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AIRWAY ASSESSMENT

Introduction
Before anaesthetizing or sedating any patient it is important to examine the airway because the airway may obstruct and you
may have to treat the obstruction. Sometimes the airway can be anatomically difficult to manage and such cases need to be
identified. Failure to adequately treat airway obstruction can lead to hypoxia and death, which accounts for up to 30%
of peri-operative deaths due entirely to anesthesia.

Factors that make airway management difficult:


1.

Pathological condition of face and oral cavity

2.

Trauma, burns and radiation to the head and face

3.

Cervical spinal injuries and immobility

4.

Beards, lack of teeth, obesity

Anatomical causes:
Difficulty airway for anatomic reasons (3 key components):
1. The relationship between the size of the tongue and the pharynx
2. The mobility of atlanta-occipital joint
3. The size of the mandible and space for sublingual structures

Three bedside examinations to assess these three factors exist. The first two are most commonly used.
1. Mallampati Classification (alone not entirely predictive of intubation difficulty)
The size of the tongue in relation to the size of the oral cavity is graded by how much the pharynx is obscured by the tongue.
The patient is examined sitting. The head is neutral or slightly extended. The patient opens his mouth as wide as possible.
The tongue is protruded as far as possible. Phonation may help. The assessor classifies the airway according to
which oropharyngeal structures he can see:
Class I

Soft palate, fauces, entire uvula, tonsillar pillars

Class II

Soft palate, fauces, uvula

Class III

Soft palate, base of uvula

Class IV

Soft palate only (uvula not seen)

There is a well recognized relationship between the ability to view faucial pillars, soft palate, uvula and the ease
of laryngoscopy. Patients with a Class I airway will also have a Grade I laryngoscopic view almost 100% of the time and
those with a Class IV airway will have a Grade III or Grade IV laryngoscopic view almost 100% of the time.

Above: Mallampati classification of the upper airway based on


tongue size & pharyngeal structures seen on mouth opening.
Below: The four grades of laryngoscopicview of the laryngeal
aperture.

Limitations of Mallampati Airway Classification:


1. Does not consider cervical spine mobility
2. Does not evaluate mandibular space size
3. Significant inter-observer variability

Atlanto-Occipital (AO) Joint Extension


Successful exposure of the glottic opening requires alignment of the oral, pharyngeal and laryngeal axes (the "sniff' position)
and this is most easily achieved when the neck is moderately flexed on the chest and the head is well extended on the neck.
Normal AOJ extension > 35o.

The patient is asked to extend the neck in the sitting position. Inability to extend the neck sufficiently suggests
that intubation will be difficult.

Figure: shows the head in sniffing poison with the AO joint extended. Provided the
head is sufficiently flexed at the AO joint and the posterior tongue can be
displaced anterior by the laryngoscope, then the glottis should be visualized.

Mandibular Space
This is the space within of arch of mandible, and forms the floor of the mouth. During laryngoscopy the tongue is pushed into
the space by the blade. If the mandible is too small, there will be insufficient room for the tongue to be displaced forward and
the post tongue and epiglottis will obstruct the laryngoscopic view of the glottis.

The size of mandibular space can be estimated by measuring the distance between the thyroid cartilage (or hyoid bone) and
the inside of the chin (mentum). If the thyroid-mental distance of less than 6 cm (or hyoid-mentum distance of less than 3 cm)
then laryngoscopy will be difficult.

The Dental Exam


Teeth can be damaged by the laryngoscope. The anaesthetist should be aware the condition of the patients teeth. There may
be loose, missing or damaged/chipped teeth. Dental prosthesis may also be present, such as crowns, bridges, dentures and
braces. It is important to note if any problem with dentition exists ahead of time, since if it is discovered later, you will not
know if occurred at the time of intubation. Many patients is Hong Kong have severe periodontal disease with poorly secured
loose teeth.

Previous Airway History


The patients medical record should be carefully examined for a history of previous difficulty with airway management.
Make note of previous findings with mask ventilation and with laryngoscopy.

AIRWAY MANAGEMENT
The patient is intubated using a size 7.0 for female, or 8.0 for male, plastic cuffed endotracheal tube, which is tapped to the
face and connected to breathing system (usually a circuit with CO2 absorber).

Endotracheal tube with pink hitch-hiker. Note the cuff (deflated) and pilot balloon
(blue). The syringe is used to inflate the cuff. The tube is disposable and make of
non-allergenic plastic. The double black lines denote the level of the vocal cords.

Short procedures
An endotracheal tube is often unnecessary and the airway can be maintained by (a)
holding a face mask or (b) inserting a laryngeal mask airway. In such cases mechanical
ventilation of the lung is often unnecessary.

Figure: Hand-held clear plastic anaesthetic face mask. Anaesthetist wears protective
gloves. Mask is connected to the anaesthetic breathing system via a filter (blue).

Figure: Classical LMA or laryngeal mask airway (adult size 4). The cuff is inflated and
sits in the patient's pharynx over the laryngeal opening. The classical LMA has been
succeeded by a newer LMA, the ProSeal. The ProSeal has an improved cuff and drain
tube (bougie in-situ) to prevent gastric aspiration.

Rapid sequence intubation


During general anaesthesia the patient is unconscious and losses the protective laryngeal reflexes that prevent food entering
the trachea and lungs (aspiration). In elective cases the patient is starved (nil by mouth) pre-operatively to make sure that
there is no food in the stomach that can be regurgitated and aspirated.

The normal guidelines are 2,6,8 rule for adults and 2,4,6,8 rule for children.
2,6,8 rule

2,4,6,8 rule

2 hours for clear fluid

2 hours for clear fluid

(* carbohydrate drinks help e.g. orange juice)

4 hours for breast milk

6 hours for non-fatty food (e.g. toast with jam)

6 hours for formula milk

8 hours for food with fat (e.g. steak)

8 hours for solid food

Some patients arrive in theatre for anaesthesia with potentially fully stomachs (i.e. emergency surgical cases, bowel
obstruction or pregnancy) or are at higher risk of regurgitation (i.e. hiatus hernia or obesity). In these cases precautions need
to be taken to prevent regurgitation and aspiration. The standard approach when inducing anaesthesia in such cases is to
perform a rapid sequence induction and intubation with the patient lying supine.

Steps
1.

Pre oxygenation of the patient for 3-minutes:


The air in the lungs is replaced with oxygen. If intubation proves difficult the anaesthetist now has more time to solve
the problem before the onset of hypoxia. His time is increased to 5 minutes. (*SpO2 = 100%)

2.

Application of cricoid pressure:


An assistant locates the cricoid ring situated just below the thyroid cartilage. Firm
pressure downwards is applied with the first 3 fingers to the cricoid to occlude the
oesophagus. This prevents regurgitation.

3.

Induction of anaesthesia using rapidly acting drugs:


An induction agent (propofol) followed by suxamethonium are injected. Sleep and
muscle paralysis (heralded by muscle fasciculation) occur within 60 seconds.
Non-depolarizing muscle relaxants tend not to be used because of their slower onset
of action.

4.

Efficient placement of the endotracheal tube with cuff protection:


A cuffed endotracheal tube should be inserted without undue delay. The inflated cuff
prevents subsequent aspiration.

5.

Verifying correct placement before releasing the cricoid pressure:


- Verify that the endotracheal is placed in the treachea, not the bronchus/oesophagus (fatal)
1.

Direct vision

2.

See chest movement

3.

Auscultating bilateral axilla for breath sounds instead of chest to prevent transmitted sound from collataeral
chest leaving bronchial intubation undiagnosed (One lung collapse + V-Q mismatch: lateral lie the patient)

4. Observe end tidal CO2 for 5 expiratory peaks (esophageal intubation could bring 2 peaks)
Acid aspiration prophylaxis
Pregnancy and labour are associated with high levels of acid in the stomach. If this acid is aspirated during induction of
general anaesthesia it can lead to acid aspiration syndrome (Mendelson's syndrome). The lungs are a severely damaged by
the acid and become oedematous. The patient will require intensive care treatment and may die. To reduce the risk
anaesthesia is induced using a rapid sequence technique. Furthermore, the acid in the stomach is neutralized before inducing
anaesthesia. At the Prince of Wales maternity unit 30 ml of 0.3Molar sodium citrate is routinely give to all women just
prior to Caesarean section. Other antacid medications are prescribed at the discression of the anaesthetist. (+/- ranitidine)

Difficult intubation
Patients anatomically difficult to be intubated can be identified by examining the airway pre-operatively. The vocal cords are
difficult, or impossible, to visualize at laryngoscopy. A number of techniques exist to overcome the problem.
1. Bougies
Most difficult to intubate patients can be intubated by use of a bougie which is passed into the larynx first and then the
endotracheal is guided over the bougie into the trachea.
* S.Tang: bend bougie within ET tube and dont get through it [trauma to airway]

2. Laryngoscope
A number of variations on the standard adult MacIntosh laryngoscope are available to help in the difficult patient.

Designs of laryngoscope used for intubating in difficult circumstances:


Far left: classical straight bladed Magill laryngoscope (one of oldest designs)
Centre: McCoy laryngoscope - has a lever & movable tip displace the epiglottis.
Far right: shortened handle of a scope used in obstetrics where pendulous (large)
breasts often make it difficult to position a regular scope.
Also note the right handed MacIntosh blade.

3. Fibre-optic intubation
The availability of fibre-optic scopes and video equipment has revolutionized the anaesthetic approach to difficult intubation.
Awake or asleep, the patient can be intubated either orally or nasally by passing a scope under camera vision through the
vocal cords and then guiding an endotracheal tube over the scope into the trachea. In difficult cases it is best to have the
patient awake so that airway obstruction and hypoxia during the procedure is avoided. The airway of the patient will need
to be anaesthetized with local anaesthetic in order that the patient will tolerate the procedure.

Figure shows a fibre-optic bronchoscope passing through the manikin's nose and into
the trachea. Video picture of the carina and two main bronchi is displayed. In the
real-life situation the nasal passage and upper airway would be anaesthetized with local
anaesthetic. The scope would be passed through an endotracheal tube that could later
be guided into the trachea.

Alternatives to intubation
When difficulty with laryngoscopy arises it is not essential to have the patient intubated. For short procedures a face mask or
laryngeal mask airway can be used to maintain the airway and administer anaesthesia. In more problematic cases one can
perform a tracheostomy under local anaesthesia.

ANAESTHETIC DRUGS
Induction:
Propofol [or thiopentone], fentanyl and muscle relaxant [suxamethonium, atracurium or rocuronium]
Maintenance:
Nitrous oxide [or air], volatile anaesthetic agent [isoflurane or sevoflurane] and increments of opiate and muscle relaxants.
Note that when muscle relaxants are used the patient needs to be ventilated.
Reversal:
The anaesthetic gases are turned off. Muscle relaxation is reversed using neostigmine and atropine. When spontaneous
ventilation returns the patient is extubated.
* Louis Mok: Neostigmine is cholinesterase inhibitor acting on all NMJ but Achs S/E includes bradycardia, so atropine is
competitive antagonist of muscarinic cholinergic receptors (in myocardiocytes!!) to maintain heart rate (but it has faster
onset than neostigmine so patient in reversal firstHR thanback to normal)

From left-to-right: Induction agents / Thiopentone and Propofol. Muscle relaxants / Suxamethonium, Atracurium and
Rocuronium. Opiates / Fentanyl and Morphine. Reversal agents / Neostigmine and Atropine.

Additional information
Thiopentone is thio-barbituate that was first used in the 1930s. It was the first intravenous anaesthetic induction agent to be
used. It is a powder that needs to be dissolved in water. It is injected into a vein and sleep occurs with 1-2 minutes. Induction
with thiopentone is very pleasant, has few side effects and its main disadvantage is a post anaesthetic hangover (compare to
alcohol).
Propofol is a recently introduced intravenous anaesthetic induction agent and has replaced thiopentone. It comes dissolved in
intralipid which accounts for its white or milk like appearance. Unlike thiopentone, it causes little post anaesthetic hangover.
It is also used as an infusion for anaesthetic maintenance (i.e. TIVA or total intravenous anaesthesia).

Suxamethonium is a short acting depolarizing muscle relaxant. It needs to be kept in the fridge to prevent degradation. Its
rapid onset of paralysis makes it useful when rapid paralysis is needed, such as rapid sequence intubations (i.e. when the
patient is at risk of gastric aspiration). Suxamethonium has many undesirable side effects which restrict its use. It causes
muscle fasciculations on injection, muscle pains after use and may cause a number of life threatening conditions such as
hyperkalaemia, prolonged (scoline) apnoea and malignant hyperpyrexia.

Atracurium is a new short acting non-depolarizing muscle relaxant. It needs to be kept in the fridge to prevent degradation. It
has a novel method of deactivation (Hoffman elimination) that does not rely on hepatic or renal elimination.
Rocuronium is also a new short acting non-depolarizing muscle relaxant. It also needs to be kept in the fridge to prevent
degradation. One of the features of a new muscle relaxant drug that the anaesthetist desires is minimal respiratory
(bronchospasm) and cardiovascular (hypotension) side effects. This was a problem with the older drugs like curare,
alcuronium and pancuronium. Rocuronium has minimal side effects and thus its has become very popular.

Fentanyl is a short acting and potent opiate. It acts on "mu" receptors. It is a potent respiratory depressant and should not be
used in the ward setting without proper patient monitoring and supervision.
Morphine is the active ingredient of opium. It is very cheap and provides good analgesia for several hours. It is still the main
drug used to treat severe pain.

Neostigmine is a cholinergic drug used to reverse non-depolarising neuromuscular block. It is the most potent cholinergic
agent available. Cholinergic drugs are also used to treat myasthenia. Neostigmine has a number of unwanted cholinergic
effects which include bradycardia and excessive salivation. Therefore, neostigmine is usually administered with atropine. The
atropine blocks these secondary effects. Ideally neuromuscular block should be monitored using a nerve stimulator. Train of
four (TOF) is a modality most commonly used. Four repeated maximal stimuli, at 0.5 s intervals, are given to assess the
degree of motor block. If muscle relaxation is not fully reversed breathing will be inadequate and airway obstruction and
aspiration may occur post operatively.

