ANESTHESIOLOGY:

CASE PRESENTATION

CASE:
XX is a 35 year old seaman who was scheduled to
undergo inguinal herniorraphy as a Same Day Surgical
Case.
A thorough pre-operative history and PE performed by
the anesthesiologist revealed a normal, healthy
patient, classified as ASA 1. The essential laboratory
and ancillary procedures done showed normal result
as well.
Since the procedure would be done on an out patient
setting, the anesthesiologist opted to do general
endotracheal anesthesia.

 History

PREOPERATIVE
ASSESSMENT

Physical Exam
Laboratory
Ancillaries

PREOPERATIVE ASSESSMENT:
HISTORY

Previous adverse reaction to anesthesia

CNS

Angina, prior MI, hypertension

Respiratory

Cerebrovascular insufficiency, history of seizures

Cardiovascular

Allergic reactions, apnea, prolonged skeletal paralysis, delayed

awakening

Dyspnea, orthopnea, smoking history

Gastrointestinal

Alcohol consumption, hepatitis

PREOPERATIVE ASSESSMENT:
HISTORY

Genitourinary

Musculoskeletal

History of DM, thyroid gland dysfunction

Coagulation

Weakness, osteoporosis

Endocrine

Nocturia, pyuria

Bleeding tendency, easy bruisability, hereditary coagulopathies

Other important information

Dentition (dentures, crowns)

Current drug therapy

Previous surgeries

PREOPERATIVE ASSESSMENT:
PHYSICAL EXAM
Airway Evaluation
CNS
Document any focal deficits

Cardiovascular
Auscultation of heart, systemic BP, peripheral
pulses, edema
Pulmonary
Auscultation of the lungs, breathing pattern

Airway evaluation

Criteria associated with possible difficult airway

1. Large protuberant incisors

2. Strong overbite
3. Inability to prognath
4. Small inter-incisor distance (<6cm)
5. Large tongue (Mallampati classification)
6. Narrow or high arched palate
7. Short thyromental distance (<6cm)
8. Excessive mandibular soft tissue
9. Short neck
10.Thick neck
11.Decreased neck range of motion

Mallampati Classification

LAB/ANCILLARY

CLINICAL INDICATION

Electrolyte
measurement

Considered if:
Abnormal results would change perioperative
management
Patient is at risk of abnormal result based on
Hx & PE

Urinalysis

Not indicated except for specific procedures

such as prosthesis implantation, urologic
procedures

Glucose

Consider for patients

With endocrine, renal or hepatic disorders
Taking certain medications or alternative
therapies

CBC

Consider for:
Pt with liver disease
Pt at extremes of age
Pt with hx of anemia or bleeding
Pt with hematologic disorders
Type of invasiveness of surgical procedure

LAB/ANCILLARY

CLINICAL INDICATION

Coagulation Testing

Consider coagulation testing with platelet

count for:
Pt with hx of bleeding
Pt with renal dysfunction
Pt with liver dysfunction
Type and invasiveness of surgical
procedure
Anticoagulant meds may present additional
perioperative risk

Chest Radiograph

Considered for the ff patients:

Smoker
History of recent URTI
With COPD
With cardiac disease
But if these conditions are chronic and
stable, pre-op chest radiograph is not
necessary

ECG

Consider in patients with:

Cardiocirculatory disease
Respiratory disease
Type and invasiveness of cardiac procedure

Choice of Anesthesia
General anesthesia
Provides loss of consciousness and loss of sensation.

Regional anesthesia
Involves the injection of a local anesthetic to provide
numbness, loss of pain or loss of sensation to a large
region of the body. Regional anesthetic techniques include
spinal blocks, epidural blocks and arm and leg blocks.
Medications can be given that will make the pt
comfortable.

Choice of Anesthesia
Monitored anesthesia (MAC)
Consists of medications to make you drowsy and to relieve
pain. These medications supplement local anesthetic
injections, which are often given by your surgeon. While
you are sedated, your anesthesiologist will monitor your
vital body functions.

Local anesthesia
Numbness to a small area, is often injected by your
surgeon. In this case, there may be no anesthesia team
member with the patient.

ASA Classification
Definition
ASA I

Normal, healthy patient

ASA II

Patient with mild systemic disease

ASA III

Patient with severe systemic disease

that is limiting but not incapacitating

ASA IV

Patient with severe systemic disease

that is a constant threat to life

ASA V

A moribund patient who is not expected

to survive without the operation

ASA VI

A declared brain dead patient whose

organs are being removed for donor
purposes

Emergency surgery

 CASE: (cont)
A few minutes after induction and before intubation
was done, the oxygen saturation of the patient
progressively decreased to 85% after which cyanosis
was observed. Laryngospasm was initially considered,
for which positive pressure ventilation and subsequent
intubation were applied.
The oxygen saturation then steadily increased to 99%.
The anesthesiologist then gave the surgeon a gosignal to proceed with the surgery.
The surgery, which lasted for approximately one hour,
proceeded uneventfully

INTRAOPERATIVE
Accdg to Schwartz:
MANAGEMENT

INTRAOPERATIVE
Accdg to Schwartz:
MANAGEMENT

INTRAOPERATIVE
Accdg to Schwartz:
MANAGEMENT

CASE (cont)

The anesthesiologist, while preparing for extubation,

observed that the patient was unresponsive to stimulation
and had regular shallow respiration. The condition
persisted one hour after.

The team decided to transfer the patient to the ICU for

cardiovascular and ventilator support. The patients
condition did not improve after 24 hours.

A neurological consult revealed that the patient suffered

from cerebral hypoxia

The patients next of kin informed the attending physicians

that they have already sought legal counsel

POST OPERATIVE
MANAGEMENT

Standards for postanesthesia care

These standards apply to postanesthesia care in all locations

May be exceeded based on the judgment of the responsible

anesthesiologist

Are intended to encourage quality patient care, but cannot

guarantee any specific patient outcome

STANDARDS FOR POSTANESTHESIA

CARE
STANDARD I
All patients who have received general anesthesia,
regional anesthesia or monitored anesthesia care shall
receive appropriate postanesthesia management

STANDARD II
A patient transported to the PACU shall be accompanied
by a member of the anesthesia care team who is
knowledgeable about the patients condition. The patient
shall be continually evaluated and treated during
transport with monitoring and support appropriate to the
patients condition

STANDARDS FOR POSTANESTHESIA

CARE
STANDARD III
Upon arrival at the PACU, the patient shall be re-evaluated
and verbal report provided to the responsible PACU nurse
by the member of the anesthesia care team who
accompanies the patient.

STANDARD IV
The patients condition shall be evaluated continually in
the PACU

STANDARD V
A physician is responsible for the discharge of the patient
from the postanesthesia care unit.

PACU Discharge Criteria

Aldrete scoring system
Measurement of recovery after anesthesia that
includes gauging a patients consciousness, activity,
respiration, blood pressure, and oxygen saturation.
A score of 0-2 is given for each of the categories, for
a max score of 10

Aldrete PACU Scoring

Admissio
n

Discharg
e

Respiration

Oxygenation

Circulation

Consciousnes
s

Breathes deeply and coughs freely

Dyspneic, shallow or limited breathing

Apnea

SpO2 >92% on room air

SpO2 >90% on oxygen

SpO2 <90% on oxygen

BP 20mmHg pre-anesthesia

BP 20-50mmHg pre-anesthesia

BP more than 50mmHg pre anesthesia

Fully awake

Arousable on calling

Not responsive

JOURNALS

Complex modulation of the cold receptor

TRPM8 by volatile anaesthetics and its
role
in
complications
of
general
anaesthesia