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Surgeons & Anesthesia
S Ahanatha Pillai
CHAPTER 1:
Introduction
Introduction
Anesthesia
CHAPTER 2:
Anesthesiologist
Learning Anesthesiology
Functions of the Anesthesiologist
Good
Efficient (Skillful)
Well Informed (Knowledgeable)
Safe
Discipline
Devotion
Dedication
Surgeon-Anesthesiologist Relations
Appraisal
Operating Theater Suite and Theater Discipline
Surgical Hand Disinfection (Scrub Up)
Operating Department Manager
CHAPTER 3:
Surgical Team
Members of Surgical Team
Job Descriptions—(Responsibilities)
Surgeon and his Assistant
Anesthesiologist
Assisting Nurse (Scrub Nurse)
Anesthetic Technician (Theater Assistant or Theater Technician)
Job Descriptions of Anesthetic Technician
Circulating Nurse
Nursing Supervisor
Unskilled Personnel Working Inside the Operating Room
Stretcher Bearer
General Worker
Sanitary Worker
A small set up in Indian Scenario
Nurse
Nursing Assistant
Anesthesia Technician
Stretcher Bearer
Sanitary Worker
Coordinator of the Team
Responsibilities of the Coordinator
Planning the Operation List
Planning the Team for Different Procedures
Planning the Postoperative Care
Maintenance of Theater Asepsis
Points for Theater Asepsis
Points
CHAPTER 4:
Safe Practice of Anesthesia
Ten Golden Rules of Anesthesia
Indian Society of Anesthesiologists
Operation Theaters: Minimum Requirements
Anesthesia Care: Principle
Staffing
Anesthesia Record and Machine
Basic Equipments
Intraoperative Monitoring
The Recovery Area
Safety in Anesthesia
Facts to be Accepted
Accidents during Anesthesia
Anesthetic Records
Patient Care
Teaching
Medico-legal Reasons
Monitoring during Anesthesia
Facts about Monitors
Demerits of Monitors
Monitoring the Anesthetic Machine
The Cardiovascular System
ECG
Monitoring the Circulation
Peripheral Pulse
Arterial Oxygen Saturation: Pulse Oximetry
CHAPTER 5:
Preanesthetic Assessment
The Purpose of Preoperative Visit
Guidelines for Preanesthetic Visit
Definition
History Taking
History of any Allergy
Physical Examination
Cardiovascular System
Respiratory System
Central Nervous System
Basic Laboratory Investigations
Hemoglobin
Urine Albumin
Urine Sugar
Blood Urea
Serum Creatinine
Routine Tests but not Indicated for all Patients
Grading of Risk (American Society of Anesthesiologists)
Fit for Anesthetic
Informed Consent for Anesthesia and Surgery
Jehovah's Witnesses
Preoperative Starvation
Practical and Simple Norms for Preoperative Starvation
Canceling Cases
Choice of Anesthesia
Age
Physical Status
Type of Surgery
The Skill and the Requirement of the Surgeon
The Skill and Preference of the Anesthesiologist
The Patient's Wishes
Teaching Purpose
CHAPTER 6:
Preanesthetic Medications (Premedication)
Definition
Timing
Preanesthetic Medication Drugs (Premedication Drugs)
Two Groups
I. Anticholinergic: Antisialagogue; Vagolytic
II. CNS Depressants
Tranquilizer
Sedative
Hypnotic
Analgesic
Narcotic
Morphine Sulphate
Pethidine Hydrochloride
CNS Depressant Drugs
Clinical Significance
The classification of Narcotic Analgesics
Natural and Semisynthetic
Semisynthetic Alkaloids
Synthetic Agents
Clinical significance
Clinical Significance
Useful Hints about Preanesthetic Medication
Effects of Premedication
CHAPTER 7:
Clinical Anesthesia: Balanced Anesthesia
The Purpose of Anesthesia
Guedel's Classification of Anesthesia
Stages and Planes of Surgical Anesthesia
Good Surgical Anesthesia
The Triad of Anesthesia
Definition of Anesthesia
Balanced Anesthesia
Clinical Significance
Definition of ‘Balanced Anesthesia’
Modern Anesthesia
Clinical Significance
The Relationship of the Various Abdominal Incisions and Requirement of Relaxants
Facts to be Remembered
Recovery from Anesthesia
Definition
Classification of Anesthesia
CHAPTER 8:
The Operating Department
Operating Department, Operating Suite, Operating Theater
Definitions
Access Zones
General Access Zone
Limited Access Zone
Restricted Access Zone
Operating Zone (Fig. 8.5)
Red Line
Patient Transport
Supplies
Disposal
Administration and Teaching
Catering
Cleaning
Design
Types of Operating Departments
Construction
Walls and Ceiling
Floors
Lighting
General Lighting
Operation Area (Task area) Illumination (Operation lights)
Color
Intensity/Pattern
Shadow Reduction
Elimination of Heat
Maneuverability
The Terminology
