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Anaes Primer - Aiims PDF
Anaes Primer - Aiims PDF
ANESTHESIA
A Primer of
ANESTHESIA
(For Undergraduates)
Editor
Rajeshwari Subramaniam MD
Professor
Department of Anesthesiology and Intensive Care
All India Institute of Medical Sciences
New Delhi, India
A Primer of ANESTHESIA
2008, Rajeshwari Subramaniam
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and
the publisher.
This book has been published in good faith that the material provided by editor is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent error(s). In case of
any dispute, all legal matters are to be settled under Delhi jurisdiction only.
Where do we begin?
For a start, it is important to attract more postgraduates to the specialty of anesthesiology.
Unfortunately the present scheme of rotation provided to undergraduates is not long enough
for the students to get familiar with anesthetic pharmacology, terminology, equipment and
skills. Further, the students find themselves at sea in the world of the modern operating theatre
and ICU equipped with hitech monitors and gadgets.
This book has been written with the primary aim of demystifying anesthesiology and
presenting the necessary theory related to pharmacology, equipments and skills in an easy-to-
understand manner.
It is hoped that better understanding of this subject at undergraduate level will lead to
enhanced appreciation and motivation to pursue it as a career.
Rajeshwari Subramaniam
Acknowledgements
I gratefully acknowledge all the contributors to this book who devoted time from their busy
schedules to write their chapters. I acknowledge with deep gratitude and humility my teachers
(Late) Prof. NP Singh, Prof. VA Punnoose, (Late) Prof. GR Gode, Prof. HL Kaul and Prof. TS
Jayalakshmi, who inculcated in me not only a sense of obligation to teach and practice
evidence-based anesthesia, but also to treat patients with respect and compassion. Their
dictum: It is the enlightened who can enlighten.
I acknowledge the vastness and majesty of this specialty without which no advancements
in modern surgical technique would have been possible.
My family who encouraged this endeavour cannot be thanked enough.
I thank production staff of M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, for
their patience for the numerous revisions and modifications I thrust upon them.
I would like to add that the photographs of ampoules/vials of drugs displayed in some of
the chapters are those in common use and I have no financial gains from the manufacturers.
My special thanks to Dr. Sunil Chumber (Additional Professor, Dept. of Surgical Disciplines,
AIIMS), who was the one who succeeded in motivating me to write this book.
If this book fulfils the expectation of its users I would give all credit to the contributors and
I take the responsibility for errors, if any.
Last but not the least, I acknowledge my colleagues and students whose faith in me is
amazing and humbling.
Contents
Section 1
THE PREOPERATIVE PERIOD
Section 2
THE INTRAOPERATIVE PERIOD
Section 3
THE POSTOPERATIVE PERIOD
Section 4
CRITICAL CARE
Index 255
Introduction
R1 R2 R3 X
Thiopentone Ethyl 1-methyl-butyl H S Rapid acting, fairly prompt recovery
Pentobarbitone Ethyl 1-methyl-butyl H O Prolonged action
Methohexitone CH2CH=CH2 CH(CH3)C=CC2H5 CH3 O Rapid action and recovery, excitatory
phenomena
Phenobarbitone Ethyl Phenyl H O Prolonged action, anticonvulsive
properties
Barbiturates
Different barbiturates were used as sedatives in
the 1920s. Since their actions were unpredic-
table, research was carried out making substitu-
tions on the barbiturate ring (Fig. 1.2a) leading
to compounds with known and/or desirable
properties. Of these, sodium thiopentone
emerged as the compound with the most
acceptable properties. Table 1.1 summarises the
effect of substitution.
period. It reduces intracranial pressure (ICP) Abolition of the eyelash reflex is used as a sign
due to cerebral vasoconstriction which leads to of completion of anesthetic induction. Skeletal
a reduction in cerebral blood flow (CBF). muscle tone is reduced in high doses; however
Cerebral metabolic rate (CMRO 2 ) is also this is inadequate for surgical purposes. In
reduced. Both these properties have made normal doses it has little effect on the uterine
thiopentone the anesthetic agent of choice in muscle. Although it crosses the placenta, the
patients with elevated ICP (head injury, fetal drug concentration is lower than the
intracranial tumor) and as an agent for cerebral maternal blood levels. Both hepatic and renal
protection (barbiturate coma). It is a potent function are transiently depressed. Thiopentone
anticonvulsant. Consciousness is regained in may induce various cytochrome P-450 iso-
510 minutes after a single IV dose. enzymes; in chronic liver disease the effects are
prolonged with delayed recovery.
Actions on the Cardiovascular System
Mean arterial blood pressure falls with Pharmacokinetics
administration of thiopentone due to a dose- Blood concentration drops rapidly after
dependent reduction in vascular tone and some intravenous injection. 75-85% drug is albumin
myocardial depression especially with high bound. In malnutrition, chronic renal failure and
doses. These effects are of concern in all patients other conditions with hypoalbuminemia, less
with low, fixed cardiac output states. This group drug is protein-bound, hence more free drug
includes hypovolemic patients (traumatic is available. Action of the drug is dependent on
shock), patients with valvular stenoses (mitral, the free plasma concentration of drug.
aortic), patients on vasodilators or beta-blockers Thiopentone rapidly diffuses into the CNS
and patients with ischemic heart disease, because of its lipid solubility and high un-ionised
constrictive pericarditis or cardiac tamponade. fraction. Consciousness returns when the brain
Hypotension can be profound, refractory concentration falls as a result of re-distribution
to treatment and can result in mortality. in the body. At this time nearly all the drug is
In fact, thiopentone had fallen out of favor in still present in the body.
1934 shortly after its introduction owing to the Thiopentone is predominantly metabolised
large number of war casualties resulting after in the liver. Metabolism is a linear process when
its use on soldiers with hypovolemic shock in single doses are concerned (1015% of the
World War II. It was then known as the ideal remaining drug is metabolised each hour).
agent for euthanasia. Hence up to 30% of drug is still in the body
after 46 hours. The metabolites are thiopental
Effects on the Respiratory System carboxylic acid (inactive), hydroxythiopental
There is often a deep breath or yawn followed (inactive) and pentobarbital (active, with half-
by a brief period of apnea. Ventilatory drive is life of 2050 hours). This leads to a hangover
reduced, leading to a fall in both the respiratory effect. With thiopentone infusions the meta-
rate and tidal volume. Bronchial muscle tone bolism follows non-linear, or zero-order kinetics
increases and occasionally bronchospasm is and significant amounts are present in the
induced. Laryngospasm may be induced if food plasma, leading to time prolonged recovery.
or secretions enter the larynx, or by surgical
stimulation under light anesthesia. Dosage and Administration
Thiopentone is administered as a 2.5%
MISCELLANEOUS EFFECTS (25 mg/ml) solution intravenously. 1-2 ml
Intraocular pressure is reduced. Conjunctival, should be injected initially to check that the
corneal, and eyelash reflexes are abolished. patient does not have pain at the site of
6 A PRIMER OF ANESTHESIA
injection. The dose in healthy adults is 45 mg/ relatively acidic pH and (ii) Vasospasm and
kg administered over 15 seconds. Conscious- thrombosis initiated by intimal damage, local
ness will be lost in 30 seconds; if the eyelash release of noradrenaline and ATP from
reflex is not lost then a further 50100 mg should damaged red cells and platelets. Treatment
be given. Children require about 6 mg/kg, and involves leaving the needle in place, injecting
elderly patients 2.53 mg/kg. In patients where 50 mg lignocaine (5 ml of 1% solution), a
the cardiovascular system is depressed (e.g. as vasodilator like papaverine (1020 ml of
in hypovolemic shock) as little as 50 mg may 0.4% solution), and performing a stellate
be required. ganglion or brachial plexus block. Intra-
venous heparin should be started and non-
Adverse Effects and Problems with urgent surgery postponed.
Thiopentone 5. Laryngeal spasm: It is likely to occur if a
painful stimulus is administered with in
1. Hypotension: This is more likely to happen adequate analgesia under the effect of
if excessive doses are given or if a normal thiopentone, e.g. anal dilatation.
dose is given to a hypovolemic patient or 6. Bronchospasm: May occur in asthmatic
one with a low fixed cardiac output. Risk of patients.
hypotension is reduced if the drug is injected 7. Allergic reactions: Severe anaphylactic
slowly. Thiopentone should not be injected reactions may occur in 1 in 14000 to 20000
in the sitting position. administrations.
2. Respiratory depression: The risk is increased
if opioids have also been administered. Indications
Thiopentone should be injected only where - For induction of anesthesia.
facilities for artificial ventilation are available. - Maintenance of anesthesia for very short
3. Tissue necrosis: Perivenous injection may procedures.
lead to local tissue necrosis. If perivenous - Treatment of status epilepticus.
injection occurs the needle should be left - To reduce intracranial pressure.
behind and hyaluronidase injected.
