synthesis Angiogenesis Remodeling Phase

Page 80 of 143

5

Cause of Delayed Wound Healing

1. Reinjury due to trauma or pressure: ischemia, crushed vasculature

2. Vascular disease: Venous: Edema due to reduced venous reflux, Compromised lymphatic function; Arterial: Arteriolsclerosis, Drug abuse

3. Nutritional deficiency: Water, Vitamines (A, B6, B12, C, Folate), Minerals (Zn, Fe, Ca), Protein, Calories

4. Compromised immune system: Immunosupressive drugs, HIV/AIDS, Advanced age, Radiation therapy

5. Metabolic disorder: DM, Gout, Porphyria, Impaired fibrin metabolism

6. Infections

6

Purpose of Wound Dressing

Absorb or draw away fluids Protect the wound from contamination Provide a more aesthetic appearance Provide pressure on the wound to help

maintain hemostasis posoperatively Proveide support to the wound site

Page 81 of 143

7

Considerations

Location of the wound Type of surgery performed Amount of drainage anticipated Postoperative care available to the patient Type of tissue encountered during surgery

8

When to change dressing?

Dressing slippage Leakage of exudate Strikethrough Unexplained pyrexia Foul smell Swelling of peripheral tissue

Page 82 of 143

9

Types of Wound Dressings

Traditional Absorbent Cellulosic Materials Tulle Gras DressingModern occlusive dressing

10

Occlusive Dressing

To create a moist wound environment To accelerate the re-epithelization To improve the quality of granulation

tissue in chronic wounds To aid debridement of necrotic wound

material To partially relieve pain

Page 83 of 143

11

Types of Occlusive Dressings

Transparent polymer films Polymer foams Gels Hydrocolloids Calcium alginates

Page 84 of 143

1

2

Acute Abdomen

any acute condition within the abdomen acute abdomen requires an acute decision.

Page 85 of 143

3

Clinical Assessment

History onset and duration of pain location and movement of pain quality and severity of pain associated symptoms past and current medical history Previous operation history Previous medical aid or not

4

Onset and differential diagnosis

Sudden onsetPerforated ulcer Acute Mesenteric infarction Ruptured abdominal aortic aneurysmRuptured ectopic pregnancyOvarian torsion or ruptured cyst

Page 86 of 143

5

Onset and differential diagnosis

Rapid onset VolvulusIntussusceptionBiliary colicDiverticulitisUreteral and renal colic

6

Onset and differential diagnosis

Gradual onset (hours)AppendicitisStrangulated herniapancreatitisPeptic ulcer diseaseInflammatory bowel disease

Page 87 of 143

7

Clinical Assessment

Physical Examination vital sign and general appearance

inspection, auscultation, percussion, palpation localization

special signs rectal and pelvic examination

8

Different pain

Visceral pain Somatic pain Referred pain: Any pain felt distal from a

diseased organ

Page 88 of 143

9

Lab

Laboratory analysis white blood cell count

Amylase / lipase urinalysis

test of pregnancy

10

image Imaging techniques

plain film radiography

ultrasonography computed tomography

contrast radiography endoscopy

MRI

Page 89 of 143

1

2

indications for inset of drains

expected post op fluid accumulationsSeroma, hematoma, biloma, lymph fluid

risk of infection without adequate drainageabscess, pseudocyst

Common Drainage device1. open or closed system 2. active or passive drainage

Page 90 of 143

3

type of drains depends on surgery

clean surgery : Lymphatic dissection, mastectomy, cholecystectomy, most liver and pancreas resection

closed-suction drainsoft silastic catheter with vaccumreservoir; ex: J-P drain +VB

Easy post op fluid or blood accumulations: thyroidectomy

Dirty or contaminated wound with residual abscess / debris : colon perforation, retriperitoneal abscess

Open-active drain ( sump drain + irrigation )

Passive drainage (Penrose) : less frequent adopted nowadays

4

Tube dislodgement

Review history, differentiate type of drain, indication for drain, recent drainage outflow condition and patient condition

Common principles : NG tube Without recent UGI operation For decompression only : re-on NG tube or keep

observations depends on recent decompressed amount

For Feeding: judge oral intake feasible or not With Recent UGI operation Ex. With recent gastrectomy: notify VS

