Mortality attributable to general anesthesia is said to occur at rates of less than 1:100,000.

Perianesthesia Management
By: Kareen Aronza Charmaine Baniqued

The CNS

A. General Anesthesia
induction of a balanced state of unconsciousness, accompanied by the absence of pain sensation and the paralysis of skeletal muscle over the entire body.

May be given through: INHALED IV

Mechanism of general anesthesia

1. Meyer-Overton theory 2. Central nervous system protein receptors involvement 3. Proposed by Linus Pauling

 HISTORY OF ANESTHESIA pain is the signal people need so theyll be aware of a disease or injury. Later, pain becomes an obstacle to recovery because it interferes with the treatment that rest could provide.

 ETHICAL ASPECT OF ANESTHESIA CARE Ethical Theories Virtue-based Theory:

Physician is genuinely virtuous person with inherent qualities of competence, sincerity, confidentiality, and altruism who naturally knows and does what is correct for the patient.

 Utilitarianism:
Actions are judged right or wrong on the balance of their good and bad consequences

Deontological Theory:
Intention is more important than outcome

Clinical Ethics
1. Informed consent -based on the ethical principle of respect for patient autonomy Requirements: Capacity/Competent Disclosure

 2. Informed refusal
informed consent is meaningless if the patient cannot also refuse medical therapy

3.Advance Directives and Surrogate Decision-Makers

documents executed by patients before incapacity to provide physicians with guidelines in medical decision-making when the patients cannot communicate for themselves

Purpose of GA
Five distinct states during surgery: analgesia, or pain relief amnesia, or loss of memory of the procedure loss of consciousness motionlessness weakening of autonomic responses

ATTRIBUTES OF GENERAL ANESTHESIA

Advantages
Reduces intraoperative patient awareness and recall Allows proper muscle relaxation for prolonged periods of time Facilitates complete control of the airway, breathing, and circulation

 Can be used in cases of sensitivity to local anesthetic agent Can be administered without moving the patient from the supine position Can be adapted easily to procedures of unpredictable duration or extent Can be administered rapidly and is reversible

 Disadvantages
Requires increased complexity of care and associated costs Requires some degree of preoperative patient preparation Can induce physiologic fluctuations that require active intervention Associated with complications such as nausea or vomiting, sore throat, headache, shivering, and delayed return to normal mental functioning

 Associated with malignant hyperthermia, a rare, inherited muscular condition in which exposure to some (but not all) general anesthetic agents results in acute and potentially lethal temperature rise, hypercarbia, metabolic acidosis, and hyperkalemia

Stages of anesthesia
Stage I Stage II Stage III, or surgical anesthesia Stage IV, or overdose

Stages of anesthesia
Four stages Stage I begins with the induction of anesthesia and ends with the patient's loss of consciousness. The patient still feels pain in Stage I.

Stage II, or REM stage, includes uninhibited and sometimes dangerous responses to Stage III, or stimuli, including surgical vomiting and anesthesia, target uncontrolled depth of surgical movement. anesthesia.

 Stage IV, or overdose, is marked by hypotension or circulatory failure. Death may result if the patient cannot be revived quickly.

Types of anesthetic agents

INHALATION ANESTHETICS. Halothane Enflurane Isoflurane Nitrous oxide (laughing gas) Sevoflurane Desflurane

 INTRAVENOUS ANESTHETICS. Ketamine Thiopental Methohexital (Brevital) Etomidate Propofol (Diprivan)

B. The Perianesthesia Assessment

A complete medical history, history of allergies in family members Patients may have a potentially fatal allergic response to anesthesia known as malignant hyperthermia, even if there is no previous personal history of reaction.

 patient's age weight, allergies to medications, and medical history, and general health, history of smoking, alcohol or drug use when deciding which anesthetic or combination of anesthetics to use.