Nitrous oxide is an inorganic gas. It is a good analgesia as well anaesthetic in higher concentrations (above 70%). It is
delivered by pipeline or cylinder. It is used with oxygen during general anaesthesia. In obstetrics mixtures of 50:50 nitrous
oxide and oxygen (Entonox) are used to provide pain relief during labour.

Figure: Cylinders of oxygen (black and white) and nitrous oxide (blue). Normally the
anaesthetic machine operates on piped gases. Gas pipelines seen far left (similar
colour coding). The cylinders act as a secondary gas supply. The anaesthetist should
check that the cylinders are full before each new patient.

Isoflurane and sevoflurane are potent anaesthetic vapours. 1-2% is sufficient to


induce anaesthesia. At room temperature they are liquids easily vaporize with low
boiling points (about 50oC). These agents have replaced Ether, chloroform and
halothane.
The two vaporizers contain Sevoflurane (left) and Isoflurane (right). Oxygen and nitrous oxide
/ air are passed through the vaporizer and the liquid anaesthetic vaporizes and enriches the
anaesthetic mixture.

Motor block monitor (Train-of-four):


-

electrodes attached to orbicularis oculi

stimuli at 60mA for 4 times, could be visualized / felt by palm put on muscle

in neurosurgery should suppressed to 0 contraction in 4 firings

in hepatectomy could tolerate 2 contractions

ANAESTHETIC PLANNING
1. Long operations
The anaesthetist must consider the duration of the operation, although this can be difficult to predict. Extent and duration of
surgery plays a major part in determining the type of anaesthetic technique chosen. Remember that the anaesthetist is not
only responsible for providing anaesthesia but is also responsible for the patient's physiological wellbeing. During longer
operations patients become cold, develop fluid and electrolyte deficit, accumulate drugs and develop pressure areas, all of
which need attention.

2. Poor access to the patient


It is very important that the anaesthetist has good access to the airway, intravenous lines and monitoring sites. Usually, this
involves the head, neck and arms. Sometimes, the operation involves the upper part of the body, such thyroid, eye and dental
surgery. In these types of surgery, the anaesthetist's access to the airway and upper limbs is restricted by the surgeons and
sterile field. Hence, he/s must take precautions to secure the endotracheal tube, intravenous lines and patient monitoring
because they may be dislodged during the operation. Re-inserting an endotracheal tube or re-sitting IV lines and patient
monitoring during the operation can be very inconvenient, difficult and hazardous to patients in these types of surgery.
Figure A: Eye operation. The anaesthetic machine, anaesthetist, tubes and monitoring have to be set-up at the foot end of the
operating table. The surgeons sit around the patient's head and use the microscope.
Figure B: Bleeding from the airway. The anaesthetist has to share the airway with the surgeon who is operating inside the
mouth. Anaesthetic access to the patient is limited.

3. Blood loss
The anaesthetist must evaluate potential blood loss during surgery. In addition to blood
grouping the patient, he/s may also have to order blood in case the need to transfuse
arises. The blood bank cannot issue blood products without typing and cross-matching
the patient. The anaesthetist should consider the blood supply of the organs involved
and their potential to bleed. When heavy blood loss is likely (>2 litres) coagulation will
be effected as platelets and clotting factors are reduced. Stored blood is deficient in
platelets and clotting factors. Therefore, platelets (4 units) and fresh frozen plasma (4
units) are also ordered.
Figure: Unit of packed cells (upper left), unit of platelets (upper right) and units of
fresh frozen plasma (frozen - lower left & thawed - defrosted right).

4. Distention of body cavities with gas


Laparoscopic surgery involves the insufflation of gas (carbon dioxide) into a body cavity, usually the abdominal cavity. The
gas distends the cavity and improves the view of internal organs. However, abdominal distention adversely effects the
circulation and lung ventilation. These effects become a concern in very fragile (babies & the elderly) and sick patients.

5. Post operative respiratory failure


Operations that involve the upper abdomen and the thorax result in injury to the muscles of respiration (i.e. abdominal,
intercostal & diaphragm) and sometimes the lungs. This results in post operative pain and inhibits respiratory muscle
movement. If lung function is already limited due to pre-existing lung disease, there is a high risk of post operative
complications including infection and respiratory failure. The anaesthetist should be aware of the possibility and take
appropriate measures. In moderate risk cases good quality pain relief (i.e. IV PCA or epidural infusion) and close attention to
post operative respiratory function (i.e. chest physiotherapy) should be sufficient. However, in high risk cases admission to
the intensive care unit with a period of post operative ventilation is needed.

6. Renal failure
For any major surgical procedure acute renal failure is always a risk, especially if pre-existing renal impairment is present.
Therefore, renal function should be assessed preoperatively and urine output measured hourly intra-operatively. The patient
should be catheterized. Patients are at high risk of renal failure if their surgery is associated with prolonged hypotension,
interference with the renal blood supply (aortic surgery) or circulating toxins (sepsis, bilirubin, free haemoglobin and some
antibiotics).

7. Temperature regulation
The development of hypothermia is of concern during any long operation. Hypothermia delays recovery and causes stress as
energy stores are depleted to generate heat. This may lead to hypoglycaemia, particularly in babies, as liver glycogen stores
are easily exhausted. Some groups of patients are at high risk of developing hypothermia, such as babies, the elderly and
those with large areas of moist exposed skin (burns) or viscera.
Example: Operation to remove the uterus and ovaries. The intestines (viscera) are exposed to cold and evaporation. This
resulted in the patient's temperature decreasing intra-operatively for 37.0 to 34.5 C.

Special equipment
Some types of operation require specialized equipment, such as microscopes, X-ray machines, operating robots and
specialized operating tables. This equipment can be bulky and place additional space limitations on the anaesthetist and
his/her access to the patient.
Figure: The operating robot in theatre 10. The patient is a small child who is hidden under the green-brown surgical drape.
Note the positions of the operating table (left) and the anaesthetic machine (right). The anaesthetist has to cope with the
presence of this sizable piece of operating equipment (far left: stand and multiple arms). Access to the patient is reduced.
Advanced planning of the anaesthetic set up is needed to prevent mistakes.

ANAESTHETIST PATIENT INTERVIEW


Introduction
The pre-operative anaesthetic interview provides an opportunity for the anaesthetist to build up a professional relationship
with the patient, the importance of which should not be underestimated.

Specific risks
It is important medico-legally that the patient is informed about the common complication that may arise during the
anaesthetic such as damage to teeth and exposure to blood transfusion. These are covered in by the anaesthetic consent form.
Additional risks related to the medical condition may also need to be discussed.

Intensive care
Following major surgery patients are often sent to the intensive care unit. This can be a frightening experience especially if
the patient wakes up to find that he/she is unexpectedly intubated and ventilated. Therefore, one should warn the patient in
advance of such experiences.

Choice technique
Certain operations (i.e. Caesarean section and transurethral resection of prostate) can be performed under both regional and
general anaesthesia. The anaesthetist should discuss the merits of each method with the patient.

Explanations
Occasionally the anaesthetic involves a new or unusual procedure such as anaesthetizing the nose for awake fibre-optic
intubation or injecting into the axilla or shoulder for a brachial plexus block. The patient may be surprised by such
procedures. The anaesthetist may also need the patient's co-operation. One should discuss the procedure with the patient.

Fears and worries


Many patients have concerns about the anaesthetic. They may have a friend or relative that has died or been aware during a
previous anaesthetic. Such fears need to be talked through with the patient and the patient reassured.

Figure: Section F provides a summary of what the patient should be told about the anaesthetic and its risks.

ASA CLASSIFICATION
ASA status refers to the American Society of Anesthesiologists physical status classification. It is a score of 1 to 4 that
provides a general appraisal of physical health and anaesthetic risk. It provides a universally accept method of classifying
anaesthetic risk.

*DC Chung: The classification is not very predictive to anaesthetic risk but reflects that the anaesthetist had completely
appraised patients medical history.

ASA Physical Status Classification System


ASA 1 A normal healthy patient
ASA 2 A patient with mild systemic disease
ASA 3 A patient with severe systemic disease
ASA 4 A patient with severe systemic disease that is a constant threat to life
ASA 5* A moribund patient who is not expected to survive without the operation
ASA 6* A declared brain-dead patient whose organs are being removed for donor purposes
* Additional categories added since June 2005
# Add an E behind the class to indicate emergency, e.g. ASA class 1E

Examples of different ASA scores:


ASA 1

A final year medical student with past good health admitted for a knee arthroscopy following an injury whilst
playing football.
A 35-year old secretary with past good health admitted for an emergency laparoscopic appendectomy. She has a
two day history of abdominal pain.

ASA 2

A 45-year old school teacher admitted for a total abdominal hysterectomy for uterine fibroids. She is a type 2
diabetic controlled by oral hypoglycaemic drugs and diet. She has been a diabetic for several years and has no
major complications from her disease.
A 27-year old business man admitted for removal of nasal polyps. He has allergic rhinitis and bronchial asthma,
for which he takes regular beconase (steroid) and ventolin inhalers.

ASA 3

A 75-year old man admitted for a transurethral resection (TURP) following an episode of acute retention of urine,
due to benign prostatic hypertrophy (BPH). He has severe chronic bronchitis and is limited to walking only 100
yards on the flat before he has to stop to regain his breath. He has had numerous hospital admissions for his chest.
A middle-aged insulin dependant diabetic admitted for an eye operation procedure. The patient is known to have
significant renal dysfunction with high creatinine levels and she is CAPD.

ASA 4

A 60 year old woman needs a laparotomy of acute lower abdomen pain. She has known mitral valve disease and
here exercise tolerance is limited to walk a few yards on the flat. She is on multiple heart medications and
regularly attends the outpatient clinic. On examination she is visibly short of breath and her legs up to the ankles
are swollen.

ASA 5

92-year old demented woman is admitted with a ruptured aortic aneurysm. She is hypotensive and struggling to
breathe.

ASSESSMENT OF CLOTTING MECHANISMS


Described simply, the clotting mechanism is triggered by injury to blood vessels which releases tissue factor. Tissue factor
activates platelets which adhere to the injured vessel wall. Platelets aggregate to form a plug that stops the bleeding. Tissue
factor also triggers the clotting cascade. There are two pathways. The intrinsic pathway triggered by surface contact and the
extrinsic pathway triggered by vascular injury. Both pathways feed into a common pathway (prothrombin & fibrinogen)
which forms fibrin and a more permanent blood clot. Finally there are mechanisms that modulate clot formation (natural
inhibitors) and breakdown clots (fibrinolysis and plasmin).

The integrity of this clotting process is vitally important during surgery, as impaired clotting leads to excessive
intra-operative blood loss and post-operative haematoma formation with poor wound healing. Good surgical haemostasis
depends on both platelets and clotting factors. Haemostais can be deranged for several reasons. Pre-operatively, the patient
may have a low platelet count (<50x109/L) or be deficient in clotting factors. Liver disease and obstructive jaundice are
common causes of the latter because most clotting factors are synthesized in the liver and some require vitamin K. The
patient may also be on anticoagulant treatment (i.e. warfarin, heparin or aspirin). Intra-operatively platelets and clotting
factors can be either lost (surgical bleeding) or used up (ongoing clot formation). They are not replaced by giving
blood/packed cells (unless fresh whole blood is used). Therefore, one needs to consider giving platelet concentrate and fresh
frozen plasma when surgical blood loss is excessive (>2L or 4 units packed cells).

The most common reasons for anticoagulating a patient are (1)prosthetic heart valves, (2)non-rheumatic atrial fibrillation
and (3)venous thromboembolism. Coumarins or warfarin are generally used. Warfarin inhibits vitamin K and the synthesis
of the extrinsic pathway clotting factors II, VII, IX and X. The integrity of this pathway is assessed by measuring the
prothrombin time (PT). As results form different laboratories vary, a normalized valve is use, the INR (International
normalized ratio). The normal INR is approximately 1.0. The aim of warfarin therapy is to maintain the INR between 2.0 to
3.0. (An INR above 5.0 is dangerously high and may lead to haemorrhagic stroke or internal bleeding). During surgery the
INR needs to be lower, less than 1.5. Regional anaesthetic techniques such as spinal, epidural and brachial block are
contra-indicated in the anticoagulated patient because of the risk of haematoma formation at the site of needle puncture.

In most anticoagulated patients the warfarin can be stopped for 4-5 days before surgery and the INR will decrease to a
safe level (<1.5). If time is an issue, vitamin K can be given which will reduce the INR to a safe level within 24-36h. In very
urgent situations fresh frozen plasma can be given to increase circulating clotting factors.

If anticoagulation is still required perioperatively heparin can be used to anticoagulate the patient. The effects of heparin can
be easily reversed by protamine. Heparin acts on the intrinsic clotting pathway. Its effect on coagulation is assessed by the
activated partial thromboplastin time (APTT). One should aim to increase the APTT by 1.5 to 2.0 times.

In summary, the most important tests of coagulation in the ward setting are the PT (and INR), APTT and platelet count.
However, other tests do exist.

Other tests:
The bleeding time requires an inflated cuff on the upper arm. A small 1 cm long by 1 mm deep cut is made on the forearm
which bleeds. The time for the incision to stop bleeding is measured (<5 min). If the bleeding time is prolonged, causes are; a
blood vessel abnormality, platelet function defect or thrombocytopenia.

The activated clotting time (ACT) is a bedside test of the intrinsic pathway. It is a simplified APTT and used to assess
heparin therapy during cardiac bypass. A venous blood sample is placed in glass tube and time for the blood to clot is
measured.
Figure(Left): Activated clloting time machine. Blood samples are placed in the two curvettes.

Thromboelastography (TEG) is used to measure the characteristics of blood clot formation. A venous blood is placed in a
small plastic cuvette (cup). A plastic pin is inserted into the blood sample. The pin rotates clockwise-and-anticlockwise by
105 degrees. As the blood clots the movement of the pin is restricted. This creates a cigar like plot against time from which
clotting is assessed.
Figure(Right): The output from the Thromboelastogram (TEG).

Other tests of haemostatis also exist. The thromboplastin time, heparin neutralized thrombin time and factor VIII and
IX levels look at specific problems with coagulation. Fibrinogen degradation products (FDPs) and D-dimers are used to
investigate fibrinolysis, such as occurs in disseminated intravascular coagulation (DIC).