Types of Operating Luminaires
Single Lamp Luminaires (Fig. 8.8)
Pendant Services
Ventilation
Plenum Turbulent Airflow System
Ultraclean Ventilation System
Storage
CHAPTER 9:
Theater Asepsis and Equipments Sterilization
Operating Theater Environment and Asepsis
History
Hospital Infections
Source of Infection
Definitions
Antiseptics
Disinfectants
Germicide
Detergent Antiseptics
Theater Disinfection Schedule
Daily
Carbolising
Weekly Washing
Commercially Available Disinfectant—Bacillocid Special
Composition
Advantages
Areas of Application
Weekly Fumigation with Formalin
Micronebulizers (OTI care or other similar devices)
Boiling
Potassium Permanganate and Formalin
Ultraviolet Rays
Ultraviolet Rays Air Cleaning System
Assessing the Adequacy of Asepsis
Microbiological Monitoring of Operation Theater Atmosphere
Microbiological Monitoring in other Sites of Operation Theater
Sterilization of Equipments
Types of Equipments
Low Risk Equipments
Intermediate Equipments
High Risk Equipments
Cleaning and Sterilization
Steps
Decontamination (Cleaning)
Disinfection
Methods of disinfection
Sterilization
General Classification of Methods of Sterilization of Equipments
Physical Methods of Sterilization (Heat Sterilization)
1. Moist Heat
Bins for Autoclaving
Ideal Packing
Advantages of Autoclaving
Testing Adequacy of Sterilization in Autoclave
Low Pressure Autoclave (Steam under Low Pressure and Temperature)
Dry Heat
Hot Air Sterilizer (Oven)
Flames
Chemical Sterilization Methods (Cold Methods)
Advantages
Disadvantages
The chemical agent may be
1. Vapor (Formaldehyde)
2. Gases (Ethylene Oxide or Propylene Oxide)
Programmable Automatic EO Sterilizer
3. Liquids
Phenol
Iodine
Ethyl Alcohol
Hexachlorophene
Chlorhexidine Gluconate
Glutaraldehyde (Cidex)
Nu–Cidex
Iodophor
Chlorine Compounds
Detergents
Gamma Rays
Filtration (Bacterial Filters)
For Open Case of Pulmonary Tuberculosis
Hepatitis B
Tests For Adequacy of Sterilization
Central Sterile Supply Department (CSSD)
Sterile Pack System
Theater Sterile Supplies
Utilization
CHAPTER 10:
Operating Table and Positions for Surgery
Positions for Surgery
Points to Note
Supine or Dorsal Recumbent Position
Trendelenburg Position
Gallbladder and Liver Position
Lateral Position of Extension (Kidney Position)
Lateral Tilt of the Table
Lithotomy Position
Position for Abdominoperineal Resection of Rectum
Prone Position
Positioning on Orthopedic Table
Supporting Pads for Positioning
CHAPTER 11:
Assessment of Blood Loss and Volume Replacement
Facts about Blood Transfusion
Assessment of Blood Loss during Surgery
Gravimetric Method
Colorimetric Method
Practically Easier Most Commonly Employed Method
Recommendations from Various Authorities Regarding Transfusion
Role of Colloid Solutions in Blood Volume Replacement
Plasma Volume Substitute
Plasma Volume Expander
The Colloid Solutions Available
Dextran 40
Dextran 70
Gelatin
Haemaccel
Gelofusine
Hyrdoxyethyl Starch (HES)
Commonly used IV Fluids, their Composition and Indications
Dextrose Injection
Benefits
Indications
Drip Rate
Contraindications
Dextrose and Sodium Chloride Injection
Electrolytes mEq/Lit
Benefits
Indications
Drip Rate
Contraindications
Ringer Lactate Solution
Electrolytes mEq/Lit
Benefits
Indications
Drip Rate
Contraindications
Acetated Ringer's Solution
Electrolytes mEq/Lit
Indications
Dose and Drip Rate
Contraindications
Sodium Chloride Injection 0.9% w/v. (Normal Saline)
Electrolytes mEq/Lit
Benefits
Indications
Drip Rate
Contraindications
Sodium Chloride Injection 0.45 w/v (Half Normal Saline)
Electrolyte mEq/Lit
Benefits
Indications
Invert Sugar 10%
Benefits
Indications
Drip rate
Contraindications
CHAPTER 12:
Vital Organ Function and Anesthesia
Anesthesia and Liver
Anatomy
Clinical Significance
Physiology
Points to be remembered during Anesthesia
Functions of the Liver
General Metabolism
Storage
Synthesis
Detoxification of Drugs
Modifications in Liver Blood Flow
Flow in the Conscious State
Flow in Anesthetised Patient
Flow during Hypotension due to Autonomic Blockade
Flow during Hypotension Associated with Vasoconstriction
Flow during Hypothermia
Flow with Vasoconstrictor Drugs
Anesthesia and Hepatic Cells
Anesthesia and Kidney
Anatomy
Vascular System
Urinary System
Nerve Supply
Physiology
Applied Physiology of Glomerular Filtration
