Procedural Anestesi

29 Desember 2015
27 September 2016
Preoperative Patient Assessment and Care

The objectives of the preoperative visit are:

• Meet the patient

• Identify the present problem requiring surgery
• Identify any previous ongoing illnesses which may influence the anesthetic or surgery,
in particular cardiac and respiratory diseases.
• Renal, hepatic, gastrointestinal, endocrine, neurological, and musculoskeletal
conditions may also influence perioperative management
• Elicit any possible concerns about previous anesthetics or any family history of
problems with anesthetics.
• Any adverse drug reaction and current medications.
• Examine the patient and in particular assess the airway
• Review any investigations and order others needed.
• Plan the anesthetic technique.
• Provide information for the patient and relatives about the anesthetic and postoperative
care including pain management.
• Ask the patient to stop smoking.
• Ensure the patient is NPO for 6 hours for solids and 4 hours for clear fluids.
• Order any premedications required and all essential routine medications to be given
preoperatively.
• Ensure adequate postoperative care is available e.g. step down/ ICU.
Assessment of the airway

• The incidence of difficult intubation is relatively low (~1:65) with a

“failure to intubate” rate of ~ 1:2000.
• In an attempt to try and identify those patients who may fall into this
category a variety of tests have been devised. Unfortunately no
single test is ideal.

Causes of difficult intubation include:

1) Congenital:e.g. Pierre Robin syndrome.

2) Anatomical: Variants of normal e.g. prominent teeth, small

receeding chin, deep protruding mandible, short thick neck,
pregnancy.

3) Acquired: e.g. scarring, swelling, malignancy, rheumatoid arthritis.

At the preoperative visit the anesthesiologist can perform a variety
of tests to try and identify those who may be a difficult intubation.
These include:

1. The Mallampati Classification: this involves getting the patient to

sit upright, open their mouth, stick out their tongue and say “Aaah”.
The view of the posterior pharyx falls into four classes:

Class I - The soft palate, tonsillar fauces and uvula are visible.

Class II - The soft palate and part of uvula visible.

Class III - Only the soft palate is visible.

Class IV - Only the hard palate is visible.

Class III and IV are associated with increasing difficulty to intubate.

2. The Thyromental distance: a distance of less than 6.5cm or
inability to admit three fingers associated with more difficult
intubation.

3. The ability to prognath:

Class I: able to move bottom teeth in front of top teeth = normal

Class II: able to align bottom set to top set = some difficulty

Class III: bottom set stays behind top set = difficult to intubate

4. Neck mobility: ability to flex the lower cervical spine and

extend the atlanto-occipital joint (sniffing the morning air
position.
This position results in axial alignment of the mouth, pharynx
and larynx.
Laboratory Investigations

These tests vary depending on the patient but a few rules can be followed.

1. Complete blood counts should be performed on all patients who show signs of anemia or
have an underlying condition which increases the risk of anemia (e.g. chronic illness, bleeding
disorder, excess alcohol consumption, chemotherapy).
- It should also be done when large blood losses are likely during surgery.
- It is routine in all women and men over 60yr.

2. Serum Electrolytes should be done on all patients over 40yr, those with renal disease,
hypertension, diuretic therapy including bowel prep., diarrhoea or vomiting.

3. A Coagulation Screen if there is a history of bleeding disorder or on anticoagulation therapy.

4. An Electrocardiogram should be done on all patients over 40yr, any patient at increased risk
of cardiac disease, have symptoms of cardiac disease, or show signs of cardiac disease on
physical examination.

5. A Chest x-ray is required in all patients with symptomatic pulmonary disease or underlying
malignancy.

6. Urinalysis is required in all patients.

All other investigations are ordered if specific problems are identified on history and physical
examination.
Pre-existing illness:

Certain diseases are especially important during anesthesia :

• ischemic heart disease
• congestive heart failure
• hypertension
• diabetes mellitus
• reactive airways disease.
Conduct of Anesthesia

There are three stages to any anesthetic:

• induction
• maintenance
• recovery.
• During all three stages there is a standard level of monitoring
employed: oxygen analyser, stethoscope, pulse oximeter, non-
invasive blood pressure, electrocardiogram, end tidal carbon
dioxide level, inhalation agent concentration, temperature probe.
• If the patient is ventilated then additional monitors are needed to
read pressures in the airway and the breathing circuit, tidal volumes
delivered and respiratory rate.
• If the patient is paralyzed then a peripheral nerve stimulator is used
to measure the degree of paralysis.

