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Basic Practice of Anesthesiology

Hany El-Zahaby, MD

Preoperative Evaluation
1. History -Current problem -Other known problems -Medical history (allergies, drug intolerance, present therapy, tobacco and alcohol intake) -Previous anesthetics, surgeries, deliveries -Family history -Review of organ systems -Last oral intake

Preoperative Evaluation

2. Physical Examination -Vital signs -Airway (Thyromental distance, Malampati sign) -Heart -Lungs -Extremities -Neurological examination

Preoperative Evaluation

3. Routine Laboratory evaluation (healthy asymptomatic) Hematocrite: All menstruating women, age >60 y, anticipated significant blood loss S. glucose, creatinine: age >60 y ECG: age >40 y Chest radiograph: age >60 y Pregnancy test: fertile women

American Society of Anesthesiology Risk Classification


ASA Class Description

1
2 3 4

Normal, healthy (0.06-0.08%)


Mild systemic disease (0.27-0.4%) Severe systemic D, not incapacitating (1.8-4.3%) Severe systemic D that is a constant threat to life (7.8-23%)

5
6

Moribund, not expected to live 24h (9.4-51%)


Care for organ donation

The Anesthetic Plan


Premedication Type of anesthesia General (airway, induction, maintenance, relaxant) Regional (technique, agents) Intraoperative management Monitoring, positioning, fluids, MABL, special techniques Postoperative management Pain control, ICU (ventilation, monitoring)

Preoperative Evaluation

Informed consent Gives the patient explanation of the options for anesthesia and its realistic risks (general, regional, local, topical, intravenous sedation) Regardless of the technique chosen, consent must always be taken for GA if other techniques prove inadequate e.g. LA

The Anesthetist-Patient relationship

Is The Patient Scared? Surgery (cancer, physical disfigurement, pain, death) Anesthesia (loss of control, not waking up, waking up during surgery, nausea, confusion, paralysis, headache)

Preoperative Evaluation

1-Unhurried, organized interview 2-Calm reassurance and expression of interest in the patients well being 3-Informing about: NPO (no solids after m.n., clear fluids up to 2-3 h unless GER) Time of surgery Premedication and other daily medications Tasks to occur on the day of surgery Postoperative recovery or ICU

Premedication

Benzodiazepines: Diazepam (5-10 mg PO 1-2 hours before surgery), never IM (pain, unpredictable) Lorazepam (1-2 mg PO), intense prolonged amnesia and sedation Midazolam (1-3 mg IV or IM) at the receiving area, 0.5 mg/kg PO for pediatrics

Premedication

Narcotics: painful fractures, planned extensive awake invasive monitoring devices Morphine 5-10 mg IM 60-90 min before surgery Anticholinergics (rare): Not Routine Glycopyrrolate 0.2-0.4 mg IV to reduce oral secretions (fibreoptic intubation)

Premedication

Prophylaxis for pulmonary aspiration: Pregnant, hiatal hernia, GER, difficult airway, ileus, obesity, CNS depression H2 blockers (ranitidine, 150-300 mg PO before bedtime and early morning) Nonparticulate antacids (sodium citrate 30-60 ml) Metoclopramide (10 mg IV 1h before surgery to enhance gastric emptying)

Premedication

Goals: Reduce anxiety, pain during vascular cannulation and regional blocks, facilitate smooth induction Reduce the dose or withhold in elderly, debilitated, upper airway obstruction or trauma, central sleep apnea, neurologically obtunded, severe pulmonary or obstructive valvular disease

Monitoring

Standard monitoring for GA: ECG, non-invasive BP, respiratory rate, oxygen saturation, end-tidal carbon dioxide, inspired oxygen concentration Standard monitoring for regional anesthesia: ECG, non-invasive BP, respiratory rate, oxygen saturation

IV access

IV access: (14-16 G if rapid fluid or blood transfusion or continuous drug infusions, better under local anesthetic infiltration)

Components of GA

Loss of consciousness Loss of reflexes (Movement to pain) Analgesia Amnesia Relaxation

Induction of Anesthesia

The environment in OR should be warm with minimal noise and all attention focused on the patient Supine position with extremities in neutral position and head on firm pillow raised to sniff position

