The practice conduct of Anesthesia

Dr. Mohamed Ibrahem El said

Lecturer of AnesthesiaZagazig university

Balanced anesthesia = narcosis loss of consciousness+ amnesia loss of memory +analgesia loss of pain+ relaxation loss of ms. toneAnesthetic management

Preoperative management Intraoperative management Postoperative management

Preoperative management

A. Preoperative History Examination Investigation Premedication

A. Intraoperative Monitoring Position Choice of anesthesia Induction Maintenance Fluids Extubation and recovery

A. Postoperative Transfer to ward or ICU Pain management Postoperative complication

Preoperative managment

History Preop. Visits + written preoperative

noteHistory of current diseaseOther Diseases ( HPT . DM ....Drugs NSAI & Aspirin ,Anticoagulants,

Steroids, Oral contraceptive pill, Magnesium

Previous anesthesia historyProblems intra /or postoperative.Anesthetic record.

Family historyHereditary diseases. Anesthetic history.

Last oral intake

Special habits Smoking

Vascular disease of peripheral, coronary and cerebral circulation

lung carcinoma. Effect of nicotine ..tachycardia and

HPT Increase in CO hemoglobin

decrease O2 delivery to the tissues. Six fold increase in postoperative

respiratory morbidity Should be stopped 6 weeks or at

least 12 hrs before surgery

Examination A full medical examination primarily by the

surgeon and documented in the patient recordThe anesthesiologist emphasize on cardiovascular,

respiratory and airway examination in addition to other relevant finding.

General examination Nutritional state Fluid balance. Skin and mucus m.(anemia –perfusion-jaundice ) Temperature

Cardiovascular exam. Dyspnoea, fatigue, chest

pain. Pulse :rate, rhythm,

volume Neck veins Blood pr. Heart sounds L.L edema

Respiratory exam. Cyanosis ( peripheral

or central). Cough Tachypnoea Tracheal shift Auscultation of all the

lung fields

Nervous system Documentation of the level of consciousness Documentation of any cranial or peripheral

nerve lesions Skeletal system Documentation of any sk. Ms. dysfunction or

syndromes Airway examination Teeth exam. ( dentures, loose teeth,

protruding upper incisors) Prediction of difficult airway (for ventilation

or ET intubation)

ASA rating ASA rating Description of patient Mortality

(%)

Class I A normally healthy patient. 0.1Class II A patient with mild systemic disease. 0.3

Class III A patient with moderate systemic disease.

3

Class IV A patient with sever systemic disease. 15

Class V A moribund patient who is not expected to survive 24 h with or without operation.

30

Class VI A brain dead patient.Class E Add as suffix for emergency operation.

Investigation Performing routine tests in all surgical

patients as a screening tool is inefficient, unnecessary, and expensive

Any disease discovered in history and examination fully investigated

Investigation which will not affect decision waste of resources

It is a misconception that routine tests provide medico-legal protection.

Young healthy adult can undergo anesthesia safely without investigation

Every organization decide its guideline Guidelines for testing can maximize the yield

and prevent waste of resource and time Tests should be done, not done, or

considered –may depend on Age bandComplexity of intended surgery;ASA gradeNature of co-morbidity if ASA III.

Eleven tests are considered :1. CBC2. ECG.3. Chest X-ray.4. PT ,PTT ,INR5. urea, creatinine, and electrolytes.6. Random serum glucose7. Urine analysis8. Blood gases.9. Lung function (peak expiratory flow rate, forced

vital capacity, and forced expiratory volume).10.Pregnancy test.11.Sickle cell hemoglobin test.

Premeditations Preop. Drugs before induction

1-5 min for i.v. drugs30 – 60 min for i.m. drugs 60 – 90 min for oral drugs

Benzodiazepines anxiolysis and relief anxietyAnticholinergics antisialagouge + decrease vagal reflexes Antiemetics Nausea and vomitingProphylaxis against aspirationAntihistaminics allergy Opoid analgesia + stress responseOthers anibiotics .. Bronchodilators ..

Intra-perative managment

• Monitoring • Standard monitor = anaesthetist +

ECG + pulse O2 + NIBP +end tidal CO2

• Position supine . Prone . Lateral .....• Choice of anesthesia general ,

regional or combined , local ...• Induction according to the case =

inhalational or intravenous Intravenous

Smooth = routine i.v + ms relaxant +fasting

Rapid sequence induction = full stomach+ succinyle or rocuronium + cricoid pressure.

i.v line + preoxygenation + slow injection

• Inhalational Indication

Young uncooperative Difficult cannulationAirway obstructionDifficult airway

Agent used fluthane or sevofuorane Single breath technique = one vital capacity

with bag filled with fluthane 5 % or sevoflurane 8 %

Breathing with O2 :N2O 70:30 then increase O2 :N2O to 30:70 then Add 0.5 % inhalational every 3 – 5 breath

• Intramuscular • Rectal induction

Maintenance Inhalational maintenance + spontanous

ventilation Relaxant anesthesia + M.V. Fluids table 4/2/1 rule 1: Deficit =Preoperative Fluid Losses

4/2/1 rule X hours of fasting 4/2/1 rule: 4 cc/kg/hr first 10 kg, 2 cc/kg/hr for the second 10 kg 1 cc/kg/hr for every kg above 20.

2: Maintenance = same

4/2/1 rule X hours of operation

3: Anticipated Surgical Fluid Losses

Minimal tissue trauma = 2-4 cc/kg/hr

Moderate tissue trauma = 4-6 cc/kg/hr

Severe tissue trauma = 6-8 cc/kg/hr

4: Unanticipated Fluid Losses

3 cc of crystalloid = 1 cc of blood loss. lap pads = (100-150 cc each)4x4s = (10 cc each).

Deficit + maintenance + loss = ½ in 1st hour , ¼ 2nd hour , ¼ in 3rd hour

•Extubation and recovery Awake extubation is the Role all patient +

full stomach. Deep extubation in Cardiac, asthmatic, CNS

patient.C - Postoperative •Transfer to ward or ICU. •Analgesia.•Manage complications.