Administration of Administration of AnaesthesiaAnaesthesia

Presenter: Dr S SpijkermanSlides: Prof EE OosthuizenSBAH & UP

TYPES OF ANAESTHESIATYPES OF ANAESTHESIA• General Anaesthetic– Unconscious

• Regional Anaesthetic– Awake / Sedated

• Combined General - Regional

• Conscious sedation – New name: Procedural sedation

PHASES OF A GENERAL PHASES OF A GENERAL ANAESTHETICANAESTHETIC

1. Pre-op evaluation and medication2. Preparation of equipment and drugs3. Intravenous access 4. Induction of unconsciousness5. Management of the airway 6. Maintenance of Anaesthesia7. Wake-up and reversal of muscle

relaxation (NDMR)8. Observation and support in PACU

Start to plan the Anaesthetic when you do

the preoperative assessment of the patient!

Factors that influence the Factors that influence the choice of Anaestheticchoice of Anaesthetic

• Physiological status of the patient(physiological reserves)

• Anatomical abnormalities• Pathology necessitating surgery• Nature of the procedure• Duration of the procedure• Current medication

Factors that influence the Factors that influence the choice of Anaesthetic choice of Anaesthetic (contd)(contd)

• Availability of equipment and drugs

• Skills and experience of the anaesthetist

• Preferences of the patient

Factors that influence the Factors that influence the choice of Anaesthetic choice of Anaesthetic (contd)(contd)

CONCLUSION:

Every Anaeshetic must be tailor-made for the individual patient and the specific

surgical procedure!

Preparation for TheatrePreparation for Theatre• Signed (informed) consent• Mass (kg)• Empty bladder• “Nil per os”• Preoperative medication• Chronic medication• Dentures / artificial limbs, eyes• Jewels

Preparation for TheatrePreparation for Theatre(cont’d)(cont’d)

• All make-up removed

• Appropriate theatre attire

• Identity and allergy tags

• Vital signs recorded

CONSENTCONSENT• Voluntarily

• Not retrospectively

• Informed

• Permission only includes permissible risks

Induction of UnconsciousnessInduction of Unconsciousness

• Surgical team must be on hospital premises• Preflight checklist of equipment and drugs• Emergency drugs and equipment• Meticulous identification of drugs• Positioning on the table• Monitors connected• Patent, running intravenous line• Vitals recorded before take-off• Proper intravenous access• Routes of induction:

IV / Inhalation / IM / Rectal

AIRWAYAIRWAY

Maintenance of the Airway– Facemask & oropharyngeal airway– Endotracheal intubation– LMA

Indications for IntubationIndications for Intubation

• Protection of the airway• Maintenance of the airway• Controlled ventilation (relaxants)• Surgery on head and neck (access)• Longer procedures (>30 minutes)• Babies & small children

Intubation techniqueIntubation technique

• Opening of the mouth• Laryngoscope in left hand• Tongue to the left• Slide blade over the tongue• Deeper & shallower to find epiglottis• Lift, not hinge• Tip of McIntosh vallecula • Tip of Miller posterior to epiglottis

Popular Laryngoscope Blades

Macintosh

Miller

Correct placement of Endotracheal Tube?

• See tube passing through cordsSee tube passing through cords• AuscultateAuscultate• See bilateral chest movementSee bilateral chest movement• Press on chest and listenPress on chest and listen• Oximetry (late sign)Oximetry (late sign)• CapnographyCapnography• High index of suspicionHigh index of suspicion

Complications of IntubationComplications of Intubation

• Sore throat• Incorrect placement• Trauma• Regurgitation / Aspiration• Bronchospasm• “Stress response”

Rapid Sequence InductionRapid Sequence Induction

To be performed on all patients with a risk for aspiration:

Not fastedDelayed stomach emptyingRegurgitation (hiatus hernia)

RSI RSI Check all equipment before take-off,

then:1. Preoxygenate for 3 minutes2. Induction with rapid acting agent3. Cricoid pressure (Sellick’s maneuver)4. Suxamethonium5. Intubate & inflate cuff6. Confirm correct placement of tube7. Release cricoid pressure

PREOXYGENATIONPREOXYGENATION• 100% Oxygen

• Tight fitting mask

• 3-5 minutes

OR

• 3-5 Vital Capacity Breaths with 100% O2

Traditional Components of a Traditional Components of a Balanced General AnaestheticBalanced General Anaesthetic

• HYPNOSIS

• ANALGESIA

• MUSCLE RELAXATION (not essential)

Duty of Anaesthetist during Duty of Anaesthetist during an Anaesthetican Anaesthetic

• Oxygenation status• Awareness• Maintain correct plane of Anaesthesia• Haemodynamic / respiratory monitoring &

manipulation• Positioning• Ensure well-being of the patient

perioperatively• Create optimal surgical conditions • Postoperative pain management

Duty of Anaesthetist during Duty of Anaesthetist during an Anaesthetican Anaesthetic

Anaesthetist / Anaesthesiologist is the perioperative physician!

Inadequate AnaesthesiaInadequate Anaesthesia

• Tachycardia / Dysrhythmias• Hypertension• Sweating / Salivation / Tears• Movement if not relaxed• Dilation of pupils• Increased breathing efforts if not

paralysed

Signs of an Overdose of Signs of an Overdose of AnaesthesiaAnaesthesia

• Hypotension without other cause

• Bradycardia

• Respiratory depression / apnoea in spontaneously breathing patients

Intraoperative MonitoringIntraoperative Monitoring

• Monitor changes in physiology

• Senses are the most valuable monitors!

• Anaesthetist must be able to integrate all the parameters and respond accordingly

• Meticulous record keeping

Record KeepingRecord Keeping

Good record keeping ensures an easy defence!

If it wasn’t recorded, it wasn’t done!