Page 91 of 143

5

Common principles

T-tube If less than 1~2 weeks Notify VS immediate IF more than 2 weeks Re-inset nelaton tubefor instead previous T-tube and

keep cutaneous fistula tract

Jejunostomy tube If less than 1~2 weeks Notify VS immediate If more than 2 weeks Re-inset feeding tube without kinking through previous

stoma site unstil mark I and check patency without resistant via clear water

6

Common principlesFoley Clear cooperated patient Keep observation and spontaneous self voiding or not Unconscious or ICU Watech for external meatus with blood clot or notif

present, consider consult urologist for cystofixor further management

Other Drainage tube sump drain: insert nelaton tube instead according to

previous direction of sump drain JP drain: keep observation any complication while

dislodgement: such as drainage site hematoma etc penrose drain: review adequacy of previous drain and

replace nelaton tube if indicated

Page 92 of 143

7

Removal of drains

Depends on color, amount, serial consistency change or drainage content

Adequacy of drain itself Purpose of drain ( monitor or just drain)

8

Common principles

NG tube

For post gastrectomy1. < 500ml/day2. Without coffee ground content3. Presence of flatus and bowel movement

For decompression only < 500ml/day or marked improvement of ileus

Technique of Remove Remove slowly and steady after informed pt

Page 93 of 143

9

Common principles J-P drainFor clean operations Clear and serosanguinous content No obvious OP site fluid accumualtions No evidence of infectionFor contaminated wound Adequacy in drainage achieved No residual intra-op site infectionTechnique of Remove Release the cap of valve Steady withdraw after remove fixation stitches Wound open care

10

Common principles

Penrose drain No more gross dirty content Absence or residual intra-op site infection Adequacy of drainage achievedTechnique of Remove Advancement 1~2 inches is the rule Remove skin stitches and fix at skin level

with safety pin

Page 94 of 143

11

Common principles

Sump d11rain Clear effluent fluid documented Inset of drain at least 10~14 days No more indication for irrigation or observation

( anastomosis etc)Technique of Remove Close suction and irrigation system first Watch for the depth and direction of sump drain Replace with proper nelaton tubing ( 1 or 2 ) fix nelaton tube at skin level with safety pin

Page 95 of 143

1

2

FractureFracture

Complete fracture Complete fracture Incomplete fractureIncomplete fracture

DislocationDislocation,,

DislocationDislocationLuxationLuxation,,

Subluxation Subluxation

Page 96 of 143

3

MechanismMechanism

Direct injuryDirect injury

Indirect injuryIndirect injury

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Page 97 of 143

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Page 98 of 143

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Page 99 of 143

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Character of the fr. LineCharacter of the fr. Line

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ststSpinal fr.Spinal fr.

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Page 100 of 143

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Page 101 of 143

13

AO ( society of internal fixation) AO ( society of internal fixation) principlesprinciples

SS(Anatomical reduction)(Anatomical reduction)

(Rigid fixation)(Rigid fixation)

DEDE (Early mobilization)(Early mobilization)

abcZabcZ(Preserve soft tissue (Preserve soft tissue and blood supply)and blood supply)

abcZ,abcZ,

14

ReductionReduction

!!AlignmentAlignment

)t0=>)t0=>Rotational deformityRotational deformity

?@!?@!LengthLength

JJAppositionApposition

Page 102 of 143

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Types of Types of fixationfixation

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B) B) Internal fixationInternal fixation1.1.wirewire2.2.pinpin3. 3. screwscrew4.4.plateplate5.5.Intramedullary nailIntramedullary nail

Page 103 of 143

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18

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Page 104 of 143

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Page 112 of 143

1

2

Practice Advisory for Preanesthesia Evaluation

* Process of clinical assessment before delivery of anesthesia care for surgery and nonsurgical procedures

* Responsibility of the anesthesiologist

* Medical records, interview, physical examination, findings from medical tests and evaluations

Anesthesiology 2002;96:485-96

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3

Purposes of Preoperative Tests

Discovery or identification of a disease or disorder that may affect perioperative anesthetic care

Verification or assessment of an already known disease, disorder, medical or alternative therapy that may affect perioperative anesthetic care

Formulation of specific plans and alternatives for perioperative anesthetic care

4

Preanesthesia History and Physical Examination

Precedes the ordering, requiring, or performance of specific preanesthesia tests

Evaluation of pertinent medical records Patient interviews Physical examination

Page 114 of 143

5

Preanesthesia Physical Examination

An airway examination

A pulmonary examination to include auscultation of the lungs

A cardiovascular examination

6

Content of the Preanesthesia Evaluation

Readily accessible medical records

Patient interview

A directed preanesthesia physical examination (assessment of the airway, lungs and heart)

