VHD for acute non cardiac surgery

VHD Anaesthesia

Arrhthmia Management

Epidural blood patch

Epidural Blood Patch.

1. CONFIRM CONFIRM CONFIRM   that headache is PDPH and NO NEUROLOGY
2. Religiously rule out other causes of headache
3. Do it after 24 hours
4. contraindication-routine like fever/coagulopathy/infection etc etc
5. Indication: Pt who has  received a 'wet tap' epidural or subarachnoid injection, and who has a headache which  is sufficiently incapacitating ,the characteristics of a PDPH, and not relieved by conservative management (bed rest in the supine position, hydration, caffeine or caffeine-containing drinks, oral simple analgesics, non-steroidal anti-inflammatory agents),
6.Techique
 Explaining the technique, hazards and anticipated success rate
 Informed consent (imp part is possibility of getting bigger hole with Tuohys needle !!!!!!!!!!!!!!!!!)
 Starting an intravenous drip
Position: left lateral, fully-flexed position. Two-operator technique.
Both operators should scrub, gown and glove as is standard in the particular institution.
Operator 1.Cleans and drapes the patient's back using a standard epidural kit and technique, Identifies the site of original puncture(or one below) and locates the epidural space using a standard technique . At the same time as operator 1 is prepping the back, the second operator cleans and drapes the antecubital area of (usually) the left (downside) arm. A second kit and drapes containing a 20cc syringe with 22G sterile straight or butterfly needle is ideal for the task. Once the epidural space is located by operator 1, the second operator, using a rigidly aseptic technique, performs a venepuncture, withdraws 20-25 mls of blood, removes the needle from the syringe, hands the syringe to the first operator (without breaching the integrity of the sterile fields) and applies pressure and a sterile dressing to the venepuncture site.
blood  injection
Inject the blood slowly until either, the patient complains of tightness in the buttocks, lower back or thighs (usually when 12 to 15ml are injected)  or, until 20 ml is injected. Withdraw the needle, apply a sterile dressing and turn the patient to the supine position. Inject the residual blood through a fresh, sterile needle into a blood culture bottle and send to bacteriology for culture and antibiotic sensitivity.
Post procedure= supine for atleast one  hour
Advise to patient
 report fever, back or radicular pain, PDPH
Results : majority of cases, expect almost instantaneous relief  and in few in  24-48 hours  period. Common feeling  of mild backache for a few days. < 2% will also have mild, transient paraesthesiae, neck pain or radicular pain

Levosimendan

This is the translated protocol document of our hospital Levosimendan

जरासी सावधानी : ज़िन्दगी मै ना रहें परेशानी

Dr.Sameer Ghotavadekar

       ( ABCDE…of Anaesthesia practice)

Dear friends,

This is in support & extension to the discussion about machine check and safe anaesthesia on our Facebook forum.

In India,institutional practice is concentrated in metros, where operation theaters are well equipped and properly managed by dedicated staff. Actually, more than 75 % of our colleagues are practicing in small to medium sized nursing homes.  Every day most of them leave their houses early in the morning (with their "dabba batli") running around from one clinic to another, knocking down patients so that surgeons can operate peacefully. 

These frequently changing ( some times absolutely unfamilier ) working environments add to the traffic and profession related stress. These circumstances are extremely vulnerable to serious human errors and life threatning accidents. Therefor,during this cross country tour one should not forget basic checks in  every setup before starting a case how so ever familiar the setup may be.  Just one mishap and career is ruined especially in this era of breaking news on electronic media.

Recent brainstorming inputs on our Facebook forum  from our colleagues from India &  different parts of the world stimulated me to go through the different international preanaesthesia safety check guidelines. WHO and WFSA (World Federartion of Societies of anaesthesiologists) have worked in depth in this area and developed useful guidelines.

In 2009 ,WHO has published the Guidelines for safe surgery under their "Safe surgery Save life campaign.”  Though extensive and supported with tons of references, it is a document worth referring.

The international task force for anaesthesia safety, in 2010, updated their previously  developed 'Standards'  which are adopted  & published by  WFSA  in their  document " International Standards for a Safe Practice of Anesthesia 2010.”