4. Intra-arterial injection: This dreaded Absolute Contraindications
complication usually occurs when thio- - Confirmed or suspected upper airway
pentone is in advertently injected directly obstruction, e.g. epiglottitis; large oral,
from a syringe into the brachial artery, an pharyngeal or laryngeal tumors.
aberrant ulnar artery in the cubital fossa, or - Porphyriabarbiturates may precipitate
an aberrant radial artery around the wrist; severe cardiovascular collapse, or lower
in each case the artery is mistaken for a vein. motor neurone type of paralysis in patients
The patient usually complains of intense with acute intermittent porphyria by inducing
burning pain. This is a strong indication the enzyme ALA synthetase.
for stopping the injection immediately. - Previous hypersensitivity to a barbiturate or
The forearm and hand may be blanched sulpha drugs.
and there may be skin blisters. Intense
vasoconstriction may lead to ischemia or Precautions
gangrene in the forearm, hand or fingers. - Cardiovascular disease: Patients with hypo-
Ischemia results due to (i) physical obstruc- volemia, mitral or aortic valvular stenosis,
tion of the arteriolar lumen by crystals of or constrictive pericarditis are very sensitive
thiopentone which precipitate in the to thiopentone. However if thiopentone is
INTRAVENOUS ANESTHETIC AGENTS AND OPIOIDS 7
injected with extreme caution it is no more hydroxide. The pH of this solution is 68.5. The
hazardous than any other IV anesthetic available preparation is a 1% (10 mg/kg)
agent. solution in a 20 ml ampoule or vial. Other
- Severe hepatic or renal disease: Thiopen- presentations include 2% solution and 50 ml
tone may be injected very slowly as the and 100 ml vials which are suitable for infusion.
volume of distribution is large, and the Pain on injection is a bothersome side effect and
protein binding is low. can be ameliorated by (i) IV fentanyl 50100
- Obstetrics: Excessive dose may lead to g, (ii) premixing the propofol with 12 ml of
respiratory or cardiac depression in the fetus. preservative-free lidocaine.
- Outpatient anesthesia: Clear-headed
recovery takes time. Slow elimination from Pharmacology
the body may result in drowsiness for 24
Central Nervous System
36 hours. Thiopentone is therefore not
recommended for brief day care procedures Anesthesia is induced in 2040 seconds after
where the patient is likely to be discharged intravenous administration. This is slower than
in a few hours. with thiopentone. Cerebral blood flow, cerebral
- Other conditions: Adrenocortical insuf- metabolic rate, intracranial pressure and intra-
ficiency, hypothyroidism, asthma: if alterna- ocular pressure are all reduced. Recovery of
tives like ketamine are available, thiopentone consciousness is rapid with minimal hangover
should be avoided. effect.
Cardiovascular System
Precautions
Arterial pressure, heart rate and pulmonary
These are similar to thiopentone. Use in
vascular resistance are increased by 2040%.
neonates and in obstetric anesthesia is not
The myocardial oxygen consumption is
recommended. However, propofol is safe in
increased. Intrinsically ketamine is a direct
porphyrias.
myocardial depressant. The increase in blood
Ketamine Hydrochloride pressure is because of its sympathetic system-
stimulating action.
Ketamine (Fig. 1.4) is a phencyclidine derivative
introduced in 1965. The unique property of Respiratory System
this drug is that, unlike other intravenous
anesthetics it produces dissociative anesthesia There may be transient apnea. However after
rather than generalised depression of the CNS. return of respiration the minute ventilation is
maintained or increased. Pharyngeal and
Pharmacology laryngeal reflexes tend to be better preserved
than with other anesthetics. However all
Central Nervous System
precautions must be taken to protect the airway
After intravenous injection it produces anes- and prevent aspiration. Tracheal intubation
thesia in 3060 seconds. The anesthetic effect should not be attempted under ketamine
lasts 1525 minutes. It is a potent analgesic at anesthesia. Bronchodilation is an advantage,
subanesthetic doses. Amnesia lasts well into the but this effect may be offset by bronchorrhea
recovery period after consciousness is regained. (excessive bronchial secretions).
Emergence is associated with restlessness,
agitation, and disorientation in some patients. Other Systems
Vivid nightmares and hallucinations may occur
Skeletal muscle tone is increased. Ketamine
cannot be used as sole anesthetic for surgery
requiring muscle relaxation.
Ketamine crosses the placenta and is
therefore not ideal for obstetric anesthesia.
Intraocular pressure increases. The eyeball
is not akinetic and nystagmus may be
observed. Ketamine is therefore not ideal
Fig. 1.4: Structure of ketamine for ocular surgery.
10 A PRIMER OF ANESTHESIA
Pharmacoki
Pharmacoki netics
macokinetics Difficult Locations
The plasma concentration falls as the drug is To provide analgesia to trauma victims for on-
distributed in the body. This reduction is not as site debridement, fracture reduction or prior to
rapid as with other intravenous anesthetic moving. Analgesia for trapped or injured victims
agents. It is metabolised in the liver to at the site of an accident can be provided with
norketamine, conjugated and excreted. IM ketamine.
- Psychiatric conditions: Emergence pheno- Anxiolysis: In smaller doses these drugs reduce
mena may be confused with psychiatric anxiety. They are therefore popular as
illness. premedicants.
is also reduced. Typically the respiratory rate is The IM dose for premedication is 0.15
reduced more than the tidal volume. Opioids 0.3 mg/kg. An antiemetic like promethazine
depress the tone of the muscles that keep the needs to be administered concomitantly to
upper airway patent. As a result of this the reduce nausea and vomiting. The normal IV
airway is likely to get obstructed. analgesic dose is 0.10.3 mg/kg. Morphine can
be used as infusion for postoperative pain relief
Cardiovascular System in a dose of 1040 g/kg/hour, titrated to require-
If PaCO2 is maintained opioids do not have any ment.
direct effect on the cardiovascular system. The
vasomotor centre is not depressed. Hypotension Pethidine (Fig. 1.9)
seen with morphine use is an indirect effect due This synthetic opioid also has atropine like
to histamine release. effects. It has lesser effects on the biliary and
renal tract than morphine. It is also shorter
Nausea and Vomiting
acting than morphine. Pethidine is metabolised
All opioids cause nausea and vomiting by to norpethidine. Norpethidine has stimulatory
stimulating the chemoreceptor trigger zone. effects on the central nervous system. Mono-
amine oxidase inhibitors (MAOIs) increase the
Cough Suppression
metabolism to norpethidine. As a result of this
Antitussive action is independent of analgesic if pethidine is given to patients on MAOIs it may
effect. Some opioids like codeine have cause convulsions, hyperthermia, and death.
significant antitussive effect but much less The IM dose of pethidine for premedication
analgesic activity. is 11.5 mg/kg, and like morphine an antiemetic
agent like promethazine (0.5 mg/kg) adminis-
Gastrointestinal Tract tered concomitantly is useful. The commonly
Opioids reduce motility and increase the tone used IV dose is 0.51 mg/kg.
of the gastrointestinal tract. Morphine increases
biliary pressure.
Other Effects
- Miosis
- Suppression of endocrine response to pain.
These hormones include adrenaline,
noradrenaline, cortisone, and glucagon.
- Pruritus
- Hallucinations Fig. 1.8: Structure of morphine
- Dependence and tolerance
Su fentanil
Sufentanil
Sufentanil is 10-15 times as potent as fentanyl,
and has a slightly shorter duration of action. It
is less likely to accumulate in the body than
fentanyl. The usual dose is 0.10.5 g/kg. It
has recently been licensed for use in India.
Fig. 1.10: Structure of fentanyl
Remifentanil
Fentanyl (Fig. 1.10) It is an ultra short-acting receptor agonist with
no cumulative effect. It is given as an infusion
This synthetic opioid is very lipid soluble and
during operation. It is metabolised by blood and
has a more rapid onset of action than
tissue esterases. Remifentanil is used in a dose
morphine. Its duration of action is much shorter
of 0.5-1 g/kg as a bolus before laryngoscopy,
than morphine while the elimination half life is and continued as an infusion of 0.250.5 g/
like morphine. The short effect is entirely due kg/min. Within 35 minutes after stopping the
to redistribution. It is about 100 times more infusion the effect of remifentanil is terminated
potent than morphine. The normal IV dose is no matter how long the infusion has been
24 g/kg. It has been used as the sole running. It is thus well suited for outpatient use.
anesthetic in patients where cardiovascular It is not yet licensed for use in India.
stability is required. The dose required for this
use is 40-70 g/ kg. Fentanyl is used as a Tramadol
transdermal controlled release patch for use in
It is a predominantly receptor agonist with a
patients with chronic pain. Fentanyl lollipops weak action. It is less likely to cause respiratory
are available for transmucosal (oral) premedica- depression than morphine. The side effects
tion in children. include nausea, vomiting, dry mouth, and
One of the alarming side effects with large urinary retention. It interacts like pethidine with
doses of IV fentanyl is chest wall rigidity which MAOIs.
makes ventilation impossible unless a muscle
relaxant is administered. A few patients cough Pentazocine
after rapid IV administration.
