Saturday, August 4, 2012

While You Were Sleeping: What I Do for a General Anesthetic




What happens after you get the "margarita" and forget everything else but Pre Op Holding? In case you were curious, let's walk down the hall to the Operating Room together.

I have sedated you, but not too much. Unless you are a nine-month old baby or smaller, I am going to ask you to scoot from that gurney to the O.R. Table.  Chances are you are bigger than me and the Filipino nurses that are in the room to help you.

I make small talk as I hook you up to the monitors. The data that I get is vitally important. Those are the hemodynamics of you awake. When your vitals approach this during surgery, I am going to deepen your anesthetic. I also have you breathe oxygen. This is Pre oxygenation. This buys me time while I am looking down your throat getting the breathing tube in. If you are claustrophobic, you can suck on the end of the circuit like a Peace Pipe. It doesn't matter how you get it, just fill your lungs with O2. For children, we smear lip smacker into the mask so it smells like cherry first. Sometimes I do this for adults, but often times they do not like a fragrance besides new plastic.

When I am ready, I ask you if you are ready to go to sleep. Then I ask you to pick a nice dream. I tell you you are going to wake up with no pain and no nausea, and with your whatever body part you are having fixed, fixed. Some people like to count backward from one hundred. I always let them think they have set a new world record when they count.

How do I know you are asleep? Well, you stop talking. Your eyes stare, and then close. You might yawn real big. But the test is that I tickle your eyelashes. Unconscious people do not flinch. Try it! You will see a little flutter on the eyelid on someone who is asleep but not unconscious-like your partner or child. Just touch the ends of the eyelashes lightly in a sweeping motion. After this I tape the eye shut so that my stethoscope and badge will not scratch your eye while I intubate or insert an LMA. Also so your eye will not dry out during the case.

I also mask you at this point. Can I get you to breathe while you are out? Sometimes I have to put in an oral airway, a piece of hard plastic that gets your tongue off the back of the throat and lets airflow through. Sometimes I have to hold the mask with both hands and have someone squeeze the anesthesia bag. If I can't breathe for you when you are sleeping, that is not good. If you have sleep apnea, this is likely to happen, cannot mask. Sometimes if the airway assessment is not favorable, I keep you breathing on your own and put the breathing tube in while you are numb and sedated but not asleep with a fiber optic scope.

Assuming I can ventilate, I open your mouth and insert a larygoscope, taking care not to catch the lip between the metal and the teeth. I look for the vocal cords. Sometimes I have a great view. Most times I have the nurse push on the Adams apple so I can see. I put the breathing tube through the cords under direct visualization. I do all these steps I thirty seconds or less. I blow up the cuff and connect the breathing circuit to the anesthesia machine and your endotracheal breathing tube. I look for an end tidal carbon dioxide waveform on the capnograph.  I tape the breathing tube in place and put a big roll of cotton for you to bite instead of my tube.

I set the anesthesia machine to breathe for you and start the anesthesia gases that will keep you asleep. During surgery, I watch all of your vital signs. I treat nausea and pain before you even wake up. I place lines if needed. I monitor fluid input and output carefully. Yes, I keep track of how much you pee! I also watch oxygen, carbon dioxide, hemoglobin, and electrolytes. All this in addition to making sure your anesthesia is enough for all the changing parts of the operation, if something is going to hurt that the surgeon does, I deepen the anesthesia first before your surgeon does that. Basically I even everything out as your surgery affects your blood pressure and heart rate.

At the end, I stop all anesthesia. I get you breathing on your own. You have to be awake enough to cough and not choke on your own spit. Then I take out the tube. I watch you closely to make sure you are exchanging air. And I give the signal for the team to roll you on the gurney. I walk with you to the recovery room, and give my report to your PACU nurse that will be taking care of you.

All this and Reiki too!

Namaste,

Reiki Doc

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