Anesthesiology

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Physical activity "Lapangan"

Anesthesiology isn't just giving gas through a mask and putting patients to sleep before an operation. Simply put, anesthesiologists handle everything that keeps a a patient alive in critical situations. And undergoing an operation with general anesthesia is a pretty critical situation. So, koas will not be spending any time in the polyclinic (that's not critical) and instead be in the operating room 90% of the time. The remaining 10% is spent in the ER, ICU, and doing a "pre-op" the night before on patients in the ward who are going to undergo surgery the next day. So, Anesthesiology involves anesthesia, fluid/electrolyte balance, airway management, pain management, maintaining vitals/homeostasis, interpreting blood/urine results, and more.

In Sardjito, the day starts at 6:30 AM with a two hour meeting of residents that koas have to join as well. Then, it's off to the operating rooms for the whole day. In the late afternoon, there is a "lapangan" activity that involves going to a futsal court or a tennis court and watching the residents play. During this time, it is tradition for the female koas to cut up a watermelon for the residents. At the end of this "lapangan", the schedule for the following morning's surgeries is released. The koas quickly select a surgery to join the next day, contact the resident in-charge of it, and contact them. After this happens, everybody goes back to Sardjito to do "pre-op". They visit their patients and do a short anamnesis and basic exams. This is to ensure that the correct anesthesia and breathing apparatus is used the following day. It is also a chance to catch any contraindications or risk factors for surgery the next day. For example, if we find a rigid neck then perhaps we should be careful before suggesting intubation (which requires extension of the neck).

Once the pre-op is done, the koas send a message to the resident with their findings. At this point, they can finally go home.

Study[edit]

Mallampati score
  1. Differences between inhaled anesthesia vs TIVA vs spinal anesthesia.
  2. Differences between devices such as LMA and ET.
  3. Pre-op anamnesis.
    1. Weight, height, age, vitals.
    2. ASA classification.
    3. Contraindications for general anesthesia.
    4. Mallampati score.
    5. Allergies.
    6. History of operation.
  4. Common drugs used for and with anesthesia.


Endotracheal Tube (ETT) Intubation[edit]

Alignment of axis
Triple maneuver
ET intubation

ET has lower risk of aspiration compared to LMA.

Equipment[edit]

  1. Laryngoscope: used to depress the tongue and reveal the trachea (the glottis) and guide the ETT into it.
  2. Stethoscope: used to confirm successful ETT insertion.
  3. ETT (endotracheal tube): 2 sizes.
  4. Mayo tube (aka oropharyngeal airway (OPA)): inserted before extubation to keep the tongue from falling back and blocking the airway.
  5. Oxygen and mask: for preoxygenation.
  6. Bag: for ventilation.
  7. Stylet: not always used. Helps to keep the tube's shape in a curve.
  8. Connector: usually already affixed to the ET tube or oxygen pipe.
  9. Suction: used to remove mucus right before extubation and rarely, before intubation.
  10. Syringe: filled with air and with the needle removed.
  11. Plaster (Hypafix) x 4: 2 thin long strips to hold ETT and another 2 small pieces to shut eyelids.


In Sardjito, a mnemonic (STATICSS) is encouraged to help remember some of the equipment:

  • S: -Scope: Stethoscope, Laryngoscope
  • T: Tube
  • A: Airway: mayo
  • T: Tape
  • I: Introducer (aka stylet)
  • C: Connector
  • S: Syringe
  • S: Suction
Cricoid pressure

Sellick maneuver - the way to do it, is BURP! on cricoid cartilage:

  • B = Backward
  • U = Upward
  • R = Rightward
  • P = Pressure

Assessing the difficulty of an intubation can be done using LEMON:

  • L = Look externally, e.g. short neck, large tongue, large teeth, etc
  • E = Evaluate 3-3-2
    • 3 = adequacy of oral access
    • 3 = to assess capacity of mandibular space to accommodate tongue
    • 2 = distance of larynx to level of base of tongue
  • M = Mallampati scoring
    • Difficulty to sit up; use tongue depressor, etc
    • difficult to do proper, complete Mallampati
  • O = Obstruction. Any signs of upper airway obstruction? Three cardinal signs of upper airway obstruction:
    • muffled voice (hot potato voice),
    • difficult swallowing secretions,
    • stridor; when stridor happens, consider that circumference of airway reduced to roughly 10% of normal caliber!!!!
  • N = Neck mobility

Laryngeal Mask Airway (LMA)[edit]

Laryngeal Mask Airway

Supraglottic.

Drugs[edit]

Midazolam[edit]

Atracurium[edit]

Naloxone[edit]

Neostigmine[edit]

Ketamine[edit]

Ketorolac[edit]

Propofol[edit]

Ampoule: 200mg/20 ml, at a concentration of 10 mg/ml.

Duration of action: 10-15 minutes.

Dosage:

  • Less than 55 years: Anesthetic Induction: 40 mg IV every 10 seconds until induction onset. Total dose required is 2 to 2.5 mg/kg with a maximum of 250 mg.
  • Less than 55 years: Maintenance of Anesthesia: IV infusion: 100 to 200 mcg/kg/min. Maximum dose 20,000 mcg/min. Maximum dose 10,000 mcg/min.

Intermittent bolus: 20 to 50 mg as needed.

Fentanyl[edit]

An opioid analgesic.

Dosage: 1-2 mcg/kg slow IV push (over 1-2 min)

Exams[edit]

Links[edit]