Use new drugs with caution

Beware of new drugs being introduced in the market...The pharmacologist and the drug industry have to criticize the old drugs to replace them with new. They have criticized Thiopentone to make way for their costly drug-Propofol. They highlight the rapid recovery of consciousness, which can be advantageously used for operations for day care surgery. But one has to remember that its use as induction agent for a prolonged surgery has no meaning. Even Thiopentone is metabolised and excreted in that time. The cost of the new drug is very high. The solvent of the drug is Egg white and soya bean oil. One raises a doubt to inject a foreign protein I.V. that may land you with serious anaphylactoid reaction and death. Thus you have to weigh the advantages and disadvantages by discussing with your colleagues and not be misled by the medical representatives.
They are now trying to throw out Scoline by propagating single long acting muscle relaxant with increased initial dose to be used for intubation. They try to highlight the bad effects of Succinylcholine Chloride. But ask yourself a simple question “How many deaths have you heard or seen in clinical practice under Scoline.” Except in cases where the drug is definitely contra indicated with raised serum potassium due to any cause at least in my practice I have not come across a single case with death due to Scoline. The first successful drug Atracurium which was successfully launched to replace Scoline was found later to cause anaphylactoid reaction due to intubating dose. It was abandoned in Europe and was being dumped in India. Luckily better drugs appeared in the market and we in India were prevented from being guinea pigs.

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#36-40: Private Practice Anesthesia- Do’s and Dont’s

1. Never start a case unless the surgeon has talked to the patient. The assistant may ask you to start under instructions from the surgeon who is not present on the premises.
   
2. Make the surgeons or the anesthesiologist colleague aware of complications seen or heard by you prior, but as far as possible do not disclose the names of surgeon or anesthesiologist or hospital.
   
3. Do not be shy to consult your senior in a difficult case and in the event of an accident try to find out the cause from as many sources until you are satisfied.
   
4. Do not start anaesthesia or even give sedation if the patient is not accompanied with a relative or friend. It is only in such cases serious complication occurs.
   
5. Remember myasthenic tendency in patients with long standing malignancy avoid using long acting muscle relaxant. If it has to be used, fractionate the dose and repeat only when absolute necessary. Tailor down the doses of all drugs that you are giving as these patients become very sensitive to all drugs.

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#31-35: Private Practice Anesthesia- Do’s and Dont’s

31. Keep a casual watch on theatre asepsis and let the surgeon know at an appropriate time. Observe the colour changing labels on the drums, and instruments supplied in between.
    
32. Always talk to the surgeon first in high risk cases where a death on table is likely. When surgeon agrees, talk to the relatives along with surgeon. Obtain consent, then only start.
    
33. Patients with respiratory obstruction, difficulty in breathing, Ludwig’s angina trismus: In these cases do not even venture to give sedation. Never think of giving anaesthesia unless the airway is secured. Topical anaesthesia, awake intubation, tracheostomy done, guided blind intubation or flexible intubating bronchoscope used to intubate are your options.
    
34. In places with very hot climate and during summer allow patients to have a glass of plain water one hour before surgery. This is especially for children.
    
35. Do not order your premed for adults. Give IV at the induction only in sepcial cases. Order the premed at the exact time. Do not give only Ketamine to an adult. Do not give Diazepam alone for patient with pain. They become incoherent and unmanageable. Same rule follows for Scopolamine for elderly patients.

#36-40: Private Practice Anesthesia- Do’s and Dont’s

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#26-30: Private Practice Anesthesia- Do’s and Dont’s

26. Patients who are obese, have thick necks, full set of teeth, micrognathia or receding chin present difficulties for intubation. Keep the nasal tube ready. If possible keep even laryngeal mask airway tube ready. Warn the surgeon and take his help. If nothing is possible attempt awake intubation under topical anaesthesia.
    
27. Before handing over a patient on IPPR to any person even for a short period, see that he can do it in your presence. Ask him to observe the quick inflation of the chest. Instruct him that during your absence he must not leave the patient to attend to surgeon in charge or the nurse in charge. Do not depend on attending doctors; they may only observe the movements of the bellows. Explain to your hand-off person that that he is breathing for the patient and stoppage will kill the patient.
    
28. When dealing with cases with high risk history of previous anaesthesia, ascertain the causes from whatever the patient tells you; consult his anesthesiologist if available.
    
29. Try to help the theatre staff if you are comfortable at your end. Remind and observe the nurse for sponge count before and at the end of surgery. Keep a watch on asepsis as far as visitors go. All this in the interest of well being of the patient.
    
30. Try to suggest the surgeon in difficulty. He may or may not agree. You may share your observations gained from previous cases.

#31-35: Private Practice Anesthesia- Do’s and Dont’s

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#21-25: Private Practice Anesthesia- Do’s and Dont’s

21. Beware of precipitous fall of BP in cases with induction of GA with regular dose of Thiopentone in failed spinal or epidural.
    
22. Patients with diabetes convert them on soluble insulin. If not possible give 10 units/ 500 dextrose. If the diabetes is mild and controlled on tablets give 10 units/ alt bottle of dextrose (5%); do not over treat. It is better to have a slightly hyperglycaemic patient rather than hypoglycaemic under anaesthesia. The only sign of caution you get is severe unexplainable tachycardia. Beware of armchair physicians who have not studied patients under anaesthesia or even entered the operation theatre.
    