CHOICE OF ANAESTHETIC
Local infiltration
The infiltration of local is reserved for localized surgical procedures, such as small skin lesions, tracheostomy and a burr hole
to evacuate a chronic subdural haematoma. Local anaesthetics tend not to work in the presence of infection.
General anaesthesia

Nearly all operations can be performed under general anaesthesia. The question is whether general anaesthesia is the most
appropriate method and whether it should be supplemented by an additional regional technique, i.e. epidural (thus reducing
the amount of general anaesthetic drugs needed).

Regional anaesthesia
Operations that are confined to a limited or peripheral part of body (i.e. tooth, eye, hand, arm or leg) can usually be
performed under local anaesthetic block. Spinal anaesthesia can be used for most operations involving the lower half of the
body. However, regional techniques involving the spine are contra-indicated when coagulation is impaired or infection is
present.

General plus regional


The addition of a regional block (i.e. epidural) to general anaesthesia reduces the amount of opiate and volatile agent required
to anaesthetize a patient. This is advantageous in long operations as post operative recovery better. The block also improves
surgical access, reduces blood loss and provides excellent post operative pain relief.

TIVA
General anaesthesia (i.e. inhalational based) is not the best method for anaesthetizing patients with intracranial pathology.
Anaesthesia based on infusions of propofol and remifentanil (Total intravenous anaesthesia (TIVA)) proved better
intracranial conditions. TIVA is also very applicable to other types of surgery and is becoming more popular.

COMPLICATIONS OF CENTRAL NEURAL BLOCK


The complications of central neural block can be divided into those relating to:
1.

The procedure

2.

The local anaesthetic agent

3.

The physiological consequences of the block

These complications will be dealt with in frequency that they occur:

1. Failed block
-

Sometimes surgery cannot proceed

Usual cause is failure to deliver sufficient local anaesthetic to the intended site. Either the local anaesthetic has been
injected into the wrong place, which can be for a number of anatomical or technical reasons, or more rarely the
patient is resistant to anaesthetic drugs.

The block can either be repeated or general anaesthesia is used instead

2. Cardiovascular effects
-

Physiology:
Both spinal and epidural block cause blockade of the autonomic nervous system. Depending on the extent of
proximal spread of the local anaesthetic (i.e. the height of block), the sympathetic reflexes that maintain the circulation
are paralyzed to greater or lesser extent. Blockade of these neural reflexes leads to hypotension via peripheral
resistance (arterial vasoconstriction) and cardiac output (venous return byvenoconstriction).

Organ Perfusion:
If hypotensive, perfusion of vital organs will be impaired with the risk of stroke, myocardial infarction and
cardiac arrest. The risk is greater in patients with arterial disease (i.e. hypertension), as higher than normal blood
pressure is required to perfuse vital organs (i.e. the heart and the cerebral circulations).

Heart rate not:


The normal physiological response to a fall in circulating blood volume or blood pressure is to increase heart rate,
thus increasing cardiac output. However, in central neural block the sympathetic pathways that increase heart rate and
contractility are blocked (i.e. cardio-acceleratory nerves) and unopposed parasympathetic activity (i.e. the vagus) may
further slow heart rate. This further aggravates the low cardiac output and blood pressure state, resulting in further
reduced organ perfusion.

Treatment:
To give IV fluid volume, either just before (i.e. preloading the circulation) or during the onset of the block. The fluid
expansion counteracts the venodilation of venous capacitance vessels and additional fluid serves to push up the
cardiac output.

Usually 500 to 1000ml of crystalloid fluid are given


intravenously. If blood pressure continues to fall despite giving
adequate fluids, a vasopressor drug is given to increase the
preload (i.e. alpha effects: venoconstrictionCO) and heart rate
(i.e. beta effect on the heart), but also to increase the peripheral resistance (alpha effects: arterial vasoconstriction).

Commonly used vasopressor agents are:


1.

Ephedrine 3-6mg i.v. voluses Q3-5min as needed, and if ephedrine fails to be effective.

2.

Phenylephrine 10mcg (a more potent pure alpha vasoconstrictor, needs to be given in small increments to
avoid excessive rises in blood pressure.)

3.

Atropine 0.2-0.6mg (vagal block effect (parasympathetic on heart) heart rate CO & BP)

Phenylephrine is a very potent vasoconstrictor and can potentially cause severe hypertension in excessive doses. It
needs to be diluted and used in small increments, thus one titrates the dose against blood pressure response

Cultural Note: Ephedrine has been used to treat low blood pressure during spinal block since its
discovery in the 1920's. Ephedrine comes from a very commonly used Chinese herbal
medicine, Ma Huang or yellow weed. It is used to treat upper respiratory conditions such
as asthma, and is the active ingredient in many over the counter Traditional Chinese Medicine
formulations. It also forms the active ingredient in many over the counter upper respiratory and
nasal Western medications.

3. Post Dural Puncture Headache (PDPH)


Aetiology & Symptoms:
-

PDPH can occur after both spinal and epidural block.


-

Spinal block: CSF leakage via the spinal puncture hole in dural sac. (Normally the puncture hole seals itself.)

Epidural block: Inadvertent dural sac puncture during epidural catheter placement using Tuohy needle (a larger hole)

PDPH presents with severe frontal and occipital headache, unlike any headache that the patient has experienced before.
The headache is made worst by sitting, standing or straining (i.e. cough, using the toilet). The patient also has
photophobia. It can be very disabling, especially in postpartum patients starting to bond with newborn.

Prevention and Treatment:


-

Using a fine bore (25 / 27 gauge) pencil point needle in spinal block

Young adults are at greater risk than the elderly. The incidence rate is
less than 1-2%. (lower in experienced hands)

Careful needle insertion must always be practiced to avoid dural


puncture when locating the epidural space.

The incidence of post spinal headache (PDPH) is reduced by using


small gauge pencil point spinal needles (i.e. 25 gauge Whitacre)

Treatment (PROMPT!!): Blood Patch


1.

The patient needs a clear explanation of what has happened.

2.

Bed rest and good hydration in a darkened room may be all that is needed, and the condition may resolve (i.e. hole closes)
within 24-hours.

3.

If PDPH does not resolve spontaneously, it should be treated with a blood patch. There is a small risk of developing a
subdural haematoma due to the low CSF pressure if the PDPH is not treated promptly.
Blood patch involves taking 10ml of the patient's venous blood and injecting it via a Tuohy (i.e. epidural) needle
into the epidural space. The blood will form a clot that closes the puncture hole and prevents further CSF leak. The
headache is said resolve as soon as the blood is injected. Great care must be taken not to introduce any infection into the
epidural space, and full sterile precautions are needed in the taking and injecting procedures.

4. Neurological Damage: Nerve injury, neurotoxicity, infection


-

The worst complication of is permanent neurological loss and paraplegia. The incidence is less than 1 in 10,000.

Neurological deficit can range from foot drop and bladder incontinence to dense paraplegia of the lower limbs.

The major causes are:

1.

Needle injury

2.

Neurotoxicity of injectate

3.

Haematoma formation in spinal canal

4.

Infection

Careful neurological examination and documentation is essential in all cases of suspected neurological damage for
follow up and medico-legal reasons.

NERVE INJURY
-

Spinal puncture must be performed below L1-L2 level (where spinal cord ends). Or the spinal cord can be traumatized
and once damaged there is usually little recovery.

If the patient reports any discomfort or sudden pain when inserting a spinal needle or injecting anaesthetic, the
procedure must be stopped immediately to prevent any further neurological damage. (So keep the patient awake during
procedure to report any discomfort or sudden pain)

In some obstetric cases where a spinal needle was inserted at a high spinal level (T12-L1) that resulted in cauda equina
syndrome (i.e. neurological deficit in the legs and bladder dysfunction). MRI with contrast showed an area of loss
contrast within the spinal cord due to cyst formation (i.e. a conus) from needle trauma.

Thoracic Epidurals: guidelines, reports of paraplegia following epidurals performed in the thoracic region.
Every thoracic epidural should to be fully justified and patients should be awake (not anaesthetized) during the
procedure, so that they can report any discomfort.
Unsuccessful attempts were made to insert a
thoracic epidural in an anesthetised patient.
Signs of spinal cord damage were observed
the following day. MRI demonstrated a
hematoma anterior to the spinal cord.
Surgical exploration revealed an intradural
hematoma and a needle puncture of the cord.
The patient suffered a permanent paraparesis.

NEUROTOXICITY
-

All local anaesthetic agents at high concentrations are toxic to nerves. There was period of 25-year in Britain (1950s to
1970s) when spinal block was seldom performed, after a series of high profile cases of paraplegia following spinal
block (n.b. the most famous was the Woolley and Roe case).

Intrathecal lignocaine (and many older spinal anaesthetic agents) caused transitory neurological symptoms (i.e. a burn
pain in the legs and back with possibly numbness) in a high percentage of patients (i.e. <30%).

The present spinal agent, Heavy Marcain (i.e. bupivacaine 0.5% in dextrose 8%), does not associated with any
neurotoxicity, or transitory symptoms.

Intrathecal use of newer LA (e.g. ropivacaine), fentanyl, clonidine and neostigmine was not fully assessed for
neurotoxic potential.
Albert

Wooley

and

Cecil

Roe

were

healthy

middle-aged men who became paraplegic after spinal


anaesthesia for minor surgery at the Chesterfield
Royal Hospital in 1947. The spinal anaesthetics were
given by the same anaesthetist (Dr Malcolm Graham)
using the same drug on the same day at the same
hospital

Published data regarding the safety other drugs injected intrathecally

Hodgson. Reg Anesth Pain Med. 1999;.88.797 (review)

Class

Drug

Experimental data

Intrathecal use

Opioids

Morphine

Extensive laboratory & clinical studies

Safe

Fentanyl
2 agonist

Clonidine

Extensive studies

Safe

Acetylcholine

Neostigmine

Limited data

Probably safe

GABA agonist

Midazolam

Conflicting results

Controversial

Baclofen
NMDA antagonist

Probably safe

Ketamine

Lijmited data

Probably safe

Amitriptyline

Needs further Ix

Best avoided

NSAIDs

NSAIDs

Needs further Ix

Best avoided

Steroids

Steroids

Lack of objective evidence regarding safety

Best avoided

Adjuvants

Adrenaline

No evidence of neurotoxicity

Safe

Phenylephrine

Poorly studied

Probably safe

Glucose

Used clinically, no evidence neurotoxicity

Safe

Antioxidants

Despite

Preservatives

preparations, most seem safe for human use

concerns

regarding

past

Excipients

HEMATOMA FORMATION
-

Spinal puncture or epidural catheter insertion bleeding into the spinal canal presses on the spinal cord & paraplegia

Urgent MRI/CT (to confirm diagnosis: grey lesion) + surgical spinal cord decompression (laminectomy)

Any patient that presents with increasing back pain and lower limb numbness / weakness following a spinal or epidural
block needs to be fully investigated.

Epidural haematoma is uncommon in adult (i.e. incidence < 1 in 10,000).

High risk medications:


1.

On anticoagulant therapy (i.e. Warfarin or Heparin infusion) [Stop LMWH 8 hours before spinal block]

2.

On drugs with anti-platelet effects (i.e. aspirin or NSAIDs) [The current consensus is for spinal block to be allowed in
patients on aspirin and NSAIDs.]

* Check the PT (INR) and APTT for evidence of impaired clotting. Avoid central neural
block when INR > 1.5. (Warfarin INR <1.5!!)

MRI SCAN OF EPIDURAL HAEMATOMA

INFECTION Epidural abscess / meningitis


Epidural abscess:
-

Staphylococcus

Epidural abscess esp. in prolonged catheter use.

If left in-situ for several weeks tunnel the catheter under skin so the skin exit point is not over the spine

Meningitis
-

Nasal streptococcus

Droplet spread from the nose and oral cavity of attendant anaesthetists droplet contamination of equipment used
for spinal puncture low grade CSF infection +/- obstetric deaths

Operator should always wears full personal protection equipment (PPE) (i.e. face mask, hat, gloves and gown)

79 reported cases of post-dural puncture meningitis reviews: aerosolized mouth commensals from medical personnel,
contamination by skin bacteria, directly/haematogenously from endogenous infection site

As the technique (i.e. use of needle & catheter), the site of injection and volume of local anaesthetic used differ between

spinal and epidural block, their complications also differ.

INTRA-OPERATIVE MONITORING
Routine monitoring
The routine standard of care for general anaesthesia in Hong Kong includes:
1.

Monitoring of anaesthetic gases and the ventilator function,

2.

Continuous E.C.G.,

3.

Non-invasive blood pressure every 3-5 minutes,

4.

Pulse oximetry,

5.

End-tidal CO2,

6.

Body temperature and,

7.

Neuromuscular block (optional): The motor block monitor is connected to the patient by two electrodes placed over the
ulnar nerve at the wrist. Other sites can be used. The nerve is electrically stimulated and the degree of motor is assessed
by the response to stimulation of the intrinsic muscles of the hand.

Urine output
The bladder should be catheterized in all major cases. Catheterization prevents over filling of the bladder which can lead to
dysfunction post operatively. It also allows urine output recording. Hourly output is measured when there is a risk of renal
failure such as pre-existing renal impairment, sepsis, jaundice, hypovolaemia or circulatory shock. Measures can then be
taken to improve the urine output and preserve renal function.

Arterial blood pressure


Catheterization of the radial artery with a 20 gauge (pink) catheter allows arterial blood pressure to be measured directly on a
beat-to-beat basis. This is useful in very sick patients or cases where acute changes in blood pressure are expected. Sudden
changes in blood pressure may be missed by conventional non-invasive measurements taken at 3-minute intervals. The
arterial line also allows arterial blood to be easily sampled for blood gas analysis, etc.
.
Figure: 20-gauge (pink) cannula inserted into the left radial artery at the wrist. Most commonly used site. The cannula is
attached to an extension set that is connected to a pressure transducer. Arterial pressure is
displayed as a continuous waveform

Central venous pressure


Catheterization of the right internal jugular vein with a central venous catheter allows central venous pressure (CVP) to be
measured which provides a guide to the volume status of the patient. This is useful in patients who may sustain a significant
fluid or blood loss during an operation or patients who have poor cardiovascular function. The central line is also useful for
infusing drugs and fluids.
Figure: Triple lumen central venous catheter inserted into the right internal jugular vein. Mid-neck approached used. The
puncture site is draped and the catheter sutured to the skin for security. Note the prominent external jugular vein.