It is a and receptor agonist and has antago-
Alfentanil nist/partial agonist effect on the receptor. It is
largely not used in the West but still commonly
Alfentanil has a rapid onset of action, and a available and used in India. It has a ceiling
shorter duration of action than fentanyl. It is analgesic effect of 60 mg in an adult. It can cause
ten times as potent as morphine and one-fourth hallucinations.
to one-tenth as fentanyl. Its elimination half life
is 8490 minutes, which is much lesser than Naloxone
fentanyl. Cumulation is much less of a problem
It is a short acting opioid antagonist. Because
with alfentanil and unlike fentanyl it is safer to
of its short duration of action the reversal of
use as continuous infusion. Most of its other
respiratory depression induced by naloxone
effects are like fentanyl. The IV dose of alfentanil may be short lived. Hence patients must be
is 510 g/kg, with supplemental doses of monitored for some time after naloxone is used.
35 g/kg. Intense pain may occur as the analgesic effect
16 A PRIMER OF ANESTHESIA
of the originally given opioid is terminated. This e. Methyl paraben is added as a bacterio-
may result in tachycardia, hypertension or even static
myocardial ischemia. 5. Thiopentone sodium
In conclusion, Intravenous anesthetic agents, a. Produces anesthesia within 30 seconds
sedatives and narcotics are an essential part of of injection
modern anesthetic practice. They have con- b. Has excellent analgesic property
tributed tremendously to patient comfort and c. Is very lipid soluble
safety. d. Reduces the CMRO2
e. Reduces intracranial pressure when
STATE WHETHER TRUE (T) OR FALSE (F) ventilation is maintained
6. Thiopentone sodium should be used
1. An ideal intravenous anesthetic very carefully in patients with
a. Should cause rapid induction of a. Epilepsy
anesthesia b. Constrictive pericarditis
b. Should have cumulative effect c. Significant mitral stenosis
c. Should not cause pain when injected d. Significant aortic stenosis
d. Should not cause muscle relaxation e. Shock
e. Should not cause respiratory depression
7. Thiopentone sodium
2. Regarding intravenous anesthetics a. Is a respiratory stimulant
a. Upper airway obstruction is an absolute b. May cause laryngeal spasm if patient
contraindication for their use stimulated in light planes of anesthesia
b. Previous known anaphylactic reaction c. Is a uterine dilator
is a relative contraindication d. Infusions lead to significant cumulation
c. All are contraindicated in porphyrias and prolonged recovery
d. Are preferred over inhalation anesthe- e. Un-noticed inadvertent intra-arterial
tics for induction injections may cause or lead to ischemia
e. All can be used as continuous infusion of the arm or fingers
3. Barbiturates 8. Propofol
a. Were the most commonly used intra- a. Is available as powder to be dissolved
venous anesthetics until the last 15 years in water
b. Methyl barbiturates like methohexidone b. Usually causes pain on injection
may cause excitation during induction c. Causes hangover
c. All are antiepileptic d. Has anti-emetic property
d. All have very quick induction and slow e. Apnea is commoner than with thio-
recovery properties pentone
e. Have been used since 1820s
9. Propofol
4. Thiopentone sodium a. Is suited for infusions
a. Is available as white emulsion b. Has no effect on gravid uterus muscle
b. Is packed in glass vials with nitrogen to tone
prevent oxidation c. Is used extensively in obstetric anes-
c. Sodium carbonate is added to keep thesia
solution alkaline at pH 10.5-10.8 d. Dose in geriatrics is significantly lower
d. Is commonly injected in concentration than young adults
of 2.5% e. May cause significant hypotension
INTRAVENOUS ANESTHETIC AGENTS AND OPIOIDS 17
Rajesh Tope
POTENCY OF INHALATIONAL
POTENCY
Physical principles- MAC, saturated vapor
ANESTHETIC AGENTS
pressure
Pharmacokinetics- uptake Just as potency of oral or intravenous drugs is
Pharmacodynamics-Theories of anesthetic measured in milligrams (or micrograms),
action potency of volatile anesthetics is associated with
Properties of an ideal anesthetic agent the term MAC (minimum alveolar concen-
Systemic effects of inhalational agents- tration).
CVS, CNS, Induction characteristics
Individual Inhalational Agents Minimum Alveolar Concentration
Diethyl ether-including stages of ether MAC is the alveolar concentration (in volume%)
anesthesia of an anesthetic at 1 atmospheric pressure that
Nitrous oxide prevents movement in 50% of a population in
response to a standard stimulus. Although the
partial pressure (in mm Hg or kPa) of the
The inhalational route, which refers to the
anesthetic appears to be a better way of
respiratory passages beginning at the nose and
expressing potency (than volume%), by
mouth, and ending at the alveoli, is nearly exclu-
convention MAC is expressed as volume%.
sively used by anesthetists. Exceptions are respi-
ratory physicians, who may use inhaled steroids
and bronchodilators. The identity of the anes- Dose-response Curve
thesiologist as the gas man originates from the
use of this route for administration of anesthesia. By definition, 1 MAC of an anesthetic is
Most adults prefer the intravenous route of equipotent to 1 MAC of another anesthetic. At
induction of anesthesia as it is rapid and clinically used concentrations MAC is approxi-
pleasant. However, inhalational anesthetics are mately additive. Hence 0.5 MAC of one
useful for (i) anesthetic induction in children, anesthetic administered with 0.5 MAC of
who dread needles, (ii) patients where controlled another will produce an effect approximately
anesthetic induction is required, as in airway equal to 1 MAC.
obstruction, and (iii) maintenance of anesthesia. Though MAC only indicates absence of
The main advantages of inhalational agents are response to surgical stimulus in 50% population,
ease of administration and titrability. an increase of 10-15% in the concentration
INHALATIONAL ANESTHETIC AGENTS 19
above MAC (or 1.3 MAC) will ensure absence given by Henrys Law, which states that the
of response in > 95% of the population partial pressure exerted by a dissolved gas is
(indicating that most patients will be proportional to the concentration of gas
anesthetised). This is because the dose response molecules in solution.
curve is fairly steep.
Unlike most other drugs used in medicine, PHARMACOKINETICS
inhalational anesthetic agents have physical We will briefly look at factors affecting absorp-
properties that determine their pharmacological tion, distribution, metabolism and excretion of
properties. We will briefly look at some basic commonly used inhalational anesthetics.
physical principles and definitions to make
physical properties more understandable. Solubility/Partition Coefficient
PHYSICAL PRINCIPLES From the inspired gas the anesthetic (in the
gaseous phase) dissolves in the blood in the
Gases exist as vapor above their critical pulmonary capillaries, from where it reaches the
temperature. Gases can be liquefied by pressure brain and other tissues. The passage of the agent
only below their critical temperature. Gases from the alveolus through various tissue
follow the Universal Gas Law (PV = nRT, where barriers or phases) is governed by certain rules.
P, V and T are the pressure, volume and When an anesthetic agent passes from one
temperature respectively and n the number of phase to another, (e.g. alveolus to blood) the
moles of gas). The pressure at the critical partial pressure across the phases and not the
temperature is critical pressure. The critical concentration tends to equilibrate. At
temperature of nitrous oxide is -37C, indicating equilibrium the concentration (in volume
that below this temperature it is possible to store percent) in the two phases (or tissues) can be
nitrous oxide as a liquid under pressure. very different and is based on the solubility
of the agent in the two phases.
