S2E6 - Maintenance

Two overarching goals for the maintenance phase of an anesthetic:Maintain appropriate depth of anestheticMaintain patient’s stabilityInhalational AnestheticsVolatile agents: sevoflurane and desflurane (most common), isoflurane (less common)Nitrous oxide: low potency, can be used in MH, flammableMinimum alveolar concentration (MAC): alveolar concentration of a specific inhaled agent that inhibits motor response to a painful stimulus in 50% of patientsIV infusionTIVA: total intravenous anestheticInfusion of a sedative agent (most commonly propofol) +/- other agents (such as opioids or benzodiazepines)Advantages: can be used in MH cases, less postoperative nausea and vomiting, can avoid airway instrumentation and aerosolization Intraoperative monitoringFor each physiologic system, consider: What parameters should I be concerned with?How can I measure or monitor them?What actions can I take to correct an imbalance? TemperatureMonitor: temperature probeAdjust: air warming device or IV fluid warmerNeuromuscularMonitor: observe patient movement, check Train-of-Four on peripheral nerve stimulatorAdjust: give neuromuscular blocker if needed, or reversal if appropriateVentilationMonitor: observe chest rise, auscultate lungs, end-tidal CO2 tracing, flow-volume loop (this goes in the opposite direction with positive pressure ventilation vs. spontaneous breathing!)Adjust: ventilator settings such as PEEP, inspiratory pressure, tidal volume, respiratory rateOxygenationMonitor: observe lips for cyanosis, pulse oximetry on the monitorAdjust: FiO2HemodynamicsMonitor: blood pressure, heart rate, ECG tracingAdjust: sedative drugs, analgesics, IV fluids; if necessary, consider rescue drugs such as phenylephrine, ephedrine, and atropineVolume statusMonitor: blood pressure, intraoperative blood loss, urine outputAdjust: IV crystalloid fluids, blood products if needed Practical things to do during the maintenance phase:Come to the OR with some questions in mind; the maintenance phase can be a good time to discuss physiology and other concepts with your staffRead up on your patient and try to anticipate any specific issues that could ariseCatch up on charting, if this is done by handDraw up medications for the next case, and ensure that your syringes are organized and labelledGo see your next patient and do a preoperative assessmentAsk your staff, “How can I help?”Support the show

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