→ The patient was moved toward the head of the operating
table.
→ (Figure 27) In this case, the laryngoscope was held by the
physician’s right hand and upon visualization of the vocal
cords, the patient’s trachea was intubated with an
endotracheal tube positioned using the left hand.
→ This procedure was followed by confirmation of proper tube
placement. Subsequent lung ventilation was successful with
normal peak pressures.
Figure 27. Orotracheal Intubation guided by Direct Laryngoscopy in Prone
Position
Figure 28. Orotracheal Intubation guided by Direct Laryngoscopy in Prone
Position (with laryngoscope held by the anesthesiologist’s left hand and
tracheal tube is inserted with the other)
Confirmation of Proper Tube/Airway Placement
● Auscultation of chest and epigastrium
→ Proper placement of tracheal tube: breath sounds are heard
equally in both lungs.
→ In cases of full endobronchial intubation, breath sounds are
absent over the left lung
● Capnographic tracing
→ Final test to confirm tube placement
→ Monitoring of the concentration or partial pressure of carbon
dioxide (CO2) in the respiratory gases
→ A carbon dioxide concentration or partial pressure of > 35
indicates error in placement of the tube.
6. INTRAOPERATIVE MANAGEMENT AND
TROUBLESHOOTING
Decreases in oxygen saturation
● Often secondary to:
→ Endobronchial intubation
→ Inadequate oxygen delivery perioperatively
→ Ventilation/perfusion mismatch from any form of lung disease
● When saturation declines, the ff can be done:
→ Auscultation of chest must be performed to confirm bilateral
tube placement
→ Intraoperative chest radiograph to identify cause
→ Intraoperative fiberoptic bronchoscopy to confirm proper tube
placement and clear mucous plugs
[Type here]
Sudden decline of end-tidal CO2
● Due to pulmonary or venous air embolism
Rising end-tidal CO2
● Secondary to:
→ Hypoventilation or increased CO2 production
→ Sepsis
→ Depleted CO2
→ Breathing circuit malfunction
Increase in airway pressure
● Due to:
→ Obstructed or kinked TT
→ Reduced lung compliance
● Tube should be suctioned to confirm patent airway
● Lungs must be auscultated to detect bronchospasm, edema,
endobronchial intubation or pneumothorax
7. EXTUBATION
● To decrease laryngospasm, it is most often performed when the
patient is either:
→ Deeply anesthetized, or
→ Awake
● Laryngospasm is usually present during a light plane of
anesthesia
→ Important to distinguish between light and deep anesthesia
during pharyngeal suctioning
→ Any reaction e.g. coughing or breath holding signals a light
plane
→ Eye opening or purposeful movements must be observed to
confirm if the patient is sufficiently awake for extubation
● Before extubation, the ff must be met:
→ A period of controlled mechanical ventilation
→ Patient weaned from the ventilator
Extubating an awake patient
● Usually associated with coughing or bucking in the tracheal tube
→ Result to increased HR, central venous pressure, arterial BP,
intracranial pressure, intraabdominal pressure, and
intraocular pressure
→ May also cause wound dehiscence and increase bleeding
→ These conditions may be decreased by administering 1.5
mg/kg of IV lidocaine 1-2 min before suctioning and
extubation
Techniques
● These must be considered regardless if the patient is awake or
deeply anestheticed
● Pharynx should be thoroughly suctioned to decrease potential
for aspiration of blood and secretions
● Ventilated with 100% oxygen in case it becomes difficult to re-
establish an airway after removal of tube
● Prior to extubation, tracheal tube is untapped and cuff is
deflated
● Tube is then withdrawn in a single smooth motion and a face
mask is applied to deliver oxygen
● Oxygen delivery must be maintained until the post-anesthesia
care
8. COMPLICATIONS OF LARYNGOSCOPY AND
INTUBATION
Airway Trauma
● Dental damages are the most common cause of lawsuits
against anesthesiologists
● With the use of a metal laryngoscope blade and a stiff tracheal
tube, airway tissues could potentially be damaged
● Vessel occlusion by excessive cuff compression once external
pressures exceed the capillary-arteriolar blood pressure
→ Ischemia → inflammation → ulceration → granulation →
stenosis
● Recurrent laryngeal nerve damage
→ Result in vocal cord paralysis and hoarseness of voice
● Glottic, laryngeal, or tracheal edema
→ Result to post-intubation croup