Saturated Vapour Pressure If an agent is highly soluble in blood, at
In an enclosed system where there is a liquid at equilibrium there will be a higher concentration
equilibrium the number of molecules of liquid (partial pressures in blood and alveolus will
that evaporate to turn into vapor are equal to equilibrate) in blood than in the alveolus. In
the number that turn back into liquid. The other words large amounts of anesthetic agent
pressure the vapor exerts is termed saturated will be needed to be taken up to reach
vapor pressure. It is independent of the equilibrium. Concurrently, the time taken for
atmospheric/ambient pressure and is determined equilibration of the blood and brain concen-
by the particular molecule and the temperature. tration (brain-blood partition co-efficient) is also
delayed. This will prolong induction of
Daltons law of partial pressures: This states that anesthesia. Hence agents with higher blood gas
in a gas mixture the pressure contributed by each coefficients (usually also have higher brain-
gas is proportional to the number of molecules blood coefficients) are slow at inducing
of that gas. The clinical implication in anesthesia anesthesia. On the other hand agents like N2O
is that since alveolar pressure is constant (760 with a low blood gas coefficient reach equili-
mm Hg) the increase in partial pressure of any bration very quickly.
gas (e.g. CO2) will be at the expense of a fall in
partial pressure of oxygen. Uptake of Anesthetic Agents
Concentration and tension (partial pressure): The rate of uptake of inhaled anesthetic agents
The relationship between these two variables is is the ratio of alveolar and inspired (FA/FI)
20 A PRIMER OF ANESTHESIA
concentration seen overtime. As more and more blood laden with anesthetic re-circulates in
anesthetic is taken up the alveolar concentration the lungs, leading to rapid build-up of
(which is zero to begin with) approaches the anesthetic partial pressure.
blood concentration. This is an exponential It can be appreciated that inhaled anesthetics
equation. As the difference between the two must pass through many barriers between the
phases reduces, less is taken up. Theoretically, anesthesia machine and the brain, which is their
at infinity, the alveolar concentration equals site of action.
inspired concentration, the ratio (FA/FI)
becomes unity and uptake ceases. Metabolism and Excretion of Inhalational
Anesthetics
Uptake = solubility cardiac output
difference in alveolar and venous partial The major portion of most agents is exhaled
pressures/atmospheric pressure. unchanged from the lungs. The agent most
metabolized is halothane (about 20%).
Factors Affecting Rate of Uptake PHARMACODYNAMICS
1. Increased inhaled concentration speeds
We do not know how exactly general anesthetics
induction.
cause reversible loss of awareness and pain.
2. Increased alveolar ventilation hastens There is no center in the brain that is specifically
induction. This will lead to higher alveolar depressed by these agents, neither are any
concentration and FA/FI will increase specific anesthetic receptors present in the
rapidly. brain. However, many theories have been put
3. Increased cardiac output delays induction forward to explain the possible modes of action
because the rate at which the agent is taken of inhalational anesthetics.
away from the alveolus increases and
hence FA/FI will increase slowly. Mayer-Overton Theory
4. A high blood-gas coefficient (increased It was observed about a hundred years ago that
solubility) delays induction. The higher the the more lipid- soluble anesthetics (having a high
coefficient (the more soluble the agent) the oil-gas coefficient: tends to dissolve more in the
higher the uptake, lower the FA/FI rise and lipid phase compared to the gas phase), were
slower the induction. more potent. These agents therefore (e.g.
5. Bio-transformation of the agent is not Trichloroethylene, Trilene) had low MAC
particularly important in the rate of uptake. values. It was then inferred that anesthetics
6. Elimination of re breathing, use of high worked on the lipid por tion of the cell
fresh gas flows and low anesthetic circuit membrane.
volume hasten induction and recovery.
7. Mal-distribution of ventilation and Pressure Reversal and Critical Volume
perfusion may delay induction. Hypothesis
8. Second gas effect (see N2O) and concen- It was observed that when anesthetised mice
tration effect hasten induction. were kept in a pressure chamber and the pressure
9. Reduction in pulmonary blood flow (e.g. of the chamber increased to 50 atmospheres,
in right-to-left shunts, as seen in tetralogy the mice woke up. It was concluded that
of Fallot) delays induction especially with anesthetics worked by cellular expansion, and
soluble agents. Conversely, a left-to-right that high ambient pressure led to reversal of
shunt is expected to speed up induction as anesthesia.
INHALATIONAL ANESTHETIC AGENTS 21
speedy induction (low B/G and low oil/gas Halothane maximally sensitizes the heart to
solubility) and acceptable odor] and also in exogenously administered catecholamines.
patients with central airways obstruction (e.g. Arrhythmias are more likely with hypoxia
tracheal/carinal) tumors. and hypercarbia. If epinephrine is to be
administered, dosage should not exceed 10
Cardiovascular effects (Table 2.3):
ml of a 1:1,00,000 solution (100 g) in 10
Isoflurane is a potent coronary vasodilator
min, and not more than 30 ml per hour.
and most prone to cause coronary and
Desflurane may exhibit coronary vaso-
cerebral steal. This is a phenomenon
dilatation and steal upwards of 2.2 MAC.
whereby healthy vasodilated vessels divert
blood away from critically perfused areas Metabolism and elimination (Table 2.4):
supplied by non-compliant vessels. In the 5% of sevoflurane is metabolized by cyto-
heart it can jeopardize ischemic myocardium. chrome P-450 producing hexafluoroiso-
Sevoflurane reduces blood pressure by propanol and inorganic fluoride. Fluoride
reducing systemic vascular resistance (SVR); levels do not reach toxic threshold described
cardiac output remains unchanged. Cardiac for nephrotoxicity (> 50 mol/l). Potentially
output is reduced by reduction in the heart hepatotoxic hexafluoroisopropanol is
rate, therefore myocardial oxygen supply is conjugated before it can cause damage.
enhanced. Sevoflurane causes less coronary Compounds A-E formation has been
dilatation than isoflurane. discussed earlier.
Halothane is a potent depressant of the 20% of halothane undergoes metabolism
myocardium. Both stroke volume and heart and it takes nearly 3 weeks for the meta-
rate are reduced. It has little effect on the bolites to completely clear. The metabolites
peripheral vascular resistance. With
reduction in the myocardial contractility the Table 2.4: Elimination of inhaled anesthetics
myocardial oxygen consumption decreases Halothane 60-80% unchanged via lung, 20%
unless there is also a marked reduction in metabolized in liver
blood pressure. Since it has little effect on Isoflurane Primarily exhaled unchanged; 0.2%
the peripheral vascular resistance, it does not metabolized in liver
cause coronary steal. Halothane decreases Enflurane Predominantly exhaled via lung;
heart rate by vagal stimulation, reduces 2.4% metabolized to fluoride
phase IV depolarization and slows cardiac Sevoflurane 95% exhaled via lung; 5% meta-
conduction velocity. This leads to ventricular bolized by cytochrome P-450
escape in the form of premature ventricular Desflurane Predominantly exhaled unchanged;
contractions (PVCs) and bigeminy. 0.02% metabolized in liver
24 A PRIMER OF ANESTHESIA
are trifluoroacetic acid, chloride and bro- cleaning. Halothane also corrodes aluminium,
mide. Nearly 50% patients show a brass and solder metal. Halothane produces
temporary increase in glutathione S- relatively more myocardial depression than fall
transferase. in SVR (manifest as a fall in blood pressure) and
this makes it uniquely useful in patients with
CNS effects (Table 2.5):
obstructive cardiomyopathy, where isoflurane is
All inhalational agents tend to increase the
relatively contraindicated. Halothane is an
cerebral blood flow (CBF) due to vasodilation excellent bronchodilator. A characteristic feature
and thereby the ICP to a lesser or greater degree. of deep halothane anesthesia is tachypnea and
Isoflurane causes the least increase in ICP and shallow respiration. Halothane induced hepatic
may exhibit steal which may be par tly dysfunction, though rare (seen more often after
responsible for this increase. Steal implies that repeat halothane anesthetics, in obese middle-
blood may be diverted from areas of vasospasm aged female patients and those with a known
to those having normal perfusion. history of allergy to halogenated anesthetics) is
SPECIAL FEATURES ABOUT INDIVIDUAL the most important reason why the drug usage
INHALATION AGENTS has drastically reduced world over. Clinically
hepatic dysfunction presents as mild elevation
Halothane (Fig. 2.1) in liver enzymes which resolves in a few days.
Thymol (0.1%) is added to halothane as Fulminant liver failure is uncommon, and
preservative. Since it does not readily evaporate mortality in these cases is between 3070%. It
but accumulates in the vaporizer, control knobs is interesting to note that hepatic dysfunction is
can stick. These vaporizers require regular extremely rare in children. It is important to
Fig. 2.3: Structure of isoflurane; bottle of isoflurane, specific vaporizer for isoflurane
avoid halothane in any patient who gives vasodilatation. Severe hypotension may occur
a history of fever or jaundice on a previous with high alveolar concentrations if not
use. The color code for halothane is red. adequately monitored. The peripheral vasodila-
tion with minimal myocardial depression and
Enflurane (Fig. 2.2) lack of myocardial sensitization to exogenous
This is the only inhalation agent which is or endogenous catecholamines makes it an ideal
epileptogenic in concentrations more than 3%. agent for control of intra operative blood
Since inorganic fluoride ions are produced pressure in patients with pheochromocytoma.
consequent to metabolism, it is best to avoid Its advantages are rapid recovery, minimal
enflurane in patients with chronic renal failure. hepatic or renal toxicity and low risk of
The color code for enflurane is orange. arrhythmias. Isoflurane is also the agent of
choice for control of intraoperative broncho-
Isoflurane(Fig. 2.3) spasm, considering the fact that these patients
Although isoflurane reduces the cardiac output would already have received sympathomimetic
only to a limited extent, it is a potent vasodilator. agents and are at increased risk of arrhythmias.