Induction of Anesthesia

Techniques: 1- IV induction preceded by oxygen via face mask until loss of consciousness using thiopentone or propofol 2- Inhalational anesthetics either by low concentration with incremental increase every 3-4 breaths or by a single vital capacity breath technique using sevoflurane or halothane

Intravenous Induction
Thiopentone Propofol

3-5 mg/kg ----Slower onset, slower recovery Hypotension ++

2-2.5 mg/kg IVI 6-10 mg/kg/h


Painful injection Rapid induction, rapid clearheaded recovery Hypotension +++

Depress respiration
Contraindicated in porphyria

Depress respiration
Less N,V

Airway Management

Face-mask with: Oro-pharyngeal airway Naso-pharyngeal airway LMA ETT with a muscle relaxant (depolarizing as succinyl choline or non-depolarizing as tracrium, cistracrium, rocuronium)

Muscle Relaxants

Depolarizing MR (succinylcholine) mimics the action of acetylcholine i.e. causes depolarization of the motor end plate and muscle membrane but for longer time than Ach. Used for rapid-sequence induction in patients with full stomach Non-depolarizing MR produce reversible competition with Ach at the motor end plate that produce relaxation for longer duration

Succinylcholine

Dose:1mg/kg produce relaxation in 1 min Side effects: Muscle pains, ganglionic stimulation, increase S. K+ level by 0.5-1 mEq/L, increase intraoccular pressure, increased intragastric pressure, increase intracranial pressure, prolonged block due to decrease or inhibition or atypical plasma cholinesterase, malignant hyperthermia

Non-Depolarizing MR

Atracurium: 0.5 mg/kg, Hofmann elimination Cisatracurium (Nimbex): 0.15 mg/kg, Hofmann elemination, less histamine release Vecuronium: 0.1 mg/kg, hepatic metabolism Rocuronium (Esmeron): 0.5 mg/kg, hepatic metabolism (short duration)

TOF

Twitch Height After Succinyl Choline

Twitch Height After Non-Depolarizing

Clinical Assessment of the Blockade

Evoked response
95% -- single twitch TOF response =1 TOF response =3 TOF ratio > 0.75 TOF ratio = 1

Clinical correlate
Good intubating condition Surgical relaxation without inhalation anesth. Surgical relaxation with inhalation anesth. Possible extubation Normal VC

Laryngoscopy and Intubation

Profound sympathetic responses (hypertension, tachycardia) can be attenuated by hypnotics, inhalation anesthetics, opioids, lidocaine, or beta blockers

ETT Size

Premature: 2.5-3 Full term: 3 6 M -1 y:3.5 2 Y: 4.5 Over 2y: 4+(age/4) 4 +(6/4) 5.5 Length (at mouth cm): 10+(age/4) 10 +(6/4) 11.5cm

Positioning

Movement of supine anesthetized patient into another position may cause hypotension due to lack of intact compensatory hemodynamic reflexes. Patients head and limbs should be protected and padded. Hyperextension or over-rotation of the neck and limbs must be avoided.

Maintenance

Depth of anesthesia (surgical anesthesia) +Muscle relaxation Signs of inadequate depth of anesthesia: Somatic responses (movement, coughing, changes of respiratory pattern) Autonomic responses (tachycardia, hypertension, mydriasis, sweating, tearing)

Stages of General Anesthesia


Stage I Amnesia Stage II Delirium Stage III Surgical anesthesia Stage IV Overdosage From induction to loss of consciousness, pain perception is maintained Exaggerated responses to noxious stimulus, dilated pupils, divergent gaze, irregular breathing Central gaze, constricted pupils, regular respiration, no somatic or autonomic responses Depressed respiration, dilated fixed pupils, marked hypotension

Maintenance

If spontaneous breathing is needed, minimal opioids with nitrous oxide and inhalation anesthetic If muscle relaxation is needed, nitrous oxide-opioidrelaxant with minimal inhalation anesthetic and controlled ventilation (Balanced anesthesia) TIVA: Continuous infusion of propofol-opioid + muscle relaxant (nothing through inhalation)

Inhalation Anesthetics

Blood-gas partition coefficient is inversely related to the rate of induction MAC: minimal alveolar concentration that prevent movement in response to a skin incision in 50% of patients

