REGIONAL TECHNIQUES NUMBERS OF PATIENTS

SPINAL ANESTHESIA 14,172

EPIDURAL ANESTHESIA 1,853

COMBINED SPINAL EPIDURAL ANESTHESIA 193

BRACHIAL PLEXUS BLOCK 113

TAP BLOCK 96

PARAVETEBRAL NERVE BLOCK 50

OTHERS 109

ULTRASOUND –GUIDED APPLICATION (SINCE 2013) 200

TOTAL OF REGIONAL TECHNIQUES (EXCLUDED LOCAL ANESTHETIC INFILTRATION)

16,480

NUMBERS OF SURGICAL INTERVENTIONS 49,708

•CLINICAL PRESENTATON

•CLINICAL SYMPTOMS

•PREVENTION AND TREATMENT

•ROLE OF 20% LIPID EMULTION

•Healthy 24 years – old man scheduled for anterior crucial ligament repair of the left knee

•Anesthesia Plan: Saphenous Block + Spinal Anesthesia

•Saphenous Block for perioperative pain relief : Adductive Canal Block (Hunter Canal Block) Ultrasound – Guided Single Shot

•Marcaine of 0.5%: 20ml

•Consciousness Deterioration

•Seizure

•Apnea

•Cardiovascular Situation ???

•ECG, PA Bandage is OUT OF PLACE!

• Well Palpated Carotid Pulse

• 100% O2 MASK VENTILATION

•MIDAZOLAM 5mg I.V, BUT STILL SEIZURING

•PROPOFOL: 50mg INTERVALS ( 200 mg TOTAL )

• LMA : AIRWAY SECURE

MANAGEMENT•CALLED FOR INTRALIPID 20% FROM PHARMACY

• HAD LIPOFUNDIN 20% AFTER 30 MIN

•RESETUP MONITORING

•MODERATE HYPOTENTION ( 80/50 mm Hg) MODERATE TARCHYCARDIA ( 90 beat/min)

• STILL UNCONSIOUSNESS

• LIPOFUNDIN 20%: BOLUS 100 ML IN 1 MIN

• INSTANT WAKE UP (~ 30 SEC)

• CONTINOUS LIPOFUNDIN 20% (400ml) IN 30 MIN

• ONE HOUR AFTER STABILITY: SPINAL ANESTHESIA FOR SURGERY

• ALLERGIC REACTION

• METHEMOGLOBINEMIA

• TISSUE TOXICITY

• CNS TOXICITY

• LOCAL ANESTHETIC SYSTEMIC TOXICITY ( LAST)

Auroy Y, et al. Major Complications of Regional Anesthesia in France. Anesthesiology 2002:97;1274-80.

• 93 CASES CONFIRMED FROM 1979 - 2009

• 60% DOMINANT CLINICAL ASPECTS

• # 40 % SUBCLINICAL ASPECTS: CVS SYMTOMPS ONLY• Di Gregorio G, Neal JM, Rosenquist RW, Weinberg GL. Clinical

presentation of local anesthetic systemic toxicity: a review of published cases, 1979-2009. Reg Anesth Pain Med. 2010;35:179Y185.

•NEVER DO SHOT CUT

•MEDICATIONS

•EMEGENCY APPLIANCES

• RESPECT DOSE

• TEST DOSE

• INTERVENCE INJECTION

• INJECTION PRESSURE

• ASPIRATION

• KEEP ALERT

• VITAL SIGNS MONITORING

• DRUG CHOISE

• NON ANESTHESIA STAFFS

• DRUG ERROR

• DOSE MAY NOT PROVIDE ADEQUATE THERAPEUTIC EFFECT (BLOCK)

• DOSES LOWER THAN RECOMMENDED LIMITS HAVE CAUSED TOXICITY

• DOSES IN EXCESS OF RECOMMENDED LIMITS HAVE NOT CAUSED TOXICITY

Polley L, Columb M, Naughton N et al - Relative analgesic potencies of ropivacaine and bupivacaine for epidural analgesia in labor: Implications for therapeutic indexes. Anesthesiology, 1999;90:944-950.

Bier Bier Block must be abandoned

• MINIMUM ANESTHESIA CARE (MAC)

• SEDATION + OPIOIDS + LOCAL ANESTHETIC INFILTRATION

EFFECT OF CO2 TO LASTEFFECT OF CO2 TO LASTHeavner, JE. Pharmacology of Local Heavner, JE. Pharmacology of Local

Anesthetics. In Longnecker DE,Brown DL, Anesthetics. In Longnecker DE,Brown DL, Newman MF, Zapol WM, Eds. Anesthesiology. Newman MF, Zapol WM, Eds. Anesthesiology.

