Perspective from The New England Journal of Medicine — What Is Value in Health Care?
Keep dry – almost no fluid prior to resection
Then catch up
A-line, CVC, +/- swan sheath
Consider iVC compression by surgeons if hypotensive
Muscle relaxant (consider infusion)
Analgesia: spinal diamorphine, wound infusion catheter (2.5mg/ml levo-bupivicaine @ 10ml/hr). If using morphine PCA – caution (with liver impairment)
Excellent editorial in the journal Anaesthesia casting comparison between high pressure high stakes environment of NASA and healthcare delivery.
Useful online educational resource for ICU covering, amongst other things, ECMO and echo.
Loading dose: 50mg/kg
NB will potentiate neuromuscular blockade
R – receive
A – appreciate
S – summarise
A – ask
Risk factors for increased morbidity & mortality:
- Peak VO2<15 ml/kg/min
- Anaerobic threshold <10-11 ml/kg/min
- Ventilatory equivalent (measured at AT) >35-40. Breathing hard to meet demands!
‘Apple’ fat distribution (central obesity)
Metabolic syndrome (3 of central obesity, hyper-tension, cholesterol, sugars, lipids)
Pre-op: STOPBANG >5 = high risk of disordered breathing/OSA
AR: Consider test dose of 50mcg fentanyl pre-induction for sensitivity for opioids
RSI: No evidence
Drug dosing: Ideally use LBW. Practically IBW + few kg. For all drugs except suxamethonium and neostigmine
Position: Reverse trendelenburg with pillow under shoulders for tragus above sternum, rather than break in the bed
Extubation: consider NPA with lidocaine
Post-op: avoid ‘tying’ to the bed e.g. with a-line, infusions
A useful practical summary of latest ruling