→ Poses significant danger especially in children
Tube malpositioning
● TT could unintentionally be intubated into the pharynx
→ To prevent this, the tip of the TT could be inspected via direct
visualization if it has passed through the vocal cords
→ Auscultation should yield bilateral breath sounds and
absence of gastric gurgling while ventilating through the TT
● Overly deep insertion → intubation of the right main stem
bronchus
→ Results to unilateral breath sounds, unexpected hypoxia with
pulse oximetry, inability to palpate TT cuff in sternal notch,
and decreased breathing bag compliance
● Inadequate insertion puts the cuff within the larynx, possibly
causing laryngeal trauma
● Minimal testing of TT include:
→ Analysis of exhaled gas for presence of CO2 which is the
most reliable automated method
→ Chest auscultation
→ Occasional cuff palpation
● Tube placement should also be rechecked every time the
patient is moved
Physiological responses to airway instrumentation
● Compensatory mechanisms like hypertension and tachycardia
kick in under light planes of general anesthesia
→ In order to avoid these, LMA could be used as it is associated
with less hemodynamic changes
→ Lidocaine, opioids, beta blockers or deeper planes of
inhalational anesthesia could also be administered IV before
laryngoscopy
→ Hypotensive agents e.g. sodium nitroprusside, nitroglycerin,
esmolol, and nicardipine could be used to reduce
hemodynamic changes
● Laryngospasm
→ Forceful involuntary spasm of the laryngeal musculature
→ Caused by sensory stimulation of the superiar laryngeal
nerve which could be triggered by:
▪ phraryngeal secretions or
▪ TT during extubation
→ Prevention of this includes having the patient deeply asleep
or fully awake during extubation
→ Another treatment includes administering lidocaine IV or
using an anesthesia bag & mask to provide PPV using 100%
oxygen
→ Small doses of succinylcholine are given when spasm
persists
● Aspiration
→ Resulting from depression of laryngeal reflexes
● Bronchospasm
[Type here]
Tube malfunction
● Polyvinyl tubes may be ignited in an oxygen or nitrous oxide
enriched environment
● Valves and cuffs could also be damaged
● TT can be obstructed from kinking, foreign body aspiration, or
thick/inspissated secretions in the lumen
D. FLUID MANAGEMENT
● Goals for intraoperative fluid management in pediatric patients
are:
→ to replete fluid deficits related to fasting
→ to optimize their preload dependent cardiac output
→ to replete intraoperative blood loss.
● Selection of which solution is appropriate for fluid management
is based on:
→ invasiveness of the surgical procedure
→ whether there are dynamic hemodynamic parameters
involved such as expected blood loss and nonhemorrhagic
fluid shifts
→ patient's comorbidities
→ planned postoperative disposition (e.g. home, ambulatory
hospital ward, critical care unit)
● For minimally invasive surgery such as excisional biopsy,
administration of isotonic crystalloid electrolyte solution
(e.g. Lactated Ringer’s or Normal Saline) may suffice if there
are no significant fluid shifts and/or blood loss.
Table 9. Fluid Infusion Rates
Body Weight Fluid Infusion Rate
<10 kg 4 ml/kg/hr
10-20 kg 40 ml/hr + 2 ml/kg/hr above 10 kg
>20 kg 60 ml/hr + 1 ml/kg/hr above 20 kg
→ Such limited fluid administration for less invasive surgery
addresses the mild dehydration caused by preoperative
fasting and is associated with less postoperative nausea
and vomiting, as well as less postoperative pain.
→ The shift from the historic use of hypotonic solutions is
based on the increasing evidence demonstrating increased
risk of hyponatremia associated with hypotonic sol’ns.
→ Exceptions to the use of isotonic solutions as initial fluid
therapy include the following:
▪ Children with polyuria due to renal concentrating defects
(eg, nephrogenic diabetes insipidus) or inability to release
ADH (central diabetes insipidus)
▪ Those with nonrenal causes of abnormally large water
loss (severe burns or severe watery diarrhea).In these
patients, hypotonic solution may be more appropriate
to replace excess water loss.
▪ Hypotension in the healthy pediatric patient during
anesthesia is often fluid-responsive (with a 10 to 20 mL/kg
bolus of normal saline or lactated Ringer's solution)
→ However, large volume resuscitation usually normal saline
may cause hyperchloremic metabolic acidosis.