Inhalation Anesthetics

Blood/gas PC
Nitrous oxide Halothane Isoflurane Sevoflurane 0.47 2.3 1.4 0.69

MAC
104 0.74 1.15 2.05

Desflurane

0.42

6.0

Ventilation

Spontaneous/assisted: All inhalation anesthetics depress respiration and moderately increase PaCO2 Can be affected by positioning, peritoneal insufflation, open chest, surgical packing and opioids

Ventilation

Controlled Ventilation: Initial setting with TV=10-15 ml/kg, RR=10-12/min, notice the PIP, If>30, decrease TV and increase RR A sudden drop in PIP circuit leak A sudden increase in PIP kink, endo-bronchial intubation, peritoneal insufflation

IV Fluids

Maintenance: first 10kg 4ml/kg/h Second 10 kg 2ml/kg/h After 20 kg 1 ml/kg/h Third-space loss: Tissue edema and evaporation, varies from 5-10 ml/kg/h Blood loss: Replaced in 1:3 with isotonic crystalloid, or 1:1 with blood

IV Fluids (60 kg fit adult fasting for 6h)

1st h
Fasting Maintenance (100ml/h) 3rd space Blood loss 300 100 5x60=300 --

2nd h
150 100 5x60=300 --

3rd h
150 100 5x60=300 --

Total

700

550

550

Estimated Allowable Blood Loss

70 kg, Hct 35 EABL = EBV X (Hctstart-Hctallowable) Hctstart EABL = 4900 X (35 27)= 980ml 35

Estimating Volume of Blood to be Transfused


70 kg, with present Hct of 23 Volume=EBV X (Hctdesired - Hctpresent) Hct transfused blood Volume=4900 X (30-23) =490ml 70

Emergence from GA

Goals: awake, responsive with full muscle strength so he can maintain patent airway, cannot aspirate and can be assessed neurologically Technique: withdraw anesthetics near the end of surgery, reverse muscle relaxation with neostigmine (0.03-0.06 mg/kg) and atropine (0.2-0.4 mg/kg)

Emergence from GA

Environment: Warm and calm Positioning: Supine, tonsillectomy if full stomach Mask ventilation: 100% oxygen, avoid stimulation of the airway during stage II

Emergence from GA

Extubation: 1-Awake (desirable) with fully recovered protective reflexes, follow simple verbal commands, breathe spontaneously with good oxygenation and ventilation (lidocaine 1mg/kg IV) 2- Deep extubation (during stage III) reduce risk of laryngospasm and bronchospasm (in asthmatic) avoid coughing ( eye surgery, hernia repair)

Emergence from GA

Agitation: due to hypoxia, hypercarbia, airway obstruction, full bladder, pain or sevoflurane and desflurane anesthesia. Treated by treating the cause, fentanyl 25g IV or morphine 2mg IV increments Delayed awakening: Continue ventilatory support and airway protection and reverse the etiology

Transport

Stable patient can be transferred without oxygen or monitor to PACU Unstable patient should be transferred with oxygen, monitors, tools for re-intubation to PACU or ICU Anesthetist should give concise but thorough summary to PACU or ICU staff

Acute postoperative pain management

Optimal pain control is an integral component of accelerated recovery Although opioids are the most effective, acute postoperative pain management is now based on multimodal analgesia and opioid sparing

Acute postoperative pain management


Psychological Preparation Assessing Pain (0-10 Verbal Analogue Scale is now the fifth vital sign to be recorded in the record) Preemptive Analgesia (peripheral injury central sensitization increase pain sensitivity

Acute postoperative pain management

Treatment Options: 1- NSADs: Oral alone mild to moderate pain, begin preop., gastric irritation, coagulopathy, mask fever Oral with opioids reduce opioid intake Parentral keorolac 30 mg then 15-30 mg/6h, expensive, can replace opioids Paracetamol (Perfalgan), 1 gm/6h

Acute postoperative pain management

2- Opioids: PO (chronic pain) IM ( morphine 0.1mg/kg, pethidine 1mg/kg) painful, unreliable IV-bolus (morphine 2mg every 5 min, max 10-15mg) IVI ( morphine 10- 20 g/kg/h) Monitor the respiratory rate