 American Society of Anesthesiologists has compiled guidelines for classifying patients according to risk levels as follows: I: healthy patient II: patient with mild systemic disease without functional limitations III: patient with severe systemic disease with definite functional limitations IV: patient with severe systemic disease that is life-threatening V: dying patient not expected to survive for 24 hours without an operation

Preparation for General Anesthesia

Materials & equipments An array of routine and emergency drugs

Preparing the patient

-reviewed by the person responsible for giving the anesthetic well in advance proper laboratory monitoring new or ongoing medical conditions discussion of any previous personal or familial adverse reactions to general anesthetics

 assessment of functional cardiac and pulmonary states development of an effective and safe anesthetic plan serves to relieve anxiety of the unknown surgical environment for patients and their families

 Physical examination associated with preoperative evaluations allow anesthesia providers to focus specifically on expected airway conditions mouth opening loose or problematic dentition limitations in neck range of motion neck anatomy Mallampati presentations

 High Mallampati scores have been shown to be predictive of difficult intubations. -identifies patients in whom the pharynx is not well visualized through the open mouth. The Mallampati assessment is ideally performed when the patient is seated with the mouth open and the tongue protruding without phonating.

 extra steps, if necessary, can be taken to prepare for fiberoptic bronchoscopy, video laryngoscopy, or various other difficult airway interventions.

Other possible or definite difficulties with airway management include:

Small or receding jaw Prominent maxillary teeth Poor dentition Tumors of the face, mouth, neck, or throat Facial trauma Interdental fixation Hard cervical collar Halo traction

Other requirements
Coming to the operating room with an empty stomach Solid food (including gum or candy) should be avoided for 6 hours prior to the induction of anesthesia Clear fluids (ie, water, Pedialyte, or Gatorade ONLY; no other liquids) should be avoided for 2-4 hours prior to the induction of anesthesia

Patients should continue to take regularly scheduled medications up to and including the morning of surgery. Except:
Anticoagulants to avoid increased surgical bleeding Oral hypoglycemics Monoamine oxidase inhibitors Beta blocker therapy (should be continued perioperatively for high-risk patients undergoing major noncardiac surgery)

 attention on the interaction between nonprescribed medications and anesthetic drugs, including interactions with vitamins, herbal preparations, traditional remedies, and food supplements.

The Process of Anesthesia

Premedication -usually conducted in the surgical ward or
in a preoperative holding area -goal of premedication is to have the patient arrive in the operating room in a calm, relaxed frame of mind -most commonly used premedication is midazolam -Atropine are now only administered routinely in anticipation of a fiberoptic endotracheal intubation.

 Induction
Critical part of the anesthesia process

The mnemonic DAMMIS can be used to remember what to check ( D rugs, A irway equipment, M achine, M onitors, I V, S uction).
most patients receive an injection of an opioid analgesic, such as fentanyl (a synthetic opioid many times more potent than morphine).

 endotracheal intubation and incision of the skin, generally raises the blood pressure and heart rate of the patient. Opioid analgesia helps control this undesirable response.

 securing the airway by manually holding the patient's jaw such that his or her natural breathing is unimpeded by the tongue, or it may demand the insertion of a prosthetic airway device such as a laryngeal mask airway or endotracheal tube.

Potential indications for endotracheal intubation under general anesthesia

Potential for airway contamination (full stomach, gastroesophageal reflux, gastrointestinal or pharyngeal bleeding) Surgical need for muscle relaxation Predictable difficulty with endotracheal intubation or airway access Surgery of the mouth or face

Prolonged surgical procedure

 Persons who, for anatomic reasons, are likely to be difficult to intubate are usually intubated electively at the beginning of the procedure, using a fiberoptic bronchoscope or other advanced airway tool. If the anesthesia provider discover that oxygenation and ventilation are inadequate during a surgical procedure, swift intubation of the patient can be very difficult, if not impossible.

Maintenance phase drugs used to initiate the anesthetic are beginning to wear off, and the patient must be kept anesthetized with a maintenance agent refers to the delivery of anesthetic gases (vapors) into the patient's lungs inhaled as the patient breathes spontaneously or delivered under pressure by each mechanical breath of a ventilator

 The most stable part of the anesthesia Appropriate levels of anesthesia must be chosen both for the planned procedure and for its various stages Ensure adequate anesthetic depth New processed EEG machines give the anesthesia provider a simplified output in real time, corresponding to anesthetic depth.

