problem solving in anesthesia every now and again as a doctor your patient will fall ill and you'll
get to work and start assessing and managing the problem in most cases the time between problem and
something bad happening can take days to weeks but under anesthesia bad things can happen much faster
the time from action to disaster is much more rapid from seconds to minutes
and when you're starting out as an anesthesia doctor this can be a puzzle
all the complex and time critical management steps can be very tricky to learn
your first steps off the mark can really make a substantial difference to the race to manage
the problem there is a big difference if you manage anaphylaxis in the first few seconds
with adrenaline versus delaying it to a minute there's a big difference in managing hypotension
when it's 80 millimeters mercury rather than when it's fallen to 40 millimeters mercury
so i want to give you the little steps that you can train to become part of your reflex response
and your muscle memory so in this presentation let's go through the puzzle of problem solving
in anesthesia and in the process give you the building blocks to make you safe effective
and grow with future knowledge and experience this framework should be able to work whether
you're a junior in isthis or an experienced synesthesis as you get more experience you'll
be able to add layers to the underlying structure now it's important to know that most of the time
you'll be very well supervised and if you're on your own you'll have to use your judgment
if you're not sure of something it may be best to wait for help to arrive and make sure you first
do no harm the four phases we will explore when managing any intraoperative issue are
safety temporizing measures diagnosis and management safety is about doing a few
critical things to mobilize resources and prevent further deterioration
i first call for help this might mean pressing an emergency buzzer
or getting someone to call your supervisor you may need help in the form of more brains or more
hands sometimes you need help with figuring out the problem and other times there's just
so many tasks that need to be done that you can solve the problem more rapidly with more people
your threshold may depend on a number of things like your experience
and the problem itself but remember that even after a lot of experience you never ever stop
calling for help there's always going to be a time when you have a diagnostic dilemma and need those
extra brains or have a problem as complex as an arrest where you may need extra hands
next i will ask the surgeon to stop what they're doing for example the patient might develop a
sudden tachycardia due to pain on incision or a sudden severe bradycardia when insufflating the
abdomen for laparoscopic surgery often this might be the only cause of a problem and the
problem will resolve immediately when they stop operating the most difficult part of this might
actually be getting the confidence to tell a senior surgeon to stop what they're doing this
is difficult due to the hierarchies that exist and learning how to say this is half the battle
i would say something like would you be able to stop for a minute i'm not sure
what's happening with the patient and i need to get some assistance the first thing you learn
in medical school about patient assessment is to check your environment and do a general inspection
anesthesia is no different i try to take in all the information at hand by stepping back
and looking at the monitors the patient and what the surgical field looks like
checking the monitors can give me a lot of context to the primary problem if the blood
pressure has fallen is the patient tachycardic or bradycardic or are the oxygen saturations dropping
at the same time and is this the first sign of anaphylaxis you don't want to miss the extra cues
glancing at the patient can give all manner of context as well does the patient have a rash
is fluid regurgitating from the mouth or is the patient coughing all these clues can fill in the
missing pieces to your diagnostic puzzle scanning the surgical field can alert you to many problems
like bleeding surgical pressure on important structures like the heart or trachea or even
the look of the surgeon being stressed so you know that something important must be happening
i also checked the accuracy of my monitor unlike most other fields of medicine
we're incredibly reliant on our fancy monitors and machines imagine the blood pressure has
suddenly increased and you immediately start treating this with anti-hypertensive agents
but then you notice that the arterial line transducer has actually dropped to the ground
this is a critical error the blood pressure is actually normal but due to the transducer being
lower than the heart the blood pressure reading is artificially elevated likewise oxygen saturations
often read lower but for no other reason than the finger probe is moving or the patient has
poor perfusion to their finger you must confirm a reading before treating the patient to reiterate
when a problem occurs call for help ask your surgeon to stop operating take a step back and
look at your environment to gather all available information and check your reading or your monitor
this is the basis of commencing your treatment and solving each problem as it occurs temporization
these are the initial measures you can action even with only a few months of experience to
prevent deterioration and stabilize things while waiting for assistance to arrive
warning remember to use your judgment and only do the actions that you're familiar with if you have
never given a medication before or done a specific maneuver you probably shouldn't do it for the
first time unsupervised but even in your first few weeks of anesthesia you can still be very
helpful by getting things ready even if you're not familiar with giving the medication or the
specific intervention for example if the patient is hypertensive you might call for help give a
small fluid bolus and then have the vasopressor ready for your supervisor to treat with
this demonstrates a lot of intuition and wisdom first that you are able to think on your feet
and follow strategy but also that you're aware of your own limitations and don't act without
sufficient knowledge and experience this is a principle you'll develop all throughout your
career as you continue to learn new skills and challenge yourself in new environments
the temporarization steps are relatively specific for each problem that could occur but let's talk
about the two common examples hypotension or low blood pressure and hypoxemia or low oxygen
saturations in future lectures we'll go through the specific temporizing measures for each problem
for hypertension the initial steps are giving a a fluid bolus and b vasopressor
giving a fluid bolus could be infusing 250 to 500 ml of fluid depending on the patient often
normal saline or crystallers such as hartman's if fluid isn't available quickly simply lifting the
patient's legs at 45 degrees in the air can be a way to immediately transfer peripheral volume
into the central area vasos presser is also a common step to take common choices are metaraminol
or ephedrine metaraminal is an agonist at alpha adrenoceptors while ephedrine acts mainly at beta
receptors with some alpha activity the decision to use one or the other is often based on the
heart rate as giving metaraminol can cause a reflex bradycardia due to the baroreceptor reflex
so generally speaking if the heart rate is above 60 beats per minute most anises would
treat hypertension with metaraminol but if it's below 60 many would choose to use ephedrine be
very careful when giving these medications they're very concentrated solutions and must be diluted
before administration do not give a whole vial of the solution often the dose for metaraminal is
0.5 milligrams and for ephedrine it starts around three to six milligrams for decreased oxygen
saturations the very first step is to increase the oxygen delivery to 100 oxygen and increase
the flow rate this will increase the amount of oxygen that can pass from the alveoli to the blood
i'll often combine this by switching the patient to the manual bagging circuit
and dial the apl valve to 20 to 40 centimeters of water pressure this expands the lungs recruits or
re-inflates any collapsed alveoli and assesses the compliance of the lungs all in one maneuver
in the next few lessons on solving common problems we'll go through
specific temporization steps for each problem
this will show you how effective and useful you can be with a good structure and concepts
the common problems that are best to start with are hypotension hypertension tachycardia
bradycardia hypoxemia and high ventilating pressures
we will go through each of these in more detail in the next few presentations i hope you enjoyed
this video please post any questions or comments below and see you next time what