The overall conduct of any anesthetic is a balance between analgesia,

anesthesia, and muscle relaxation.
• Induction can be intravenous or inhalational technique.
• Inhalation induction is usually done
- on very young children who may be difficult to get an
intravenous in awake
- in certain airway conditions where it is important that the
patient maintains spontaneous respiration.
• The inhalation agents used are halothane and sevoflurane
since they smell nice, are relatively non-irritant, and, in the
case of sevoflurane, quick.
• Intravenous induction is the more usual technique as it is
fast, controlled and pleasant for the patient.
• The agents commonly used are pentothal and propofol.
Maintenance of anesthesia:
• is usually by administering inhalational agents
• mixture of nitrous oxide and oxygen with one of the following
volatileagents: halothane, enflurane, isoflurane, sevoflurane,
desflurane.
• Nitrous oxide is a very weak anesthetic but adding it to the
mixture means that less of the volatile is needed and so
decreases the likelihood of side-effects (hypotension,
arrythmias).
- Minimum alveolar concentration or MAC is the concentration of a
vapour in the lungs that is needed to prevent movement (motor
response) in 50% of subjects in response to surgical (pain) stimulus.
- MAC is used to compare the strengths, or potency, of anaesthetic
vapours.
- MAC was introduced in 1965.

- MAC actually is a median value, not a minimum as term implies.

- The original paper proposed MAC as the minimal alveolar
concentration, which was shortly thereafter revised to minimum
alveolar concentration.
- A lower MAC value represents a more potent volatile anesthetic.

- Other uses of MAC include MAC-BAR (1.7-2.0 MAC), which is the

concentration required to block autonomic reflexes to nociceptive
stimuli
- MAC-awake (0.3-0.5 MAC), the concentration required to block
voluntary reflexes and control perceptive awareness.
- MAC is higher in infants and lower in the elderly.
- Also, MAC increases with hyperthermia, hypernatremia and
chronic alcohol ingestion.
- Likewise, hypothermia, hypotension (MAP < 40 mmHg), and
pregnancy seem to decrease MAC.
- Duration of anesthesia, gender, height and weight seem to
have little effect on MAC.
- Opioid analgesics and sedative-hypnotics, often used as
adjuvants to anesthesia, decrease MAC
Values are known to decrease with age and the following are
given are based on a 40-year-old (MAC40):

- Nitrous oxide - 104

- Xenon - 72
- Desflurane - 6.6
- Ethyl Ether - 3.2
- Sevoflurane - 1.8
- Enflurane - 1.63
- Isoflurane - 1.17
- Halothane - 0.75
- Chloroform - 0.5
- Methoxyflurane - 0.16

https://en.m.wikipedia.org/wiki/Minimum_alveolar_concentration
Alternatively: continuous intravenous infusion technique.
• The agent used for this is propofol
• it is a technique most frequently employed in patients who
are sensitive to the volatile agents.
• This sensitivity is known as malignant hyperthermia and as
the name implies it causes anincrease in body temperature.
As well as the rise in body temperature symptoms include
muscle rigidity, tachycardia, hypoxia, hypercarbia, acidosis.
• Without treatment there is a 70% mortality rate; with
treatment it is 2-3%.
• The treatment is dantrolene and supportive measures.
Recovery
• commences once surgery has finished and involves
stopping the nitrous oxide and volatile agents and
increasing the oxygen to 100%.
• The agents will diffuse out of the body down a concentration
gradient. With the decrease in concentration the patient
begins to waken.
• If the patient has been paralysed for surgery then this will
need to be reversed before waking the patient.
• This is done using an acetylcholinesterase inhibitor such as
neostigmine and edrophonium wich increase the
concentration of acetylcholine at the receptor.
• This reverses the competitive inhibition of the muscle
relaxant at the receptor and so reverses the paralysis.
• These drugs can cause a bradycardia and so are usually
given with either atropine or glycopyrrollate.
• If succinylcholine is the only muscle relaxant used then there
is no need for using a reversal agent.
• This drug loses its effect through metabolism by
cholinesterase.
• Normally this is not a problem but occasionally a patient will
have abnor mal cholinesterase and the effect of
succinylcholine will be prolonged. This condition is known
as “sux apnoea”.
• When the patient is breathing spontaneously, maintaining
their airway, and cardiovascularly stable --> the patient is
moved to the recovery room.
• In the recovery room the patients vital signs are monitored.
• When the patient is awake, protecting their airway
adequately, cardiovascularly stable, and comfortable they
are transferred to the floor (Aldrete score)
Anesthetic agents used

• Inhalational agents:
halothane, enflurane, isoflurane, sevoflurane, desflurane,
nitrous oxide

• Intravenous agents:
pentothal, midazolam, propofol, ketamine, etomidat
Adjuncts to anesthetic agents

There are a variety of drugs used to supplement the anesthetic

agents.

Benzodiazepines: e.g. midazolam.

• Used as a sedative to decrease the intravenous induction agent
and minimize its side effects.
• Also acts as an amnesic.

Narcotics: e.g. fentanyl, morphine, sufentanil.

• Analgesics which also help in reducing anxiety preoperatively,
decrease the cardiovascular response at intubation, decrease the
amount of agent need to maintain anesthesia.
Muscle relaxants:
• depolarizing relaxants (succinylcholine)
• non-depolarizing relaxants ( atracurium, cis-atracurium,
rocuronium, vecuronium, pancuronium).

They are used in anesthesia for a variety of purposes:

a) facilitate endotracheal intubation
b) facilitate surgery on the abdomen or thorax, and make
surgical access easier
c) to prevent reflex patient movements during anesthesia.