 If muscle relaxants have not been used, inadequate anesthesia is easy to spot. The patient moves, coughs, or obstructs his airway if the anesthetic is too light for the stimulus being given.

 If muscle relaxants have been used, then clearly the patient is unable to demonstrate any of these phenomena. In these patients, the anesthesia provider must rely on careful observation of autonomic phenomena such as hypertension, tachycardia, sweating, and capillary dilation to decide whether the patient requires a deeper anesthetic.

 Excessive anesthetic depth is associated with decreased heart rate and blood pressure, and, if carried to extremes, can jeopardize perfusion of vital organs or be fatal. Or may result in slower awakening and more adverse effects.

 As the surgical procedure draws to an end, close communication with the surgeon enable the anesthesia provider to predict the time at which the application of dressings and casts will be complete. In advance of that time, anesthetic vapors have been decreased or even switched off entirely to allow time for them to be excreted by the lungs. If a ventilator has been used, the

 Supplemental oxygen Monitor vital signs EKG, cardiovascular function, pulse rate, oxygen saturation, respiratory function, and temperature Monitor airways Level of consciousness Excess bleeding Pain Nausea and vomiting

Care Of The Post Anesthesia Patient

 In addition, patients may feel drowsy, weak, or tired for several days after the operation, a combination of symptoms sometimes called the hangover effect. Fuzzy thinking, blurred vision, and coordination problems are also possible. For these reasons, anyone who has had general anesthesia should not drive, operate machinery, or perform other activities that could endanger themselves or others for at least 24 hours, or longer if necessary.

 Postoperative hydration Nursing management in the post anesthesia care unit Assessing the patient Frequent assessment of the patient oxygen saturation, pulse volume and regularity, depth and nature of respiration, skin color ,depth of consciousness.

Maintaining a patent airway: The primary objectives are to maintain pulmonary ventilation and prevent hypoxia and hypercapenia. The nurse applies oxygen, and assesses respiratory rate and depth, oxygen saturation.

Maintaining cardiovascular stability: assesses mental status, vital signs, cardiac rhythm, skin temperature, color and urine output. Central venous pressure, arterial lines and pulmonary artery pressure. The primary cardiovascular complications include hypotension, shock, hemorrhage, hypertension and dysarrythmias.

Relieving pain and anxiety: Opioid analgesic. Assessing and managing the surgical site: The surgical site is observed for bleeding, type and integrity of dressing and drains. Assessing and managing gastrointestinal function: Nausea and vomiting are common after anesthesia. Check of peristalsis movement.

Assessing and managing voluntary voiding: Urine retention after surgery can occur for a verity of reasons. Opioids and anesthesia interfere with the perception of bladder fullness. -Abdominal, pelvic ,hip may increase the likelihood of retention secondary to pain.

Encourage activity: Most surgical are encouraged to be out of bed as soon as possible. Early ambulation reduces the incidence of post operative complication as ,atelectasis ,pneumonia, gastrointestinal discomfort and circulatory problem.

d. Management Of Postanesthesia Problems/ Emergencies

Anesthetic toxicity
Inhalation anesthetics are sometimes toxic to the liver, the kidney, or to blood cells. Halothane may cause hepatic necrosis or hepatitis. Mgt: intralipid
-lipid rescue mechanism of action is not completely understood it may be that the added lipid in the blood stream acts as a sink, allowing for the removal of lipophilic toxins from affected tissues.

Malignant hyperthermia
caused by an allergic response to a general anesthetic especially halothane. signs of malignant hyperthermia include rapid, irregular heartbeat; breathing problems; very high fever; and muscle tightness or spasms

 Treatment Dantrolene sodium, the only available medical treatment for malignant hyperthermia The current treatment of choice is the intravenous administration of dantrolene, the only known antidote, discontinuation of triggering agents, and supportive therapy directed at correcting hyperthermia, acidosis, and organ dysfunction.

Airway emergencies
Rapid Sequence Intubation
Equipment Positioning sniffing position for adequate visualization; flex the neck and extend the head. This position facilitates visualization of the glottic opening.
Recent studies have shown that simple head extension alone (without neck flexion) was as effective as the sniffing position in facilitating endotracheal intubation.