Tranoesophageal echocardiography
Tranoesophageal echocardiography or TOE is not routinely used in the operating theatre because the equipment is bulky, the
probe has to be inserted into the oesphagus and training is needed to interpret the ultrasound picture. TOE is most useful in
patients with poor cardiac function, such as those having open heart surgery.
Figure: The flexible probe of the transoesophageal echo, or TOE, is pasted 30 cm into the mouth of the unconscious patient,
so that the imaging probe lies just behind the heart. The screen and machine are seen in the background. The operator has
visulised the four chambers of the heart.

Bispectral index
The bispectral index or BIS is a type of cerebral function monitor that measures depth of anaesthesia. BIS measurements
range from 0-100%. BIS is used mainly with TIVA (total intravenous anaesthesia).
Figure shows the Bispectral Index (BIS) monitor which measures brain activity via the frontal EEG (note electrode montage upper) and converts it to index that represents depth of anaesthesia (lower).

HYPOKALAEMIA
Physiology
Potassium is the predominant intracellular cation (98%) at a cellular concentration of 150 mEq/L, whereas sodium is the
predominant extracellular cation. The concentration of potassium in the serum (extracellular) is much lower, 3.5 - 4.0 mEq/L.
In a 70 kg man the intracellular potassium accounts for 3500 mEq, whereas the extracellular accounts for just 70 mEq.

Potassium plays an important role in membrane physiology and in particular the activity of muscles and nerves. Potassium
imbalance has significant cerebral, cardiovascular and motor effects.

Input / output
The normal dietary intake of potassium is 50-200 mEq/24h. Excess potassium is excreted by the kidneys (30-150 mEq/24h),
with a small amount being lost from the gut and skin. Kidney excretion of potassium is controlled by aldosterone.

Certain situations can lead to potassium depletion, such as poor dietary intake, diarrhea and vomiting and chronic loss from
the kidneys due to diuretic medications.

Relationship between serum potassium concentration and


changes in total body potassium content.

Treatment
Replacement of potassium deficit may take several days because of the large intracellular volume (3500 mEq in a 70kg man).
Potassium can be given orally, but replacement will be slow and take many days. Intravenously, potassium chloride
(2mEq/ml) is used. This is highly osmotic and irritant solution that has to be given slowly via a large vein. Normally 20 mEq
of KCl is dissolved in 100-500 ml of crystalloid. The maximum rate of infusion is 0.5 mEq/kg/h or 35 mEq/h for a 70 kg man.
Total correction may take several days.

However, once the deficit is corrected, the serum potassium rises much more quickly and hyperkalaemia ensues (see figure).
This has a very important implication on treating hypokalaemia: The potassium should not be replaced to rapidly. It is
serum level of potassium rather than the body deficit that is most important.

The serum potassium reflects the intracellular pool. However, a number of other factors also effect the balance between intra
and extra-cellular levels. These include the acid-base balance, insulin and catecholamines.

ROUTINE LABORATORY INVESTIGATIONS


List of laboratory investigation routinely ordered before surgery:
1.

Complete blood count

2.

Urea and electrolytes

3.

Random blood glucose

4.

Chest X-ray

5.

12-lead E.C.G.

6.

Coagulation screen

7.

Blood sample for transfusion service

(This list should be memorized)

Complete blood count


Preoperative patients usually have their blood count checked. The haemoglobin (or equivalent) provides a baseline for blood
transfusion, as well as screening for anaemia. The blood count also screens for white cell and platelet abnormalities. Healthy
young adults admitted for minor procedures, unless female with heavy periods (menstruation), do not require a blood count.

Urea and electrolytes


Preoperative patients usually have their urea and electrolytes checked. This screens the patient for renal impairment and
electrolyte anomalies. Healthy young adults admitted for minor procedures are very unlikely to have an abnormal test and do
not require a urea and electrolytes.

Random blood glucose


The random blood glucose screens for the patient for diabetes. If raised, the patient will need peri-operative 6-hrly blood
glucose monitoring, a dextrose-insulin-potassium infusion regimen if glucose levels remain high, and a medical referral.
However, if the admission urinalysis is negative and there is no other indication, the patient does not require a random blood
glucose test. (See notes on Diabetes)

Chest X-ray
Routine chest X-ray examination is not necessary in all patients. Its values is to screen the patient for pulmonary (i.e.
tuberculosis and malignancy) and cardiac disease (i.e. enlargement of the heart, valve defects and pulmonary oedema). The
anaesthetist may use the chest X-ray to assess the trachea, the thoracic inlet and the cervical spine (i.e. before insertion of an
endobronchial tube, thyroid surgery and trauma cases). The chest X-ray also provides a reference for post operative care (i.e.
intensive care admission). Healthy young adults admitted for minor procedures are very unlikely to have pulmonary
pathology and do not require a routine chest X-ray.

E.C.G.
Routine E.C.G examination is not necessary in all patients. Its value is to screen for undiagnosed heart disease (i.e. rhythm
abnormalities, heart block, ischemia, old infarcts and hypertension). The E.C.G also provides a baseline for any post
operative cardiac problems. Healthy young adults admitted for minor procedures do not require an E.C.G.

Coagulation profile
Routing coagulation screening is not necessary in most patients. The screen includes the prothrombin time (PT), also
expressed as an international normalized ratio or INR, and the activated partial thromboplastin time (APTT) which measured

the integrity of coagulation. The platelet count is part of the full blood count. Patients having epidural or spinal procedures
require a coagulation screen because of the risk of spinal canal haematoma. Patients with cirrhosis, obstructive jaundice,
sepsis or pre-eclapsia and those on heparin or warfarin are likely to have abnormal clotting and require a coagulation screen.

Transfusion
Routine blood group typing (and serum saved) is required in all surgical patients where significant blood loss requiring
transfusion is a possibility. Blood should be cross matched when there is a high likelihood of blood transfusion. When
massive (over 4 units) blood transfusion is anticipated clotting factors (fresh frozen plasma) and platelets should also be
ordered. Usually 4 units of each are ordered.
Figure: Unit of type A blood / packed cells being given via Y connector pump set and warming coil into the patient's left arm.
Figure: Unit of packed cells (upper left), unit of platelets (upper right) and units of fresh frozen plasma (frozen - lower left &
thawed - defrosted right). Below is oscillating water-bath use to defrost the fresh frozen plasma.

Predicted blood loss and pre-operative order from blood bank:


Expected blood loss during surgery Need for blood transfusion Risk of coagulopathy Pre operative order sent to blood bank

None

Omitted

Some

Group (& save)

Moderated (<1 L)

Possibly

2-units packed cells

Severe (+2 L)

Definitely

Possibly

4-units packed cells

Massive (+1-blood volume)

Major blood loss

Yes

8 units blood plus FFP and platelets

NON-ROUTINE LABORATORY INVESTIGATIONS


Blood gases
Arterial blood gases analysis provides information on gases exchange in the lungs and acid bases status. It is reserved for
cases where there is lung disease or the patient is acutely ill.

Liver function: They indicate liver damage and help to differentiate between the causes of jaundice.
Amylase: The serum amylase is raised when the pancreas is injured.
Endocrine function: There are a number of endocrine tests that assess adrenal, pituitary and thyroid function.

Lung spirometry
Operations that involve the upper abdomen and thorax may affect lung ventilation. The respiratory muscles may be cut and
the lungs bruised from handling during surgery. Post operative breathing is often painful and restricted, leading to
complications and even respiratory failure. Lung spirometry (i.e. FEV1.0, FVC and FEV/FVC) provides an objective
assessment of the respiratory reserved and the risk of post operative respiratory failure. Having assessed lung function,
measures can be taken to prevent or treat post operative respiratory failure.

Echocardiography: In patients being suspected or having underlying heart disease, echocardiography is used to assess the
heart valves and left ventricular function.
Radiological: Further X-rays and scans can assess the airway, cervical spine, thoracic inlet and intracranial pathology.

OPERATING TABLE POSITIONS


Supine
This is the "default position". The arms may be extended on arm boards or by the side of the patient. The supine position
provides excellent surgical access to most parts of the body. The anaesthetist also has excellent access to the airway and
upper limbs. Furthermore, the patient is unlikely to sustain any injury from lying in an awkward position for a prolonged
period of time.
Figure: The patient is supine. The anaesthetic machine is at the head of the operating table
providing excellent anaesthetic access to the patient. The patient is very comfortably
positioned. Note the tourniquet on the left upper arm which is used to control bleeding, as the
left arm requires surgery.

Lithotomy
For operations around the perineum, such as anorectal, gynaecological or urological
procedures, the lithotomy position is used. The patient is supine with the hips are flexed and
the legs supported by stirrups. The anaesthetist still has excellent access to the airway and
upper limbs.

Lateral
Some operations involve a lateral approach and optimum surgical access is achieved by
having the patient lying on their side. To prevent the patient moving straps are commonly
used. The lateral position restricts the anaesthetists access to the airway in particular, so
intubation and insertion of lines are usually performed with the patient supine, before turning
lateral.
Figure: The patient is in a lateral position. An operation on the left thoracic cavity has just
been completed (note dressing). The airway is maintained by a double lumen endobronchial
tube.

Prone
Some operations involve the patients back and surgical access is only achieved by having the
patient lying face down or prone. Anaesthetist has limited access to the airway and ventilation
is impeded. The airway is particularly difficult to access, so a secure endotracheal tube that cannot be easily displaced is
required. The prone position also obstructs chest and abdominal movement making breathing difficult, so the lungs are
usually mechanically ventilated. There is a risk of injury by lying in an awkward position or pressure on the eyes, nerves or
arteries is greater. Intubation and insertion of lines are usually performed with the patient supine, before turning the patient
prone.
Trendelenburgh (head down) [ Louis Mok ]
The operating table can be tilted into variety of positions, head-down (trendelenburgh), head-up (reverse trendelenburgh)
and lateral. Tilting can be very useful in facilitating surgical access. For example, during abdominal surgery putting the
patient head down improves the surgical access to pelvic as the bowel moves proximally. Tilting can also be useful regarding
the circulation. Trendelenburgh restores the circulation by improving venous return to the heart, whereas
reverse-trendelenburgh reduces venous oozing during head and neck surgery.

STANDARD PATIENT SET UP FOR ANAESTHESIA


Patient Monitoring
1.

Anaesthetic gases and the ventilator function.

2.

E.C.G.,

3.

non-invasive blood pressure,

4.

pulse oximetry, (not the BP side)

5.

end-tidal CO2,

6.

temperature and,

7.

neuromuscular block (optional).

Figure: Anaesthetised patient. Note monitoring modalities: ECG lead (1-of-3, left shoulder). Non-invasive blood pressure
cuff right arm. Pulse oximetry probe left thumb. IV cannula inserted dorsum of left hand. Patient identification bracelet left
wrist. End tidal CO2 sampling line proximal to blue breathing filter. No temperature probe/neuromuscular stimulator present.

IV Access
A single 20-gauge (pink), or 18-gauge (green), canula is inserted into the dorsum of hand, or forearm and attached to a simple
JMS giving set used to infuse crystalloid (normal saline or ringers lactate solution).

18-gauge (green) IV cannula inserted

20-gauge (pink) IV cannula inserted

Simple JMS intravenous giving set

in the forearm. Note the one-way-valve

into the dorsum a 4-y-o child. The

connected to a 500 ml bag of normal

and Luer lock connector attaching the

cannula is connected by a fine bore

saline. Note the piercing point used to

cannula to a short extension set with

extension set to a three way tap (blue)

insert into the saline bag, the drip

three way tap (blue).

and 10 ml syringe of saline.

chamber, the flow regulator, rubber


injection port and Luer connector.

PERIOPERATIVE DIABETIC REGIMENS


Traditional management regimens
1.

Scheduling the patient for the first case in the morning,

2.

Stopping the morning insulin / oral hypoglycaemic dose and starting a dextrose 10% infusion. This prevented
hypoglycaemia.

3.

Checking the blood glucose level peri-opertively and giving insulin 10 units intramuscularly if the blood glucose was
too high (+10 mmol/L). This prevented ketoacidosis.

4.

Post operatively, starting the patient back on their normal diet and giving half the regular insulin dose.

Such regimens are still quoted in the older text books of anaesthesia and date back to an era when infusing drugs (i.e. insulin)
and bedside monitoring of blood glucose levels were not easily available. These regimens made anaesthesia safe even if the
control of the blood glucose level was poor.

Modern day management regimens


Modern day practice is to monitor blood glucose levels 4-6 hourly and infusing short-acting soluble insulin.

The DKI regimen consists of a 500 ml bag of Dextrose 10% to which is added insulin (according to a sliding scale regimen
based on the blood glucose measurement) and 10 mmol KCl. The latter also has to be monitored and adjusted. Normally the
infusion is run at 100 ml/h. The concept of having dextrose, insulin and potassium in
the same bag was to protect against giving the insulin too fast (i.e. infusion set at
wrong rate and the whole 500 ml bag is infused in 1 h) or too slow (i.e. the IV site
tissues and no insulin is given for several hours). In North America there is a tendency
to give insulin by syringe pump and the dextrose and potassium separately.

At the PWH we use one single recommended diabetic regimen. This provides extra patient safety because:
1.

Everyone in the hospital is familiar with the same DKI regimen,

2.

The addition of dextrose 10% prevents hypoglycaemia from too much insulin being given.

3.

The added potassium (10 mmol per bag) prevents hypokalaemia as insulin causes extracellular potassium to migrate
into the cells.

Emergency surgical cases


In emergency cases the diabetic control is often unstable with poor glucose control, polyurea, dehydration, electrolyte deficit
and keto-acidosis.

The patient frequently needs to be stabilized / resuscitated before surgery can be scheduled. In severe cases intensive care
admission is needed for fluid resuscitation and insulin administration. Insulin is normally titrated in these situations by
infusion pump. Frequent blood glucose measurements are needed.

