Anecdotes in Anesthesia: IPPR

Saturday, May 24, 2008

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.
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.
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.
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.
Try to suggest the surgeon in difficulty. He may or may not agree. You may share your observations gained from previous cases.

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.
Rising BP; not the colour or consciousness, indicate inadequate reversal. Transfer only if the BP is steady and the patient is conscious.
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.
Patients having long acting spinal anaesthetic drugs must be under observation with written instructions for maintenance of BP in post-operative period.
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.

Anecdotes in Anesthesia