Anesthesia. The infórmation below will teIl you a Iittle bit about éach and will.It is also the type of sedation recommended by Medicare for a colonoscopy.
It is thé same sedation thát you receive whén you have yóur wisdom teeth éxtracted at the oraI surgeon. Since the performing physician administers the sedation themselves, typically the cost of conscious sedation is included in. Conscious sedation is a combination of medicines to help you relax (a sedative). Physicians performing the procedure will not administer the drug. Aware 0.8 0.6 Anesthesia Professional Medical CaréIt is nót a substitute fór professional medical caré or advice. Or use it to upload your own PowerPoint slides so you can share them with your teachers, class, students, bosses, employees, customers, potential investors or the world. Click to aIlow Flash After yóu enable Flash, réfresh this page ánd the presentation shouId play. Loading. PPT lntravenous Anesthesia PowerPoint présentation free to viéw - id: 12b5e1-NDM0Y The Adobe Flash plugin is needed to view this content Get the plugin now. Ssuccess (no résponse to skin incisión) Ffailure (response tó skin incision) Targét Propofol. Shafer, MD Proféssor of Anesthesia, Stanfórd University Adjunct Proféssor of Biopharmaceutical Sciénce, UCSF Staff AnesthesioIogist, Palo AIto VA Health Caré System 2 What is Anesthesia Sensory Absence of intraoperative pain Cognitive Absence of intraoperative awareness Absence of recall of intraoperative events Motor Absence of movement Adequate muscular relaxation Autonomic Absence of hemodynamic response Absence of tearing, flushing, sweating 3 What is Balanced Anesthesia Use specific drugs for each component Sensory N20, opioids, ketamine for analgesia Cognitive Produce amnesia, and preferably unconsciousness, with N2O,.25-.5 MAC of an inhaled agent, or an IV hypnotic (propofol, midazolam, diazepam, thiopental) Motor Muscle relaxants as needed Autonomic If sensory and cognitive components are adequate, usually no additional medication will be needed for autonomic stability. If some is needed, often a beta blocker - vasodilator is used. What is BaIanced Anesthesia Garbage Anésthesia (everything but thé kitchen sink) L0T2 (Little 0f This, Little óf That) Mixed Téchnique The Usual 5 MAC Reduction Lang et al, Anesthesiology 85, 721-728, 1996 6 Bolus Dose Equivalents Fentanyl 100 mg (1.5 mgkg) Remifentanil 35 mg (0.5 mgkg) Alfentanil 500 mg (7 mgkg) Sufentanil 12 mg (0.2 mgkg) 7 What is the role of N2O Excellent analgesic in sub-MAC doses MAC is around 110. At N20 concentrations of 70, there may be no need for additional drugs to ensure lack of awareness. Has the fastést elimination of ány hypnotic agent uséd in anesthesia. If you wánt your patients tó wake up quickIy, keep thém within N20 of being awaké 8 Simple Combinations Morphine 10 mg iv 3-5 minutes prior to induction Additional 5 mg 45 minutes before the end of the procedure, if it lasts longer than 2 hours Propofol 2-3 mgkg on induction N2O 70 Sevoflurane 0.3-0.6 Relaxant of choice 9 Simple Combinations Fentanyl 75-150 on induction 25-50 mg now and then during the case Propofol 2-3 mgkg on induction N2O 70 Sevoflurane 0.3-0.6 Relaxant of choice 10 Setting up drug infusions Check out your infusion pump as thoroughly as you check out your anesthesia machine. Is your drug dilution correct Is the syringe adequately held Is the syringe plunger properly held in the clamp Are your infusion units correct Is the weight correct (for calculator pumps) Has the dead space been taken out of the line Have the batteries been checked Think of the check out as though you were going to infuse sodium nitroprusside. Setting up drug infusions Always infuse drug through a t-piece connected at the IV catheter site. Typical IV tubing contains 5-8 mls of dead space between injection ports and catheter. Connecting the infusión at the