Preoperative tests when indicated

Other consultations when appropriate

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7

Evaluations, Tests and Consultations

Reasonable expectation-- benefits> potential adverse effects

A change in the content or timing of anesthetic management or perioperative resource utilization improve the safety and effectiveness of anesthetic processes

Adverse effects-- interventions that result in injury, discomfort, inconvenience, delays or costs that are not commensurate with the anticipated benefits

8

Page 116 of 143

9

10

Page 117 of 143

11

Page 118 of 143

1

2

Information Often Given to the Nurse at the Time of Information Often Given to the Nurse at the Time of Admission to the Postanesthesia Care UnitAdmission to the Postanesthesia Care Unit

* Patients name and age* Surgical procedure and type of anesthetic including drugs used* Other intraoperative drugs (antagonists, antibiotics,diuretics,

vasopressors, antidysrhythmics)* Preoperative vital signs* Co-existing medical diseases* Preoperative drug therapy, including preoperative medication* Allergies* Intraoperative estimated blood loss and measured urine output* Anesthetic and surgical complications* Special medications or procedures that will be necessary in the

postanesthesia care unit , including pain management ,arterial blood gases, and radiolographs

Page 119 of 143

3

Physiologic Disorders that May Manifest in the Physiologic Disorders that May Manifest in the Postanesthesia Care UnitPostanesthesia Care Unit

Upper airway obstruction Arterial hypoxemia Hypoventilation Hypotension Hypertension Cardiac dyshythmias Oligouria Bleeding Decreased body temperature Agitation (emergence delirium) Delayed awakening Nausea and vomiting Pain

4

Factors leading to Postoperative Arterial HypoxemiaFactors leading to Postoperative Arterial Hypoxemia Right left intrapulmonary shunt (atelectasis) Mismatching of ventilation to perfusion (decreased functional residual capacity) Decreased cardiac output Alveolaar hypoventilation (residual effects of anesthetics and/or muscle

relaxants) Inhalation of gastric contents (aspiration) Pulmonary edema Pneumothorax Posthyperventlation hypoxia Increased oxygen comsumption (shivering) Advanced age Obesity Diagnosis

* PaO2 < 60 mmHg (arterial blood gas) * clinical S/S: hypertension, hypotension, tachycardia, bradycardia, dyshythmias,

agitation are nonspecific. Low Hb impair detection of cyanosis Treatment

* postoperative oxygen therapy * find causing factors ex; naloxone for residual opioid* tracheal intubation---if hypoxemia persists despite 100% O2 administration---mechanically ventilation with PEEP

Page 120 of 143

5

Postoperative HypoventilationPostoperative Hypoventilation Etiology

* drug-induced central nervous system depress (volatile anesthetics, opioids)

* residual effects of muscle relaxants * suboptimal ventilatory muscle mechanics* increased production of carbon dioxide * co-existing chronic obstructive pulmonary disease

Diagnosis* PaCO2 > 44 mmHg (arterial blood gas)* sign---tachycardia and hypertension are nonspecific

Treatment* maintain a patent upper airway* find causing factors than resolve it

6

Factors Leading to Postoperative HypotensionFactors Leading to Postoperative Hypotension

Arterial hypoxemia* hypovolemia (most common cause)* decreased myocardial contractility

(myocardial ischemia, pulmonary edema)* decreased systemic vascular resistance

(residual effects of anesthetics, sepsis)* cardiac dysrthmias* pulmonary embolus* pneumothorax* cardiac tamponade

Dianosis and Treatment* oligouria (< 0.5ml/kg/h)---hypovolemia or decreased

myocardial contractility* fluid challenge---CVP or PA pressure* inotropics (dopamine) and vasopressor (phenylephrine)

Page 121 of 143

7

Postoperative HypertensionPostoperative Hypertension

Etiology* arterial hypoxemia* enhanced sympathetic nervous system

activity ( pain, bladder distension )* preoperative hypertension* hypervolemia* pain

Dianosis and Treatment* accuracy of the blood pressure measurement* find causing factors than resolve it* anti-hypertension drugs and arterial line monitor if necessary

