Anaesthesiologist as Perioperative Physician* (Our Experience of Last 2 Decades)

Name: Anaesthesiologist as Perioperative Physician* (Our Experience of Last 2 Decades)
Uploaded: 2023-04-19T17:14:50.000Z
Duration: 3 h 12 min 21 s

Foreign Language

The video starts with foreign language music playing in the background.

Introduction

The introduction continues with music playing in the background.

Thank You

A person thanks the audience while music plays in the background.

Delayed Start

The speaker apologizes for a delayed start and mentions that some participants are missing due to Zoom capacity issues.

Request for Mute

The speaker requests everyone to go on mute as it is an important meeting.

Admitting Participants

The speaker admits participants into the meeting and tries to shift some of them to another platform due to capacity issues.

Foreign Language Music

Foreign language music plays in the background.

Starting the Meeting

The meeting officially starts, and Dr. Heyman Shinde introduces Dr. Bala Venkat Subramanyam as a senior consultant with 31 years of experience. They discuss a case where a physician did not properly optimize a patient, leading to complications.

The Role of Anesthesiologists as Perioperative Physicians

Dr. Balavenkat Subramanyam discusses the importance of anesthesiologists in perioperative care and introduces himself.

Introduction

Dr. Balavenkat Subramanyam is introduced as a highly respected anesthesiologist with extensive experience.

He has been chosen to speak on this topic due to his expertise in the field.

Qualities of an Ideal Anesthesiologist

An ideal anesthesiologist should be highly compassionate, knowledgeable, and adaptive.

Dr. Subramanyam possesses these qualities and more, including being deeply spiritual and involved in social work.

He is also a pioneer in techniques such as ultrasound-guided nerve blocks.

Ganga Hospital

Ganga Hospital is the largest private orthopedic hospital in Coimbatore, India, with 32 operation theaters managed solely by anesthesiologists.

Dr. Subramanyam explains how they have contributed significantly to orthopedics and plastic surgeries across five states in India.

Importance of Anesthesiology in Perioperative Care

Patients undergoing surgery are concerned about survival and pain management.

Anesthesiologists play a crucial role in ensuring patient safety during surgery and managing pain post-surgery.

Dr. Subramanyam emphasizes the importance of communication between surgeons and anesthesiologists for optimal patient outcomes.

Conclusion

Dr. Subramanyam concludes his talk on the vital role of anesthesiologists as perioperative physicians.

The Importance of Core Values

In this section, the speaker emphasizes the importance of having strong core values to achieve success in life.

Strong Core Values

Having strong core values is essential for personal and professional growth.

Anesthesiologists should strive to become perioperative physicians and be recognized for their work.

Believing in oneself and having high values are necessary to achieve one's dreams.

Introspection

Regardless of one's background or upbringing, anyone can achieve great things with hard work and determination.

Strategizing one's day is crucial for achieving goals.

Work ethics and discipline are important qualities that lead to success.

Professional Organizations

In this section, the speaker discusses various professional organizations related to anesthesiology.

Indian Society of Anesthesiologists

The Indian Society of Anesthesiologists celebrates its Platinum Jubilee.

The mission of each member should be known as a perioperative physician.

Academy of Regional Anesthesia of India

The Academy of Regional Anesthesia of India celebrated its decade-long pioneering work in regional anesthesia.

Workshops were conducted during the Ganga Anesthesia Refresher Course to enhance anesthesiologist skills.

World Congresses

The World Congress of Regional Anesthesia will be held in Paris in September.

The World Congress of Anesthesia will be held in Singapore in March.

Attending these congresses is an opportunity to showcase clinical work and network with other professionals.

Conclusion

In this section, the speaker concludes the presentation by emphasizing the importance of considering work as a prayer.

Work as Prayer

Work is a prayer and should be considered as such.

Greetings are extended from Ganga Medical Center and Hospital.

Anesthesiologists as Perioperative Physicians

In this section, the speaker discusses the role of anesthesiologists as perioperative physicians and their responsibilities in pre-operative care.

Anesthesia Branch Responsibilities

Anesthesiologists are responsible for pre-operative optimization, pre-anesthetic room, and intensive care.