Most of their recommendations give very clear message about what should be done, where  & how.

Points described & recommended in above documents, ideally, are expected to be meticulously followed, but during our cross country tour, it is not always possible.

Therefore, I have made a tailor made checklist suitable to our practice.

Airway:

Appropriate sized Airways & masks,Ambu bag with oxygen tubing, Intubation tray i.e. Functioning laryngoscope, endotracheal tubes. One should also have a bougie in case of unanticipated difficult intubation. Functioning suction with appropriate sized suction catheter. Functioning Operation table.

Breathing:

Oxygen - ensure enough supply even if case is in local or regional anaesthesia. Appropriate  & functioning ventilation circuit .(Because you never know when you will have to go in for GA or in worst case resuscitation.)

Circulation:

Appropriate sized venous canulas, availability of i.v. fluids.

Drugs :

Emergency resuscitation drugs: Atropine, Adrenaline, Sodium Bicarbonate, Calcium Chloride, Aminophylline, Amiodarone,Dopamine,Steroid,Antihistamines etc.

Anaesthesia Drugs: Adequate amount of drugs needed to continue anesthesia for at least 50% more time than surgeon has predicted

Equipments:

Pulse oximeter,B.P.Apparatus,CO2 monitor,ECG monitor, Suction machine,Anesthesia machine.          The equipment check guidelines are elaborately listed in the document of Anesthesia Patient Safety Foundation. ( fig.2 ,fig.3)

File:  

Check for patient related factors which may put us in trouble. Take a thorough history about previous illnesses, surgeries, allergies, lab reports and other relevant investigations. During examination,airway should be meticulously evaluated and if necessary, difficult intubation tray should be made available.(fig.1) If needed by virtue of patient's condition and limitation of small setup one should be frank to tell surgeon & patient about conducting the case in an institutional setup with ICU back up. Most important point is to obtain/confirm existence of valid consent. 

Glucose:

Be sure that your own glucose level is normal i.e.you are physically and mentally fresh to conduct the case. Physical and mental fatigue can take a toll on decision making especially in unexpected emergency situations.

Humor:

Say hallo to surgeon and crack  a joke!! This is to ensure  that surgeon and anesthetist are in a good mood & comfortable working with each other. Uneasiness in operating room atmosphere again may affect performance of both surgeon and anesthetist.

Incentive : ????? 

After Amir Khan's program on Doctors, I have deleted this point from my checklist. But it is important for us, because surgeon and management might not have seen Amir Khan's program and might cancel the case if the patient has not paid the advance.This will waste the drugs, and disposables.

These are few thing I could recollect that we should go through but suggestions and additions are most welcome for safety of anesthetist and patient.( there are still 17 alphabets remaining.  )

 Refrences :

Proposed New Anaesthesia Checklist Sign In

International Standards for a Safe Practice of Anaesthesia 2010

New Guidelines Available for Pre-Anesthesia Checkout

Fig.1

Fig.2

fig.3

                                                                                                 Dr.Sameer Ghotavadekar
                                                                                                                                 Consultant Cardiac Anaesthetist

                                                                                                                                 Ruby Hall Clinic ,Pune.
                                                                                                                                 Maharashatra,India.
                                                                                                                                 sameer.ghotavadekar@gmail.com

Tips & Tricks

Dear friends !!                                           

During our successful career we have seen many ups and downs, many acute and panic moments. We have worked in many adverse surroundings and difficult situations.  To avoid complications we all must have modified our practices by doing some simple tricks suitable to the situation.These tricks are not given in any textbooks and  may not be practically applicable in all situations.   You are quite  successful & happy   with your improvisation but doubt that  the tricks will be accepted in a  formal scientific platform. If you believe that they are  worth sharing, please forward it to interactive anesthesia forum so that other colleagues who  probably  are in similar situation may benefit from it  .

Let us help each other to make our practice safe and better .

We are attaching few such examples .





Smart use of Used Ventilator tubing to organize the cabels of monitor and tranducer cords.
Avoids many accidents ,gives more space. 