8

Postoperative Cardiac DysrhythmiasPostoperative Cardiac Dysrhythmias

Etiology* arterial hypoxemia* hypovolemia* pain* hypothermia* anticholinesterases* myocardial ischemia* electrolyte abnormalities

hypokalemia ; hypocalcemia* respiratory acidosis* digitalis intoxication* preoperative cardiac dysrhythmias

Treatment* correct underling cause, patent upper airway and adequacy of PaO2* special drugs---atropine for bradycardia, verpamil for tachycardia, lidocaine

for VPCs

Page 122 of 143

9

Patient at High Patient at High RiskRisk of Postoperative Renal of Postoperative Renal DysfunctionDysfunction

Co-existing renal disease Major trauma Sepsis Advanced age Multiple intraoperative blood transfusions Prolonged intraoperative hypotension Cardiac or vascular operations Biliary tract surgery in presence of obstructive

jaundice

10

Possible Explanations for Delayed Awakening in the Possible Explanations for Delayed Awakening in the Postanesthesia Care UnitPostanesthesia Care Unit

Residual drug effects (opioids, benzodiazepines, anticholinergics)

Hypothermia Hypoglycemia Electrolyte disturbances Arterial hypoxemia Increased intracranial pressure (CVA) Air embolism Hysteria Treatment

* find causing factors* special drugs---naloxone for opioid overdose, physostigmine

for reversing CNS effects odf anticholinergic drugs and flumazenil antagonist for benzodiazepines

Page 123 of 143

11

Factors Associated with an Increased IncidenceFactors Associated with an Increased Incidenceof Postoperative Nausea and Vomitingof Postoperative Nausea and Vomiting

History of postoperative emesis Female gender Obesity Postoperative pain Type of surgery (eye muscle surgery,

middle ear surgery, laparoscopic surgery) Anesthetic drugs (opioids, nitrous oxide?) Gastric distension Treatment

* R/O other causes ex: hypoxia, hypotension,hypoglycemia andIICP

* prophylactic antiemetic for high risk patient---ondansetron4-8mg iv, metoclopramide 10-20 mg iv less efficacy, transdermal scopolamine is good

12

Postoperative Respiratory TherapyPostoperative Respiratory Therapy

Postooperative decrease in VC and FRC, poor cough, retension of secretions and atelectasis---pneumonia, hypoxemia

Factors that influence the incidence of postoperative pulmonary complications---site of surgery, co-existing pulmonary disease, cigarette smoking, obesity, and advanced age

Page 124 of 143

13

Postoperative Respiratory therapyPostoperative Respiratory therapyOO22 TherapyTherapy

Nasal cannula---O2 concentration is increased about 4% for each 1 l/min of O2 delivered, max. 6 l/min (44% O2)

Face mask* simple mask---no valve or reservoir bag, can provide inhaled O2 concentration between 35% and 60% with O2 flow rate 5 to 8 l/min

* partial rebreathing---valveless with O2 reservoior bag,O2 flows higher than 10 l/min, inhaled O2 concentrations are between 50% and 65%

* nonrebreathing---unidirectional valve plus an O2reservoir bag, inhaled O2 concentration can increased to near 100%. Difficult to provide a sufficiently tight mask fit and the flow rate of O2 into the system should be sufficient to maintain an inflated reservoir bag

14

Postoperative Respiratory TherapyPostoperative Respiratory Therapy

Oxygen therapyAir-entrainment (venturi) mask---inhaled O2 concentration 24-40% (2-12 l/min O2 flow)

Humidification and Aerosol therapy* bubble-through humidifiers---37c relative humidity near 100%* jet nebulizers---humidity inspired gases, decrease the viscosity of

airway secretions,and deliver bronchodilator drugs (epinephrine, albuterol) directly to the airways

Bronchial hygiene mucocillary clearance; coughing; tracheal suctioning; chest physiotherapy

Interventions to increase resting lung volumes voluntary deep breathing and ambulation; intermittent positive pressure breathing; incentive spirometry

Page 125 of 143

1

2

Definition of Anesthesia

General concept of anesthesia

The role of anesthesiologistProvide anesthesia

Provide intensive care during the operation

Provide postoperative analgesia

Page 126 of 143

3

Types of Anesthesia

Local anesthesia

Regional anesthesia (Peripheral nerve blockade)

Neuraxial anesthesia

General anesthesia

4

Local anesthesia (LA)