In less severe cases the patient's diabetes can be adequately controlled by a DKI drip and 4-6 hourly blood glucose
measurements.

* sometimes the indication to operation could be a cause of poor diabetes control (e.g. wound abscess worsen DM control
requiring surgical debridement and drainage)

POST OPERATIVE NURSING CARE


Recovery
The recovery room can provide one-on-one nursing care for critically ill patients that need close supervision post
operatively. This includes ventilation and cardiovascular support. However, having sick and demanding patients in recovery
is not ideal as it affects the provision of care of other post operative patients and hinders the flow of patients through theatre.
Sometimes patients cannot be transferred from the operating room to recovery because recovery is full and no nursing staff
are available. Ideally patients should stay in recovery no longer than 2-hours and critically patient should be transferred
elsewhere (i.e. intensive care).

General ward
Some patients need ventilation or cardiovascular support post operatively. This requires one to one nursing care by specially
trained nurse. This level of nursing care cannot be provided on the general ward.

High dependency unit (HDU)


It provides patients who need constant supervision, but are not critically ill, a higher level of nursing care. Post operative
patients with problems such as airway obstruction following wiring of jaw for a fractured mandible, difficult medical
management problems such as unstable diabetes or hypotension due to a thoracic epidural are more appropriately managed
on the HDU.

Intensive care
The intensive care unit provides a high level of nursing care that cannot be provided outside the unit. This enables critically
ill patients to receive mechanical ventilation and advance organ support. Not all patients need this level of care post
operatively, especially as intensive care is a very expensive and much sought after facility.

POST OPERATIVE PAIN MANAGEMENT


No pain relief: Minor surgical and investigative procedures are often associated with minimal or no post operative pain.
Paracetamol 1g Q4-6H
For surgical procedures associated with mild pain paracetamol two tablets (500 mg @) Q4-6H provides very good pain relief.
Oral analgesics are particularly useful when the patient is ambulatory and wishes to return home soon after surgery.
* routes: oral, iv, rectal suppository; known as Tylenol in North America

Aspirin tends not to be used because of its potential to cause gastric erosions. Aspirin can be used for its antiplatelet effect in
low doses of 75mg tablets, or in higher doses of 300mg tablets for its analgesic and antipyretic effects. The usual analgesic
dose is 1-2 tablets 6-hourly

Stronger analgesics
For surgical procedures associated with moderate pain more powerful non-opiate analgesics are available, including the
NSAIDs, Dologesic and Tramadol. However, care needs to be taken with the administration of these drugs because of
unwanted side effects. NSAIDs can cause acute renal failure in patients with renal impairment (contraindicated).
* Dologesic = Paracetamol 500mg + phenyltoloxamine 30mg. [Phenyltoloxamine is an antihistamine which promotes the
action of paracetamol.]
* NSAID achieves good pain control, e.g. ketorolac, Voltaren
* Tramadol 50mg po Q6H prn / Tramadol injectable 100mg/ml formulation in the immediate post operative period.
* Tramadol is not an opioid, but acts on mu-receptors, Noradrenaline and Serotin receptors. It was released in 2007.

Mild opiates
Moderate strength opiates such codeine 30mg 6-hourly is useful for more severe pain.

Anti-inflammatory drugs
Sometime an anti-inflammatory drug is chosen such as NSAIDs and COX-2 inhibitors. A variety of choices exist, for
example Brufen and Naproxen. These drugs may be given to a patient following extraction of wisdom (back) teeth or minor
musculo-skeletal surgery to reduce the swelling. NSAIDs have injectable forms such as Ketorolac (30mg IV) and Voltaren
(IM).

Titrated morphine
Titrated IV morphine (morphine protocol) is very useful in controlling acute pain, such as seen in patients recovering from
anaesthesia in the recovery room. Small boluses of 1-2 mg IV are given at 5-10 minute intervals until the pain resolves.
However, the titration has to be carefully supervised by a trained nurse or overdose and respiratory depression (arrest) may
occur. Therefore, this type of pain management is only suitable for the recovery room and specialized units.

IM morphine
Intramuscular morphine given 3-4 hourly on request is the simplest method of prescribing morphine in the ward setting. It is
the traditional method of prescribing post operative morphine. The morphine is released from the injection site over several
hours thus maintaining blood levels. Its main disadvantage is that many patients receive inadequate analgesia because of
delays in administration and release from the injection site.

Morphine infusion
Morphine infusion provides continuous pain relief. However, it is easy to overdose the patient and cause respiratory
depression and arrest. Thus, a high level of nursing supervision is required and the level of sedation, respiratory rate and
blood pressure all need to be regularly checked hourly.

Patient-controlled analgesia (PCA)


Patient control analgesia became possible due to advances in
microprocessor technology. The patient can receive small injections of
intravenous morphine on demand without causing overdose. Thus, the
patient can receive almost continuous pain relief. However, the use of the
pump needs to be supervised by trained personnel (i.e. Acute pain
service).

Figure: Intravenous PCA pump. Syringe contains 60 mg of morphine in 60 ml of saline. Drug prescription form has stamp
to stop other forms of pain relief being given.

MORPHINE PROTOCOL:
Background:
During surgery most patients receive an opioid for analgesia, usually IV morphine.
However, quite severe pain may be experienced as the patient regains consciousness
from the anaesthetic and surgery in the recovery room. It is common to give IV
morphine to treat this pain. To make sure that the morphine is given safely a regimen
called "Morphine Protocol" has been developed at the PWH. The protocol is a
standing order that allows the recovery nurse to administer morphine to a patient in
pain. The anaesthetist authorizes the order by writing on the recovery record sheet.

MORPHINE PROTOCOL ORDER

Administration:
The protocol allows the nurse to give small boluses of morphine (1 to 1.5mg) IV at 5 minute interval up to a maximum
of 5 doses. It is common practice for the anaesthetist to make up a 10 or 20ml syringe of morphine in the operating theatre,
and for the syringe with unused morphine to be handed over to the nurse when the patient arrives in recovery. (if day
discharge case, dont hand over morphine unless patient replied yes when asked whether theres pain.) The syringe must be
labelled with the drug (morphine), dose (usually for 10ml syringe 1.5mg/ml: and 20ml syringe 1.0mg/ml), and patient
identification (gum label with name and HKID number).

If the patient is still in pain after 5 doses, a further 5 doses can be prescribed by the anaesthetist. However, severe post
operative pain that does not respond to reasonable doses of morphine may be caused by some other surgical complication,
such as internal bleeding, and needs to be investigated by the surgeon.

Morphine protocol tends to be used during the early stages of recovery when the patient is not sufficiently alert to use an APS
pump. Eventually the patient's pain will need to be controlled by some other method, usually IV PCA morphine.

FIG 8: MORPHINE SYRINGE USED FOR MORPHINE PROTOCOL


FIG 9: PATIENT USING IV PCA PUMP
Older Graseby IV PCA pump attached to drip stand, soon to be replaced in service by the Alaris pump. Note the infusion line
going from morphine syringe contained in locked antitheft/tamper chamber at the top of pump. The line is going to
dedicated IV acces. A one-way anti-syphon valve is connected to the IV cannula. The IV site is also labeled IV. P.C.A. A
handset (Graseby version) is being held by the patient. The grey button is pushed to trigger a morphine delivery.

Local block
For limited surgical incisions wound pain can be reduced by infiltrating local anaesthetic. However, there is limit to the
amount of local anaesthetic that can be injected because of systemic toxicity. Therefore, this technique is not suitable for
large surgical incisions. Local anaesthetic agents are not very effective in the presence of infection.

Regional blocks
Single injections, repeat injections via indwelling catheters and continuous infusions can all be used to block the nerves
supplying the operation site. These methods provides excellent post operative pain relief, reduce post operative stress and
morphine consumption. Particularly popular are lumbar and thoracic epidurals, paravertebral catheters and brachial plexus
blocks. However, the patient has to be suitable. Placement of a regional catheter can be time consuming and stressful to
patient and therefore should only be used in more major cases. As the catheter may need to remain in-situ for several days
local and systemic infection is a major concern, especially when the spinal canal is involved (i.e. epidurals). Haematoma
formation at the site of puncture is also a concern, especially in the spinal canal. Patients with impaired clotting should be
excluded from such procedures.

COMMONLY USED ANALGESIC DRUGS


Oral analgesic drugs are not sufficiently strong to treat moderate to severe surgical pain, thus IV morphine or regional block
is required. However, the techniques used to deliver these modes of pain treatment are potentially dangerous (i.e. they can
cause morphine overdose or cardiovascular collapse) and need to be closely supervised (i.e. by the APS). Therefore, they
should not be used unnecessarily and treatment should be withdrawn as soon as reasonably possible, and replace with safer
oral analgesic alternatives.

TOLERATING ORAL FLUIDS:


However, surgery and anaesthesia are associate with a period when the patient is not allowed (i.e. risk of aspiration), or
cannot tolerate (i.e. ileus), oral fluids, and during this period the patient cannot be given oral medications. The critical phase
in the pain management is when the patient starts tolerating oral fluids and can first start taking oral medications (usually day
2 or 3, depends on surgery).

ACUTE PAIN SERVICE (APS)


BACKGROUND:
The APS was set up to provide pain management for post operative patients with moderate to severe surgical pain. At the
PWH the APS was established about 10-15 years ago. This coincided with the development of the first commercially
available pain pumps. The service now covers the whole hospital and manages over 30 pain pumps. The APS overlaps with
the chronic pain service, which handles referrals, joint clinics and theatre sessions for performing pain blocks. Because the
pumps used by APS can cause potentially life threatening opioid or local anaesthetic agent overdose, there is a need for a
level of supervision that cannot be provided by the ward nursing staff.

FIG 1: LIST OF PAIN PUMPS AND PATIENT ALLOCATION IN


RECOVERY

Board kept in theatre recovery showing the daily allocation of pain


pumps, Alaris (upper left) Gemstar (upper right), and Graesby 3300
(lower right).

Traditionally post operative pain was treated by morphine10-15mg IM 3-hourly as required. This prescription could be safely
administered by ward nursing staff. However, there were a lot of limitations with administering IM morphine.
PROBLEMS WITH IM MORPHINE AS REQUIRED PRESCRIPTION
1. Morphine administration was frequently inadequate and delayed because the patient had to ask for pain relief and it
took time to administer, particularly if the ward was understaffed and busy.
2. IM morphine has a slow onset. It takes time for the drug to be absorbed systemically from the injection site.
3. There is a lot of "red tape" before giving IM morphine. Being a DDA (i.e. dangerous drug of addiction) its use has to be
carefully regulated. Morphine is kept in a locked cupboard. Two responsible persons (i.e. sister & second nurse) have to
check (every ampoule needs to be accounted for) and dispense the drug (there is a DDA book that needs to signed).
4. There was a general reluctance by nursing staff to give morphine because of the fear of causing morphine overdose.
( fatal respiratory depression)

FIG 2: SIGNING FOR MORPHINE IN THE DDA BOOK


DDA cupboard in background (locked) with green PWH/OT recovery
DDA book in front left. Book is shown open to Morphine
15mg/ampoule page (right), with four morphine ampoules (top) to be
used to prepared 60mg syringe of morphine (i.e. 1mg/ml) for Alaris
IV PCA pump.

Good pain relief following surgery leads to less stress response, faster
recovery and fewer complications such as chest infection and wound infection.

THE ROLE OF THE APS:


The APS is staffed by a senior anaesthetist, junior anaesthetist and pain nurse. The day to day running of the service is by the
pain nurse, with evenings and nights covered by the on call obstetric anaesthetist (i.e. Pain MO). There is a morning ward
round when all the patients under the APS are visited and their pain management reviewed. It is essential that every patient
on pain management from the APS is seen at least once every day by the pain team nurse and doctor. They should record the
daily assessment of the patient and any changes to the pain management regimen.
Patients having surgery are booked for APS care, usually the night before their operation. A booking form exits.

With so many hospital patient receiving acute pain


management at any one time, it is helpful for the pain nurse to
know ahead of time who will requires a pain pump, so that she
can plan ahead of time the distribution of pumps for that day.

The pain nurse may also be contacted on day of operation. She


arranges the allocation of pain pumps. The pumps are kept in
recovery, in main operating theatre complex.

FIG 5: PAIN PUMPS USED BY PAIN SERVICE


The pain pumps used by the APS at the PWH are kept in a cupboard
in recovery. On the left are the Alaris pumps and one Graseby 3300
pump. On the right are the Gemstar pumps.
The patient should have his/her post operative pain management
explained by the anaesthetist before surgery at the pre-anaesthetic
consultation. The anaesthetist usually sets up the pain pump in the
operating theatre during the case. There is a pain service trolley in
recovery that can be wheeled to theatre for use by the anaesthetist,
which provides all the equipment needed to set up the pain pumps.

FIG 6: PCA TROLLEY KEPT IN THEATRE RECOVERY


The PCA trolley contains all the syringes, saline bags, infusion systems, paper work
and labels required by the anaesthetist, or pain nurse, to set up a PCA pump or
infusion. The pumps are kept elsewhere in theatre. The trolley can be easily taken to
the theatre where the surgical operation is in progress so that the anaesthetist does
not have to leave the patient in order to prepare the pain management.
Once the patient is sufficiently awake in the recovery room, he/she is shown how to
use the pain pump. This is done by the recovery room nurse. There are differences
between how patient controlled analgesia (PCA) and continuous infusion pumps are
used.
It is only once the patient has arrived back on the surgical ward, having recovered
sufficiently from the anaesthetic, that he/she is first visited by the pain nurse (or
after-hours Pain MO).