 Protection Sellick maneuver (firm pressure over the cricoid cartilage to compress the proximal esophagus) be initiated to prevent regurgitation of gastric contents, literature is lacking in support of this technique and in fact may impede laryngeal view.
Initiate this maneuver upon observing the beginning of unconsciousness.

Placement Visualize the ET tube passing through the vocal cords. Confirm tube placement.
Two pilot studies have shown that ultrasonography can reliably detect passage of a tracheal tube into either the trachea or esophagus without inadvertent ventilation of the stomach.

Postintubation management Secure the ET tube into place. Initiate mechanical ventilation. Obtain a chest radiograph.
Assess pulmonary status. Note this modality does not confirm placement; rather, it assesses the height above the carina. Ensure that mainstem intubation has not occurred.

 Administer appropriate analgesic and sedative agents for patient comfort, to decrease O2 demand Complications Esophageal intubation Iatrogenic induction of an obstructive airway Right mainstem intubation Pneumothorax Dental trauma

 Postintubation pneumonia Vocal cord avulsion Failure to intubate Hypotension Aspiration

Cardiovascular emergencies
SHOCK (neonate) -from excessive blood loss -sign:
The estimated blood volume of a newborn is 80-85 mL/kg of body weight. Clinical signs of hypovolemic shock depend on the degree of intravascular volume depletion, which is estimated to be 25% in compensated shock, 25-40% in uncompensated shock, and more than 40% in irreversible shock.

MANAGEMENT Blood transfusion is preferred, but in an emergency, colloids or crystalloids can be used. If circulatory insufficiency persists, this dose can be repeated.

 MONITORING & TREATMENT In the absence of CVP, titration against clinical parameters should be completed. Use of crystalloid or colloid solutions is appropriate unless the source of hypovolemia has been hemorrhage, in which case whole or reconstituted blood is more appropriate. If blood is needed in an emergency, type-specific or type O (Rh-negative) blood can be administered

Agent Type

Agentssodium 10-20 mL/kg Used To Treat Volume Isotonic expanders chloride solution intravenous (IV) Neonatal Shock Albumin (5%) 10-20 mL/kg IV
Plasma Lactated ringer solution Isotonic glucose Whole blood products Reconstituted blood products Dopamine Dobutamine 10-20 mL/kg IV 10-20 mL/kg IV 10-20 mL/kg IV 10-20 mL/kg IV 10-20 mL/kg IV 5-20 mcg/kg/min IV 5-20 mcg/kg/min IV 0.05-1 mcg/kg/min IV

Agent

Initial Dosage

Vasoactive drugs

Epinephrine

Additional Factors Inexpensive, available Expensive Expensive Inexpensive, available Inexpensive, available Limited availability Use type O negative Never administer intra-arterially Never administer intra-arterially Never administer intra-arterially

 Hypovolemic Shock Clinical Presentation (Adult) Do not rely on systolic BP as the main indicator of shock; this practice results in delayed diagnosis. Compensatory mechanisms prevent a significant decrease in systolic BP until the patient has lost 30% of the blood volume.

 More attention should be paid to the pulse, respiratory rate, and skin perfusion. Also, patients taking beta-blockers may not present with tachycardia, regardless of the degree of shock.

Classes of hemorrhage have been defined, based on the percentage of blood volume loss. Class I hemorrhage (loss of 0-15%)
minimal tachycardia is seen Usually, no changes in BP, pulse pressure, or respiratory rate occur. A delay in capillary refill of longer than 3 seconds corresponds to a volume loss of approximately 10%.

Class II hemorrhage (loss of 15-30%)

Clinical symptoms include tachycardia tachypnea, decrease in pulse pressure, cool clammy skin, delayed capillary refill, and slight anxiety. The decrease in pulse pressure is a result of increased catecholamine levels, which causes an increase in peripheral vascular resistance and a subsequent increase in the diastolic BP.

Class III hemorrhage (loss of 30-40%)

marked tachypnea and tachycardia, decreased systolic BP, oliguria, and significant changes in mental status, such as confusion or agitation. require blood transfusions

 Class IV hemorrhage (loss of >40%)

marked tachycardia, decreased systolic BP, narrowed pulse pressure (or immeasurable diastolic pressure), markedly decreased (or no) urinary output, depressed mental status (or loss of consciousness), and cold and pale skin. immediately life threatening.

