ANESTHESIA Procedures 2

Tracheal Intubation

Follows 1V induction of anesthesia.

Objectives

· To ensure a clear airway for anesthetized patients.

· To protect airway from regurgitation and aspiration.

· To aid and assist in control of ventilation when muscle relaxants are used.

· To facilitate suction of respiratory tract.

· To prevent collapse of lungs in thoracic operations.

Position for Laryngoscope and Intubation

· Supine.

· Flexion of the head at the neck and extension of the head at the atlanto-occipital level, the so called‘sniffing’ position.

· The head is elevated placing a low pillow or ring Oral cavity axis (OA); Pharyngeal axis (PA) and laryngeal axis (LA) are different. In this all three axis brings into alignment position and vocal cords will be viewed best with laryngoscope.

Procedure

· Awake intubation in neonates sometimes.

· Emergency awake intubation in adults when airway is compromised.

· Adequate anesthesia and muscle relaxation is the usual technique.

· After 1V or inhalational induction of anesthesia, short acting depolarizing muscle relaxant, Suxamethonium (Scoline) (! To 1.5 mg/kg) or non-depolarising relaxant 1V given.

· Assited ventilation is maintained via mask with 100% O_{2 or} with 50% N₂O in Oxygen till the muscle relaxation occurs and then tracheal intubation is performed.

· Handle of the laryngoscope held in the left hand.

· The laryngoscope blade is inserted between the teeth at the right side of the mouth and the tongue is displaced on the left side.

· The blade is advanced until the epiglottis comes into view and then lifts it upwards.

· The vocal cords will be identified.

If they are not seen, an assistant is asked to push downward on the larynx.

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ANESTHESIA Procedures 1

Anesthesia Procedures

Preoperative Check

Objectives

· Patient identification and consent check for operation and anesthesia.

· Availability and check functioning of anesthesia machine, intubation sets, drugs, monitors.

· Casenote confirmation of operation decided upon for that particular patient.

Intravenous Induction

Objectives

• To induce loss of awareness rapidly at the start of anesthesia.
• Induction is achieved with intravenous agents (thiopentone 3-5 mg/kg, methohexitone 1-1.5 mg/kg, etomidate 0.3 mg/kg, propofol 1.5-2.5 mg/kg or ketamine 2 mg/kg).

Position

• Supine.

Premedication

Any combination of anxiolite and antisialgogue.

Procedure

• Intravenous cannula inserted into a peripheral vein, preferably on the dorsum of the hand and infusion fluid attached.
• Drugs prepared in syringes and labeled (IV induction agent, muscle relaxant, atropine)
• Patient connected to the monitor for ECG, non-invasive blood pressure (NIBP), and oxygen saturation.
• 100% oxygen by mask before the drugs are injected.
• Small test dose of intravenous induction agent given and effects observed for any anaphylactic reaction.
• Rapid sequence induction technique used in emergency situation where the stomach is full or chances of regurgitation are a potential problem.
• Anesthesia maintained with inhalational agent.
• Tracheal intubation done using muscle relaxant.

Instruments

• Intubation tray
• Anesthesia machine ( check list 1, see page 99 )
• Breathing circuits, face mask, inhalation set ( check list 1, see page 99 )
• 1V cannula, infusion, fluid, spirit and iodine swab, adhesive plaster.
• Drug tray and labels.
• Normal saline bottle for dilution of drugs.
• Induction agents-Thropentone, Propofol, Ketamine.
• Arm boards.
• Patient monitors for ECG, Spo_2, NIBP, and ETCO2.
• Anesthesia machine monitors (Oxygen analyser, gas monitor)
• Emergancy drug tray(check list 11, see page 102 ).

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PROCEDURE 14

                                                          TOTAL  COLECTOMY

When is entire colon removed?

Entire colon is removed in the following cases:

 .Injury

.Lower GIT bleeding where site cannot be located

.Ulcerative colitis

.Multiple cancers poly of the bowel

.Removal   of   right,  transverse and descending colon.

Position of the patient

Supine.

Anaesthesia

General

SURGICAL Steps

.Mobilise the right  , transverse and left colon by incising lateral peritoneum

(fig.2.31a).in benign conditions , retain the greater omentum.

In malignancies, separate it from the stomach and take it with the colon.

.Ligate the right Colic, Ileocolic, middle Colic and inferior mesenteric Vessels at their base.

.Remove the divided bowel taking precautions to avoid spillage.

.Anastomose terminal ileum to rectum using interrupted non-absorb-able sutures in one layer.

.Closed  the abdomen without drainage.

Instruments   required

.General set.

.Laparotomy set.

.Harrington splanchnic retractors

.Leyland-Jones clamps,1 pair

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PROCEDURES 13

LEFT HEMICOLECTOMY

When is the procedure indicated?

Left Hemicolectomy is required in the following cases:

·       Tumours of the splenic flexure and descending colon

·       Diverticular disease with perforation or bleeding with the removal of part of transverse descending and sigmoid colon. 

Position of the patient

Supine.

 Anesthesia

General.

Surgical steps

·       Midline incision is given

·       The Descending colon and splenic flexure are mobilized.

·       The inferior mesenteric vessel is divided between ligatures at its take off.

·       The greater omentum is separated from the stomach to take it with the left half of the transverse colon.

·       Now colon is divided between clamps removing left lateral third of transverse colon and descending and sigmoid colon.

·       Then anastomose transverse colon to the rectum using a single layer of interrupted non-absorbable suture.

·       To avoid tension, it may be necessary to mobilise the right transverse colon.

·       The abdomen is closed without drainage.

Instruments

·       General set

·       Laparotomy set

·       Harrington splanchnic retractor

Peans intestinal forceps, 1 pair

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PROCEDURES 12

Rt HEMICOLECTOMY

When is the right colon removed ?

Removal may br needed:

*Cancer of ceacum or rt colon

*Tumour of the appendix or ileum

*Trauma to ceacum or ascending colon

Position of patient

supine

Anaesthesia

General

Procedure

*Midline incision

*Lateral peritoneum is incised mobilise rt colon and ileum

*Devide ileocolic and rt colic and branches between ligatures

*Mesentry of terminal ileum devided between igatures.

*Greater omentum attached to rt colonremoved with colon.

*Bowel devided between to sets of clamps.

*Two layer anastomosis ileum and tranverse colon.

Approximate mesentry

Close abdomn in layers.

Intruments required

Lap set

Gen Set

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