Tubular Reabsorption
Renal Blood flow in Conscious Patient
Renal Blood flow in Anesthetized Patient
Effects of Hemorrhage on Renal Blood flow under Anesthesia
Effects of Vasopressor Drugs
Renal Damage in Relation to Anesthesia and Surgery
Anesthesia and Brain
Cerebral Metabolism
Blood Supply to Brain
Anatomy of Circulation
Venous Drainage
Factors Affecting the Cerebral Blood flow
Arterial PCO2
Arterial PO2
Cerebral Perfusion Pressure
Venous and Intracranial Pressures
Autonomic System
Temperature
Blood viscosity
Age
Drugs
Failure of Autoregulation
Intracranial Pressure
Definition
Munro Kellie's Doctrines
Causes of Increased Intracranial Pressure
Causes of Reduced Intracranial Pressure
Cerebrospinal Fluid
Anesthesia and Heart
Anatomy of Coronary Arteries
Coronary Artery Blood Flow
Oxygen Saturation in the Blood
Cardiac Output
pH of Blood
Blood Pressure
Coronary Artery Dilators
The Heart Rate
Cardiac Output
Venous Return
Effects of Anesthetic Agents on Cardiac Output
Vascular System
Arterial System
The Capillaries
The Venous System
Myocardial Oxygen Consumption under Anesthesia
Tachycardia
Bradycardia
Autonomic Imbalance
CHAPTER 13:
Recovery Room: Postanesthesia Care Unit (PACU)
Postanesthesia Care
History
Recovery Room
The Transport to Recovery Room
Intensive Therapy Unit (ITU)
High Dependency Unit (HDU)
The Purpose of Recovery Room
Systems Mainly Affected during Recovery
Some Facts to be Remembered during the Observation of Postanesthetic Patients
Recovery Criteria
Clinical Assessment of Adequacy of Reversal of NMB
Recovery Room: Postanesthetic Care Unit
Common Postoperative Problems
Guidelines for Postanesthetic Care
Expectations
Formulating Guidelines
1. Infrastructure
2. Staffing (Personnel)
3. Procedure Protocol
Central Nervous System Recovery
Ensure
Respiratory System: Ensure
Cardiovascular Stability: Ensure
Surgical Wound: Observe for
Conclusion
CHAPTER 14:
Local Anesthetic Drugs and Regional Anesthesia
Definition of Regional Anesthesia
Advantages of Regional Anesthesia
Disadvantages of Regional Anesthesia
Pharmacology of Local Anesthetics
Structure of Pharmacological Relationship
Mechanism of Action
Disadvantages
Amide Linked Local Analgesics
Advantages
Xylocaine
Availability
Usual Concentrations Needed for Various Applications
Bupivacaine
Toxic Reactions of Local Anesthetics
Manifestations of Toxicity
Central Nervous System
Manifestations
Cardiovascular System
Techniques of Regional Anesthesia
Central Neural Block
Spinal Anesthesia (Spinal Analgesia, Subarachnoid Block)
Some Facts to be Remembered
The Famous Case of “Woolley and Roe”
Anatomy
Lumbar Puncture
The Drugs
Physiology of Spinal Anesthesia and Related Problems
Positioning the Patient
Care During the Technique
Order of Blockade
Recovery
Circulatory Effects of Spinal Anesthesia
Spinal Hypotension
Control of Arterial Pressure
Organ Perfusion
Cerebral Circulation
Coronary Circulation
Renal Perfusion
The type of block and the degree of hypotension
The obstetric patient and spinal hypotension
Management of Spinal Hypotension
Vasopressors
Ephedrine
Mephentermine
An Example
Epidural Anesthesia
Drugs
Advantages
Disadvantages and Complications
Total Spinal
CHAPTER 15:
Guidelines for Emergency Abdominal Surgeries
A Clinical Approach
CHAPTER 16:
Postoperative Nausea and Vomiting
Common Recovery Room Problems
Nausea
Vomiting
Retching
Regurgitation
Hydrodynamics of Vomiting
Harmful Effects of Nausea and Vomiting
Effect on Patients
Medical Effects
Economic Effects
Factors that Affect the Incidence of PONV
Patient Factors
Surgical Factors
Anesthetic Factors
Prevention and Management
Dopamine 2, 5HT3 (Serotonin), Histamine 1, Cholinergic (Muscarinic) and Opioid
Dopamine 2, and 5HT3 (Serotonin) Receptors
Histamine 1 and Cholinergic (Muscarinc) Receptors
Opioid Receptors
Vomiting Center
Chemoreceptor Trigger Zone of Borison and Wang (CTZ)
Stimuli from Periphery
Stimuli from Center
Various Receptors and their Locations
Preponderance of Receptors
Vomiting Center
CTZ
Receptors and Antagonists
The Afferent Inputs Affecting the Relevant Receptors Involved in the Vomiting Reflex
Prevention
Avoid
Psychological Factors
Olfactory
Visual
Auditory
Treatment
Facts
Guiding Principles
Steroids
Conclusion
INDEX
TOC
Index
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