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  SGD 1AnesthesiologyCase:  A 21 year old female, 50 kg, was scheduled for excision of left breast mass.VS are as follows ! #100$%0, &#%5$min, &&#1'$min, (em)erature#*%+ .1.What are the goals of your perioperative assessment?a.The cornerstones of an eectivepreoperative evaluation are themeical history an physicale!amination #hich shoulincluications ta$en %y thepatient in the recent pastii.all pertinent rug ancontact allergiesiii.responses an reactions toprevious anesthetics%.This evaluation shoul inclue anyinicate iagnostic tests imaging proceures orconsultations from otherphysicians.c.&urposes of perioperativeassessment inclues:i.'entify those fe# patients#hose outcomes li$ely #ill %e improve %y implementationof a speci(c meical treatmentii.'entify patients #hose conition is so poor that thepropose surgery might only hasten eath #ithoutimproving the )uality of life..The preoperative evaluation can ientify patients #ith speci(ccharacteristics that li$ely #ill in*uence the propose anestheticplan.  e.+o#ever the anesthesiologistshoul not %e e!pecte to proviethe ris$,versus,%ene(t iscussionfor the propose proceure- this isthe responsi%ility an purvie# of the responsi%le surgeon.f.The preoperative evaluation is anopportunity for theanesthesiologist to escri%e thepropose anesthetic plan in theconte!t of the overall surgical anpostoperative plan provie thepatient #ith psychologicalsupport an o%tain informeconsent for the proposeanesthetic plan from the surgicalpatient.What is your choice of anesthetics?a./en0oia0epines %in the same set of receptors in the centralnervous system as %ar%iturates %ut %in to a ierent site on thereceptors. /en0oia0epine %ining to the GA/A A receptorincreases the fre)uency of openings of the associate chlorieion channel.%.The chemical structure of %en0oia0epines inclues a %en0enering an a seven,mem%er ia0epine ring. Su%stitutions at variouspositions on these rings aect potency an %iotransformation. The imia0ole ring of mia0olam contri%utes to its #atersolu%ility at lo# p+. Dia0epam an lora0epam are insolu%le in#ater so parenteral preparations contain propylene glycol #hichcan prouce venous irritation. c./en0oia0epines are commonly aministere orally intramuscularly an intravenously to provie seation or lesscommonly to inuce general anesthesia. i.Dia0epam an lora0epam are #ell a%sor%e from thegastrointestinal tract #ith pea$ plasma levels usuallyachieve in 1 an  h respectively. .'n contrast mia0olam an lora0epam are #ell a%sor%e afterintramuscular inection #ith pea$ levels achieve in 23 an43 min respectively. 'nuction of general anesthesia #ithmia0olam is convenient only #ith intravenous aministration. e.&araverte%ral %loc$s provie surgical anesthesia or postoperativeanalgesia for proceures involving the thoracic or a%ominal#all mastectomy inguinal or a%ominal hernia repair an moreinvasive unilateral proceures such as open nephrectomy.  f.&araverte%ral %loc$susually re)uireiniviual inectionselivere at thevarious verte%rallevels thatcorrespon to thearea of %oy #all to%e anestheti0e.i.A simplemastectomy#oul re)uire%loc$s atlevels T256ii.7or a!illarynoeissection aitional inections shoul %e mae from C8through T.g.+ypotension seconary to sympathectomy can %e o%serve #ithmultilevel thoracic %loc$s.h.With the patient seate an verte%ral column *e!e eachspinous process is palpate counting from the prominent C8 forthoracic %loc$s. 7rom the mipoint of the superior aspect of eachspinous process a point .9 cm laterally is measure anmar$e. 'n the thora! the target nerve is locate lateral to thespinous process a%ove it ue to the steep angulation of thoracicspinous processes eg the T; nerve root is locate lateral to thespinous process of T2<.i.'f local anesthesia is use you may %e given a seative to rela!you uring the %reast lump removal. 'f you=re given generalanesthesia you=ll %e in a painless sleep uring the entireproceure.2.+o# #ill you put the patient into sleep?;.+o# #ill you maintain the patient in anesthesia?a.During surgical incision the patient move #hat #ill you o?%.Thirty minutes into surgery /& roppe from 13>3 to 3>63mm+g. What #ill you o?c.7inally the surgical proceure #as over #hat #ill you o?i.After accompanying the patient to the postanesthesia careunit &AC@< the anesthesiologist shoul remain #ith thepatient until normal vital signs have %een measure anthe patient=s conition is eeme sta%le.ii./efore ischarge from the &AC@ a note shoul %e #ritten%y the anesthesiologist to ocument the patient=s recoveryfrom anesthesia any apparent anesthesia,relate  complications the immeiate postoperative conition of the patient an the patient=s isposition. iii. ecovery from anesthesia shoul %e assesse at least once#ithin ; hours after ischarge from the &AC@ in all in,patients. &ostoperative notes shoul ocument the generalconition of the patient the presence or a%sence of anyanesthesia,relate complications an any measuresunerta$en to treat such complications.
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