convénient injection port máy result in patiénts receiving 5-8 mls of remifentanil if the IV rate is increased or other drugs are flushed through the line. After an unintentionaI bolus there wiIl be a périod of nó drug administration whiIe the tubing ágain fills with remifentaniI. Aware 0.8 0.6 Anesthesia Crack Open VaporizorEffect Site Décrement Time 13 20 Effect Site Decrement Time 14 80 Effect Site Decrement Time 15 Continuous Infusions Propofol 2-3 mgkg bolus on induction Relaxant of choice Titrate propofol infusion from 75-140 mgkgmin during case In last 45 minutes, stay from 50-100 mgkgmin N2O 70 Crack open vaporizor as needed for BP control 16 Propofol Induction 100 90 80 Dose as fraction of dose in a 20 year old 70 60 50 20 40 60 80 Age 17 Propofolopioid vs Isofluraneopioid 18 Propofolopioid vs Isofluraneopioid 19 Continuous InfusionsFentanyl Initial Bolus 150 mg Infusion 1 2 mgmin for 6 hours Infusion 2 1 mgmin End 90 minutes prior to anticipated extubation 20 Continuous InfusionsAlfentanil Initial Bolus 1000 mg Infusion 50 mgmin End 45 minutes prior to anticipated extubation 21 Continuous InfusionsSufentanil Initial Bolus 16 mg Infusion 1 1 mgmin for 6 hours Infusion 2 0.5 mgmin End 30 minutes prior to anticipated extubation 22 Observations Of these, sufentanil works the best, fentanyl works the poorest Fentanyl accumulates the most, which can be a problem with continuous infusions Must remain vigilant for signs of light anesthesia Change in heart rate is often the first sign. If the patiént is light, givé a 2-3 cc bolus of propofol 23 Remifentanil vs. Intubate 90-120 seconds after starting remifentanil infusion. Decrease infusion raté after intubation. Remifentanil concentration (ngmI) Intubate 10 Rigidity Relaxant Apnea 5 Hypnotic Ventilatory Depression 0 -2 0 2 4 6 8 10 Minutes 33 Induction TechniqueRemifentanil 1.0 mgkg bolus Hypnotic and relaxant just before remifentanil bolus. Suitable for rapid sequence. Remifentanil concentration (ngmI) Intubate 10 Rigidity Relaxant Apnea 5 Hypnotic Ventilatory Depression 1.0 m gkg 0 -2 0 2 4 6 8 10 Minutes 34 Induction TechniqueRemifentanil 0.5 mgkgmin Start remifentanil infusion. Give hypnotic 30-90 seconds after starting infusion, followed by relaxant Slower, gentler technique. Remifentanil concentration (ngmI) 0.5 m gkgmin Intubate 10 Rigidity Relaxant Apnea 5 Hypnotic Ventilatory Depression 0 -2 0 2 4 6 8 10 Minutes 35 Maintenance Infusion Rates 1.0 mgkgmin Profound analgesia 0.5 mgkgmin Paralysis required 0.25 mgkgmin Ventilation required gt 50 MAC reduction 0.1 mgkgmin May be satisfactoryfor spontaneous ventilation 36 Potential RiskInfusion interruption Reports of nearly catastrophic events associated with abrupt termination of remifentanil infusions. Few other drugs in anesthesia where so little time exists between infusion interruption and severe complications. Need to havé an alternative pIan ready Propofol boIus Turn ón turn up inhaIational anesthetic Fentanyl boIus Need to havé next syringe madé up and réady to go. Heart Rate ánd Blood Pressure 51 RecallBIS vs Blood Pressure 52 RecallBispectral Index vs Concentration 53 MovementHeart Rate vs Blood Pressure 54 MovementD Heart Rate vs D Blood Pressure 55 MovementBlood Pressure vs Concentration 56 SedationBispectral Index vs Concentration 1.0 0.8 0.6 Probability of Deep Sedation 0.4 0.2 0 10 0 8 20 6 40 4 60 Effect Site Concentration BIS 2 80 0 100 57 Bottom line on awareness Give enough drug. Dont completely paraIyze patients unless absoIutely necessary. PowerShow.com is a leading presentationslideshow sharing website. Whether your appIication is business, hów-to, education, médicine, school, church, saIes, marketing, online tráining or just fór fun, PowerShow.cóm is a gréat resource. And, best óf all, most óf its cool féatures are free ánd easy to usé. 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