• New tools for airway management • New minimally invasive hemodynamic monitoring and goal directed fluid therapy • Oxygenation and ventilation monitoring • Closed loop drug delivery • Older and sicker patients undergoing extensive surgical procedures • Emphasis on shorter hospital stay and fast- track surgery • Realization that intraoperative management influences postoperative outcome Wilmore and Kehlet: BMJ 2000; 322: 473-6 • New airway management tools • CNS monitoring • Oxygenation (SaO 2 ) and ventilation (CO 2 ) monitoring • Non-invasive cardiac output monitoring • Patient and fluid warming systems • Anesthesia machine – digital ventilation • MRI compatibility machine and monitoring devices • Hazards air handling, gas evaluation, gas piping systems • Automated anesthesia record keeping system • Communication technology • Home infusion pumps and acute management systems
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• New tools for airway management
• New minimally invasive hemodynamic monitoring and goal directed fluid therapy
• Oxygenation and ventilation monitoring
• Closed loop drug delivery
• Older and sicker patients undergoing extensive surgical procedures
• Emphasis on shorter hospital stay and fast-track surgery
• Realization that intraoperative management influences postoperative outcome
Wilmore and Kehlet: BMJ 2000; 322: 473-6
• New airway management tools
• CNS monitoring
• Oxygenation (SaO2) and ventilation (CO2) monitoring
• Non-invasive cardiac output monitoring
• Patient and fluid warming systems
• Anesthesia machine – digital ventilation
• MRI compatibility machine and monitoring devices
• Hazards air handling, gas evaluation, gas piping systems
• Automated anesthesia record keeping system
• Communication technology • Home infusion pumps and acute management
systems
Intubation
Mask Ventilation
Supraglottic Devices
Airway Management
Laryngeal Mask Airway (LMA)
• Improves visualization of larynx • Difficulty in tracheal intubation
despite excellent visualization of the larynx
• Need to modify laryngoscopy technique – Laryngoscope blade placed in midline – Drop down the larynx such that the
laryngeal view is not complete – Use bougie or fiberscope
Video Laryngoscopes: Limitations
Right palatopharyngeal fold Can J Anaesth 2007; 54:322-324
• Anterior tonsilar perforation
AnesthAnalg 2007;104 1610-11
• Right palatopharyngeal arch perforation Can J Anaesth 2007;54:54-7
• Soft palate injury
J Clin Anesth 2007;19:619-21
Can J Anaesth 2007;54:588-9
Anesth Analg 2007;104;1609-10
• Pharyngeal injury
Otol Head Neck Surg 2007;37:175-6
• Versatile • Battery operated • Combination with video
laryngoscopes
Limitations • Fragile • Hard to clean
• Preoperative fasting
• Bowel preparation
• Intraoperative losses – Blood loss
– Evaporation
– Third spacing
• General and regional anesthesia – Vasodilatation
Joshi GP: Anesth Analg 2005; 101: 601-5
• We have become desensitized to administration of high fluid volumes (5-6 liters for major surgical procedures) – Kudsk: Ann Surg 2003; 238: 649-50
• Patients typically gain 5 kg of body weight after major surgical procedure – Lobo et al: Best Prac Res Anaesthesiol 2006;
20:439-55
• Perioperative hypervolemia increases postoperative morbidity and mortality
• Holte et al: Br J Anaesth 2002; 89: 622-32
• Perioperative fluid overload is a contributory cause of postoperative complications and death
– National Confidential Enquiry into Perioperative Death (http://www.ncepod.org.uk)
• Individualized fluid therapy that adapts to changing patient needs during the periop period
• Prevents subtle hypovolemia and hypervolemia that might lead to organ dysfunction, increase perioperative complications, and delay recovery
• Goal: maximize tissue O2 delivery with minimal cardiac O2 consumption – Stroke volume most commonly used – Optimal goal remains to be determined
• Fluid challenges to optimize dynamic (flow-related) goals
• Fluid bolus increases stroke volume in hypovolemic state
• In absence of hypovolemia: no change in stroke volume with fluid bolus
Daniels J, et al: Curr Opin Anaesthesiol 2009; 22: 775-81 Allows monitor the patient, surgical field and the patient's vital signs simultaneously without having to turn around to scan the monitors Liu D et al: Curr Opin Anaesthesiol 2009; 22: 796-803
The Microvision Nomad ND2000 (Bothell, WA) head-mounted display Liu D et al: Curr Opin Anaesthesiol 2009; 22: 796-803
• Numerous new technology are being introduced
• Adopting new technology WILL increase healthcare costs!
• Before any new technology is adopted for routine clinical practice, they MUST prove improved perioperative outcome and facilitate recovery Modern Practice