V. POSTOPERATIVE MANAGEMENT
A. POST ANESTHESIA CARE UNIT (PACU)
● PACU functions as a more intensely monitored location that
allows close monitoring of the patients to prevent or expedite
the management of a variety of serious complications following
 completion of surgical procedure and the concomitant primary → Urinary osmolality > 450 mOsm/L
anesthetic care. → Hypernatremia
→ PACU is under the Department of Anesthesiology. Any → BUN-to-creatinine ratio > 10:1
complications encountered in the PACU will be addressed by ● Non-laboratory examinations used to monitor patient’s
the department. condition:
● Factors closely monitored in PACU are the following: → Vital signs
→ Ventilation → Level of pain
→ Oxygenation → Neurological examination
→ Hemodynamics
→ Temperature C. PONV MANAGEMENT
→ Nausea
→ Pain ● PONV is the most common significant complication following
● Close attention is also given to the following: general anesthesia.
→ Urine output → Occurring in approximately 30% or more of all patients
→ Ongoing bleeding ● It also occurs at home within 24h of an uneventful discharge in
→ Drainage a significant number of ambulatory surgery patients.
● At the conclusion of any procedure requiring anesthesia, after
anesthetic agents are discontinued, monitors are disconnected Table 10. Portfolio of prophylaxis for PONV management
and the emerging patient is taken to the PACU. Prophylaxis/Treatmen Description
● All patients are taken to the PACU on a bed or gurney that can t
be placed in either of the following positions: Propofol Anesthesia ● Reported to decrease the
→ Head-down (Trendelenburg): useful for management of incidence of PONV
Selective 5- The following are reported to be
hypovolemic patients
hydroxytryptamine effective in preventing PONV, and to
→ Back-up position: useful for patients with underlying
(serotonin) receptor 3 a lesser extent, in treating
pulmonary dysfunction
(5-HT3) antagonists established PONV:
→ Lateral position: for patients at increased risk of vomiting;
Ondansetron
helps prevent airway obstruction and facilitates drainage of
● 0.1mg/kg in children
secretions
● Usually effective immediately
● During transport, supplemental oxygen is given by nasal
● Orally disintegrating tablet prep
cannula or mask and the patient is monitored with pulse
– may be useful for treatment
oximetry.
or, and prophylaxis against,
→ This is done as transient hypoxemia (SPO2<90%) develops
PONV
in as many as 30-50% of patients during transport while
Dolasetron
breathing room air.
● 0.035 mg/kg in children
● Requires 15 min for onset of
EQUIPMENT action
● In the PACU, the following equipment are used for monitoring: Granisetron
→ Pulse oximetry ● 0.01-0.04 mg/kg in children
→ Electrocardiogram Transdermal ● Effective but can be associated
→ Automated noninvasive blood pressure monitors Scopolamine with side effects including the
→ Non-invasive thermometers: oral, axillary, tympanic following:
membrane o Sedation, dysphoria,
→ Urinary catheter not indicated in the case blurred vision, dry
→ This is done as inadequate monitoring in the PACU can lead mouth, urinary
to serious morbidity and mortality. retention,
exacerbation of
B. MONITORING/FOLLOW-UPS glaucoma (in elderly
patients)
● Indirect indices of vascular volume are: Intravenous ● 0.10 mg/kg in children
→ Serial hematocrits
dexamethasone ● When utilized as an antiemetic,
→ Arterial blood pH
has additional advantages of
→ Urinary specific gravity
providing a varying degree of
→ Urinary osmolality
analgesia and sense of patient
→ Urinary sodium or chloride concentration
well-being
→ Serum sodium
● Effective for up to 24 h, may be
→ Blood-urea nitrogen (BUN)
useful for postdischarge nausea
→ Presence of radiographic examination (Kerley B lines) or
and vomiting
diffuse alveolar infiltrates may indicate volume overload Nonpharmacologic ● Adequate hydration – 20 mL/kg
● A patient may be dehydrated if he/she presents with the after fasting
following laboratory results:
● Stimulation of P6 acupuncture
→ Rising hematocrit and hemoglobin
point (wrist)
→ Progressive metabolic acidosis
→ Urinary specific gravity > 1.010
D. DIET/NUTRITION AND FLUID THERAPY
→ Urinary sodium < 10 mEq/L

[Type here]
 → Use Opioid-sparing strategies
● Intake of energy substrates, water and nutrients after surgery ▪ Premedication with NSAIDS, acetaminophen, and
may be decreased gabapentin or pregabalin
→ Review: Fall in the blood glucose leads to increased
▪ Other modalities utilizing local anesthetics such as
glucagon secretion and decreased insulin release
intraoperative wound infiltration, postoperative wound
→ Hepatic and renal glycogenolysis, and gluconeogenesis
catheter infusions, single shot and continuous catheter
increase
peripheral nerve blocks, and continuous epidural
→ Fat becomes the principal energy source through lipolysis
infusions.
which leads to ketone bodies formation and dependence
● For MILD TO MODERATE PAIN
(brain, kidneys and muscles)
→ PO: Acetaminophen, ibuprofen, hydrocodone, or oxycodone
● Prolonged postsurgical starvation is no longer practiced.