Local anesthetics infiltration

Usually performed by the surgeon

Limited by:Less pt satisfaction

Operation range & depth

Toxicity of local anesthetics

Page 127 of 143

5

Regional anesthesia (RA)

Peripheral Nerve blockadeBy local anesthetics

Contraindications:Patient refusal

Coagulopathies

Pre-existing neuropathies (relative)

6

Neuraxial anesthesia

Types of neuraxial anesthesiaSpinal anesthesiaEpidural anesthesiaCaudal anesthesia

ContraindicationsPt refusalCoagulopathiesCNS lesion/IICP conditionsPre-existing neuropathies (relative)Spine deformities (relative)Hypovolemic statusSepsisPre-existing infection at puncture site

Page 128 of 143

7

General anesthesia (GA)

Types of GA:IVGA/Heavy sedation

Only suitable for short duration, mild stimulation procedures

GA with mask/LMGA (GA with laryngeal mask)ETGA (GA with endotracheal tube)

Contraindications:No absolute contraindicationsRisk & Benefit considerations in certain

conditions

8

Anesthetic agents

Local anestheticssodium channel blockersLidocaineBupivacaine

General anesthesia agentsInhalation agents

Desflurane Sevoflurane N2O

Intravenous agents Hypnotics Analgesics Muscle relaxants

Page 129 of 143

9

Hypnotics (IV Induction agents)

BarbituratesThiamylal (Citosol); Induction dose 3-5 mg/kg

Propofol (Fresofol)Induction dose 1.5-2.5 mg/kg

BZDsMidazolam (Dormicum); Induction dose 0.1-0.2 mg/kg

EtomidateInduction dose0.2-0.4 mg/kg

KetamineInduction dose 1-2 mg/kg

10

Analgesics

OpioidsMorphine

Meperidine

Fentanyl

Alfentanil

Other adjuventsLidocaine

NSAIDs Ketorolac

Ketamine

Page 130 of 143

11

Muscle relaxants

Depolarizing agentsSuccinylcholine

Short duration, fast onset Do not need a reversal agent Dose for muscle relaxation in 60 seconds: 1-1.5 mg/kg Numerous side effects include hyperkalemia & lethal malignant

hyperthermia

Non-depolarizing agentsRocuronium

Dose for muscle relaxation in 90-60 seconds: 0.6-1 mg/kgCis-atracurium

0.1 mg/kg will achieve muscle relaxation in 3-4 minutes Not suitable for rapid sequence intubation (RSI)

Necessisate a reversal agent Neostigamine (should give in association with atropine)

12

Thank you very much!

Reference:1. Millers Anesthesiology, 6th edition

2. Clinical anesthesia, 5th edition

Page 131 of 143

1

Endotracheal Intubation

2

Ambu Masking

Thumb and index finger of left hand in the shape of a Cpress down

The other three fingers at the inferior ramus of the mandible and lift the mandible up (jaw thrust)

Page 132 of 143

3

In Case of Suspected C-spine Injury

Trauma chin lift Trauma jaw thrust

4

The Optimal Position of Head and Neck During Intubation

The sniffing position: flexion of the neck and extension of the atlantooccipital joint

Page 133 of 143

5

Holding a Laryngoscope

Hold the handle of the laryngoscope with your left hand unless you are left-handed

6

Open Mouth Techniques

Hyper-extension technique (no touch technique)

Cross fingers techniques

Page 134 of 143

7

Inserting the Blade

Advance blade over tongue until uvula and tonsillar folds are seen.

Then move it to right side of mouth so it lies between aryepiglottic folds and tongue. This maneuver displaces tongue to left.

Advance blade further until its tip lies in vallecula.

8

Lifting Up a Laryngoscope

Pull the blade forward and upward using firm but steady pressure without rotating the wrist

If possible, avoid leaning on the upper teeth with the blade

Page 135 of 143

9

Exposure of the Larynx

In most situations the vocal cords should become visible .

If not, exert gentle pressure over the cricoid area to help bring them into view

10

BURP Maneuver

Backward: posterior pressure on larynx against the cervical vertebrae

Upward: superior pressure on larynx as far as possible

Right: lateral pressure on larynx to the right

Page 136 of 143

11

Role of an Assistant

To provide the endotracheal tube with stylet to the operators right hand

To apply circoid pressure

Facilitates intubation using BURP maneuver

Page 137 of 143

1

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