23. Hypertensive patients who are controlled on drugs typically continue the drugs even before operation. If the BP is high, mainly due to fear in most cataract patients, administer 5-10 mg Nifedipine under the tongue on operation table before you start.
    
24. High risk patients, toxaemic, gasping with electrolyte imbalance: In this case, your first duty is to keep the patient alive. Avoid Thiopentone or if you do use it for your satisfaction administer homeopathic doses. Forget about Scoline twitchings and awareness of intubation. If Boyle’s Apparatus is available, do nitrous oxide, oxygen induction till eyelash reflex disappears. Give full dose (100 mg) of Scoline, do not compromise. Fractionate the muscle relaxant dose (long acting) or avoid if you can manage with repeated dilute Scoline. The dose needed may be unimaginably small.
    
25. Plan your method of anaesthesia well. Do not give spinal if the operation is not likely finish in time. Do not give Thiopentone only for surgeries causing immense pain. Use a combination of drugs with analgesic and amnesic drug.

#26-30: Private Practice Anesthesia- Do’s and Dont’s

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#16-20: Private Practice Anesthesia- Do’s and Dont’s

16. Never be in a hurry to send the patient back to the ward if the procedure was done under a muscle relaxant. If in doubt try IPPR; if permitted the patient needs reintubation or IPPR with mask till he is completely reversed.
    
17. Rising BP; not the colour or consciousness, indicate inadequate reversal. Transfer only if the BP is steady and the patient is conscious.
    
18. All patients who have received muscle relaxant (long acting) must be reversed with at least 0.5 to 1 mg. Prostigmin for even a small dose of muscle relaxant.
    
19. Patients having long acting spinal anaesthetic drugs must be under observation with written instructions for maintenance of BP in post-operative period.
    
20. In patients with known full stomach or even expected full stomach induce with head up tilt, remove the Ryle’s tube after proper suction in different positions. Oxygenate with 100% oxygen. Do not ventilate after Scoline. Ask the surgeon to give tracheal pressure, introduce the laryngoscope blade only when the patient is fully relaxed and intubate. Study your position for intubation (take a flat stool to stand on if necessary) with head up tilt.

#21-25: Private Practice Anesthesia- Do’s and Dont’s

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#11-15: Private Practice Anesthesia- Do’s and Dont’s

11. Get acclimatized to the nursing home. Find out whether things and injectables are available and where they are stored.
    
12. Palpate the vein before puncturing or cannulating. Ask the patient as to where he is taking the injections. Choose the site of puncture depending on nature of operation and the position of the patient during surgery. This is your lifeline. In obese and small children spend some time to find a vein. Do not use the vein on the side where arterio-venous fistula is created.
    
13. Listen to the patient his choices and thoughts. Work according to his choice if possible or try to convince him what is best for him.
    
14. Children for IV puncture usually cooperate well in sitting position and talking to them explaining what you intend to do. Some children may not cooperate. Avoid premedication by injection as far as possible.
    
15. Plan your anaesthesia in such a way that patients are fully conscious as far as possible at the end of procedure. If not make sure they are at least rousable. If the patient is deep observe before sending him back to the ward. Before releasing the patient, try the “Gharpure sign”--The patient on closing both nose and mouth must involuntarily open the mouth to breathe.

#16-20: Private Practice Anesthesia- Do’s and Dont’s

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#6-10: Private Practice Anesthesia- Do’s and Dont’s

6. Ask the patient about dentures, special drugs and medications, and valuables he may be carrying.
   
7. Check that the consent form is signed and witnessed. Make sure there is a separate consent form per operation when the patient visits regularly.
   
8. Do not impose your choice of anaesthesia. If there is disagreement discuss and convince the surgeon or the patient. Do not use spinal for investigative procedures and procedures that likely to be repeated very often.
   
9. Do not insist on the procedures you are taught in teaching hospital. For example, spinal, general or cannulating a vein in an infant for EUA or IV infusion when not necessary.
   
10. Carry your own tourniquet do not expect any help.
    

#11-15: Private Practice Anesthesia- Do’s and Dont’s

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#1-5: Private Practice Anesthesia- Do’s and Dont’s

1. Keep calm – very easily said but difficult to practice. There are so many difficulties at each step. Do not bring your worries into the operation theatre.
   
2. Keep to your time schedule; it may not always work. Delays by the surgeon, nursing staff, unforeseen emergencies will always delay your schedule. If late or delayed say sorry and start. Do not argue even if you are not in the wrong.
   
3. Know your operation schedule the previous night before. In case of doubt, communicate; do not take things for granted. Hernia told to you may mean bilateral hernia, incisional hernia, umbilical hernia or obstructed hernia. Keep the time schedule accordingly. Inform the next surgeon about your delay. Leave the choice to him to arrange another anesthesiologist.
   
4. Check your equipment and drugs and replace them immediately.
   
5. Always check the notes or find out the information you need from the patient or the surgeon. Check the name and side of operation from the notes and confirm them by asking the patient. Check whether the patient is accompanied by a relative or responsible person.

#6-10: Private Practice Anesthesia-Do’s and Dont’s

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