Fig 1.

A Simple Arm Positioning Aid  for Fracture Table Cases 

Problem:

When positioning a patient on the fracture table for open reduction/internal fixation of a femoral neck fracture, it is commonly necessary to secure the arms over the chest in a crossed fashion to avoid contact with the fluoroscope. Most hip fracture patients are elderly, and are at risk for skin abrasions if tape is used for this purpose. Wrapping sheets around the patient to secure the arms can prevent access to the peripheral intravenous site, and may not adequately restrain the arms during manipulation of the lower extremities by the surgical team.

There has been succefully used  a soft foam donut-style headrest to gently but securely restrain the patient's arms across the chest. This method is well tolerated by a conscious patient with a regional block. It allows unobstructed access to hands and arms for peripheral venous or arterial line manipulation, and permits the use of a standard safety belt to hold the patient on the table.

To use a foam doughnut headrest for this purpose, first insert the patient's left arm into the hole and advance the headrest above the elbow until it is around the distal third of the humerus. Position that arm across the chest with the left hand lying over the right biceps area. Then cross the right forearm over the left forearm so the left wrist rests in the antecubital area of the right arm, and insert the right hand and wrist into the hole. The circular insert from the foam headrest may then be placed between the arms to pad one from the other. Of course, right and left arm positions may be switched as dictated by line placement or convenience. The final arrangement is shown in figure 1.

Please forward your inputs  on    interactiveanaesthesia@gmail.com 

( Do not forget to include your name,email address and institute.We are creating a page called TIPS &TRICKS .Your inputs will be included both in the main page and in the TIPS & TRICKS section.)

Have a Nice Day

                                                                                                  Interactive anaesthesia

Dear friends !!
This is small information about blog.

 A blog  is a personal journal published on the Internet consisting of discrete entries ("posts") typically displayed in reverse chronological order so the most recent post appears first. Blogs are usually the work of a single individual, occasionally of a small group, and often are themed on a single subject.
The emergence and growth of blogs in the late 1990s coincided with the advent of web publishing tools that facilitated the posting of content by non-technical users. (Previously a knowledge of such technologies as HTML and FTP had been required to publish content on the Web.)
Although not a must, most good quality blogs are interactive, allowing visitors to leave comments and even message each other via GUI widgets on the blogs and it is this interactivity that distinguishes them from other static websites. In that sense, blogging can be seen as a form of social networking. Indeed, bloggers do not only produce content to post on their blogs but also build social relations with their readers and other bloggers.
Many blogs provide commentary on a particular subject; others function as more personal online diaries. A typical blog combines text, images, and links to other blogs, Web pages, and other media related to its topic. The ability of readers to leave comments in an interactive format is an important part of many blogs. Most blogs are primarily textual, although some focus on art (art blog), photographs (photoblog), videos (video blogging or vlogging), music (MP3 blog), and audio (podcasting). Microblogging is another type of blogging, featuring very short posts.

As of 16 February 2011 (2011 -02-16) there were over 156 million public blogs in existence.
Our blog is provided by  Google and hence if we want to  write a blog,post comment on the blog or reply to the comment, it is easier  if we have a gmail account as our name automaticaly appears in the comment.
Please use this facility and be more interactive .
                                                                                 Interactive anaesthesia
Source : Internet various websites

I would request all my colleagues to creat gmail I.Ds ( I am sure most of us have one ).

Please send the i.d. to the account interactiveanaesthesia@gmail.com.
We can send you invitation to creat your own page and write your own blog ( its a  like a column  in a newspaper )
The author has freedom to upload videos ,images etc on their own page.
If you need any assistance  in creating a page,writing a blog,uploading videos,images etc please send your queries to the above mentioned email address.

Hello Friends 
We are creating this blog because many of our friends have tons of information to share. But because of space limitation and nature of interaction ( question and answer ),we thought we should create enough space for our colleagues .Those who have  important information ,good pictures,video clips, x- rays, articles etc to share,  can  upload in comments. Those who want to share their published/unpublished scientific work can attach in their own blog after creating own blog page .


                      Dr.Sandeep Mutha