The drop in blood pressure is due to peripheral The color code for isoflurane is mauve.
26 A PRIMER OF ANESTHESIA
It has a high blood gas solubility coefficient Ether stimulates ventilation; hence minute
of 12; as it is irritant to the respiratory mucosa ventilation is maintained till stage three plane
the concentration in the inspired gas can be three. It is a potent bronchodilator. It also
increased only slowly. These factors make relaxes the skeletal and uterine muscles.
induction slow. It depresses the CNS like other It is a direct cardiovascular depressant.
agents. The inhibitory cortex is depressed However, it is a potent stimulator of the sympa-
initially resulting in excitatory phase. Later the thetic system. This results in maintained blood
entire CNS is depressed. As ether is slow acting, pressure. In deeper planes it causes hypoten-
it is possible to see all the classic stages of anes- sion. It does not sensitize the myocardium to
thesia described by Guedel (Figs 2.7 A and B). circulating catecholamines.
Respiratory centre depression is followed by More than 15% is metabolised to carbon
depression of the vasomotor centre. dioxide and water. Other products of meta-
As ether is irritant to the mucosa, it causes bolism are alcohol and acetaldehyde.
coughing, breath holding, profuse secretions of Clinical use: Ether has a higher therapeutic
the respiratory and salivary glands. Premedica- ratio than other agents like halothane, and
tion with atropine or glycopyrrolate is essential. isoflurane. This makes it safer to use in unskilled
28 A PRIMER OF ANESTHESIA
hands and with uncalibrated vaporisers than impurities (including ammonia, nitric acid, nitric
other agents. Inspired concentration of up to oxide, and nitrogen dioxide) can be dangerous
20% is required for induction. Anesthesia can if inhaled and are removed. It is stored as liquid
be maintained with 36% concentration. In the in blue cylinders at 5000 kPa pressure.
late 19th century ether was administered by Nitrous oxide is sweet smelling and non
open drop method where a mask made of a irritant. It is a good analgesic but a poor
steel framework, covered with layers of gauze anesthetic because it has a high MAC of 105. A
(Schimmelbusch mask) was placed over the MAC of 105 means it is difficult to measure.
patients face and ether dropped on it from a In experiments it can be measured at two
bottle (Fig. 2.8). The early anesthesia machines atmosphere ambient pressure when the MAC is
had a mounted ether bottle (Fig. 2.9). 52.5%. Since it is essential to administer a patient
Subsequently, the EMO (Epstein, Macintosh at least 30% oxygen under anesthesia, only close
and Oxford) vaporizer (Figs 2.10 A and B) was to 70% MAC can be provided by nitrous oxide;
designed which is a sturdy and reliable inhaler the rest has to be provided by some other
still in widespread use in field locations and anesthetic given concurrently. It has a blood/
peripheral rural health facilities. gas coefficient of 0.47. That makes it a very fast
The incidence of postoperative nausea and acting anesthetic as only a small amount needs
vomiting is high with ether. to dissolve in blood to achieve equilibration
pressure with the alveolar N 2O. It is not
Nitrous Oxide metabolised and exhaled unchanged from the
Amongst inhalational agents, nitrous oxide is respiratory system.
the only true gas (other agents being vapors). It has little effect on the respiratory system.
It was also called laughing gas. It is prepared It is a myocardial depressant but also stimulates
by heating ammonium nitrate. Various the sympathetic system hence blood pressure
INHALATIONAL ANESTHETIC AGENTS 29
Fig. 2.9: The Boyle ether bottle Fig. 2.10B: Internal structure of EMO vaporizer
solubility, the amount of nitrous oxide (in ml) synthesis of vitamin B12. Nitrous oxide also
leaving the blood and entering the alveolus is affects folic acid metabolism. The effect on these
more than the nitrogen entering the blood from two vitamin metabolism takes place on
the alveolus. This leads to dilution of the other exposure longer than 8 hours. Megaloblastic
gases in the alveolus. These are oxygen and anemia, aplastic anaemia, myeloneuropathy is
carbon dioxide. The low oxygen partial pressure also very rarely seen after prolonged exposure.
in the alveolus causes hypoxia. It lasts about 10
To conclude, developments in inhalational
minutes and can be significant in the sick patient.
agents has resulted in availability of sevoflurane
Thus it is important to administer 100% oxygen
and desflurane, which have favourable
at the end of the anesthetic to prevent
pharmaco-kinetic profiles compared to older
hypoxemia.
agents like halothane and isoflurane. Develop-
Effect on closed gas spaces: There are closed ments in vapourizers and circuits have resulted
spaces in the body where air exists. These are in accurate delivery of inhalational agents to
the bowel lumen and the middle ear cavity. patients, with maintenance of stable hemo-
Additionally, in pathological conditions air can dynamics and enhanced recovery.
exist in the pleural cavity (pneumothorax), the
peritoneal cavity or in the blood vessels (air
STATE WHETHER TRUE (T) OR FALSE (F)
embolus). When nitrous oxide containing
blood comes in contact with such cavities nitrous 1. About volatile anesthetics
oxide diffuses faster into this cavity than nitrogen a. Gaseous route for delivery of anesthetic
into the blood from the cavity. This temporarily more likely to be used in adults than in
leads to higher gas volume in this space. The children
extra volume in the space stays till the nitrogen b. Potency is measured in MAC
is eventually slowly absorbed in the blood. If c. MAC is approximately additive
this closed space in the body has boundaries d. 1 MAC anesthesia ensures anesthesia
rigid (like the middle ear cavity) then the extra
in 99% patients
gas leads to high pressure. This has implications
e. Inhalational route is safer than
when a graft is placed in the middle ear cavity
intravenous route in patients with upper
over the ear ossicles (during modified mastoi-
airway obstruction
dectomy), when the graft tends to get lifted
off. When air is injected for contrast during a 2. Physical principles governing volatile
pneumoencephalogram in an anesthetized anesthetics
child inadvertently receiving N2O, Nitrous oxide a. Gases can be liquefied only above their
diffuses into the injected air bolus and may critical temperature
increase ICP to dangerous levels. If N2O is used b. Critical pressure is the pressure at critical
as part of the anesthetic technique in a patient temperature
who is undergoing surgical repair of retinal c. Partial pressure and not concentration
detachment with intraocular injection of gas equilibrates when a gas passes through
(SF6), significant increase in IOP and blindness different tissues
can result. Avoiding nitrous oxide is a good d. Induction of anesthetic is quicker when
option in these conditions. the agent is highly soluble in blood
Toxicity: Nitrous oxide inhibits the enzyme e. Uptake of an anesthetic is more in the
methionine synthetase. This enzyme affects the initial period after induction
INHALATIONAL ANESTHETIC AGENTS 31
Anatomy and physiology of the neuro- called muscle relaxants. In 1942, Harold
muscular junction Griffith published the results of a study using a
Physiology of neuromuscular transmission refined extract of curare, a South American
arrow poison, during anesthesia. Griffith and
Mechanism of action of depolarizers and
Johnson suggested that d-tubocurarine was a
non-depolarizers
safe drug to use during surgery to provide
Properties of an ideal muscle relaxant
surgical relaxation. In 1952, succinylcholine was
Depolarizing relaxants-suxamethonium introduced into clinical practice by Thesleff and
Non-depolarizing relaxants Foldes which become popular as a short acting
Side effects of neuromuscular blocking muscle relaxant. It was extensively used to
drugs facilitate tracheal intubation. The introduction
Drug interactions of vecuronium and atracurium, in the early
Antagonism of neuromuscular blockade 1980s led to extensive use of muscle relaxants
Neuromuscular disease affecting action of in clinical practice for tracheal intubation and
relaxants in the form of infusions for surgical relaxation;
Monitoring of neuromuscular block significant development in anticholinesterases
also occurred, enhancing the safety margin in
the use of these drugs. While muscle relaxants
Skeletal muscle relaxation facilitates surgical have rapidly become an essential component
procedures by allowing adequate surgical of the drug arsenal used by the anesthesiologist,
exposure. It also ensures good conditions for it is vital to remember that they merely provide
endotracheal intubation, tolerance of the tube what their name suggests, i.e. only muscle
by the anesthetized patient and facilitaties relaxation and not unconsciousness, analgesia
mechanical ventilation of the lungs. or amnesia. They are adjuvants and not
Reduction in skeletal muscle tone can be substitutes for anesthesia. As an important
achieved by deep levels of inhalation anesthesia, component of the balanced anesthesia
regional nerve block or by the use of neuro- technique they have revolutionized the practice
muscular blocking agentscommonly of modern anesthesia.