Contacting the Acute Pain Service (APS):


Pain nurse: Direct Phone 6172 (Mon-Fri 08:000 16:00)
Pain MO: Pager 1067 (24-hour)
For Resuscitation Dial 2468 (at PWH)

TYPES OF PAIN RELIEF:


The method of post-operative pain relief chosen depends on the predicted level of pain associated with the surgery.
METHODS OF PAIN RELIEF USED BY THE ANAESTHETIST
Intra-operatively, the anaesthetist uses a combination of anaesthetic agents (i.e. inhalational agents or propofol infusion),
systemic opioids (i.e. fentanyl, morphine or remifentanil infusion), and possibly regional anaesthetic blocks (i.e. epidural
block).
Near the end of surgery he/she may add an injectable analgesic such as ketorolac 30mg IV (NSAID) or Tramadol 50-100mg
IV (pseudo-opiate) to provide analgesia for the early post operative period.
Post operatively, if mild post operative pain is expected the patient can be given oral analgesics such as paracetamol &
aspirin (mild), dologesic (mild to moderate), or a NSAID, such as Voltaren (moderate to severe).
If moderate to severe pain is expected then the patient should be managed with IV morphine (i.e. Morphine protocol
progressing to IV PCA morphine), or an appropriate regional blocks (i.e. continuous infusion of local anaesthetic and
opiate).
As the level of surgical pain decreases post operatively, these methods can be down graded to oral analgesics (dologesic).

DISCHARGE FROM RECOVERY:


Historical note:
The development of special areas (i.e. recovery rooms) where patients recovering from anaesthesia and surgery could be
properly supervised was a major step forward in anaesthetic patient safety. It followed the 1980s trend to build theatre
complexes (i.e. grouping operating theatres together), rather than having isolated operating theatres connected to surgical
wards. In the past patients had to recover in theatre or on the surgical ward where they were often poorly supervised and
occasionally developed cardio-respiratory arrest from a combination of residual anaesthetic and opioid overdose. Cases of
brain damage following such an arrest were not uncommon 30-years ago.

Today, most anaesthesia departments have strict protocols concerning discharge criteria before a patient is transferred from
the recovery to the wards. A number of criteria need to be met before the patient is discharged form recovery.
Alertness

Alert, talk sensibly

Oxygenation (SpO2)

>94% (with oxygen)

Breathing (Resp Rate)

RR: 12-25 /min

Circulation (BP)

SBP: 100-180mmHg

Discomfort (pain, nausea/vomiting, & shivering)

Minimal discomfort

TABLE 3: CRITERIA FOR DISCHARGE FROM RECOVERY in PWH


The above criteria are a summary of a more elaborate ten point Aldrete Postanaesthetic Recovery Score which needs to be
achieved by the patient before discharge. The patient's clinical state (i.e. recovery score) needs to be recorded on arrival and
discharge from the recovery room. No patient should be discharged from recovery until all the criteria are fulfilled and their
score is 10 out of 10. The anaesthetist who performed the anaesthetic should sign to authorize the patient's discharge.
FIG 10: RECOVERY SCORE AND STANDING ORDERS

This form is kept in the recovery room and it provides instructions to the recovery room nurses on what observations should
be made and how to evaluate the patient's recovery. A five category three point (0, 1 or 2) score is used (top of form). The
patient should achieve an Aldrete score of 10 before he/she is discharged to the ward.

DOCUMENTATION
When setting up an IV PCA, or continuous opioid/local anaesthetic infusion, it is essential that the anaesthetist fully
documents his/her orders. A well defined set of forms and gum labels have been developed by the PWH APS (n.b. until
recently rubber ink stamps were used). The forms cover prescriptions, doctor's notes and nursing observation records.

When a patient is reviewed on the ward by the APS nurse or doctor, it is also essential to document important findings and
any changes to the pain management regimen in the the patient's notes, and to the APS record sheet.

FIG 1: APS WARD ROUND NOTE IN PT RECORDS

Written record in patient notes of Acute Pain Service visit and assessment made by the MO on the third day post operatively.
The patient is on IV PCA. Pain scores at rest and movement are 2/10 and 7/10, respectively. Total morphine usage over past
24-hours was 6mg. Vital signs are stable. The pain team plans to stop (cease) the IV PCA, and change the IV tramadol to oral
panadol and tramadol. They also prescribe piriton for itchiness. Pain service observations are continued 4-hourly.

APS FORMS:

Drug prescription form:


The yellow non regular drug prescription from is used. The most common APS prescription is IV PCA morphine which is
prepared, usually in theatre during the operation by the anaesthetist, in a standard 60ml syringe. The prescription is for
nursing staff to refill the syringe. Otherwise the pain nurse or on call pain MO would have to refill empty syringes, which
would be impractical now that 20-30 pumps are in use in the hospital at any one time. The prescription does not determine
the pump settings. The prescribing is made easy by the production of a gum label (IV PCA Morphine: lower label) and all
that is required is a signature to authorize the prescription.

However, the prescription of other opioid and sedative drugs when a patient is on IV PCA morphine is potentially dangerous
because of synergistic effects. Therefore a second label is used stating that no other such drugs should be prescribed. This
label is adhered to the top of the yellow non regular prescription form.

IV PCA MORPHINE AND NO OTHER OPIOIDS


ORDER.
* Note that the white label has been replaced by a red label.
* Note no other opioid sedative odrer (top)
* Continuous infusions are prescribed in a similar manner.
Examples of three difference infusion regimens are shown.

APS Prescription & Observation record:


A white record form is used by the APS to manage cases and the form is kept in the patient's records. The front page contains
details of the patients method of pain relief and pain prescription, including drug dose and pump settings.

FIG 4: APS PERSCRIPTION SHEET


Patient details and pain prescription (upper) and nursing standing orders (lower).
The back page contains a pain management observation record (2-pages).

FIG 5: NURSING OBSERVATIONS RECORD FOR APS PATIENTS


The record sheet is two A4 pages and nursing observations are made every 1-hour or 4-hours, depending on progress. Note
the different types of patient assessment (left).

Written record in patient notes of Acute Pain Service visit and assessment made by the MO on the third day post operatively.
The patient is on IV PCA. Pain scores at rest and movement are 2/10 and 7/10, respectively. Total morphine usage over past
24-hours was 6mg. Vital signs are stable. The pain team plans to stop (cease) the IV PCA, and change the IV tramadol to oral
panadol and tramadol. They also prescribe piriton for itchiness. Pain service observations are continued 4-hourly.

APS follow up:


There is also an APS follow-up-record which is kept by the APS. There is folder that contains all the follow-up record sheets
of patients under the care of the APS receiving pain management.

The APS has a record of all patients in the hospital currently receiving pain management and needing daily follow up. Note
the security keys for gaining access to the pumps and the ruler for patients to visually scoring their pain.

The chart show a pain service record for a patient on IV PCA morphine. The patient has been seen daily for 4 days by the
Pain Service. The first visit was on the evening after surgery. Note how the prescription has remained unchanged except the
4-hourly maximum dose. One can also see the daily verbal analog pain scores at rest and movement, and the PCA usage
(accumulative) and total morphine dose. The frequency of observations is increased from hourly to 4-hourly on day three. At
the bottom of the page there are notes recording the addition IV tramadol to the pain management and later oral analgesics
and piriton for itchiness.

Labeling Drug Infusions:


All drug infusions, 60ml syringes and 250ml saline bags, should be labeled with the
patients name, the added drug(s) and the date prepared. A green label is provided.

Record in the patient notes:


Following setting up IV PCA, or a continuous infusion block, a record of the prescription should be made in the case notes. A
white APS post operative care gum label is provide to facilitate record keeping.

FIG 9: APS POST OPERATIVE CARE LABEL IN PROGRESS NOTES

Continuous Infusion prescriptions:


Occasionally a patient receives a continuous opioid and/or local anaesthetic block with an indwelling catheter, such as an
epidural or paravertebral block. The documentation for these modes of pain relief is basically the same as IV PCA, with the
exception of drug prescriptions. A number of different white gum labels exist for different regimens.

FIG (Left): CONTINUOUS INFUSION REGIMENS FOR EPIDURALS


FIG (Right): INK STAMPS ON TROLLEY USE FOR PRESCRIPTION and stamps on non regular prescription form
(lower). Only recently has the APS changed to using gum labels.

PATIENT CONSENT:
When pain management is part of the anaesthetic technique and after care provided to the patient, it is unnecessary to
specifically consent the patient for an IV PCA or an epidural. However, a note to this effect can be added to the consent form.
However, if a pain block such as epidural analgesia in labour is to be used then the patient needs to be separately consented.
The joint surgical and anaesthetic consent form is used at the PWH.

FIG 12 SECTION OF CONSENT FORM ABOUT RISKS (Additional information is added about the risks of using a
thoracic epidural.)

PATIENT EDUCATION & COMMON SIDE EFFECTS


USING THE PUMP CORRECTLY:
The patient needs to be shown how to use the IV PCA pump correctly (not necessary for continuous infusion modalities), and
also to recognize potential side effect. The recovery nurses will instruct the patient on use before he/she leave the recovery
area. The pain nurse will later check that the patient knows how to use the pump correctly and reinforce his/her understanding
of the more difficult points, such as anticipating painful activities. Several key points need to be understood by the patients.
1.

The purpose of the PCA handset

2.

The effect of the "lock-out time"

3.

When should the patient use the PCA

4.

Who is allowed to use the handset

5.

Common side effects of IV PCA morphine, see below


FIG 1: ALARIS HANDSET

The purpose of the PCA handset is to deliver a small IV dose (injection) of analgesic drug, usually morphine. The patient
should understand that by pushing the handset button, will receive pain relief.

The lockout time prevents repeated doses of morphine being given for a set time period after a bolus dose, usually 5-10min.
Thus, the injection of morphine is given time to take effect, before the next dose is given. It prevents the patient from being
overdosed by repeated injections of morphine over a short period of time. The patient should understand that the button is
pushed only once and then he/she has to wait for the onset of pain relief before pushing the button again. The IV PCA pump
records the number of successful and unsuccessful demands (i.e. button pushes), and this information tells the pain team
whether the pump is being used correctly.

The pump should be used whenever the patient experiences pain. Most patients have no problem understanding this
instruction. However, the patient should also be taught to use the pump before any painful activity, such as sitting up in bed,
coughing, chest physiotherapy or change of dressings. Patients often have to be reminded several times. Part of the pain
teams assessment of patients on IV PCA is to assess the level of pain during movement, in addition to at rest.

The handset should only be used by the patient. To have a friend, relative or child pushing the button, often repeatedly, can
lead to an overdose. Sometime if the patient is unable to use the handset because of their age, mental impairment or physical
disability (i.e. burns to both arms) a nurse or relative (i.e. parent) can use the handset for the patient (i.e. NCA nurse
controlled analgesia).

COMMON SIDE EFFECTS:


IV PCA morphine can cause nausea and vomiting, dizziness and itching.

These symptoms are easily treated with antiemetics (i.e. Maxalon 5-10mg IV 6hrly, or Ondansetron 2-4mg IV 8hrly) and
antipruritics (i.e. Piriton 5-10mg IV / IM 8hrly) (Chlorpheniramine). The patient should be made aware of these side effects
so that he/she can tell nursing staff and receive appropriate treatment.

Metaclopramide (Maxalon: proprietary name) is an anti-emetic and also promotes gastric emptying. It is Dopamine-2
receptor antagonist. It's antiemetic action is via D-2 receptors in the chemoreceptor trigger zone.

Ondansetron (Zofran: proprietary name) is a serotonin 5-HT3 receptor antagonist. It reduces the activity of the vagus nerve,
which activates the vomiting center in the medulla oblongata, and also blocks serotonin receptors in the chemoreceptor
trigger zone. * Amy Poon: could be used for prophylaxis too!

FIG 2: MAXALON AND ONDANSETRON AMPOULES

PUMP MALFUNCTIONS:
The PCA pump has an alarm to warn of malfunction, such as line occlusion (i.e. blockage) or empty morphine syringe.
Similarly for continuous infusion pumps, if the problem cannot be easily resolved by the ward nursing staff or surgical MO,
the follow action should be taken:
(i) Remove the handset from the patient.
(ii) Inform the APS (i.e. pain nurse or pain MO)

APS ASSESSMENT OF PATIENTS


At every consultation by the APS the patient's level of pain and potential side effects are assessed at bedside:
1.

Pain score

2.

Sedation score

3.

Side effects

4.

BP and pulse

5.

Respiratory rate

6.

Pump usage and settings

7.

Pump set up and working correctly

1. PAIN SCORES
The level of pain is assessed both at rest and during exertion. METHODS USED FOR ASSESSING PAIN:
1. Verbal numerical pain score (0-10)
2. Visual analog scale (0-10)
3. Verbal categorization (no, mild, moderate or severe pain)
4. Facial expression (children)

The simplest at the bedside method of assessing pain is to ask the patient to score their pain from 0-10, where 0 = no pain and
10 = worst imaginable pain. Alternatively, the patient can also be asked to mark on linear scale of 0-10 where they score their
pain (i.e. visual analog scale).

FIG 1: VISUAL ANALOG SCALE PAIN SCALE and PAIN SCALE BASED ON FACIAL EXPRESSION
The patient is asked to adjust the pointer to a level that best represents their pain. This can be performed by marking a paper
scale of 0-10 or using an aid such as a ruler with sliding pointer.

If the patient is unable to give a score, they can be asked to more simple classify their pain as no pain, mild pain, moderate
pain and severe pain (i.e. a four category score). In young children who cannot communicate their level of pain, facial
expression, (i.e. miserable to happy), can be used.
The pain score is used to assess the quality of pain relief, which can simple be (i) excessive, (ii) about right or (iii) inadequate,
and based on the finding the level of pain management can be (i) kept unchanged, (ii) increased and (iii) reduced.

In general, a pain score persistently greater then 3/10 at rest and 6/10 during exertion is considered unacceptable and needs
treatment, usually by increasing the pump settings.

When changing pain management settings consideration also needs to given to potential side effects (i.e. sedation, itchiness)
and whether oral medications can be tolerated, as eventually the pain pump will need to be withdrawn and replace by less
risky oral analgesics.

2. SEDATION SCORE:

Morphine in high enough doses causes sedation and this is a prelude to overdose and respiratory depression. So thesedation
score has to be assessed in all patient of opioid infusions (IV PCA /continuous). SEDATION SCORE AND ACTIONS:
Score

Level

Action required

Alert

All is well

Easy to rouse

Advise patient not to use handset


Closely observe

Difficult to rouse

Remove PCA handset


Nursing staff on full alert
(RR, BP, pin point pupils)
Naloxone (if RR<8 / min)
Call Pain MO

Unconscious

Urgent resuscitation
Give Naloxone
Stop PCA / Call Pain MO

Heavily sedated patients (i.e. levels 3 & 4) need their pain management stopped, close monitoring of respiratory rate, pupils
check of morphine overdose (i.e. pin point) and possibly resuscitation including IV naxolone. (Beware of short duration)

3. SIDE EFFECTS:
The pain nurse will ask the patient about COMMON SIDE EFFECTS OF BOTH IV PCA AND INFUSIONS:
1.

Nausea and Vomiting, usually due to opioids.