The managing director and two directors allowed anesthesiologists to be perioperative physicians.

Super specialists are available on call when needed.

Case Study: Run Over Injury

A 24-year-old engineering student was run over while going to college.

She became an ASA grade 5 patient upon arrival due to breathing difficulties.

The patient was immediately shifted to the resuscitation room where she was intubated and assessed by anesthesiologists.

E-fast was done by the anesthesiologist which showed splenic rupture.

Resuscitative laparotomy was done immediately followed by massive transmission protocol initiation.

The patient went post-operatively ventilated for 48 hours and extubated.

Advantages of Perioperative Physician Work

Minimizing time between arrival of patient to table can save lives.

Proactiveness of anesthesiologists working as perioperative physicians has saved many lives.

Perioperative Medicine

In this section, the speaker discusses how perioperative medicine is becoming one of the important components of pre-operative care.

Perioperative Medicine

Perioperative medicine is going to be one of the important components of pre-operative care.

Anesthesiologists can become very good perioperative physicians.

The Future of Anesthesia Practice

In this section, the speaker discusses the future of anesthesia practice and how creating elective surgical pathways based on patient needs rather than provider convenience can lead to radical change in care delivery.

Anesthesia Paradigm Shift

Ronald Miller led a task force for the American Society of Anesthesiologists to identify possible anesthesia paradigms.

Miller suggested that anesthesiologists need to diversify their practice paradigms to ensure future leadership positions in medicine.

Becoming pre-operative physicians is essential for future anesthesiologists.

Multimodal prehabilitation will lead the next generation of anesthesiologists to spend more time in prehabilitation for excellent post-operative outcomes.

Quality of Anesthesia

In this section, the speaker discusses how quality anesthesia should be measured by six domains: effectiveness, equity, timeliness, efficiency, safety, and patient-centeredness.

Measuring Quality of Anesthesia

Quality anesthesia should be measured by six domains: effectiveness, equity, timeliness, efficiency, safety, and patient-centeredness.

Pre-operative physicians must focus on these domains to provide quality care.

Advancements in Anesthesia

In this section, the speaker discusses how advancements in anesthesia have led to changes in anesthesiology curriculum and how anesthesiologists are now giving anesthesia to patients with significant organ dysfunction.

Changes in Curriculum

With advancements in anesthesia and super specialization (e.g., cardiac anesthesia), the anesthesiology curriculum has completely changed.

Anesthesiologists now give anesthesia to patients with significant organ dysfunction (e.g., liver transplantation).

To become perioperative physicians, it's important for anesthesiologists to know about various organ systems in the body.

Point of Care Ultrasound

In this section, the speaker discusses how point of care ultrasound is evolving and will soon be used by every anesthesiologist to see what is in a patient's stomach.

Point of Care Ultrasound

Every anesthesiologist should possess the ability to use ultrasound in point of care ultrasound.

Point of care ultrasound allows anesthesiologists to see what is in a patient's stomach (e.g., liquid or solid) and determine appropriate anesthesia.

Becoming a Perioperative Physician

In this section, the speaker discusses the importance of skill, knowledge, evidence-based practice, honesty, integrity, and humility in becoming a successful perioperative physician.

Key Points:

Skill, knowledge and evidence-based practice are important for pre-operative care.

Honesty and integrity with patients is crucial.

Humility is necessary to work effectively with surgical teams.

Case Study: Fractured Dislocation Ankle

In this section, the speaker presents a case study of a patient with multiple comorbidities who required surgery for a fractured dislocation ankle. The speaker emphasizes the importance of site-specific analgesia and how anesthesiologists are fit to be perioperative physicians.

Key Points:

Patient had multiple comorbidities including hypertension, diabetes, obesity and coronary artery disease.

Site-specific analgesia was used to provide excellent pain relief.

Anesthesiologists are fit to be perioperative physicians due to their extensive training in various medical specialties.

Importance of Perioperative Care

In this section, the speaker discusses why anesthesiologists are uniquely qualified to provide perioperative care due to their extensive training in various medical specialties.

Key Points:

Anesthesiologists have extensive training in various medical specialties such as physiology of premature neonates and centenarians.