PHYSIOLOGY OF NEUROMUSCULAR BLOCKADE AND NEUROMUSCULAR PHARMACOLOGY 33
Fig. 3.5: Sodium channel opens when 2 ACh molecules occupy both subunits
Fig. 3.7: Depolarizing block. Red squares (suxamethonium) resemble ACh in structure, block ACh receptors;
Na channels open, depolarization occurs (seen as fasciculations); Na channels close after some time.
Muscle is in resting state (flaccid). Channels cannot re open till receptors are free of suxamethonium and
repolarization occurs
Fig. 3.8: Non-depolarizing block; relaxant molecule occupies non-ACh site but prevents ACh from occupying
its receptor. No depolarization, therefore no fasciculation seen; depolarization can occur only after relaxant
diffuses away and/or is outnumbered by ACh molecules
binding to the receptors (Fig. 3.8) and no EPP mechanism is unknown and desensitization (see
can develop. As they compete with ACh for below) by succinylcholine may be a factor.
binding sites they are also known as Compe- Persistent weakness after succinylcholine
titive antagonists. indicates a phase II block.
Phase II block: This is a complex event which
Desensitization block: The ACh receptor can
occurs if the neuromuscular junction is continu-
exist in many states. If the receptors do not
ously exposed to depolarizers. The junction
undergo the conformational changes required
is depolarized initially by the application of the
to open the channel in spite of binding to the
drug but the membrane potential slowly returns
to normal. It appears to be caused by ionic and agonist they are said to be desensitized. Drugs
conformational changes that accompany which may cause desensitization and hence
prolonged muscle depolarization and depends weaken neuromuscular transmission include
on duration of exposure to the drug, the drug volatile anesthetics, antibiotics (polymyxin B),
used and its concentration. In spite of becoming cocaine, alcohols, barbiturates, decametho-
repolarised, the postjunctional membrane does nium, anticholinesterases, local anesthetics,
not respond normally to ACh. The exact phenothiazines and calcium channel blockers.
PHYSIOLOGY OF NEUROMUSCULAR BLOCKADE AND NEUROMUSCULAR PHARMACOLOGY 37
DEPOLARIZING RELAXANTS
Suxamethonium: Succinylcholine, as it is
Fig. 3.9B: Succinylcholine vial
commonly known (Figs 3.9A and B), is the only
depolarizing relaxant in clinical use. Doses of opening of the ion channels and leakage of
0.51.5 mg/kg intravenously produce rapid potassium ions (K+) from the interior of the cells
(3060 seconds) onset of skeletal muscle enough to cause an increase in the plasma K+
paralysis. The depolarization produced by the concentration by 0.5 mEq/L. Succinylcholine
initial administration of the drug is initially has a brief duration of action (5-10 minutes)
manifested by transient skeletal muscle due to rapid hydrolysis by plasma pseudocho-
contractions known as fasciculations which start linesterase which is synthesized in the liver.
on the face and spread rapidly over the upper Owing to the rapid hydrolysis only a fraction of
extremities, abdomen and lower limbs. These the original dose (10%) reaches the NMJ. The
fasciculations are associated with a sustained neuromuscular block terminates by diffusion of
the drug away from the NMJ and back into the prolonged paralysis due to atypical
circulation to be metabolized by pseudocholine- cholinesterase is mechanical ventilation with
sterase. The initial metabolite is succinylmono- sedation till the block wears off. Although
choline which is metabolized more slowly to fresh frozen plasma is another alternative,
succinic acid and choline. the infectious risks of transfusion outweigh
What are the reason/s for prolonged neuro- its benefit. The Fluoride number is useful
muscular block after suxamethonium? where an abnormal genotype, associated
A. Low levels of normal pseudocholinesterase: with a normal dibucaine number, is resistant
i. Factors that decrease the normal enzyme to fluoride.
levels are liver disease, pregnancy, burns, D. High doses of suxamethonium: At over
increasing age, malnutrition and neoplasia. 6 mg/kg, Phase II block (see above) develops
Hypothermia decreases the rate of hydro- which lasts longer than the depolarizing block
lysis. produced by normal doses.
ii. Anticholinesterase drugs: An example is
chronic exposure to organophosphorus Clinical Uses of Suxamethonium
compounds like ecothiopate. This group Despite certain drawbacks with suxametho-
of drugs causes ACh to accumulate, nium, it remains the drug of choice in situations
prolonging the block, and also reduce where it is necessary to intubate the trachea
hydrolysis of suxamethonium. rapidly after induction of anesthesia, as in
B. Antagonism of normal levels of pseudocho- patients who are termed full stomach (refer
linesterase: to chapter on airway management). The
Drugs competing with pseudocholinesterase: potential problems with succinylcholine are
MAO inhibitors, oral contraceptives, diescribed below.
cytotoxic drugs, tetrahydroaminacrine,
hexafluorenium, metoclopramide, trimetha- Undesirable Effects Associated Specifically
phan, phenelzine, bambuterol and esmolol. with the use Succinylcholine
C. Presence of atypical pseudocholinesterase:
About 1 in 50 patients has one normal and 1. Pediatric patients: Following succinylcholine
one abnormal gene for pseudocholine- there may be sudden cardiac arrest in
sterase expression and this prolongs the apparently healthy children and adolescents.
action of suxamethonium by 3040 Hyperkalemia, acidosis and rhabdomyolysis
minutes. One in 3000 patients are homo- have been demonstrated with the muscle
zygous for the abnormal gene and the biopsy showing subclinical muscular dys-
atypical pseudocholinesterase results in trophy. The highest incidence is seen in
paralysis lasting up to 68 hours. This males less than 8 years of age. Succinyl-
abnormal gene is diagnosed by the choline should perhaps be avoided in this
dibucaine number. age group, if alternatives are available.
Dibucaine is a local anesthetic that inhibits 2. Cardiovascular effects: Succinylcholine
the action of normal pseudocholinesterase stimulates cholinergic autonomic receptors,
up to 80% (normal) and only 20% of the nicotinic receptors on sympathetic and
abnormal enzyme. The percentage of parasympathetic ganglia and muscarinic
inhibition of activity is termed the Dibucaine receptors in the sinus node of the heart. The
Number. Dibucaine number is related to effect on heart rate is dose-related. In low
pseudocholinesterase function and not to the doses both negative inotropic and chrono-
quantity of enzyme. The treatment of tropic effects are seen; with higher doses
PHYSIOLOGY OF NEUROMUSCULAR BLOCKADE AND NEUROMUSCULAR PHARMACOLOGY 39
Priming is the use of small doses (20 % of the bile as a parent compound and 12%
ED 95) of the relaxant given 24 minutes undergoes conversion to 3-desacetyl
before giving a larger dose for intubation. This vecuronium. 25% of vecuronium is excreted
hastens the onset of the larger dose allowing by the kidney and this combined organ
tracheal intubation within 90 seconds. However, clearance gives it a clearance of about 36 ml/
the dose required for intubation following kg/min.(ii) Atracurium is metabolized by
priming is 50-100% higher than the usual dose Hofmann elimination in the plasma and by
(which is 23 times the ED 95). Preoxygenation, Ester hydrolysis in the interstitial fluid. It is
patient preparation and reassurance are cleared 23 times more rapidly than the long
important as some patients may experience acting drugs. Hofmann elimination is a
weakness or lose airway control after the priming chemical process which does not require renal,
dose. If doses more than 5 times ED 95 are to hepatic or enzymatic function and occurs at a
be used, priming may be unnecessary. physiological pH and temperature. (iii)
The rapid onset of action of succinylcholine Cisatracurium is also metabolized by Hofmann
is unmatched by any other relaxant. However, elimination but there is no ester hydrolysis of
rocuronium also provides satisfactory intubating the parent molecule. It is about 45 times more
conditions at high doses (1.2 mg/kg) in 90 secs potent than atracurium. (iv) Rocuronium is
and can replace succinylcholine where side taken up by the liver and excreted mainly in
effects are of concern, e.g. hyperkalemia or the bile. Thus, the intermediate acting relaxants
perforating eye injury. have a clearance in the range of 36 ml/kg/min
due to multiple pathways of degradation which
Metabolism and elimination: Generally, the accounts for their intermediate duration of
hydrophilic nature of the non-depolarizing action. (v) Mivacurium is rapidly hydrolyzed by
relaxants implies that they are eliminated plasma pseudocholinesterase at a rate 7080%
primarily by the kidney and their rate of that of succinylcholine, which results in an action
clearance is limited by the glomerular filtration duration much shorter than atracurium and
rate (12 ml/kg/min). There are a few vecuronium but about twice that of succinyl-
exceptions to this rule: (i) Vecuronium is more choline. The metabolism of muscle relaxants is
lipid soluble. Therefore, 3040% is cleared in shown in Table 3.3.
pyridostigmine. The doses required are or better still, by movement of the reservoir
7-20 g/kg of atropine with 0.5-1.0 mg/kg bag of the breathing circuit or abdomen. If
of edrophonium and 7-15 g/kg of glyco- the block has significantly receded, the
pyrrolate with neostigmine 40-60 g/kg. patient may even open his eyes on
command or make attempts to expel the
Pharmacokinetics endotracheal tube.
