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.
- Differences between inhaled anesthesia vs TIVA vs spinal anesthesia.
- Differences between devices such as LMA and ET.
- Pre-op anamnesis.
- Weight, height, age, vitals.
- ASA classification.
- Contraindications for general anesthesia.
- Mallampati score.
- History of operation.
- Common drugs used for and with anesthesia.
Endotracheal Tube (ETT) Intubation
ET has lower risk of aspiration compared to LMA.
- Laryngoscope: used to depress the tongue and reveal the trachea (the glottis) and guide the ETT into it.
- Stethoscope: used to confirm successful ETT insertion.
- ETT (endotracheal tube): 2 sizes.
- Mayo tube (aka oropharyngeal airway (OPA)): inserted before extubation to keep the tongue from falling back and blocking the airway.
- Oxygen and mask: for preoxygenation.
- Bag: for ventilation.
- Stylet: not always used. Helps to keep the tube's shape in a curve.
- Connector: usually already affixed to the ET tube or oxygen pipe.
- Suction: used to remove mucus right before extubation and rarely, before intubation.
- Syringe: filled with air and with the needle removed.
- 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
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)
Ampoule: 200mg/20 ml, at a concentration of 10 mg/ml.
Duration of action: 10-15 minutes.
- 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.
An opioid analgesic.
Dosage: 1-2 mcg/kg slow IV push (over 1-2 min)