Anesthesiologists deal with multiple comorbidities and medications making them well-suited for perioperative care.

Anesthesiologists: The One-Stop Solution Inside the Hospital

In this section, the speaker discusses the role of anesthesiologists in treating critically ill patients and trauma resuscitation. They also highlight the various skills and procedures that anesthesiologists are experts in.

Anesthesiologists' Role in Treating Critically Ill Patients

Anesthesiologists are involved in treating critically ill patients, with 60% of Indian ICU patients being looked after by anesthesiologists.

They are experts in invasive monitoring, echocardiogram, e-fast, coagulation profile with thromboelstography, bis monitoring, flow volume loops, ABG near-infrared spectroscopy.

Anesthesiologists use the largest amount of intravenous fluid therapy and deal with total parental nutrition and blood component therapy.

They also get involved in chest physiotherapy, DVT prophylaxis, acute pain management, elective ventilation and have upscaled their skills to do percutaneous tachyostomy intercostal drainage bronchoscopies in the ICU.

Pre-operative Assessment

To become a one-stop solution inside hospitals for patient care it is important to take a proper pre-operative assessment very carefully.

During pre-anesthetic assessment careful listening is required to account for every symptom that he gives based on which we will build a plan tailored to each patient's anesthesia requirement.

Spending time with patients during pre-operative period is the best pre-medication that they can have.

Mannerisms Required During Pre-Anesthetic Assessment

During pre-anesthetic assessment, it is important to be calm and confident while dealing with a patient who has come for surgical admission.

Effective communication is required to take the relatives into confidence and convince the patient that the pre-operative period will be smooth.

Privacy should be assured during history taking followed by an immaculate physical examination with a lot of focus on the cardio-respiratory system.

Additional Help

If additional help is needed, anesthesiologists start incentive spirometry, nebulization for smokers, thiamine supplements for alcoholics.

Based upon the surgical procedure, blood bank is called to discuss with the surgeon and fix for the number of Bloods that need to be arranged.

Perioperative Medication Management

In this section, the speaker discusses the importance of perioperative medication management and informed consent.

Importance of Medication Management

Medication errors are a common cause of perioperative morbidity and mortality.

Pre-operative physicians play an important role in managing medications to optimize patient outcomes.

Physiological arrangements such as electrolyte balance and fluid balance are important considerations when managing medications.

Informed Consent

Informed consent is based on a patient's right to determine what will be done to them, including the right to consent or refuse treatment.

The pre-operative physician, in conjunction with the surgeon, must explain the nature of the intervention, its benefits and risks, and available alternatives.

Documented informed consent signed by both the patient and their attendant is crucial.

Hospital-Acquired Infections

This section focuses on hospital-acquired infections and their impact on patient outcomes.

Importance of Hand Hygiene

Hospital-acquired infections are a significant cause of morbidity and mortality in surgical patients.

Pre-operative physicians must follow protocols for hand hygiene to minimize infection risk.

Importance of Early Surgery

Early surgery is crucial for certain conditions such as hip fractures.

Delaying surgery can lead to physiological deterioration that enhances morbidity.

Pre-operative physicians should take up the challenge of doing these cases at the earliest possible time.

Anecdotal Studies

This section provides anecdotal studies related to orthopedic surgeries.

Importance of Dehydration Management

Patients undergoing orthopedic surgeries are often dehydrated due to not eating or drinking before surgery.

Managing dehydration through IV fluids is crucial for patient outcomes.

Importance of Early Catheter Removal

Removing urinary catheters as soon as possible can help avoid neurosexis.

Pre-operative physicians should take steps to minimize catheterization time.

Pre-operative Assessment

In this section, the speaker discusses the importance of pre-operative assessments and planning for surgeries such as hip replacements.

Importance of Pre-Operative Assessments

Assessments such as blood loss, type of surgery, and comorbidities should be done in the pre-operative period.

The speaker emphasizes the importance of maintaining mean arterial pressure (MAP) equal to the age of the patient during surgery to ensure adequate organ perfusion.

The use of a combined spinal epidural and low dose spinal is recommended to maintain MAP without compromising systemic vascular resistance.