→ IV: ketorolac (0.5 mg/kg) or acetaminophen (15 mg/kg, or 1 g
→ Accelerated recovery programs such as early enteral feeding
if patient is more than 50 kg)
are acceptable even for patients who have undergone
gastrointestinal surgeries
→ Patients with ongoing critical illness must receive immediate Notes from Dr. So:
nutritional support immediately ● REMIFENTANIL: short-acting opioid; does not cause
→ Well-nourished patients may receive support after 5 days of significant respiratory depression when compared with
postsurgical starvation other opioids
● Well-nourished patients may become fasted for up to a week ● Local Anesthetic Infiltration
postoperatively, without adverse reactions on outcomes → BUPIVACAINE – long-acting
→ Importance of accelerated nutrition programs may be linked → LIDOCAINE – short-acting
to degree of malnutrition, number of nutrient deficiencies, ● KETOROLAC
and severity of illness/injury → effective for immediate postop pain management
→ Patients who have depleted nutrients may acquire → Must not be given for more than 3 doses
complications such as delayed wound healing → It tends to cause soaking of wound/ bleeding
● Daily energy requirements of postsurgical patients may be ● Proper Pain Management
approximated using: → Continuous dosing or around-the-clock dosing at fixed
→ Resting metabolic rate measured using indirect calorimetry intervals
or metabolic cart → Administer LOADING DOSE as soon as the surgeon
→ Estimating energy expenditure using standard nanograms starts to close the surgical site
(Harris-Benedict equation) ● Pediatric analgesic doses
→ Another approach would be to assume that a patient may → Higher dose should be given due to higher volume of
require 25-30 kcal/kg daily distribution
● Procedures that do not significantly alter the hemodynamic → Be careful (TITRATE) because of immature liver and
mileau such as those with small volume of blood loss (<250 kidney function
mL), short course of anesthesia (<3 hours), small volume of
intravenous fluid administration during surgery (<30 mL/kg),
little to no extravascular fluid shift, can be managed with F. ADDRESSING POSSIBLE COMPLICATIONS AND
administration of postoperative intravenous maintenance ADVERSE EFFECTS
fluid (Siparsky, 2019)
● Patients with extensive traumatic or surgical tissue injury, critical
1. COMPLICATIONS OF PROCEDURE
illness or sepsis may warrant administration of replacement fluid
● Hematoma
therapy in addition to maintenance therapy (Siparsky, 2019)
● Isotonic fluids are said to be preferable as maintenance IV → Can be prevented by the use of postoperative dressings and
solution for patients aged 28 days to 18 years with appropriate ice
Potassium Chloride (KCl) and dextrose (Feld et al., 2018). ● Surgical site infection
→ Composed of 0.9% NaCl with 5% dextrose → Can be prevented by:
→ Done to address the risk of hyponatremia ▪ Proper wound care with daily cleaning and bandage
● Blood glucose and electrolytes should be monitored closely in changes
giving fluid therapy (Feld et al., 2018). ▪ Prophylactic antibiotics
→ First plasma sodum may be measured between 6 and 12 ● Bleeding at the surgical site
hours

2. COMPLICATIONS OF GENERAL ANESTHESIA

E. POST-OP PAIN MANAGEMENT

● Plans for postoperative pain management should be discussed Respiratory Complications

● The most frequently encountered serious complications in the
with the family and made before surgery.
PACU
● The basic elements of pharmacologic treatment include type of
analgesic, dose, timing, and routes of delivery.