MUSCLE RELAXANTS SHOULD NEVER BE USED UNLESS

THE PERSON ADMINISTERING IT HAS THE SKILL AND
EQUIPMENT AVAILABLE TO ESTABLISH AND MAINTAIN AN
AIRWAY
Perioperative Fluid Management:

A knowledge of fluid and electrolyte physiology is required before fluid

management can be approached.

the average adult is composed of:

~60% water –of this 2/3 is intracellular and 1/3 is extracellular

-extracellular fluid consists of intravascular and interstitial fluid

-the blood volume (intravascular volume) is ~ 70ml/kg

This can be shown as:

Total body water 42 litres
Intracellular fluid 8 litres
Extracellular fluid 14 litres
Plasma Volume 3 litres
Interstitial fluid 11 litres
- Sodium is the major extracellular cation
- potassium the major intracellular cation

- cells are impermeable to sodium but there is free movement

of water and sodium between the interstitial space and
plasma
- water moves freely across cell membranes to maintain
osmotic equilibrium between the intracellular and
extracellular compartments
The following is a guide to the commonly available fluids for intravenous
administration:

• Isotonic crystalloids:
- normal saline:154 mol Na,154 mmol Cl, osmolality 308 mosm/l

- Ringers lactate: 130 mmol Na, 109 mmol Cl, 28 mmol lactate, 4 mmol K,1.5 mmol
Ca, osmolality 272 mosm/l

These solutions have approximately the same osmolality as plasma and contain
sodium as the major cation.
When given intravenously they distribute throughout the extracellular space (75%
interstitial, 25% intravascular). They do not move intracellularly.

• Hypotonic crystalloids
- 5% dextrose-no electrolytes –essentially water so distributes throughout all
compartments, osmolality 252 mosm/l

- 5% dextrose/ 0.45% saline-77 mmol Na –77 mmol Cl –osmolality *** mosm/l

• hypotonic solutions alone will cause the red blood cells at
the site of injection to swell and burst.
• once in the body the dextrose is metabolised and only the
electrolytes and water remain for distribution.
• Since there is more free water then more of the solution
goes intracellularly. The electrolytes again remain
extracellularly.
Colloids:
- pentaspan, hetastarch, 5% albumin, fresh frozen plasma
- high molecular weight substances which cannot diffuse out
of the intravascular space.
- They also contain electrolytes similar to plasma.
- The overall oncotic pressure they exert in the plasma
maintains the fluid in the intravascular space and prevents
the fluid leaking into the interstitial space.
- The solutions contain either synthetic compounds in the
form of large molecular weight carbohydrates or biological
protein.
• The main objective during anesthesia and surgery is to
maintain intravascular volume.
• During surgery there can be large shifts in fluid out of the
intravascular space:
- blood loss
- increase in fluid shifts into the interstitial space as a result of
trauma to tissue --> third space fluid.
There are 4 components to fluid requirements during surgery:

1) maintenance fluids

2) replacing existing fluid losses from preop. fasting etc

3) replacing third space fluid loss

4) replacing blood lost

Maintenance fluids: 4:2:1 rule

• 4ml/kg for first 10 kg

• 2ml/kg for next 10 kg

• 1ml/kg for each additional 10 kg

thus:
• 4 kg baby needs 16ml/hr
• 70 kg man needs 110ml/hr
Fluid deficits:

• Patients fasted for surgery need compensating for fluid not

taken.
• Hence if they have been starved for 10 hours then they will
need 10x their hourly maintenance fluid during the surgical
procedure.
• Other deficits must also be replaced e.g. those patients who
have had bowel preps or have bowel obstruction.
Third space losses:

This is proportional to the extent of surgery i.e:

• Minor (appendectomy)~2ml/kg/hr

• Intermediate (cholecystectomy)~ 4ml/kg/hr

• Extensive (AP resection)~6ml/kg/hr

• Very extensive(aortic aneurysm)~ 10-12ml/kg/hr

This type of loss contains electrolytes so it is important to

replace them accordingly using isotonic crystalloids.
Blood losses:

• Patients do not require small amounts of blood loss to be replaced

with blood.
• Initially it is the volume itself and not the hemoglobin that must be
replaced.
• Isotonic crystalloids up to 4 times the blood loss will maintain
intravascular volume ( this is because only 25% of the solution will
remain intravascularly).
• Replacing the hemoglobin itself will depend on the individual patient
and weighing up the risk:benefit of giving blood products.
• Hence the hemoglobin level at which you would transfuse an elderly
patient with ischemic heart disease will be much higher than a fit,
healthy young adult.
• If there is any possibility of the patient needing a transfusion this
must be discussed beforehand and the patients consent obtained. If
the patient makes an informed choice not to be given blood under
any circumstances then this must be respected whatever the
outcome. Anything else would be assault.
• Whenever fluids are given do not rely solely on formulae
• look at the patient and assess their vital signs:
- heart rate
- blood pressure
- peripheral perfusion
- urine output
• Once fluid has been given these parameters need to be
reassessed and management altered accordingly.

http://anesthesiology.queensu.ca/
Thank You