2.

Pruritus usually due to opioids given spinally.

3.

Leg weakness and numbness due to excessive epidural block.

4.

Hypotension and bradycardia due to excessive sympathetic block from the epidural block.

5.

Slow respiratory rates (RR) and poor oxygen saturations due to opioid depression

6.

Severe headache and backache, fever, prolonged or increasing sensory and/or motor block are all signs and symptoms of
a more serious problem that need urgent investigation.

Continuous epidurals may cause leg weakness and numbness which is a sign of excessive block. Motor block is scored as
no leg weakness, some leg weakness and unable to move leg (i.e. Epidurals only). The treatment is to stop, or reduce, the
epidural infusion.

4-5. VITAL SIGNS:


The ward nurse will record the patient's vital signs on the APS observation record, initially every hour for the first 24-h and
then every 4-hrly, depending on the condition. The BP and pulse provide addition evidence of whether the patient's pain is
well controlled (i.e. normal BP and pulse), or poorly controlled (i.e. high BP and pulse). However, the patient's BP and pulse
must be considered in the context of their age and pre-existing BP, especially if there is pre-existing hypertensive.

The RR (i.e. respiratory rate) and SpO2 are indicators of respiratory depression and morphine overdose. All patients on IV
PCA should receive oxygen overnight following surgery, and a low SpO2 is suggestive of hypoventilation. An RR of <10 is
of concern and <8 needs treatment with naloxone, see later.

6. PUMP SETTINGS AND USAGE:


From the IV PCA pump console one can read the pump register. The pump should have been reset at the beginning of
therapy (i.e. In theatre / recovery prior to connection to the patient). Important readings are:

OUTLINE OF PROGRAMMING STEPS FOR ALARIS PCA PUMP


Clear previous settings
1

The syringe size [i.e. 60ml BD Terumo syringe]

The concentration of morphine [usually 1mg/ml]

The bolus dose [usually 1.5mg/ml (range: 1-2mg/ml)]


The above settings determine the IV morphine delivery per bolus.

Number of DEMANDS [i.e. button pushes]

Number of SUCCESSFUL DEMANDS


This information tells the APS assessor how often the pump is being used, whether the patient is getting sufficient
morphine (too many unsuccessful demands) or whether the patient understands the lockout time and how to use the
pump correctly.

The lockout time [usually 5-10min]

The 4-hrly morphine dose [usually 15-30mg]


In the ALARIS pump the duration and dose are set separately
These settings (6&7) protect the patient from morphine overdose because they put a limit on pump usage. The APS
must decide on the best limits depending on quality of pain relief. If the patient's pain relief is insufficiently and the
demands greatly out number successful deliveries, then the settings need to be adjusted to provide more morphine.
If the pain relief is good and the patient is sedated (score 2) then the setting may need to be reduced.

TABLE 5: PROGRAMMING STEPS FOR ALARIS PUMP

FIG 3: CONSOLE SHOWING PUMP USAGE and ATTACHMENT OF IV PCA


IV PCA morphine syringe is connected to dedicated IV cannula. IV tubing is labeled so that it is not mistaken.

7. PUMP SET UP AND WORKING CORRECTLY:


A very import aspect of the pain nurse's job is to make sure that the pumps are set up correctly, and this includes:
(i) the IV cannula attachments and one-way anti-syphon valves, and
(ii) the epidural catheter and its insertion site,
and making sure the pumps are working correctly. The later point includes that the patient knows how to use the pump
correctly, see section on patient education.

When a patient on IV PCA or continuous infusion is transferred back to the ward from recovery, it is vitally important that
the pain service nurse (or Pain MO after hours) checks that the pump is correctly connected and working properly. This
should be done shortly after the patient has arrived back on the ward (i.e. after 1 to 2-hours).

MAJOR COMPLICATIONS OF PAIN MANAGEMENT


BACKGROUND:
The use of IV morphine infusions and continuous infusions blocks have a number of potentially life threatening
complications that necessitate close supervision of the patient whilst on these treatments (i.e. morphine overdose and severe
hypotension / bradycardia with cardiac arrest). When a patient receiving "high tech" pain relief is discharged to a ward for
theatre recovery, the nursing staff on that ward must be familiar with looking after patients receiving advanced pain relief.
Before a pain service, such as IV PCA, is introduced onto a ward the nurses on that ward need to the taught how to manage
the IV PCA pumps and treat any complications, such as morphine overdose.
The management of the pump settings is the responsibility of the APS team. The settings cannot be changed without
unlocking the pump using a key. The team reviews the patient's pain management at least once per day.

MORPHINE OVERDOSE:
Connecting the patient to such large quantities of morphine via and IV line creates the possibility of morphine overdose.

STRATEGIES USED TO REDUCE THE RISK OF MORPHINE OVERDOSE:


1.

The IV PCA pump is designed to give small increments of morphine in a very controlled manner with limited total
dose (i.e. lockout time and maximum 4-hrly dose).

2.

The pump settings and patient pain management are reviewed regularly by the APS.

3.

Very clear instructions are given regarding how much morphine the syringe contains and what analgesics the patient
can receive.

4.

Very clear standing orders of how IV PCA should be administered on the ward.

5.

The patients vital signs are monitored by the ward nursing staff (i.e. Q1H Observations, reducing to Q4H on Day2-3)
Several important pain management domains are monitored (i) pump usage, (ii) sedation, (iii) pain level, (iv) BP and
pulse, (v) respiratory rate and oxygen saturation, and (vi) motor score (epidurals only)
See Observation chart on P.40

6.

Protocols for treating suspected overdose.

7.

The PCA syringes and giving sets are tamper proof (i.e. looked within a sealed chamber)

NALOXONE: (Narcan)
-

To counter the effects of opioid overdose (e.g. morphine)

To reverse life-threatening depression of the central nervous and respiratory systems caused by opioids.

Competitive antagonist with extremely high affinity for -opioid receptors

Route: iv or im

Onset within minutes and last up to 45 minutes. Therefore, having reversed the effects
of morphine overdose, one must always closely monitor the patient (especially
conscious state and breathing) for several hours after giving naloxone in case the
overdose recurs.

.
Dosages:
-

Each 1ml ampoule of naloxone contains 0.4 mg and each 2 ml ampoule contains 0.02 mg/ml (0.04mg)

For ? morphine OD: 0.4 - 2 mg intravenous naloxone; Q2-3 min if no improvement in the patients condition

For IV PCA/ continuous infusion overdose: 0.1mg iv naloxone (by APS team)

For postoperative opioid depression partial reversal: 0.1-0.2 mg iv naloxone Q2-3min to the desired degree of
reversal (i.e., adequate ventilation and alertness without significant pain or discomfort).

For children: 0.01 mg/kg body weight given intravenously

FIG 4: CRITERIA AND MANAGEMENT FOR OPIOID OVERDOSE


The criteria that are used for managing morphine overdose and in particular the respiratory depression. Note the emphasis
placed on respiratory rate and sedation.

MORPHINE THEFT:
The pumps contain bags or syringes of morphine (60mg plus), a nice bounty for any would be thief. To prevent thief the
pumps are locked to the drip stands. The bag / syringe is only accessible by unlocking the pump locked chamber with a key.
Having the morphine inaccessible during patient use also prevents any tampering with the bag / syringe.

FIG 5: ANTI-TAMPERING AND ANTI-THIEF DEVICES


The Alaris pump has a plastic chamber to prevent access to
the morphine syringe whilst in use. The chamber is locked by
a key.

CONTINUOUS INFUSIONS:
-

Mixtures of LA with opioid are used to prolong intra-operative blocks and provide post operative pain relief.

The most common post-operative APS blocks to receive continuous infusions are:
1.

Epidural / lumbar or thoracic (bilateral)

2.

Plexus / brachial (arm)

3.

Paravertebral (unilateral chest and abdomen)

The main complications encountered with continuous infusion blocks are:


1.

Hypotension and bradycardia

2.

Respiratory depression

3.

Local anaesthetic toxicity

4.

Catheter migration

5.

Motor (leg) weakness

6.

Bladder dysfunction

7.

Pruritus, nausea & vomiting

1. Hypotension and bradycardia: (potentially life hreatening)


-

excessive sympathetic nervous system blockade hypotension and bradycardia cardiovascular collapse

associated with epidural (local anaesthetic infusions).

adding an opioid (i.e. fentanyl) to the epidural infusion reduce LA concentration and thus the hypotension.

FIG 5: LOCAL ANAESTHETIC AND OPIOID CI REGIMENS

By adding an opioid, such as fentanyl, to the local anaesthetic used for continuous infusion (CI) techniques, the
concentration of local anaesthetic can be reduced, and thus the degree of sympathetic block and hypotension.

Assessment & Risks:


The extent of the block should be regularly assessed by the APS (i.e. the sensory level to temperature and light touch and the
degree of motor block[no leg weakness, some leg weakness and unable to move legs]).
Persistent hypotension (systolic

BP

<100mmHg)

is

caused

by

excessive

epidural

block.

Potentially

it

can

cause stroke and myocardial ischemia / infarction to susceptible patients (i.e. pre-existing risk of stroke or coronary artery
disease, and chronic hypertension). Very high block can result incardiovascular collapse and arrest even in healthy young
adult patients. If the block is too high the epidural infusion needs to be stopped until the height of the block has regressed to a
safe level. Only then should the epidural infusion be restarted, but at a reduced infusion rate.

Treatment:
1.

Lying flat the patient + giving oxygen by a mask.

2.

Stop the infusion, then 500-1000mL NS IV

3.

Vasopressors and atropine can be given to treat severe hypotension and bradycardia, if necessary

4.

Unconsciousness and cardiovascular collapse should be treated by ambu-bag and face mask, assessing for CPR, and
calling for help 2468.

2. Respiratory depression:
Aetiology:
When opioids are used in the spine, they can travel up to the brain in the CSF and much lower doses than used systemically
can cause depression of the respiratory centres, leading to respiratory arrest. This is a particular problem with spinal
morphine, and fentanyl is preferred because of its shorter half-life intrathecally (4-6h versus 24h plus).
Treatment:
-

Epidural infusions opioids closely monitored. (esp. respiratory rate & conscious level (i.e. sedation level).

Respiratory depression should be treated with naloxone, as per APS standing orders, see previously.

3. Local anaesthetic toxicity:


General Discussion:
Systemic toxicity from local anaesthetics can lead to circulatory collapse. However, relatively low doses of local anaesthetic
are used during in epidural infusions, compared to the large bolus doses when establishing some block. Accumulation of drug
over time could still occur. Recently, the infusion regimens at the PWH have been changed from bupivacaine containing
infusions to less systemically toxic agents, such as ropivacaine and levo-bupivacaine. Evidence of increasing toxicity may be
picked up on the 1-hrly nursing observation charts (i.e. Sedation score, BP and pulse rate), though classic symptoms such as
twitch and convulsion may not occur.

FIG

6:

NEWER

CARDIOTOXICITY Both

LOCAL

ANAESTHETICS

ropivacaine

(Naropin)

and

WITH

LESS

levobupivacaine

(Chirocaine) were marketed because of the concern about bupivacaine (Marcain)


and its cardiotoxicity especially during epidural and regional block.

4.

Catheter migration:

A catheter placed in the epidural space can migrate (i.e. erode) into a vein resulting in an ineffective block and systemic
injection, though the infusion rates (i.e. 4-8ml/h) are very low and to low to cause systemic effects. It can also migrate into
the dural sac and CSF, which is more serious because a dense spinal block may result, causing a total sympathetic block (i.e.
severe hypotension and bradycardia) and total paralysis of respiratory muscles including the intercostals and diaphragm (i.e.
Phrenic nerve C2-4), a total spinal block. The patient will need ventilatory and circulatory support until the block wears off.
If unrecognized, or incorrectly treated, the patient may die form a treatable condition.

Catheters used in other blocks may also migrate. Usually this results in failure of the block. In paravertebral block, due to the
proximity to the spinal canal, the catheter can migrate into the epidural space, thus mimicking an epidural block.

5. Motor weakness:
Leg weakness is mainly a problem of epidural blocks and the use local anaesthetic infusions. Patients may be unable to stand
and walk, which is potentially dangerous if the patient wants to get out of bed. Patients have to be confined to bed which
limits mobilization after surgery. Motor weakness can be reduced by using lower concentrations of local anaesthetic with
opioid (i.e. fentanyl).

6. Bladder dysfunction:
Incontinence is a well recognized complication of continuous epidural block. The sympathetic and sacral parasympathic
nerve block due to the use local anaesthetics results in loss of the reflexes that:
(i) Sense and trigger bladder emptying,
(ii) Relax the sphincters, and
(iii) Trigger detrussor muscles contraction.
(i.e. nerve pathways S2-4 & T10).

If these reflexes remain blocked the bladder can become over distended, which may damage the detrussor muscle (i.e.
contractile function), and can also cause incomplete emptying of the bladder. Residual urine after bladder emptying is a
potential source of urinary tract infection. Therefore, to avoid these complications the patient needs to be catheterized.

Even after the ability to pass urine returns and the catheter is removed, the bladder may still not fully empty because of
continuing block of the sacral plexus. Full recovery of bladder function can be delayed for up 24-hours with Epidural
opiates, in particular morphine.

EPIDURAL ANALGESIA
Epidural analgesia is provided via a catheter sited in the spinal canal. The catheter is usually sited before surgery starts, so
that the epidural can be used during the operation.