1. Airway Obstruction
● Postoperative pain management encompasses the use of
different classes of drugs, including opioids (See appendix for ● Most commonly due to the tongue falling back against the
the list of commonly used drugs) and nonopioid analgesics posterior pharynx in an unconscious patient
● For MODERATE TO SEVERE PAIN → Management: combined jaw-thrust and head-tilt maneuver
→ Use Oral and Parenteral Opioids and insertion of an oral or nasal airway
▪ Can cause significant AEs: N&V, respiratory ● Degree of obstruction
depression, pruritus, ileus, and urinary retention → Partial – usually presents as sonorous respiration
→ Near-total or Total
[Type here]
 ▪ Leads to cessation of airflow
▪ Absence of breath sounds
▪ May be accompanied by paradoxic (rocking) movement
of the chest
Additional information from Morgan & Mikhails, 5th ed
● Management of other causes
→ Laryngospasm
▪ More apt to occur following airway trauma, repeated
instrumentation, or stimulation from secretions or
blood in the airway
▪ Jaw-thrust maneuver combined with gentle positive
airway pressure via a tight-fitting mask
▪ Insertion of an airway down to the level of the vocal
cords
▪ Suctioning of secretions or blood
▪ Refractory laryngospasm
− small dose of IV succinylcholine (10-20 mg in
adults) and positive-pressure ventilation with
100% oxygen
− endotracheal intubation (occasionally)
− cricothyrotomy or transtracheal jet ventilation
(indicated if intubation is unsuccessful)
→ Glottic edema
▪ Important cause of airway obstruction in infants and
young children because of the relatively small
airway lumen
▪ IV corticosteroids (dexamethasone,0.5 mg/kg, 10
mg dose maximum) or aerosolized racemic
epinephrine (0.5 mL of a 2.25% solution with 3 mL
of normal saline)
● Postoperative wound hematomas following neck
procedures
→ Managed by opening the wound to relieve tracheal
compression
● A retained throat pack or blood in the airway
● External pressure on the trachea
2. Hypoventilation
● Defined as a PaCO2 of >45 mm Hg
● Commonly occurs following general anesthesia
→ Most cases are mild and are undiagnosed
● Clinically apparent when the PaCO2 is >60 mm Hg or arterial
blood pH is <7.25
→ Signs include somnolence, airway obstruction, slow RR,
tachypnea with shallow breathing
● Most commonly due to the residual depressant effects of
anesthetics on respiratory drive (in the PACU)
→ Residual muscle paralysis may be caused by inadequate
reversal, pharmacological interactions, altered
pharmacokinetics, and metabolic factors
● Diagnosis
→ Using a nerve stimulator in unconscious patients
→ Assessment of the head lift and grip strength in awake
patients
● Treatment
→ Cholinesterase inhibitor
▪ Given in cases of residual muscle paralysis
▪ If paralysis is still present after a full dose, controlled
ventilation should be maintained and closely observed
until spontaneous recovery occurs
[Type here]
→ Immediate and aggressive respiratory and hemodynamic
intervention
▪ Indicated when signs of obtundation, circulatory
depression, and severe acidosis (arterial blood pH
<7.15) are already present
Additional information from Morgan & Mikhails, 5 th ed
● Management of other causes of hypoventilation
→ Opioid-induced respiratory depression
▪ Characteristically produces a slow respiratory rate
with large tidal volumes
▪ Patient is excessively sedated but often responsive
▪ Treatment
− Titration of naloxone in small increments (80 mcg
in adults) followed by close observation for
recurrence of opioid-induced respiratory
depression
→ Splinting due to incisional pain, diaphragmatic
dysfunction
▪ May be caused by upper abdominal or thoracic
surgery, abdominal distention, and tight abdominal
dressings
▪ Administration of IV or intraspinal opioid, IV
ketorolac, epidural anesthesia, or intercostal nerve
blocks
→ Shivering, hyperthermia, or sepsis
▪ May increase CO2 production even in normal
patients recovering from general anesthesia
3. Hypoxemia
● Mild hypoxemia is common in patients recovering from
anesthesia when supplemental oxygen is not given.
● Mild to moderate hypoxemia (PaO2) is initially well-tolerated
in young healthy patients
→ Increasing duration or severity may lead to progressive
acidosis and circulatory depression
● May present with signs of restlessness, tachycardia, or
cardiac irritability
→ Late signs are obtundation, bradycardia, hypotension, and
cardiac arrest
● Usually caused by hypoventilation and/or increased right-to-
left intrapulmonary shunting in the PACU
→ Increased intrapulmonary shunting from a decreased FRC
relative to closing capacity is the most common following
general anesthesia
● Routine monitoring of SaO2 using a pulse oximeter is done in
the PACU to ensure early detection and prevent its
progression
● Treatment
→ Oxygen therapy with or without positive airway pressure –
cornerstone of treatment
▪ Routine administration of 30 to 60% oxygen is usually
enough to prevent hypoxemia
Circulatory Complications
1. Hypotension
● Most commonly caused by hypovolemia in the PACU
→ Absolute hypovolemia can result from