Anesthesia Administration

In this section, the speaker discusses anesthesia administration for patients with multiple comorbidities undergoing hip replacement surgery.

Safe Anesthesia Administration

Patients are given a block on arrival and then another block before surgery.

A combined spinal epidural is used even for short surgeries to maintain MAP equal to the age of the patient.

Phenylephrine is used for tachycardia while ephedrine or mephitol are used for bradycardia during anesthesia administration.

Postoperative Care

In this section, the speaker discusses postoperative care for patients undergoing hip replacement surgery.

Postoperative Complications Prevention

Leukodepleted packed cells are used instead of whole blood transfusions to prevent temperature-related complications.

Body warming and DVT prophylaxis are initiated intra-operatively to prevent hypothermia and coagulopathy postoperatively.

Importance of Analgesia in Major Surgical Procedures

In this section, the speaker discusses the importance of analgesia in major surgical procedures and how it can impact patient outcomes.

Understanding the Intensity of Damage Without Analgesia

Patients without analgesia experience poor eating and sleeping habits, delirium, dehydration, and electrolyte imbalances.

Standardizing Protocols for Surgical Procedures

The department closely monitors patients to establish protocols for every procedure. This includes preemptive analgesia, monitoring blood loss and hemodynamics, nausea/vomiting rescue analgesia, cognitive dysfunction monitoring.

Standardized protocols are established for each type of surgical procedure to ensure excellent outcomes.

Learning from Cognitive Dysfunction Cases

Anesthesiologists must read up on cases with cognitive dysfunction to learn more about them.

Reading articles like the Pre-operative Brain Health Initiative can help anesthesiologists improve their knowledge base.

Treating Acute Symptomatic Hyponatremia

In this section, the speaker discusses a new guideline for treating acute symptomatic hyponatremia.

Prompt Treatment is Key

Promptly infusing 150 ml of 3% hypotonic saline intravenously over 20 minutes is recommended when treating acute symptomatic hyponatremia.

Consider checking serum sodium concentration again after 20 minutes while if it is still low repeated.

Post-Operative Urinary Retention in Elderly Patients

In this section, the speaker discusses post-operative urinary retention in elderly patients and how it can lead to neurosepsis.

Identifying the Problem

Many total knee replacement patients experienced post-operative urinary retention leading to urosepsis.

Investigation revealed that the problem was due to a lack of awareness and education on the issue.

Addressing the Issue

The department worked with urology clinics to address post-operative urinary retention in elderly patients.

Education and awareness campaigns were launched to help prevent future cases of neurosepsis.

Importance of Being a Perioperative Physician

In this section, the speaker emphasizes the importance of anesthesiologists being engaged in improving surgical outcomes and taking ownership of the patient's journey. He also stresses the need for good communication with patients and families, as well as proper documentation to protect against potential lawsuits.

The Importance of Holistic Patient Care

Anesthesiologists should look at patients holistically to learn from mistakes made during surgery.

Anesthesiologists are best equipped to correlate post-operative complications with what happened during surgery.

Measuring work is important for improving surgical outcomes.

Preventing Complications

Anesthesiologists can help prevent complications by providing competent and compassionate care, good communication, and excellent documentation.

Becoming a perioperative physician is key to becoming more engaged in improving surgical outcomes.

Ethics and Empathy

It's important not to equate everything to money when performing procedures.

Developing empathy towards patients and staff is crucial for becoming a successful perioperative physician.

As anesthesiologists become more respected, they must remain humble and approachable.

Conclusion

The speaker believes that if anesthesiologists continue on this path, they will see a generation of young anesthesiologists who are highly respected and needed throughout the world.

Difficulties in Geriatric Patients with Neuraxial Anesthesia

In this section, the speaker discusses the difficulties of administering neuraxial anesthesia to geriatric patients due to degeneration in the spine and lack of exposure to sunlight leading to osteoporosis.

Degeneration and Osteoporosis

Degeneration happens in all parts of the body, including the spine, making it difficult to administer neuraxial anesthesia.

Lack of exposure to sunlight can lead to osteoporosis in geriatric patients, making it even more challenging.