Acute postoperative pain management

3- PCA: Provide analgesic doses immediately based on patient needs using microcomputer-controlled infusion pumps which avoids extreme swings in plasma levels. Special order sheet is needed with detailed pump setting (demand dose, start dose, delay time, basal rate) and monitoring (pain level, sedation level, verbal response)

Acute postoperative pain management

4- Epidural Analgesia Abdominal , vascular & L.L. surgery Contraindications: patient refusal, coagulopathy, LMWH, bacteremia, local infection 0.1% Bupivacaine + 1-2 g/ml Fentanyl 5-10 ml/h Bupivacaine if hypotension or motor block Fentanyl if pruritis Complications: Inadequate analgesia, PDPH, epidural hematoma or abcess

Acute postoperative pain management

5- Neuraxial Morphine (preservative-free) Epidural: 1-4 mg Intrathecal: 0.1-0.4 mg (Respiratory depression) 6- Intraoperative Neural Blockade (esp. children)

Local Anesthetics Ester/ Amide

Aromatic Ring

Amine

Local Anesthetics
Esters: procaine, chloroprocaine, tetracaine (metabolised by plasma esterase, allergen) Amides: lidocaine, bupivacaine, ropivacaine (liver metabolism)

Local Anesthetics

Potency lipophilicity
Duration protein binding Onset pKa (pH at which 50% are uncharged ions diffuse to nerve membrane)

Local Anesthetics

Sequence of block: Sympathetic pain & temp. proprioception touch & pressure motor Additives: Epinephrine 1:200,000prolong duration, systemic toxicity, intensity of block, surgical bleeding Sodium bicarbonate: 1 meq:10ml lidocaine, 0.1meq:10 ml bupivacaine (avoid ppt)fasten onset

LA: Systemic Toxicity

CNS Light-headedness, tinnitus, metallic taste, visual disturbance, cicumoral numbness, muscle twitching, seizures, loss of consciousness Treatment: stop injection, oxygen, midazolam 1-2 mg, thiopentone 50-200 mg CVS contract., conduct., VD collapse (esp. Bupivacaine) Treatment: oxygen, volume, vasopressors ACLS

Local Anesthetics: Spinal Anesthesia

Spinal Needle: 25G pencil point with 19G introducer Position: Sitting or lateral Level: L3-4, L4-5 Approach: Midline or paramedian Drugs: Bupivacaine (Heavy) 0.5% 2-3 mls

Local Anesthetics: Spinal Anesthesia

Complications: Hypotension0.5-1L of LR before the block, ephedrine 5-10 mg boluses Bloody tap if does not clear rapidly, withdraw & reinsert Nausea & vomiting treat hypotension Apnea (total spinal) support ventilation PDPH: bed rest, IV fluids, analgesics, caffeine 30mg, epidural blood patch

Local Anesthetics: Epidural Anesthesia

Epidural Needle: 17G Tuohy needle Position: Sitting or lateral Level: L3-4, L4-5 Approach: Midline or paramedian Drugs: Bupivacaine 0.125- 0.25% 15-20 ml Techniques: Loss of resistance Hanging drop method Test dose: 3 ml lidocaine 1% with epinephrine 1:200,000

Local Anesthetics: Epidural Anesthesia

Drugs: 1.5 ml/segment Decrease dose 50% in old age Decrease dose 30% in pregnancy Epinephrine increase duration Opioids (fentanyl 50-100 ) improve the quality Sodium bicarbonate speeds the onset

Local Anesthetics: Epidural Anesthesia

Complications: Dural puncture 1% Convert to spinal Reinsert one space above Inability to thread the epidural catheter (too lateral, partial bevel insertion) Insertion into a vein (withdraw) Catheter break off (inform patient & leave it)

Local Anesthetics: Combined Spinal-Epidural Anesthesia

Combine advantages and avoid disadvantages of both techniques Rapid onset, solid sacral block, less volume Longer time, more control on level

Local Anesthetics: Caudal Epidural

Through the sacrococcygeal membrane Can reach high level in children: 1 ml/kg Bupivacaine 0.2-0.25% with 1;200,000 Epinephrine reach T6-8 level

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