Gas Monkey
Anaesthesia for JMOs
Dr Ben Piper
ICU and Anaesthetic Registrar
What we will cover today
1. Acute Pain on the wards•
Some “go-to” moves.
2. Special circumstances•
Problems after Spinal and Epidural anaesthesia
If we have time…
1. My patient needs surgery•
What does the anesthetist want to know?
Pain
• What is pain?
– An unpleasant sensory and emotional experience
associated with actual or perceived tissue damage.
• Types of Pain- “the good, the bad and the ugly”
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–
–
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Somatic- good
Visceral- bad
Neuropathic
Psychogenic (careful now)
Ugly
Multi Modal Analgesia
Case Study
• 46yo 140kg lady 12hrs post ORIF of patella
• 10/10 pain in anterior knee
• Screaming, sweaty, tachycardic
– Currently on Paracetamol 1g QID, Endone 5-10mg Q4H,
• What sort of pain is this?
• Why now?
• What can you do? What do you do?
Options…. What would you do?
1.
2.
3.
4.
5.
6.
Endone: give double stat dose (20mg)
NSAIDs STAT and chart regular dose
Oxycontin 20mg BD
IM Morphine 0.1mg/kg
Lean body mass!!!!!
IV Morphine 0.05mg/kg
Say: “What did you expect, this is
surgery- harden up princess”.
7. Page the Anaesthetic Registrar
Pain is like fire……
Get it before it gets you……
Case Study cont…
• Your plan:
– Damage control- “put out the fire”
•
•
•
•
IV morphine 5mg STAT
IV morphine 2mg increments every 10min
Patient will need supplemental Oxygen
Regular obs- Q15min for 1hr post IV morphine
– Planning ahead
• Chart regular ibuprofen 400mg TDS
• Increase Endone frequency to 10mg Q3H
• If not controlled call APS for help
Case Study cont…
• Your excellent plan worked…1hr later
– Pain is now 1/10
– RR 7
– Sat 92% on 3L
• What is going on? What will/can you do?
Case Study cont…
• O/E: pupils 2mm R=L, drowsy.
– You increase Oxygen to 100% NRBM
– Sats now 94%
• What is the problem?
• How long does morphine “last”
• You decide on Naloxone
– What about the pain?
– How much?
– How often?
Morphine and Naloxone
Much longer than most think!
• Morphine
Endone peak 30min duration 1-2 hrs
– IV Peak 10-20min Duration 1-2hrs
– IM Peak 30min
Duration 2-3hrs
• Naloxone
– IV 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!
Fixed
• After 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!
Take home message
•
•
•
All 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:
1. Help when you are unsure
2. Yourself and the patient out of trouble!
–
Have a few “go to moves”
Special Circumstances
“Stuff that fancy pants
Anaesthetic doctors do but don’t
tell anyone about” – Anonymous JMO
Case study: “No sympathy”
• 64yo man returned to ward post TURP
– Bkg: HTN, smoker, BPH
• Nurse calls for clinical review:
– Obs: BP 90/40 HR 60
– O/E: pain free, talking to you
• What do you do?
Choose your own adventure
1.
2.
3.
4.
Bolus IVF 500mL
Don’t worry his HR is not elevated (60)
Withhold tonight's perindopril dose
Panic
Case study: “No sympathy”
• You bolus 500mL and with hold his
perindopril
• 15min later:
– BP75/40, HR 52, nauseated
– What do you do? What is going on?
– Why is this man not maintaining his BP?
Memory scratcher
Sensor
Response
Case study: “Overly sympathetic”
• You check his sensation:
• “He is numb to the nipples”
• “High Block”:
–
–
–
–
This is a medical emergency
Stop any intrathecal medications
Call a MET
Give IVF, elevate legs, ACLS
• Treatment: 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”
Case Study: “Morphology”
• 56yo man, 4hrs post TKR
– PMHx: OA, OSA
– Nurses ask for review b/c RR 6 sat 98%
• Initial thoughts?
• What do you need to know?
Case Study: “Morphology”
• On Exam:
– Drowsy but can answer questions, Pupils
3mm reactive.
– Pain free
– No opiates have been given post operatively.
– Block height to umbilicus starting to wear off.
Case Study: “Morphology”
• RR now 5
• Sat 92%- bugger.
• 100% NRBM/MET call
• The anaesthetic registrar gives naloxne in 100mcg
increments- plan basically the same as before!
• Why??
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?
Take home message
• Neuro-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!!
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 preoperatively 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???
My MET call mantra- “ABC and…”
•
•
Have a basic plan for the nurses:
Identify the nurse looking after the patient, “Jane”:
“Jane, can you please:
1. Increase the oxygen to 100%”
“Jane, can you please get someone else to:
1. Check a BSL
2. Do an ECG
3. Get me the notes
So that you can tell me about what has happened”.
“Thankyou Jane-”
•
This:
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–
–
Gives the impression that you are not panicking,
gives others confidence in you and themselves,
and gets things done
Thanks
“Have fun at work:
– do Anaesthetics and/or
Intensive Care”
My patient needs Surgery…
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?
A basic approach (there are many)
• Airway & Anaesthetic History:
• Breathing: Respiratory function/reserve
• Circualtion: Cardiovascular function/reserve
• Drugs: what, why and when?
• Eating: When, what
Airway & Anaesthetic History:
• Airway:
– Can their mouth open?
– Can their neck move?
– Can you see their oropharynx? MP score
– Are they obese?
• Have they had previous anaesthetics?
– Were there any problems?
Breathing: Respiratory
function/reserve
• Respiratory
– Smoker?
– SOB: when, why
– WOB due to either
• Restriction from parenchyma (fibrosis/APO)
• Obstruction to flow (asthma/COPD)
– Spirometry -if available• FEV1
• FVC
– Concurrent infection
Circualtion: Cardiovascular
function/reserve
Cardiovascular:
(more than just “patient has history of IHD”!! We all say it, but it means nothing!!)
– Exercise tolerance- the best test
• Walking distance/stairs/what actually stops them
– Cardiac Failure: what type, symptomatic?
– Angina: when, why, new?
– Valve disease: Murmur, symptomatic?
– Stents of surgery: what, when
Drugs: what, when and why?
• Special attention to:
– Cardiac meds
– Antiplatelets
– Anticoagulants
– This will effect the type of anaesthesia that
can be utilized.
• E.g. Spinal vs General