The L4-L5 and L5-S1 are not part of scoliosis in a degenerative spine, making them ideal for inserting neuraxial anesthesia.

Spinal Dosages Based on Age Groups

In this section, the speaker explains how spinal dosages are determined based on age groups and why low doses are preferred.

Determining Spinal Dosages

Spinal dosages are determined based on age groups.

Low doses are preferred because they help maintain mean arterial pressure and prevent polypharmacy.

The amount of circulating CSF volume is less in geriatric patients, so a smaller volume is sufficient for surgical anesthesia until day 10.

Two-segment regression starts happening 45 minutes after giving spinal anesthesia. Each lumbar segment needs about 1.5 ml of local anesthetic.

Administering Epidural Anesthesia

In this section, the speaker explains how epidural anesthesia is administered to maintain surgical anesthesia until the end of surgery.

Administering Epidural Anesthesia

Three mL of 0.5 percent BP vacant is substituted epidurally to produce surgical anesthesia.

The process is repeated every 20 minutes until the end of surgery.

This method helps maintain hemodynamics and prevents the need for additional drugs or IV fluids.

Regional Anesthesia Techniques

In this section, the speaker discusses regional anesthesia techniques used for hip fracture patients and epidural analgesia.

Types of Blocks Used

Femoral blocks are given to practically every patient.

Graduated from anatomical blocks to peripheral stimulator and now use only ultrasound.

For hip fractures, Supra and infragluteal or femoral block with little femoral cutaneous is used.

Elastomeric infusion pumps are used for epidural analgesia.

Dosages Used

Volume given is approximately 15 to 20 ml with a concentration of 0.25k or 0.2 percent rupivacaine.

Elastomeric pumps are available in different volumes (2ml -12ml).

For hip fractures, either 0.2 percent rupivacaine or 0.125 percent bupivacaine at about 6 ml per hour is used.

Unilateral vs Bilateral TKRs

The speaker prefers unilateral TKR due to discomfort levels, degenerated spine, difficulty in ambulation when both knees are involved, more cement usage leading to subclinical hypoxemia and higher blood loss.

Dual substratorial plexus block can be used for bilateral blocks but it makes ambulation difficult.

Spinal vs General Anesthesia for Hip Fractures

No relevant bullet points found in the transcript.

Analgesia without Conscious Sedation

Dr. Bara discusses the importance of minimizing opioids and sedatives for patients undergoing combined spinal epidural anesthesia.

Minimizing Opioids and Sedatives

Dr. Bara prefers to avoid conscious sedation during combined spinal epidural anesthesia.

Literature suggests that there is no major difference between general anesthetic and regional anesthesia in terms of cognition, but this may not be applicable in India due to differences in post-operative care.

Immediate post-operative care, including availability of qualified nurses and monitors, can affect the risk of complications from opioids and sedatives.

In the absence of immediate post-operative care, a conscious patient who can take care of themselves may be preferable.

Medical Legal Issues

Dr. Bara discusses medical legal issues related to perioperative physicians working alone without specialty consultation.

Perioperative Physician Liability

Dr. Bara addresses whether a perioperative physician working alone without specialty consultation can be protected in court if something goes wrong.

The attitude of the physician is more important than their specialty when it comes to avoiding liability.

Pre-operative care by an anesthesiologist as a physician is only possible if someone is available 24 hours a day for continuity of care.

If there is no anesthesiologist available inside the hospital, especially in small private hospitals, it would be difficult to provide adequate pre-operative care.

Patient Care

Dr. Bara discusses the importance of clear communication with patients and their attendants, as well as the role of in-house physicians.

Clear Communication and In-House Physicians

Dr. Bara emphasizes the importance of clear communication with patients and their attendants to avoid any perception that the patient was not attended to when needed.

At Dr. Bara's institution, anesthetists speak directly with critically ill patients and explain all possible complications before surgery.

Medical legal experts suggest that having an in-house physician is more important than seeking specialty consultation from outside the hospital.

There is no harm in taking a physician's opinion when it's a multi-specialty hospital, but it may not be feasible in small private hospitals without an in-house physician.