Pyridostigmine has a longer elimination half 2. Drug used for antagonism: The reversal of
life and longer duration of action as compared block is most rapid with edrophonium, then
with neostigmine. 50% of neostigmine and neostigmine and then with pyridostigmine.
75% pyridostigmine are excreted by the renal However edrophonium becomes less
route. In patients with renal failure the plasma potent with respect to neostigmine as the
clearance of these anticholinesterases is reduced depth of block becomes more intense.
3. Dose of antagonist: Increasing the dose of
to the same extent or even more than the long
anticholinesterase (up to a maximum)
acting muscle relaxants. Recurarisation (the
increases the antagonism of the block more
situation where concentration of NMB rises at
rapidly and completely than with smaller
the NMJ due to waning action of anti-
doses. Beyond this maximal dose any further
cholinesterase) is therefore, not a problem in
increase in dose will not improve antagonism
these patients if NMBs are used with careful
of the block. The maximum dose for
monitoring. Edrophonium is so short acting that
neostigmine is 60-80 g/kg and for
it may be unsuitable for clinical use; however
edrophonium, 1-1.5 mg/kg. The maximum
with large doses a sustained antagonism of
effect of neostigmine occurs at 10 min. If
neuromuscular block has been seen.
adequate recovery does not occur by this
Gamma cyclodextrin derivatives and Potassium time, any further recovery is likely to be slow
channel blockers are the other group of drugs and depends on clearance of the drug from
being evaluated for antagonism of neuro- the plasma. Administration of higher doses
muscular blockade. The former can encapsulate will have no effect.
and chelate steroidal NMB drugs. 4. Rate of spontaneous recovery of the block:
It is not enough to know the dose of anti- This is the natural process of decrease in
cholinesterase to be given- far more important plasma concentration of the relaxant due to
is the timing of the reversal (as termination its elimination. Recovery of block is quicker
of action of NMB is colloquially known). Unless and easier when some spontaneous
NMB is adequately reversed the patient runs recovery has occurred. This is why reversal
the risk of inadequate breathing, hypoxemia of NMB is easier for short or intermediate
or aspiration in the post operative period. acting drugs.
5. Concentration of inhaled anesthetic:
The speed and adequacy of reversal of the block Recovery from NMB is delayed by the
are affected by the following: presence of inhalation anesthetics.
1. Depth of block at time of administration of 6. Respiratory acidosis: This can hasten
antagonist: A more intense block takes recovery due to stimulation of the
longer to recover and antagonism should respiratory centre by carbon dioxide. In fact
not be attempted until some spontaneous it was standard practice (after introduction
recovery of neuromuscular block is seen. of NMB in anesthetic practice) to add CO2
Clinically, this is evidenced by a perceptible before administering anticholinesterase. This
respiratory effort as seen on the capnograph, was to overcome the hypocarbia produced
PHYSIOLOGY OF NEUROMUSCULAR BLOCKADE AND NEUROMUSCULAR PHARMACOLOGY 45
Pattern
Patternss of Stimulation c. Tetanic stimulation is high frequency
a. Single twitch: This is the simplest form of stimulation (30, 50 or 100 Hz) which results
stimulation and consists of a single 0.1- in sustained or tetanic contraction of the
0.2 msec impulse delivered at supramaximal muscle. During normal neuromuscular
current at a frequency of 1Hz. A control transmission or a phase I block the response
value is recorded before administering the to tetanus is sustained. During a non-
relaxant. During a nondepolarising block depolarising block and phase II block a fade
there may be no reduction in its height until is seen on tetanic stimulation. During a
at least 70-75% of receptors are occupied tetanus large amounts of ACh are released
or blocked. The 1 Hz stimulation results in a from the immediately available ACh stores.
faster apparent onset of block as compared As these stores get progressively depleted
to 0.1 Hz stimulation. this is balanced by an increased synthesis
b. Train of four (TOF) was first described by and transfer of transmitter from its
Dr Hasan Ali, and consists of a sequence of mobilization stores and thus, normally,
4 stimuli delivered at a frequency of 2 Hz, neuromuscular transmission is maintained.
i.e. one stimulus every 0.5 sec. At this The presence of a nondepolarizing block
frequency the immediately available store reduces the number of free cholinergic
of ACh is depleted and the amount released receptors and also impairs the mobilization
by the nerve with each impulse decreases. of ACh within the nerve terminal resulting
Normally, even this reduced amount of ACh in a fade in the response to tetanic
is enough to elicit normal muscle contraction stimulation. When the TOF ratio is more
due to the wide margin of safety in neuro- than 0.7 the response to tetanus at 50 Hz
muscular transmission. In the presence of for 5 secs is sustained and no fade is seen.
nondepolarizing block this margin of d. Double burst stimulation consists of 2 short
safety is reduced and some end plates will tetanic bursts separated by enough time to
fail to develop propagated end plate allow relaxation, i.e. 750 msecs. These
potentials. This causes a fade in the TOF minitetani fatigue the NMJ to a greater
responses which is expressed as TOF ratio extent than 2 single twitches so that fade is
(TOFR) and is the height of the fourth exaggerated allowing a better visual and
response expressed as a percent of the first. tactile appreciation of the degree of
The disappearance of the fourth response fade. The most promising pattern seems to
in TOF corresponds to a 70-75% depression
be two trains of 3 impulses at 50 Hz
in the single twitch height. During depolari-
separated by an interval of 750 msec.
sing blockade there is no fade seen and the
e. Post-tetanic count (PTC) is based on the
height of all the twitches is uniformly
principle of post tetanic facilitation. It is
reduced. Fade in TOF after succinylcholine
useful in intense block when there is no
implies the development of a phase II block.
response to single twitch, TOF or tetanus.
When TOF stimulation is used there is no
need for a pre relaxant baseline stimulus as Tetanic stimulation results in an increase in
it is the relative height of the fourth response the store of immediately available ACh and
to the first response (the ratio) which is taken a single twitch delivered after the tetanus will
into account. It is more sensitive than single be greater than that elicited before the
twitch to detect lesser degrees of block. The tetanus. A tetanic stimulus is applied at
degree of fade is similar to that with 50 Hz 50 Hz for 5 sec and is followed 3 sec later
tetanic stimulation and it is less painful. by single twitch stimulation at 1 Hz. The
PHYSIOLOGY OF NEUROMUSCULAR BLOCKADE AND NEUROMUSCULAR PHARMACOLOGY 49
number of post tetanic twitches evoked is tion mode can be selected and the relaxant
called the post tetanic count (PTC). This given. Endotracheal intubation can be done
can be repeated not earlier than 6 min. PTC once response to TOF disappears or one can
is a prejunctional event and depends on wait a further 30-90 secs to ensure better
the relaxant used. A PTC of 8-9 implies that conditions. The onset of neuromuscular block
the first response to TOF is about to return. at the larynx is faster and corresponds to the
The main use of this mode is to: (i) monitor time when response at the adductor pollicis
intense degrees of blockade, (ii) when shows palpable weakening.
sudden patient movement is undesirable, A minimum level of neuromuscular block
and (iii) to predict time to reappearance of should be maintained to ensure adequate
first response to TOF. abdominal muscle relaxation. Intense Block
The response seen to various kinds of stimuli usually occurs 3-6 mins after injection of an
in the presence of depolarizing, nondepolarizing intubating dose of relaxant, termed the period
and Phase-II block is shown in Figure 3.11. of no response as there is no response to TOF
or single twitch. The time to return of TOF can
Method of clinical use: The nerve stimulator be estimated by PTC. If intense block is required
should be set up prior to induction of anesthesia as patient movement would be detrimental to
but stimulation should be started only once the the patient, as in ophthalmlology or neuro-
patient is asleep. The stimulation should surgery, PTC can be kept at 0 at the thumb. A
commence with single twitch at 1 Hz to select PTC of <1 indicates a deep level of paralysis,
the supramaximal stimulus. Then TOF stimula- PTC of 2-8 indicates moderately deep block
50 A PRIMER OF ANESTHESIA
whereas a PTC > 9 correlates with a TOF count If TOF count is 1-2, neostigmine is the reversal
of 1 and is usually adequate for most surgical agent of choice. Reversal should not be
procedures. attempted if TOF count is 0.
