Providing an anesthetic for the trauma victim is among the greatest challenges for an anesthesiologist. In many cases, care must be rendered to a patient about whom one knows very little, who may be physiologically unstable, who may possess obvious comorbidities that increase anesthetic risk, and for whom one has very little time to prepare. Additionally, necessity may demand that an anesthetic be provided with nothing more than basic monitoring modalities, using the simplest of anesthetic techniques. Consequently, it is helpful for the surgical practitioner to possess a basic working knowledge of anesthetic principles and practice.
AN OVERVIEW OF THE ANESTHETIC PLAN
The anesthetic plan must encompass preoperative, intraoperative, and postoperative care. During the preoperative phase, the fitness of the patient for the intended anesthetic and surgical procedure is determined; the urgency of surgery determines much of the time devoted to this phase. The postoperative period includes monitoring the recovery of the patient from the anesthetic, maintaining an attitude of vigilance in respect to the development of postoperative complications, and managing postoperative pain. The American Society of Anesthesiologists has published specific guidelines that outline the provision of care during these periods, which can be modified as circumstances demand. The responsibility for the preoperative and postoperative care of a patient is shared by nursing personnel, surgeons, and anesthesiologists, who work together for the benefit of their patient. In contrast, the intraoperative phase of the anesthetic care plan is the realm of the anesthesia professional. It has three components: induction, maintenance, and emergence. An anesthetic plan of action arises from the needs of the patient, the experience of the anesthesiologist, and the constraints placed upon both by the proposed surgical procedure. In particular, a trauma anesthetic needs to be dynamic and responsive to rapid changes in patient condition. The design of such a plan is aided through the employment of a decision tree, which is constructed by answering three questions: “why,” “what else,” and “what if.”
The “Why?” Question One seeks the answers to any number of questions, from “How did the injury occur?” to “Why are these lab values abnormal?” to “Is my plan still what this patient needs—and if not, why not?”
The “What else?” Question Questions posed include, but are not limited to, those such as “If general anesthesia is not an option, what else can I do” or “If succinylcholine is contraindicated, what else can I use?” or “If my patient gets nauseated when he gets opiates, what else can I do for his pain?”
The “What if?” Question Of course, the classic question is “What if I can’t intubate the patient?”, and there are innumerable others, including “What if my block fails,” “What if he arrests when the aortic clamp comes off,” and “What if he develops malignant hyperthermia?”
The successful execution of the plan requires vigilance, adaptability, ...