Pre-Operative Care and Anesthesiologists

The speakers discuss the importance of anesthesiologists in pre-operative care and the need for them to be competent in their knowledge and skills. They emphasize the need for anesthesiologists to work closely with surgeons and physicians to provide optimal patient care.

Importance of Getting Expert Opinion

It is important for anesthesiologists to seek expert opinions from other specialists when necessary.

Surgeons may call on physicians for their opinion, but it is ultimately up to the anesthesiologist to make decisions about patient care.

The degree of confidence that a surgeon has in their anesthesiologist can affect how willing they are to collaborate.

Upscaling Knowledge and Skills

Anesthesiologists must be competent in detecting medical issues beyond anesthesia, such as arrhythmias.

To improve patient care, anesthesiologists must continually upscale their knowledge and skills.

In the future, it is likely that all medical professionals will recognize the importance of anesthesiology in pre-operative care.

Collaboration with Physicians

While it is important to seek opinions from physicians, anesthesiologists should not rely solely on them.

Anesthesiologists have 24-hour coverage of patients and are responsible for making decisions about drug administration.

Case Study: ICD Placement

The speakers discuss a case study involving ICD placement through lung parenchyma. They emphasize the importance of attitude and commitment to patient care.

Case Study Description

The speakers discuss a case in which an ICD was placed through lung parenchyma.

Despite the report indicating that the placement was incorrect, the patient survived for 20 years.

Attitude and Commitment to Patient Care

The speakers emphasize the importance of attitude and commitment to patient care.

They hope that in the future, anesthesiologists will be recognized as important contributors to pre-operative care.

Attendee Feedback and Thank You

An attendee expresses gratitude for the lecture and thanks the listeners. The speaker acknowledges the feedback and thanks Dr. Balabanket for moderating the session.

An attendee, who is an anesthesiologist, suggests that Kevin should have one good lecture by Dr. Azam.

The attendee expresses gratitude to all the listeners and notes that this was the biggest webinar they have attended in their lifetime with over 600 people from across ten countries attending.

The attendee acknowledges that there were difficulties with logging in but notes that more than 200 people immediately joined on the Zoom link.

The speaker thanks Dr. Balabanket for moderating the session and Dr. Azam for providing facilities.

Question on Pre-operative Spinal Pain Relief

A question is asked about pre-operative spinal pain relief, specifically which of three options is preferred.

Dr. Bharat asks a question about pre-operative spinal pain relief, specifically which of three options (bank block, FICB or femoral block) is preferred.

Dr. Azam responds by saying that all three are equally good if done properly but recommends beginners use femoral or supra and venel facialiaka pink block as they are easier to perform.

He notes that femoral nerve blocks are easiest because you can see the nerve while FICB or compartment blocks require slightly more competence to perform.

Ultrasound is required to perform FICB.

Optimizing Daycare Surgery Patients

A question is asked about optimizing daycare surgery patients.

Rajesh KC asks how optimization works for daycare surgery patients who come on the day of surgery without coming the night before.

Dr. Azam responds that optimization happens at home and patients are seen by the anesthetic clinic on the day they decide to go for surgery.

The process of optimization starts from then on, for example starting iron supplements and folic acid if necessary.

Daycare surgeries have to be worked up earlier to optimize them.

Conclusion and Final Thoughts

The speaker thanks everyone for attending and adds some final thoughts.

The speaker thanks everyone for attending and notes that it was a nice informative talk.

Dr. Naveen adds that talking to your surgeon and patient is a long process but important in gaining confidence as a perioperative physician.

He notes that over time, respect is earned, and understanding each other's positives and negatives leads to better decision-making.

Dr. Azam agrees with Dr. Naveen's comments about building relationships with surgeons and patients over time.

Importance of Patient Confidence

In this section, the speaker discusses the importance of patient confidence and shares an incident to illustrate his point.

The Speaker's Experience

After 10 years of practice, the speaker has gained confidence in treating patients.

The speaker emphasizes the importance of making patients feel confident in their treatment.

The speaker shares an incident where a patient refused to undergo anesthesia until he was assured that the speaker would be present during surgery.

The patient was a doctor who had previously undergone a pre-anesthetic checkup with the speaker.

Overall, this section highlights how important it is for doctors to build trust and confidence with their patients.