 CARDIAC ARREST cessation of normal circulation of the blood due to failure of the heart to contract effectively.

ACLS Algorithm (Adult)

ACLS Algorithm (Pedia)

AED

Cardiopharmacology
VENTRICULAR FIBRILLATION & PULSELESS VENTRICULAR TACHYCARDIA DRUG INITIAL SUBINTERMAXISEQUENT VAL MUM EPINEPHRINE 1mg 1 mg 3-5 min none
VASOPRESSIN AMIODARONE L IDOCAINE

40 units
300mg 1-1.5 mg/kg

none
150 mg 0.5 0.75 mg/kg

none
10 min 5- 10 min

40 units
2.2 g in 24 hours 3 mg/kg

VENTRICULAR TACHYCARDIA with PULSE & STABLE BP DRUG INITIAL SUBINTERMAXISEQUENT VAL MUM ADENOSINE 6 mg 12 mg 2 min 3rd dose
AMIODARONE

150 mg

150 mg

10 min

1-1.5 mg/kg PROCAI20 NAMIDE drip mg/min

S OTANOL DRIP

L IDOCAINE

0.5 0.75 mg/kg Depends on pts response

5-10 min
17 mg/kg

2.2 g in 24 hours 3 mg/kg

20 mg/min

ASYSTOLE & P.E.A DRUG EPINEPHRINE VASOPRESSIN INITIAL 1 mg 40 units SUBSEQUENT 1 mg none INTERVAL 3-5 min none MAXIMUM none 40 units

ATRIAL TACHYCARDIA/ SVT ([+] pulse & stable BP)

DRUG

INITIAL

SUBSEQUENT 12 mg

INTERVAL 2 min

MAXIMUM 3rd dose

ADENO SINE

6 mg

 Drug Study

 END

Journal Updates..
1. Mode of anaesthetic for category 1 caesarean sections and neonatal outcomes
Background Birth by emergency caesarean section (CS) is common and often considered urgent (category 1). In the UK, over half of all category 1 CS are performed under general anaesthesia (GA). In this setting, little is known about the effect of the mode of anaesthesia on the neonate.

 Methods

A retrospective cohort study was performed using routinely collected de-identified data from Mater Health Services, Brisbane, Australia. The data set included 533 term babies born by category 1 CS for presumed fetal compromise between 2008 and 2011. Bivariate and multivariate analyses were undertaken.

 Results
The outcomes of 81 babies born by GA CS were compared with 452 by CS under regional anaesthesia (RA). Compared with a category 1 CS under RA, the decision-todelivery interval for a GA CS was almost eight minutes faster. When adjusted for confounders, babies born by category 1 GA CS were significantly more likely to have an Apgar score < 7 at five minutes, to require Neopuff or bag/mask ventilation for > 60 seconds and to be admitted to a neonatal intensive care nursery.

 Conclusions General anaesthesia was associated with short-term neonatal morbidity of term babies born by category 1 CS for presumed fetal compromise, despite enabling a more rapid delivery of the baby. These data should help inform the discussion between anaesthetist and obstetrician, in balancing the risks and benefits of the mode of anaesthesia.
2012 The Authors ANZJOG 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

2. For Obese Children Having General Anesthesia, Less Is More

In obese children, the appropriate induction dose of propofol is lower than in nonobese children when doses are based on actual body weight, researchers reported here at the American Society of Anesthesiologists (ASA) 2011 Annual Meeting. The findings are being called practice-changing.

 It is important, therefore, for anesthesiologists to decide whether anesthetic drug doses should be based on a childs actual weight or lean body weight. The general assumption has been that lean body weight should be used, John Dombrowski, MD, head of the ASA communications committee and director of the Washington Pain Center in Washington, DC, told Medscape Medical News.

 In obese children, 75% of the excess weight is fat tissue, which alters lipophilic drug distribution, and the remainder is lean mass, which changes drug clearance. The recommended induction dose of propofol, probably the most widely used lipophilic agent, is 2.5 to 3.5 mg/kg intravenously.