Using an epidural block during surgery has a number of distinct advantages.:


The epidural facilitates the surgery: [chances of long term survival and curative treatment ]
(i) It provides good muscle relaxation facilitating surgical access.
(a)

(ii) It reduces bowel motility and distension also improving surgical access.
(iii) It reduces local bleeding. This improves the surgical dissection of small structures such as lymph nodes, as their view
is not obstructed by the continuous ooze of blood.
It reduces blood loss and need for blood transfusion. In Caesarean section epidural anaesthesia reduces blood loss by up

(b) to 50%, compared to general anaesthesia. The reason for the reduced bleeding and blood loss is not understood.
The epidural supplements the anaesthetic. Because painful stimuli from the operation site are blocked by the epidural,
the anaesthetist needs to provide only sufficient anaesthesia to cause unconsciousness. This reduces the total volatile
(c) agent and opioid requirement. Post operatively the patient is much more awake with fewer residual effects, such as
nausea, dizziness and headache.
The epidural also reduces the stress response due to surgery, because noxious stimuli that trigger stress arising from
(d) the site of surgery are blocked by the epidural. Reducing stress is particularly important in diabetic patients, because
stress has a catabolic effect that worsens the control of hyperglycaemia.

Where to put the catheter?


When deciding on the level of catheter insertion the anaesthetist must determine from where in the body pain originates and
what dermatomes the epidural will block.

Higher insertion sites such as T6 are used for upper abdominal and thoracic surgery. A band of epidural analgesia
extending from T4 to T10 is needed to block pain from the upper abdominal incision.

In a case of radical hysterectomy for cervical cancer, Mrs. Ding's pain will have two sources:
(i) Abdominal wall pain from the midline abdominal wall incision, extending from the umbilicus (T10) down to pubis (L1).
(ii) Cancer resection site pain which is visceral in nature and much less well defined, causing generalized lower abdominal
pain and rectovaginal pain.

The epidural will block dermatomes that supply the abdominal wall (somatic pain). Pain in these dermatomes is made worse
by movement such as turning, sitting up, deep inspiration and coughing. (more severe in an upper abdominal incision) Mrs.
Ding's epidural should be sited at the L1 level, high lumbar. Her wound pain will originate mainly from the T10 to L2 spinal
dermatomes. Her pelvic and visceral pain will arise from lower dermatomes. By placing the catheter at the L1 site a band of
analgesia will be produced that extends from T10 to L2, depending on the volume of anaesthetic agent injected. This is ideal
for blocking pain that arises from her lower abdominal incision. The epidural space is usually at a depth of 3-4cm from the

skin in the upper lumbar region

However, pain will also arise from the pelvic structures where the cancer has been removed (pelvic and visceral pain). This
pain involves the lower lumbar and sacral nerve roots, and visceral (autonomic) nerve pathways. Therefore, rather than being
blocked by segmental dermatomes, the visceral pain is blocked by drugs given epidurally diffusing into the CSF (spinal fluid)
and blocking the lower lumbar and sacral nerve roots. The epidural catheter needs to be sited so that it will cover not only the
somatic pain from the T10 to L1 dermatomes, but also the visceral pain arising from the lower peritoneal cavity and pelvic.

Procedure
Initially the anaesthetist will manage the epidural catheter by injecting local anaesthetic, such as 0.25% plain bupivacaine.
Boluses of 3 to 5ml are commonly used. Following each injection the anaesthetist waits 5 to 10min before judging the effects.
A fall or settling of arterial blood pressure and heart rate is seen when analgesia becomes adequate. Once the operation site is
well blocked and the patient exhibits no response to surgical stimulation, the anaesthetist can set up a continuous infusion of
local anaesthetic to maintain the epidural block, rather than injecting boluses of local anaesthetic.

General anaesthesia is still provided to keep the patient a sleep during the long surgery, but less anaesthesia is needed. In
particular analgesic drugs such as morphine. The anaesthetist is provided with a Gemstar pump. Pumps used for pain
management have a cover with security key to prevent the syringe or bag of drug being stolen. Pain service pumps can
contain up to 150mg of morphine which would be quite a prize for a thief. The
Gemstar pump is prepared by adding the analgesic drugs to a 250ml bag of
saline. For children, a 100ml bag of saline is used.

The program is set to continuous infusion mode.The Gemstar pump is preferred


to the Alaris and Graseby pumps for continuous infusion techniques because the
pump has a larger capacity. More than 300ml compared to 60ml once drugs
added. As the infusion rate of these pumps varies between 4 to 12ml/h, the
Alaris or Graseby pump could need to be refilled every 6 hours, which would
require several visits per day for the pain team.

The drugs used for epidural block have increased over the last decade. Until
recently only lignocaine and bupivacaine were available. Today several
alternative drugs have been introduced into clinical practice. The drugs used are
0.1% Levobupivacaine and Fentanyl 2.5mcg/ml, which are draw up into a bag containing 320ml of normal saline, set to run
at 8ml/h. Delivery is controlled by a Gemstar pain pump. Levobupivacaine was chosen because of its long tissue half life and
that it is less cardiotoxic than bupivacaine. Levobupivacaine is the safer left spiraled isomer of bupivacaine. Ropivacaine
could also be chosen as a local anaesthestic but trends to cause more motor block. Fentanyl is added because of its synergistic
properties with epidural local anaesthetics, reducing the required drug concentration.

Removal of catheter
When removing an epidural catheter it is import to check that the catheter is intact and no broken fragment is left in Mrs.
Ding's spinal canal. This was done by a qualified person, the pain nurse, and documented.

Spinal Anaesthesia
This is a type of regional block which involving the injection of an anaesthetic drug into the CSF. Usually a small volume of
long acting local anaesthetic is used such as 2.0 to 3.5 ml of heavy Bupivacaine 0.5% solution.(last for 3-4 hours) Recently,
there has been a vogue to add an opiate, such as fentanyl 15 g (or 0.6 ml), to the local anaesthetic solution, because it
improves the quality of anaesthesia. A fine gauge needle (orange 25 gauge pin point) is used to puncture the dura in the
lumbar (or lower back) region.

Figure: A 25 gauge spinal needle (orange) is inserted, via introducer (yellow), into the patients back at the lower lumbar
region. The needle enters the spinal canal, punctures the dural sac and enters the CSF. 3 ml of heavy Bupivacaine 0.5% is
then injected. Note the sterile technique.

Advantages of SA for TURP surgery:


(i) Good analgesia in the immediate post operative period,
(ii) Reduces blood pressure which in turn reduces blood loss and the need for blood transfusion and,
(iii) Allows the anaesthetist to monitor the patient for TURP syndrome.

However, the main reason for choosing a particular anaesthetic technique is that it has the lowest incidence of adverse effects
and it provides good surgical operating conditions.

In an elderly patient general anaesthesia, which includes airway management and ventilation, causes an increased risk of lung
complications (i.e. lung collapse, hypoxia and infection). General anaesthesia also causes some degree of post operative
cognitive dysfunction (memory loss and subtle changes in personality. [Controversial view but studies exist that support this
claim]). Therefore, it is good practice to avoid general anaesthesia whenever possible in the elderly.

However, spinal anaesthesia is not without its own associated complications.

Digoxin Toxicity

Various ECG changes are associated with the use of digoxin. Most commonly the ST segment is depressed and T wave
inverted. This is most prominent in leads V5-6. It produces the reversed tick pattern, Fig 1 and 2. These changes become
more extensive in digoxin toxicity.

Other changes that may also occur are bradycardia, prolonged PR interval, shortened QT segments and arrhythmias
(especially heart block / bigeminy).

The patient's ECG shows ST changes consistent with digoxin, but no inverted tick pattern is seen. The patient has a
bradycardia (HR=52). The digoxin level is high but reflects the level taken three weeks ago. It is difficult to say whether or
not the patient has digoxin toxicity.

Digoxin toxicity is important because it depresses cardiac conduction. If the level is too high, say 5.1 mmol/L, then if the
patient develops an arrhythmia and arrests, it could be difficult to restore the heart back to some acceptable rhythm and
prevent death. During anaesthesia many things happen that upset the ionic balance across the cardiac muscle membrane, such
as changes in pH caused by over ventilation or just giving an anaesthetic drug. Normally these changes are of no
consequence. However, in a patient who is digitoxic before anaesthesia they could become critical. Because the consequences
of being wrong and anaesthetizing a grossly digitoxic patient are so grave, it is essential that the digoxin status of the patient
is determined before she is anaesthetised.

The intern (i) inquires about clinical symptom of digoxin toxicity,


(ii) stops the patients regular digoxin medication and
(iii) sends an urgent blood sample to the laboratory for a digoxin level.

Hypertension

1.

Patients with SBP > 200 mmHg and DBP > 110-120 mmHg should be cancelled and have their blood pressure
stabilized.

2.

Refer to medical team and stabilized on antihypertensive drug therapy for at least 1-2 weeks before surgery. (Unless
surgery is very urgent, the patient should not be started on antihypertensive treatment and operate on the next day,
because the body needs sufficient time to adapt to a new drug therapy. The blood pressure intra-operatively will even
more unstable.)

3.

Screen for secondary end organ damage

Incidental heart murmur in pre-op assessment


Assess symptoms
Two examples are provided:
1. A young patient with a septal defect (hole-in-the-heart) may become hypoxic and cyanosed under anaesthesia. This
can be explained by reversal of the blood flow through the septal shunt. There are specific management strategies that
the anaesthetist can adopt in his anaesthetic technique to prevent / treat reversal of the shunt.

2. A patient with severe aortic stenosis can suddenly develop heart failure under anaesthesia because the greatly
increased load on the left ventricle due to the narrowed valve. Such patients need to be anaesthetized with great care and
better still have their aortic valve replaced before any surgery.

Ventilation-perfusion mismatch
V/Q mismatch is a difficult concept to grasp. The lungs can be considered to be made up of many small alveoli or
respiratory units. Each alveolus is ventilated with air and perfused with blood. Ideally each alveolus should provide perfect or
100% gas exchange. However, this does not happen and not all alveoli oxygenate the blood a 100%. When the contributions
from all the alveoli are taken together (their average), the overall gas exchange is not 100% or perfect. This failure to fully
oxygenate the blood is known as V/Q mismatch or shunt.

The effect of positive pressure ventilation and volatile anaesthetic agents (isoflurane) on the alveoli is to worsen the
mismatch and impair oxygenation. This can be overcome by increasing the inspired oxygen content but the shunt remains.

In patients with chronic lung disease the V/Q mismatch becomes worse.

Lung volumes
Lung capacity is a measure of the total volume of the lungs during maximal inspiration. It includes the max. inspired, max.
expired and residual (non-expired) volumes. It is reduced in severe lung disease. However, we only use a tenth of this
capacity for every day activity [Tidal volume = 300 to 500 ml compared to lung capacity = 4-5 litres].

Functional residual capacity (FRC) is more important and represents the resting volume of the lungs when the elastic recoil
of lungs and the rib cage/diaphragm are in equilibrium, Fig (lung volumes).

The value of (FRC) effects the V/Q mismatch because when it is low and the lungs are collapsed more shunting occurs and
the degree of hypoxia become worse. Abdominal distension and factor which push up the dome of the diaphragm impair FRC,

V/Q and cause hypoxia.


SOB scoring system to predict the post operative

The extent and site of surgery will increase the risk of a

respiratory outcome

poor post operative outcome. [Add (+1 or +2) to the score]

Score Degree of SOB Prognostic groups & Outcomes

Score Level of surgery

no impairment

surgery well tolerated

minor procedure Cystoscopy

walking up hill

surgery well tolerated

+1

moderate surgery Hystectomy

walk on the flat

should breath adequately

+2

major surgery

on minimal effort may develop ventilatory failure

at rest

Example

Gastrectomy

definitely needs post op support

expected to die

In a normal subject the resting lung volume is about 2.5 litres and the inspiratory and expiratory volumes are about 2 litres. If
a patient has a decrease in residual lung function by 50%, then these volumes fall to 1 litre. Similarly, when the residual lung
function decreases to 25% of normal these volumes become 500 ml, which is very close to tidal volume, which is 300 to 500
ml. Therefore, a residual volume of 25% provides very little margin for increase and coughing. Inadequate ventilation is very
likely.

Our patient is able to cough up sputum and walk some distance on the flat. Therefore his reserve must be above 25%.
However, he still has significant lung disease, so it is below 50% of normal. A threshold of 50% is usually set for moderate to
severe lung disease. Above 50% is compatible with mild lung disability and equivalent to an exercise tolerance of walking up
hill (grade 1 to 2). Below 50% is equivalent to walking on the flat (grade 2 to 3). Below 25% indicates that patient is
arespiratory cripple (score of 4).

Figure 1 shows a normal pulmonary function laboratory result. Note that in addition to standard spirometry, lung volumes,
resistance (flow loops) and diffusion (transfer factors) can be provided.

Data from our patient is provided below (pre and post bronchodilator
therapy)
PRED MEAN (pre) %PRED MEAN (post)

%PRE
D

FVC

3.0

1.1

37%

1.3

43%

FEV1

2.2

0.6

27%

0.7

32%

FEV1/FVC

54%

This data would put our patient in the 25 to 50% range and a risk score of 2 to 3 (review previous scoring system).

The benefits of ceasing smoking:


Ceasing smoking can do much to improve the patient. Improvement can be considered under immediate, short term and long
term effects.

The stimulatory effects of nicotine on the CNS and circulation will resolve within 12h. Whether this is significant to the
provision of anaesthesia is doubtful.

The effect of carbon monoxide on oxygen delivery will take 24h to resolve, as carbon monoxide bonds almost irreversibly
with haemoglobin. This is more beneficial to anaesthesia.

The action of the cilia and clearance of sputum will recover from the toxic effects of inhaled smoke within a few days. This
helps to prevent sputum retention and thus post operative chest infection.

The absence of chronic irritation from inhaled smoke will result in less hypersecretion of mucin. This will improve sputum
retention and chronic infection.

Hypertrophy of the bronchial walls will take several months to resolve, but this will improve the chronic wheeze and small
airways obstruction.

Structural damage to the lungs, such as seen in emphysema does improve over several years after ceasing smoking.

There are also significant benefits to the patient from no longer being exposed to carcinogens. Smoking not only causes lung
cancer, but also causes other types of cancer, such as stomach (our patient) and renal cancer. Smoking also has significant
detrimental effects on the cardiovascular system causing ischemic heart disease, peripheral vascular disease and cerebral
vascular disease or stroke.