New Evolutions in Anesthesia Deep NMB How and when to achieve, How to reverse. 5 dec 2013 ...

52 Pages·2013·27.53 MB·English

by  Jan Mulier

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1150 1850 1947 1977 2010

New Evolutions in Anesthesia
THURSDAY, DECEMBER 05, 2013

08:00-09:00 Registration
Deep NMB

09:00-11:0H0 ow aPnardal lewl Sheessinon t 1oA -a Ecahrliye Avssee,ss mHeontw, A itrwoa yr eMvaenargseem.en t Hall C
Moderator: Prof. Yeshayahu Katz, Rambam Health Care Campus - Hospital, Haifa

09:00 Rapid Sequence Induction and Intubation
5 dec 2013, Tel Aviv Israel
Prof. Alexander Zlotnik, Soroka Medical Center, Beer Sheva,
09:30 Difficult Airway in Trauma
Jan Paul Mulier MD PhD
Prof. Tiberiu Ezri, Wolfson Medical Center, Holon
Anaesthesiologist
10:00 Early Assessment of Injured Patient
Sint-Jan Brugge-Oostende, Belgium
J P Mulier 4 dec 2013
Dr. Avi Shapira, Soroka Medical Center, Beer Sheva,

10:30 Lung Separation in the Difficult Airway and Trauma
Prof. Edmond Cohen, The Mount Sinai School of Medicine, New York, USA

09:00-11:00 Parallel Session 1B – Military trauma and Neurotrauma Hall D
Moderator: Prof. Yoram Shapira, Soroka Medical Center, Beer Sheva
09:00 Head Trauma – New Concepts or Old Fashioned Way?
Dr. Orit Nahtomi, Sheba Medical Center, Tel Hashomer,
09:30 New Evolutions in Anesthesia - Supported by MSD
Dr. Jan Mulier, AZ Sint Jan Hospital, Brugge, Belgium
10:00 Anesthetic Management of the Head Trauma Patient
Dr. Elliott Yussim, Rambam Health Care Campus - Hospital, Haifa
10:30 My Brother's Keeper 2020- Eliminating Preventable Deaths in the IDF
LTC Elon Glassberg M.D MHA, The Trauma & Combat Medicine Branch
Israel Defense Forces

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Potential conflicts of interest.
—  I have been giving lectures for or received research
funding from following companies in the last two years:
—  Abvie
—  Astellas
—  Baxter
—  General Electric
—  Janssens Pharmaceutics
—  Medec
—  Merck
—  Orion
—  No important share holder in any medical company
03/06/13 ESA 2013 J P Mulier
What surgeons request from anaesthesia?
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I’m gonna try a new surgery
Who cIa wn irlle tdruyc teh e surgery without
approach. Do not disturb unless
theasnea seusrtghiecsaila . Sure if you dWoehsenr’et did you study
You cannot keep him alive.
deamthinsd? pain and discomforatn aesthesiology?
Don’t worry. My Anesthesiologist
makes surgery simple.
I did not know that a peri
operative physician takes care of
me after the operation.
Hurry up, anaesthesia
—  In the past time is limited.
—  Trying to operate without anaesthesia.
—  A reliable anaesthesiologist available when they have problems.
—  Protecting the patient allowing them to take risks.
—  Being disturbed only when absolutely needed.
—  In the future
—  Allowing the surgeon to work faster and in better surgical
conditions.
—  Improving the surgical outcome by adapting anaesthesia and
having a surgeon defending our peri operative care.
J P Mulier 4 dec 2013
Anesthesia should focus on surgery 4
instead of improving further its own safety only.
Surgery
Health
care
Anesthesia
J P Mulier 4 dec 2013
Bariatric Center Bruges, Belgium
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Head Surgeon: Bruno Dillemans,
Head Anaesthesiologist: Jan P Mulier
J P Mulier 4 dec 2013
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We need to think what the others
need to improve their outcome.

then we remain important as a
peri operative physician.
—  J F Kennedy 50 y ago:
—  Inventor of the transdisciplinarity
—  ‘Ask not only what the anaesthesiologist can do for you,
ask also what you can do for the anaesthesiologist.’
Suggestion “ask that your surgeon requests also your hospital
for the drugs you need to give deep NMB and OFA.”
J P Mulier 4 dec 2013
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Main elements of ERAS
—  Multimodal recovery programme for elective bowel
surgery.
—  Henri Kehlet Denmark 2001
—  Lassen K. ERAS Group recommendations. Arch surg 2009;
144: 961-969
J P Mulier 4 dec 2013
Adapted ERAS protocol 8
for laparoscopic bariatric
surgery
—  1. Pre op elements
—  No premedication no sedatives, No prolonged fasting
—  Antibiotic, trombo prophylaxis ( beach chair)
—  Weight reduction > 10 kg by only high protein diet 3 weeks before
—  2. Per op elements
—  Short acting anesthetics, local infiltration and non opioid anesthesia
—  Provide sufficient surgical workspace to shorten surgical time and improve
work
—  Abd compliance monitor, Deep NMB with ctu infusion, beach chair,
—  Reduce inflammation and avoid salt & water overload but cave rhabdomyolysis
—  Maintain normothermia loading up with sufficient non opiod analgesia
—  Avoid lung atelectasis, silent aspiration, volutrauma
—  Beach chair, CPAP, LRM, early PSV, permissive hypercapnia
—  Increase blood pressure above 140 mmHg to clip bleeding vessels to prevent
post op bleeding and visualize ischemic zones
—  Strong leak test to avoid leaks
—  3. Post op elements
—  Full decurarisation to 90% and full awake before extubation.
—  Non opoid oral analgesia/NSAIDs
—  Prevent PONV
—  No nasogastric tube and stimulation of gut mobility
—  Early removal catheters, mobilisation legs and deep inspirJa tPi oMnul,i eor r a4 ld necu 2tr0i1t3i on
J P
Muli
er 4
Can we do something to improve this 9
dec
201
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situation?
—  Surgeon: The abdomen is flat, I have no
space to operate.
—  Anesthesiologist: your problem. The
patient is asleep and stable, everything fine
at my side.
—  Surgeon: Look at the video screen. How do
you want me to operate in so little space?
And the pressure is already 18 mmHg.
—  Anesthesiologist: The patient will not
tolerate higher pneumoperitoneum
pressures. An experienced surgeon can
handle this.
—  Surgeon: Do you want me to change to a
laparotomy? When was the last time you
gave a musclerelaxant, and by the way why
do I always have to ask that?
Intraabdominal pressure ? —  Anesthesiologist: The patient has only one
Intraabdominal volume? TOF response in the AP. Last time this was
enough. Why not today with you?
Workspace?
—  Surgeon: I don’t know what “one TOF
response” means. What I said is I can´t
work with you. Call your supervisor!
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What is Deep block: TOF =0 and PTC < 5 counts
Posttetanic Twitch Twitch
count count response
Level of block Intense block Deep block Moderate block Superficial block
Response to TOF TOF count 0 TOF count 0 TOF count 1-3 TOF count 4
Response to PTC PTC 0 PTC ≥1 PTC ≥20 T4 / T1 %
—  Intense blockade: no response to either TOF or PTC stimulation
—  Deep blockade: response to PTC but not to TOF stimulation
—  Moderate blockade: reappearance of response to TOF stimulation
—  Superficial blockade: T4 response divided by T1 response
PTC, posttetanic count; TOF, train-of-four.
J P Mulier 4 dec 2013
Fuchs-Buder T, et al. Acta Anaesthesiol Scand. 2007;51:789-808.