Presentation on theme: "Dr Ben Piper ICU and Anaesthetic Registrar"— Presentation transcript:
1 Dr Ben Piper ICU and Anaesthetic Registrar Gas MonkeyAnaesthesia for JMOsDr Ben PiperICU and Anaesthetic Registrar
2 What we will cover today Acute Pain on the wards-Some “go-to” moves.Special circumstances-Problems after Spinal and Epidural anaesthesiaIf we have time…My patient needs surgery-What does the anesthetist want to know?
3 Pain What is pain? Types of Pain- “the good, the bad and the ugly” An unpleasant sensory and emotional experience associated with actual or perceived tissue damage.Types of Pain- “the good, the bad and the ugly”Somatic- goodVisceral- badNeuropathicPsychogenic (careful now)Ugly
5 Case Study 46yo 140kg lady 12hrs post ORIF of patella 10/10 pain in anterior kneeScreaming, sweaty, tachycardicCurrently on Paracetamol 1g QID, Endone 5-10mg Q4H,What sort of pain is this?Why now?What can you do? What do you do?
6 Options…. What would you do? Endone: give double stat dose (20mg)NSAIDs STAT and chart regular doseOxycontin 20mg BDIM Morphine 0.1mg/kgIV Morphine 0.05mg/kgSay: “What did you expect, this is surgery- harden up princess”.Page the Anaesthetic RegistrarLean body mass!!!!!
7 Get it before it gets you…… Pain is like fire……Get it before it gets you……
8 Case Study cont… Your plan: Damage control- “put out the fire” IV morphine 5mg STATIV morphine 2mg increments every 10minPatient will need supplemental OxygenRegular obs- Q15min for 1hr post IV morphinePlanning aheadChart regular ibuprofen 400mg TDSIncrease Endone frequency to 10mg Q3HIf not controlled call APS for help
9 Case Study cont… Your excellent plan worked…1hr later Pain is now 1/10RR 7Sat 92% on 3LWhat is going on? What will/can you do?
10 Case Study cont… O/E: pupils 2mm R=L, drowsy. What is the problem? You increase Oxygen to 100% NRBMSats now 94%What is the problem?How long does morphine “last”You decide on NaloxoneWhat about the pain?How much?How often?
11 Morphine and Naloxone Morphine IV Peak 10-20min Duration 1-2hrs IM Peak 30min Duration 2-3hrsNaloxoneIV Dose 100mcg at a time wait 1min- repeat.(slow and steady, you can always give more!!)Duration 30-60min HENCE need to remain monitored and may need repeat dosing (it wears off before morphine!)What are you aiming for?Here is an ampoule- draw it up as you would use it!Much longer than most think!Endone peak 30min duration 1-2 hrs
12 FixedAfter two doses of 100mcg the patient is less drowsy, RR 14, sat 98%You keep her on Oxygen with 15min Obs for the next hour, 30min the hour after that.Pain is settling and she gets a good nights sleep! She thinks you are a hero!
13 Take home messageAll doctors need to have a plan for the patient with severe pain!All patients on IV/IM opiates need Oxygen!Get to know your core drugs- discuss a plan with a senior and try it in daylight hours!(alone at night is not the time!)Know how to get:Help when you are unsureYourself and the patient out of trouble!Have a few “go to moves”
14 Special Circumstances “Stuff that fancy pants Anaesthetic doctors do but don’t tell anyone about” – Anonymous JMO
15 Case study: “No sympathy” 64yo man returned to ward post TURPBkg: HTN, smoker, BPHNurse calls for clinical review:Obs: BP 90/40 HR 60O/E: pain free, talking to youWhat do you do?
16 Choose your own adventure Bolus IVF 500mLDon’t worry his HR is not elevated (60)Withhold tonight's perindopril dosePanic
17 Case study: “No sympathy” You bolus 500mL and with hold his perindopril15min later:BP75/40, HR 52, nauseatedWhat do you do? What is going on?Why is this man not maintaining his BP?