 Obese vs nonobese
The study showed that the ED95 of propofol for loss of consciousness is much lower in obese than in nonobese children when doses were based on the child's actual body weight. Obese children needed a mean propofol dose of 1.99 mg/kg to bring about unconsciousness at induction; normal-weight children needed 3.18 mg/kg, which amounted to 50% to 60% more propofol

 Loss of lash reflex correlated positively with the degree of sedation on the University of Michigan Sedation Scale in both groups. Systolic and diastolic blood pressures were also significantly lower 2 minutes after propofol therapy. Propofol decreases systemic vascular resistance, and doses larger than that required for loss of consciousness may result in moderate to severe hypotension

 Administration of ED95 of propofol based on the actual body weight allows for a more precise dosing for the desired outcome. He said the findings could change practice, and anesthesiologists who continue to dose on the basis of ideal body weight should exercise caution.

 We obviously have an epidemic of obesity and are seeing more of these children. We always believed we should dose the medication on their ideal body weight, not their actual body weight, but this study shows that you actually need to give less than their ideal body weight would dictate to get the same level of sedation, probably because of the excess fat tissues that alter drug distribution," Dr. Dombrowski said.
American Society of Anesthesiologists (ASA) 2011 Annual Meeting; Abstract 1124. Presented October 17, 2011.

 Abstract It has been assumed that anaesthetics have minimal or no persistent effects after emergence from anaesthesia. However, general anaesthetics act on multiple ion channels, receptors, and cell signalling systems in the central nervous system to produce anaesthesia, so it should come as no surprise that they also have nonanaesthetic actions that range from beneficial to detrimental.

3. Are Anaesthetics Toxic to the Brain?

 Accumulating evidence is forcing the anaesthesia community to question the safety of general anaesthesia at the extremes of age. Preclinical data suggest that inhaled anaesthetics can have profound and long-lasting effects during key neurodevelopmental periods in neonatal animals by increasing neuronal cell death (apoptosis) and reducing neurogenesis. Clinical data remain conflicting on the significance of these laboratory data to the paediatric population.

 At the opposite extreme in age, elderly patients are recognized to be at an increased risk of postoperative cognitive dysfunction (POCD) with a well-recognized decline in cognitive function after surgery. The underlying mechanisms and the contribution of anaesthesia in particular to POCD remain unclear. Laboratory models suggest anaesthetic interactions with neurodegenerative mechanisms, such as those linked to the onset and progression of Alzheimer's disease, but their clinical relevance remains inconclusive.

 Prospective randomized clinical trials are underway to address the clinical significance of these findings, but there are major challenges in designing, executing, and interpreting such trials. It is unlikely that definitive clinical studies absolving general anaesthetics of neurotoxicity will become available in the near future, requiring clinicians to use careful judgement when using these profound neurodepressants in vulnerable patients.

 Conclusions Accumulating evidence from animal studies justifies recent concerns regarding the neurotoxic potential of anaesthetic drugs, particularly at the extremes of age. In the young brain, neurodevelopmental factors predispose to anaesthetic excitotoxicity and effects on neurogenesis and synaptogenesis that can impair neurocognitive performance after early anaesthetic exposure. In the old brain, progressive neurodegenerative disease pathways can be exacerbated by anaesthetics in laboratory studies.

 The clinical impact of these preclinical findings has not been established owing to difficulties in designing definitive studies and the significant delay between exposure and testing. Clearly further investigations, both experimental and epidemiological, are warranted to establish the clinical relevance and possible neuroprotective strategies for these untoward effects. Alternatives to surgery and general anaesthesia are usually not available and pain itself can cause longterm neurodevelopmental deficits.

 As current data do not support significant changes in practice other than avoiding purely elective procedures, anaesthesiologists should strive to minimize unnecessary exposure to general anaesthetic agents and other factors that might potentiate toxicity in susceptible patients.
A.E. Hudson; H.C. Hemmings Jr Posted: 07/20/2011; Br J Anaesth. 2011;107(1):30-37. 2011 Oxford University Press