Developing Anesthetic Management Plan

Developing Anesthetic Management Plan

In anesthesia as in most area of medicine and surgery, you will need as much knowledge and skill to make the right choice of anesthetic technique you will have to implement. The best anesthetic in any given situation depends on your training and experience, the range of equipment and drugs available and the clinical situation.

One "golden rule" is worth remembering, however strong the indication may seem for using a particular technique, especially in an emergency, will be one with which you are most experienced and confident.

Factors to Be Considered When Planning Anesthesia Technique

Some of the factors to bear in mind when choosing and planning your anesthesia technique are:

• Training and experience of the anesthetist and surgeon
  
• Availability of drugs and equipment
• Mmedical condition of the patient
• Time available
• Emergency or elective procedure
• Presence of full stomach
• Patient's preference

Not all these factors are of equal importance, but should be considered, especially when the choice of technique is not obvious.

Choice of Anesthetic Technique for a Particular Operation

Table 1 is intended to help you decide what type of anesthetic technique might be most suitable for a given surgical procedure. For minor emergency operations (for example the suture of a wound or manipulation of an arm fracture), when the patient probably has a full stomach, conduction (regional) anesthesia is probably the wisest choice. For major operations, there is often little difference in safety between regional and general anesthesia. It is a dangerous mistake to think that regional anesthesia is always safe.

Table 7.1 Suitable Anesthetic Techniques for Different Types of Surgery

Regular Review of Plan With Multi-Disciplinary Team

When you have come to a decision, discuss it with the surgeon and theater team, who may give you further relevant information. For example, the proposed operation may need more time than can be provided by the technique you have suggested, or the patient may need to be placed in a different position. Also check that you have all the drugs and equipments you need.

By now you will probably have decided, in principle, in one of the following techniques

• General anesthesia with drugs given intravenously or by inhalation
  
• General anesthesia with intramuscular Ketamin
  
• Spinal anesthesia
  
• Nerve block
  
• Infiltration anesthesia
  

There can be advantages in combining light general anesthesia with a conduction block because such a technique reduces the amount of general anesthesia that the patient requires and allows a rapid recovery, with postoperative analgesia provided by the remaining conduction block.

Planning General Anesthesia

Figure 1 shows the possibilities you should consider when planning general anesthesia. The right-hand side of the diagram shows the recommended effective universal anesthetic technique, which can be used for almost any operation and which you should master and practice regularly.

For general anesthesia, tracheal intubation should be routine, unless there is a specific reason to avoid it. Tracheal intubation is the most basics of anesthetic skills, and you should be able to do it confidently whenever necessary. In smaller hospitals, most of the operations are emergencies, and the lungs and the lives of the patients are in danger if you do not protect using proper maneuver.

Risks of Anesthesia

In general, there are potential risks with all types of anesthesia, general or conduction (regional) techniques. These can be minimized by careful assessment of the patient, thoughtful planning of the anesthetic technique, and skilful performance by the anesthetist. You should keep records of all the anesthetics that you give, and regularly review complications and morbidity. Some of the possible complications are listed in the following table.

Remember that all relaxants are contraindicated prior to tracheal intubation if the patient has abnormality of the jaw or neck or if there is any other reason to think that laryngoscopy and intubation might be difficult.

If you find intubation unexpectedly difficult after giving the patient suxamethonium and you do not succeed in intubating within 30 seconds of starting laryngoscopy, you must restore oxygenation by ventilating the patient with a face mask for 10 good breaths. Make one attempt, and if you are still unsuccessful after another 30 seconds, adopt the "Failed intubation drill"

Management of Anesthesia Risks

Anesthesia risks can be minimized by careful assessment of the patient, thoughtful planning of the anesthetic technique, and skilful performance by the anesthetist.

Documentation and Reporting of Anesthesia Plan

Your entire anesthesia plan should be properly documented in the permanent client document. This will serve as an evidence document and for reporting your plan accordingly. You should keep records of all the anesthetics that you give, and regularly review complications and morbidity.