What anaesthetists do???

I am attached to the surgical department in may 2008. As a result i get to see how the anaesthetists and surgeons work in the operation theatre once a week. The anaesthetist i met was Dr Suwee. She was so nice and she liked to ask questions. Her favourite questions were "what can go wrong with this procedure?" and "how to make sure this procedure has done correctly?" So i am here to explain what's happening in the anaesthetic room before the patient was sent to the theatre.

I have only seen 2cases of epidural. The anaesthetist would locate spaces in btw T8-T12 vertebrae, and local anaesthetic was injected into the skin. Then a needle was pierced through the skin, then to the supraspinous ligament, then to the infraspinous ligament then finally going through the ligamentum flavum, that's the destination-- epidural space. To make sure the needle is in the correct place, while piercing the needle, saline was injected through a syringe until the needle reaches a point of strong resistance, that is the ligamentum flavum. Once the resistacne towards the injected saline has gone down, it means that the needle has passed through the ligamentum flavum. A tube was inserted followed by the needle and the needle was taken out after that. The anaesthesia was given by injecting through the tube, an extra 1ml has to be injected as there is a dead space in the epidural. The tube was then stuck to the back of the patient and it was left open just in case extra anaesthesia was needed during the operation.

Then is the time to give sedation. Two infusions were given, they were propofol & remifentanil. The infusion rate was increased for abt 1min?? to make the patient asleep. And then it was switched bec to a lower rate to maintain the sedative state. How do u make sure the patient is in deep sleep? first n foremost, it a very straightforward method, by calling the name loudly and wait for response. Next, it;s a very unpleasant way, by pulling the eyelashes gently and wait for response. Normally, if the patient doesnt open his eyes, meaning that he's already in deep sleep. These are the manual method, they do have a monitor to check for the level of consciousness which i dont khow to interpret.

After that, here comes the intubation to maintain the air supply. After the intubation, i was asked to listen to the chest to ensure that the tube has gotten into the trachea, not the oesophagus. The breath sound has to be equal on both sides, and look at the chest movements and look for steam in the tube. If all these are present, u can be pretty sure that the intubation was done correctly. Then, check the patient's ability to breathe on it's own, keep an eye on the SP O2 level on the monitor, basically that's all.

What comes next? Maintenance of blood circulation, checking for blood pressure and heart rate. A mini ultrasound was used to locate right internal jugular vein & carotid artery. This is the most direct way to know the BP. A tube was inserted to the int jugular vein all the way down to assess the right atrial pressure. the tube was left open as well just in case IV infusion or blood transfusion were needed. It's normal to see the patient of 80/60mmHg as the BP was suppressed to prevent uncontrolled bleeding. One litre of saline was given to maintain the blood volume and to prevent the patient goes into hypovolumic shock.

On the other hand, (literally means the other hand as one has the saline infusion, the other hand has another infusion), muscle relaxant was given as an injection. this is to relax the muscle so that the surgeon would easily cut through the muscle layers.

so here comes the favourite question, what can go wrong with these procedures...
1) bleeding as so many needles and tubes piercing through the skin
2) risk of infection as so many foriegn materials were introduced to the body
3) anaphylaxis as there might be allergic reactions to the drugs
4) air embolism as air bubbles might be introduced into the bloodstream

that's all i could remember, i believe there are much more risks in giving anaesthetics. One simple word- Anaesthetic, concludes what i have all mentioned. It sounds simple but it takes about 20-30min to get it done. Do u think that's the end of the job? No, the anaesthetist has to send the patient in the theatre and monitor the cardiac and respiratory function, level of consciousness, amount of analgesia... throughout the whole surgery. In other words, the patient's life is in the anaesthetist's hand. After the surgery, the patient was monitored to recover to his optimum state in terms of cardiac & respi function. So the anaesthetist has to review the patient the next day after surgery to make sure the patient is back to normal.

Now this the end of the story.
To my fellow colleagues, think twice if you really decided to become a anaesthetist.