Anaesthetic considerations for robotic surgery

Key points:

Maintain muscle paralysis while robot is docked – consider infusion of relaxant

Meticulous positioning with pressure point protection

Difficult to access patient intra-op

Have enough slack on lines

If steep trendelunburg e.g. prostatectomy caution with fluids, raised ICP and IOP, airway oedema.

Recipe for radical prostatectomy:

GA, ETT, 2x IVI, a-line

O2/air/desflurane. MAC 0.8-1.0

Remifentanil (0.1-0.2mcg/kg/min) and atracurium infusion

<500ml prior to anastomosis, max 2000ml in total (if no significant blood loss).

NHS Consultant productivity

A very interesting article and comments, arguing that although Consultant numbers have increased,  Consultant productivity has decreased due many systemic factors including workforce planning (including lack in increase in nurses), social and community care capacity limiting patient flow, and capital e.g. lack of ICU beds, IT infrastructure.

Many questions are raised though, such as how can ‘productivity’ be a accurately and meaningfully measured in a useful and comparable way in such a complex system. Also, how does one account and value ofter features such as quality and safety? It’s complex!

Link: http://www.bmj.com/content/356/bmj.j1520

 

Personal reflection – Cognitive bias

Case of acute and evolving intrinsic cord lesion in pregnancy presenting as unusually bizarre, but evolving neurology, referred as ‘cauda equina?’

When faced with an unusual presentation, particularly if it does not fit with anything ever seen before, and even if on probability it is very unlikely to be pathalogical, need to exclude the relevant and not be biased towards preliminary diagnosis planted by others. Consider Bayesian modelling.

Have an open mind and think broader than the problem presented. Is this something that we have neither yet considered nor ever seen before? How to prove/disprove this? Consider safety nets and worst case scenario. Accept uncertainty in an uncommon, undeclared situation rather than over-confidence. Observe evolution over time with multiple snap shots and opinions.

14th Annual Critical Care Symposium

Ventilation

6ml/kg, <30 cm H20, PEEP, SpO2 94-98%, recruit

 

Trials to review:

Recruitment, FEAT, FACTT, ACBIOS

 

Successful ward round

Patient, Doc, nurse, MDT

My name is (first name) to team, Dr xx to patient. call them by surname

Family present at WR. Adv: gain new info, open/honesty. Pre-claimer. Teach & treat.  Will translate.

White board next to each patient with important info, plan details.

Start at same time everyday – good for MDT

Daily plan understood by all, nurse/junior repeats back. To do list. Check

Interactive, educational, professional, fun

 

Crit care practitioner

service need, fill rota gaps. crit care practitioner podcast

robust ciricullum, education, cpd + appraisal pathway/training. Some can prescribe. know your limits. consistency, permanent

P. paradoxus – downwards swing in pleth/BIP in SV patient on inspiration

Digital Meeting

Positive reporting in Datix

Education – twitter journal clubs

‘Rapid weaver’ – Mac based website development

Safety events/handoever every 12 hours

[c.f. neonates WR – learning point of the 24 hours/week]

ipad/screen next to ABG with learning message

Use raspberry Pi

Check out portsmouth crit care