Anaesthesia for JMOs

1. Gas Monkey Anaesthesia for JMOs Dr Ben Piper ICU 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 anaesthesia If we have time… • My patient needs surgery- • What does the anesthetist want to know?

3. 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” • Somatic- good • Visceral- bad • Neuropathic • Psychogenic (careful now) Ugly

4. Multi Modal Analgesia

5. 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?

6. Options…. What would you do? • Endone: give double stat dose (20mg) • NSAIDs STAT and chart regular dose • Oxycontin 20mg BD • IM Morphine 0.1mg/kg • IV Morphine 0.05mg/kg • Say: “What did you expect, this is surgery- harden up princess”. • Page the Anaesthetic Registrar Lean body mass!!!!!

7. 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 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

9. 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?

10. 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?

11. Morphine and Naloxone Much longer than most think! • Morphine • 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! Endone peak 30min duration 1-2 hrs

12. Fixed • After two doses of 100mcg the patient is less drowsy, RR 14, sat 98% • You keep her on Oxygenwith 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 message • All doctors need to have a planfor 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 unsure • Yourself 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 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?

16. Choose your own adventure • Bolus IVF 500mL • Don’t worry his HR is not elevated (60) • Withhold tonight's perindopril dose • Panic

17. 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?

18. Memory scratcher Sensor Response

19. 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”

20. 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?

21. 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.

22. 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??

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 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!!

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 youplease: • Increase the oxygen to 100%” • “Jane, can you please get someone else to: • Check a BSL • Do an ECG • Get me the notes • So that you can tell me about what has happened”. • “Thankyou Jane-”

27. Thanks “Have fun at work: • do Anaesthetics and/or Intensive Care”

28. My patient needs Surgery…

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/reserve • Circualtion: Cardiovascular function/reserve • Drugs: what, why and when? • Eating: When, what

31. 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?

32. 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

33. 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

34. 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