19 Case study: “Overly sympathetic” You check his sensation:“He is numb to the nipples”“High Block”:This is a medical emergencyStop any intrathecal medicationsCall a METGive IVF, elevate legs, ACLSTreatment: Hopefully the cavalry will arrive!IVF- Starling may help a bit!Vasopressor + chronotropy: Alpha and beta agonist!Don’t do this unless you know what you are doing!!Get advise from someone who knows!This is a registrar “go to move”
20 Case Study: “Morphology” 56yo man, 4hrs post TKRPMHx: OA, OSANurses ask for review b/c RR 6 sat 98%Initial thoughts?What do you need to know?
21 Case Study: “Morphology” On Exam:Drowsy but can answer questions, Pupils 3mm reactive.Pain freeNo opiates have been given post operatively.Block height to umbilicus starting to wear off.
22 Case Study: “Morphology” RR now 5Sat 92%- bugger.100% NRBM/MET callThe anaesthetic registrar gives naloxne in 100mcg increments- plan basically the same as before!Why??
23 Case Study: “Morphology” As it turns our morphine and Fentanyl in commonly used in spinal anaesthetics.Here are some charts: these are the areas to look at on the anaesthetic chart for this info.Was it the Morphine or the Fentanyl? Why the delay?? Any ideas?
24 Take home messageNeuro-Axial blockade can cause major disruption in cardiovascular/Resp function- it can be delayed and present on the ward.It must be recognised!!Management of Post Op patients needs an understanding of basic physiological principles that many of us forget after med school!Read the Anaesthetic sheet! Its full of goodies!If in doubt ask!! We don’t bite!!
25 Quick: other pearls for the ward.. Beta Blockers: It is quiet rare that you need to withhold these (bradycardia, heart block) – generally don’t do it, even if NBM!!Oxycontin: Do not withhold chronic opiates pre-operatively even if NBM!Special patients:The classic “possible opiate seeker”, give the patient the benefit of the doubt initially- seek higher level input thereafter. Tramadol can be handy here- less “buz” but good analgesic.Palliative care: seek higher advise early!! They are lovely people to deal with!Any questions???
26 My MET call mantra- “ABC and…” Have a basic plan for the nurses:Identify the nurse looking after the patient, “Jane”:This:Gives the impression that you are not panicking,gives others confidence in you and themselves,and gets things done“Jane, can you please:Increase the oxygen to 100%”“Jane, can you please get someone else to:Check a BSLDo an ECGGet me the notesSo that you can tell me about what has happened”.“Thankyou Jane-”
27 Thanks“Have fun at work:do Anaesthetics and/or Intensive Care”
29 My patient needs Surgery… What does the anaesthetic team need to know?(A part from the basic PMHx and current problem)We want to know what degree of stress/trauma a person can withstand?The surgeons are about to unleash their fury on them.Key Question:What is their physiological reserve?
30 A basic approach (there are many) Airway & Anaesthetic History:Breathing: Respiratory function/reserveCircualtion: Cardiovascular function/reserveDrugs: what, why and when?Eating: When, what
31 Airway & Anaesthetic History: Can their mouth open?Can their neck move?Can you see their oropharynx? MP scoreAre they obese?Have they had previous anaesthetics?Were there any problems?
32 Breathing: Respiratory function/reserve Smoker?SOB: when, whyWOB due to eitherRestriction from parenchyma (fibrosis/APO)Obstruction to flow (asthma/COPD)Spirometry -if available-FEV1FVCConcurrent infection
33 Circualtion: Cardiovascular function/reserve (more than just “patient has history of IHD”!! We all say it, but it means nothing!!)Exercise tolerance- the best testWalking distance/stairs/what actually stops themCardiac Failure: what type, symptomatic?Angina: when, why, new?Valve disease: Murmur, symptomatic?Stents of surgery: what, when
34 Drugs: what, when and why? Special attention to:Cardiac medsAntiplateletsAnticoagulantsThis will effect the type of anaesthesia that can be utilized.E.g. Spinal vs General