New York: McGraw Hill; 2008:954-73New York: McGraw Hill; 2008:954-73..

Minimal Anesthesia Care

Maximum Anesthesia Care

Most Anesthesia Concern

Joan Rivers's doctor 'took a SELFIE' with the comedian as she was under anesthesia and just moments before she went into cardiac arrest that ki l led her: http://www.dailymail.co.uk/news/art icle-2758736/

• Livepool Heart and Chest Hospital, U.K

• 50 % SURGEONS DO NOT KNOW TO CALCULATE THE DOSE

• 25 % MEDICAL STAFFS DO NOT KNOW THE MAXIMUM DOSE

• 7% KNOWN LIPID IS A DRUG TO TREAT THE L.A.S.T

• 3% KNOWN THE INITIAL BOLUS DOSE OF LIPID

• “Awareness of local anaesthetic toxicity issues among hospital staff,” Anaesthesia, vol. 65, no. 9, pp. 960–961, 2010. J. McKevith, S.Rathi, H.El Sayed, K.Mills.

: 35 mg/kg!?

MAXIMUM DOSE: 35 mg/kg

ASA Closed Claims database (2012)

9,536 RELATED TO ANESTHESIA

18 RELATED TO LIPOSUCTION

8 DEATHS

4 PERMANENT BRAIN DAMAGES

Los Angeles study

9 DEATHS DUE TO LIPOSUCTION

2 NO MEDICAL FILES (1996)

7 DEATHS FROM 1999 – 2010

ALL DEATHS: ANESTHESIA OUTSITE HOSPITAL

As Liposuction Deaths Mount, Study Exposes Cracks in Safetyhttp://www.anesthesiologynews.com/ViewArticle.aspx?d=Clinical+Anesthesiology&d_id=1&i=October+2012&i_id=890&a_id=21743

• “Moreover, it is necessary that any physician using local anesthetics be aware of the current recommendations for managing local anesthetic systemic toxicity, including its prevention, diagnosis and treatment,” Dr. Weinberg

• “Hơn lúc nào hết tất cả thày thuốc sử dụng thuốc tê cần phải cảnh giác với những khuyên cáo hiện tại về xứ lý ngộ độc thuốc tê toàn thần bao gồm phòng ngừa, chẩn đoán và điều trị” BS Weinberg

• Hospital fined £100,000 after wrong drug killed new mother

• Mayra Cabrera died after giving birth in Swindon when she was accidentally dosed with bupivacaine, a potent anaesthetic

• http://www.theguardian.com/society/2010/may/17/mother-killed-myra-cabrera-bupivacaine

•

• HANOI UNIVERSITY HOSPITAL

PAIN PACKAGE

A-Z RESPOSIBLE TEAMS

REWARDS

PATIENTS CENTER CARE

• 88 % AIVALABLE

• THE REST: HOSPITAL STOCK

• AT LEAST: 95% CAN PROVIDE Lipid 20% <30 MIN

• “LIPID SINK”- LIPOPHILIC LOCAL ANESTHETIC IS SEQUESTERED IN A LIPID PHASE IN THE PLASMA

• METABOLIC EFFECTS:

• IMPROVED FATTY ACID TRANSPORT

• DIRECT INOTROPIC EFFECT

• ACTIVATION OF CALCIUM AND POTASSIUM CHANNELS

LIPID 20% trong ngộ độc thuốc tê

58 YEARS OLD, INTRACALENE BLOCK

20 ML MARCAINE 0,5%, 20 ML MEPIVACAINE 1,5%

20 MIN OF CRP AND ALSR

100 ML INTRALIPID 2O% BOLUS, 0,5ML/KG/MIN MAINTENANCE

FULL RECOVERY

• VARIABLES, BUT CONSENSUS

DO NOT WAIT TILL THE CARDIAC COLLAPSE

EARLY LIPIDE INFUSTION CAN PROTECT CARDIOVASCULAR COLLAPSE

DO NOT AGREE TO STRART TO USE IN LIGHT CLINICAL SYMPOMS

MOST AGREE TO USE WHEN THE CARDIOVASCULAR SYMPTOMS OCCUR OR RAPIDLY CLINICAL DETERIORATION