Interface Anesthesiology Guide lines
Welcome to the exciting world of plastic and reconstructive surgery for adults and childrenwith UCSD Interface. Surgery and anesthesia in remote parts of the globe can be very rewarding but it can also be very challenging and filled with may potential pitfalls. These guidelines are the result of many years of giving anesthesia under difficult circumstances. The goal of this document is to allow you top prepare yourself for an upcoming mission. As always these are just guidelines and are subject to many factors present and absent at the location and facility you will be using.
It is important to remember participation in these missions are a privilege not a right. These patients are entitled to the same level of medical care that is delivered at home. That said, you will not have all the conveniences of a modern operating room, but that should not cloud your judgment and clinical skills you bring with you.
It is very difficult to coordinate these missions and much preparation goes into travel arrangements and equipment transportation. All of the money for interface trips are donated and the equipment is either donated or bought by interface with donated money. Obviously there is a limited budget and decisions must be made as to what can be brought on the trips.
Below is a list of of equipment interface provides for anesthesia:
- Monitors including manual blood pressure manometer and cuffs, Pulse oximeters, anesthesia circuits, vaporizers and bags. There are now two automated monitoring workstations.
- Box of supplies and equipment including; drugs, needles, syringes, tape, ett's and drugs
- IV fluids and sets, iv catheters, portable suction machine and suction catheters
- Anesthesia vaporizer, Bain Circuit, Bags, Masks, Volatile anesthetic
List of of equipment I recommend you bring yourself
- Box of Gloves, hats, masks and shoe covers
- Laryngoscopes
- Flashlight (Important for frequent blackouts)
- T- connecters/stopcocks
- Connector tubing for earpieces
- Tegaderm/ opsites
- Waterless hand cleaning solution.
- Nelcor pulse oximeter probes (stickers probes)
- Identification badge
- At least 2 sets of scrubs (do not wear to hospital)
- Monaural stethescope
- Tape of your choice (hytape -pink ett tape , silk tape)
- Camera and film
- Arm boards
- Foam donut
- kidney (emisis) basin
- Pliers/Multipurpose tool
There are no modern anesthesia machines available for use at most locations and when there are machines available I highly recommend against using them for a number of reasons. We use bain circuits with flows of 2-4 l/minute to prevent rebreathing. The circuit is fashioned to an iv pole via a bain mount. to an iv pole via a bain mount .
A free standing vaporizer is attached to an H cylinder using duct tape. Mexicali now has wall oxygen, but I recommend using free standing H-cylinders at least for backup Oxygen as there has been oxygen supply failures. Each time the vaporizers are used they must be filled and then drained at the end of the mission to prevent contamination. Care must be taken to avoid accidentally tipping the vaporizer,which can lead to overdose of volatile anesthetic.
A regulator is used to decrease the gas supply pressure to the vaporizer. Teflon tape is used to prevent leaking from the coupling. It is important to position the H cylinder against the wall to prevent the vaporizer from tipping. Make sure there is enough length on the hoses so you are not hampered in connecting the circuit to the patient.
We now have a standardized anesthesia equipment boxes. The contents can be viewed here. We have medications for most emergencies including Malignant hyperthermia. ( see emergency equipment section below). Induction for the pediatric patients is most often by mask, followed by insertion of an IV. There should always be a second anesthesia provider for back up support and to help with the IV. Adults can be induced intravenously. We do bring some propofol and ketamine. Hopefully by the time you read this document all of the halothane vaporizers will be retired and switched out to sevo. Although halothane is a fine anesthetic agent, we have had several near cardiac arrests from halothane overdose. To minimize the potential hypotensive effects of volatile anesthetic, we recommend using Mivacurium (0.1-0.2 mg /kg) after induction, to facilitate intubation. The paralytic effect usually lasts less than 5 minutes and the patient will need some mask ventilation during that time. Using this technique, we have not had any difficulties with hypotension. There is a potential for prolonged paralysis secondary to pseudocholinesterase deficiency but this is not a major problem. The other issue with Mivacurium is histamine release leading to rubor and vasodilataton. This can be minimized by slowing the injection of the drug. Using this technique we have not had to use any succinylcholine for laryngospasm.
Patients are maintained on volatile anesthetic, obviously with spontaneous ventilation. Care must be taken to prevent patients from having an accident on the OR table. Many times the tables are unstable and we brace and stablize them buring the setup process. We use opioids sparingly and usually have both fentanyl and morphine available. Patients are extubated awake because of the minimal monitoring in the PACU. For post operative analgesia we try to use local anestheitic at the wound site liberally. We also use rectal Tylenol (20-40 mg/kg, placed after induction) for pain and fever. Dexamathasone (0.1mg/kg) is used frequently to prevent swelling and nausea in cleft palate repair patients
The recovery room is usually a very busy place. There is usually a pediatrician on the trip to assist with recovery room problems, but the anesthesiologist, usuallly the team leader will responsible for supervising all patient care. Oxygen, suction and pulse oximetry are available in the pacu. We have some antiemtics available, and many patients experience nausea and vomiting. Some patients stay the night but not all. Many patients livef a great distance from the clinic and need follow up examinations in the morning. The surgeons make rounds in
The code box has now been revamped. It has multiple levels of redundancy, for safety. Please click here to see the file and review its contents. Interface always brings a defibrillator. It must be checked out before the start of any cases. A document reviewing the check out of the defibrillator and some images can be seen by clicking here. We now have difficult airway box for emergencies. it consists of nasal airways, lma's, combitube, needle cric set, intra osseous needles and ez caps.for a full list click here. Interface always brings dantrolene sodium for treatment of malignant hyperthermia. We now have a kit that includes dantrolene, sterile water, bicarbonate, syringes and the MHAUS guidelines. Please click here to review the contents of the kit.
There are many different levels of training and experience of the anesthesia providers who come on interface missions. We bring cRNA's, residents, private practioners, and pediatric anesthesiologists. Some people have been on many interface missions and know the system well. When I arrange the anesthesia teams I keep in mind the concept that one anesthesiologist will be the team leader, and be an extra body and not take primary repsonsibilities for giving anesthesia. The team leader will ususally be a trained pediatric anesthesiologist but not always. Having an experienced free hand is invaluable for interfacing with the staff in planning the schedule, and assisting getting cases started. There also should always be one person available to be able to respond to a problem in the PACU. It is important that the team leader be familiar with all of inteface's emergency equipment and check out the defibrillator. The team leader will also be responsible for lectures and other education for the residents on the trip.