Moderate/surgical blockade begins when Adequate clinical recovery: This implies that it
the 1st response appears on TOF. With this first is safe to extubate the trachea and that the
response, twitch depression is 90-95%. When patient has adequate protective laryngeal
the 4th response appears twitch depression is reflexes and adequate respiration. Once all 4
60-85%. Adequate relaxation for most responses appear on TOF and there is no
surgeries is provided up to the appearance of detectable fade, the TOFR may be 40-100%.
the second twitch. Correlation between TOFR and recovery is
Recovery of the block: The return of the 4th given in Table 3.5.
response in TOF heralds the onset of the It is wise to use as many tests possible to
recovery phase. Response at the adductor ensure that no residual block exists. The
pollicis indicates that the laryngeal muscles and commonly used tests are tabulated in Table 3.6.
diaphragm are recovering. For adequacy of Reliable versus unreliable clinical tests are listed
reversal TOF count should be 3-4 prior to in Table 3.7. These are used when neuro-
attempting reversal of neuromuscular blockade. muscular monitoring is not available.
PHYSIOLOGY OF NEUROMUSCULAR BLOCKADE AND NEUROMUSCULAR PHARMACOLOGY 51
It is important for all physicians to have a superior consisted of inhalers like the EMO
working knowledge of the anesthesia machine, apparatus (Fig. 4.2), where gas flow occurred
breathing circuits and various airway devices. during inspiration and was dependent on patient
Apart from administration of anesthesia, these effort.
are useful for emergency airway management, Oxygen (as gas) and nitrous oxide (as liquid)
oxygenation and cardiopulmonary resuscitation are stored under high pressure in cylinders which
(CPR). cannot be directly administered to a patient
The anesthesia machine in use nowadays is owing to the danger of barotrauma. Further, at
termed a continuous flow machine since there high pressures flow rates are difficult to control.
is no interruption to gas flow in the respiratory The modern anesthesia machine overcomes
cycle. In earlier times ether or chloroform was these problems and serves the following
dropped on to a wire mask covered with layers functions:
of gauze or lint (Open-drop anesthesia 1. Can deliver compressed gases under
through a Schimmelbusch mask; Fig. 4.1). The physiologically safe pressures.
concentration of vapor delivered, oxygenation, 2. Enables the anesthesiologist to adjust flow
carbon dioxide elimination and depth of and composition of inhaled gases.
anesthesia were all variable with this technique. 3. Is capable of delivering accurate amounts
The draw-over apparatus which was more of volatile anesthetic agents.
54 A PRIMER OF ANESTHESIA
(* Some textbooks describe the cylinders, yoke blocks and pressure regulators as high pressure area, and the area from the
cylinder pressure regulating valves up to the flowmeter valves as intermediate pressure and from the flowmeters up to the
common gas outlet as low pressure).
THE ANESTHESIA MACHINE 55
Fig. 4.3: Pin index safety system for medical gas cylinders
cylinders are hydraulically tested every 5 years. for nitrous oxide and the third the pressure of
These cylinders are provided with a flush type the hydraulic test. It is the fourth side which
pin index valve (Fig. 4.3). gets attached to the machine which bears the
The contents in a cylinder, if a gas, is gas outlet and the pin index safety system
indicated by the pressure gauge. A formula that (Fig. 4.4B).
is helpful in determining how long an oxygen The pin index system (Fig. 4.3) consists of
cylinder can last is given by: seven holes positioned on the circumference of
Approximate remaining time (hours) = a circle of 9/16 inch radius centered in the port,
oxygen cylinder pressure (psig)/200 with a pair of positions designated for each gas
oxygen flow rate (l/min). If the contents are (Table 4.2). The two pins projecting from the
liquid ( as with nitrous oxide) the cylinder should inner surface of the yoke get inserted into two
be weighed and the empty weight subtracted. corresponding holes in the cylinder valve block
Reserve gas cylinders are fitted to the rear when the cylinder is suspended on the machine.
of the machine.That part of the cylinder which The arrangement of these pins is specific for each
is attached to the anesthesia machine is known gas and therefore its cylinder. The pin index
as the pin index valve block (Fig. 4.4A). It is a system prevents an incorrect cylinder
solid cuboid with four faces. One face shows being mounted at the place belonging to
the empty weight (tare), the second the symbol another gas.
56 A PRIMER OF ANESTHESIA
Table 4.2: Pin index system The pipeline inlets: Oxygen, nitrous oxide
and, in some hospitals, medical air are supplied
Gas Index Pins from a central manifold (which contains banks
Oxygen 2,5 of cylinders) through metal pipelines to the
Nitrous oxide 3,5 operating room and ICUs. These pipes are color
Cyclopropane 3,6
coded (white for oxygen, blue for nitrous
O2 -CO2 (CO2>7.5%) 1,6
O2 He (He>80.5%) 4,6
oxide). On the wall of the operating room, or
Air 1,5 the ceiling of the operating theatre, the pipeline
Nitrogen 1,4 from the manifold terminates in the form of self-
N2O-O2 (N2O 47.5%-52.5%) 7 closing sockets with quick coupling attach-
ments (Fig. 4.5). The coupling pairs are
specific in size and shape for each gas and vary
with the manufacturer. These sockets may be
present in modern theatres as gas columns and
permit only the end of the correct hose to engage
in them and open them. At the machine end,
the diameter-indexed safety system (DISS, Fig.
4.6) permits the attachment of the correct hose
only to be screwed on to the machine so that
interchangeability is virtually eliminated.
Yoke Assembly
The hanger yoke assembly (Fig. 4.7) orients and
supports the cylinder and connects it to the
machine. A gas-tight seal is provided with a
Bodok sealing washer, made of rubber with a
Fig. 4.4A: Face of pin index block showing tare
weight, company and ISI marking metal periphery. This should be inspected for
integrity every time a cylinder is changed. The
pins on the yoke (which are part of the Pin Index
system) are 4 mm in diameter and 6 mm long.
A one-way check valve present immediately
downstream of the hanger yoke has three
important functions:
i. It prevents a cylinder under higher pressure
from emptying into one with lower pressure.
ii. It allows change of cylinder on the machine
without gas leaking out.
iii. It prevents leaking and emptying of a
cylinder left open even if one cylinder is
absent from a yoke.
There is usually a single pressure gauge for
two similar cylinders hung on the machine
Fig. 4.4B: Face of pin index block of nitrous oxide downstream of the check valve and it shows the
cylinder showing holes for pins pressure in the cylinder having the higher
THE ANESTHESIA MACHINE 57
Pressure Regulator
The pressure in a cylinder is high and variable
as it changes with the contents and temperature.
The cylinder pressure regulator is a pressure-
regulating valve which converts the high variable
pressure in the cylinder into a constant
working pressure suitable for use in anesthesia
machine, usually 45-47 psig. These regulators
Fig. 4.5: Quick coupling attachments
work on the principle that high pressure exerted
by the cylinder contents over a small area is
balanced by reduced pressure exerted over a
large area.
Fig. 4.7: The hanger yoke assembly:shows retaining screw opened (l) and in place (r).
note bodok washer and pins
58 A PRIMER OF ANESTHESIA
Fig. 4.8: The flowmeter assembly (l) and an enlarged view of the Thorpe tube (r)
oxygen failure protection device) which flow by a chain-gear system and cannot be
proportionately reduces the pressure of nitrous independently turned on; this way a minimum
oxide as oxygen pressure falls. of 21-25% oxygen is always present in the gas
mixture.
Flowmeter Assembly Minimal oxygen flow of 150 ml/min which
All the flow meters have a flow control valve, a starts as soon as the machine is switched on is
graduated stem (which is a glass tube) to another safety mechanism.
measure and see the flow and an outlet. The
flow meter used in modern anesthetic machines Oxygen Analyser
is of the variable orifice type and is made up of The use of an oxygen analyzer with an
a transparent tapered tube known as Thorpe anesthesia system is the single most foolproof
tube (Fig. 4.8). A float which moves up when
the gas is turned on and keeps rotating indicates
gas flow. The flow control valve is a needle valve
or pin valve used to adjust the amount gas
entering the flowmeter block. The knob which
rotates the needle valve is color and configu-
ration coded; the oxygen knob is large,
fluted and white and always situated towards
the gas outlet of the machine (Figs 4.9A to C).
This is to prevent escape of oxygen and delivery
of a hypoxic mixture in the event of a crack in
the flowmeter (Fig. 4.10). Another safety feature
of the machine incorporated in the flowmeter
assembly is the flow controller mechanism
whereby the nitrous oxide is linked to oxygen Fig. 4.9A: Large, fluted oxygen flowmeter knob
THE ANESTHESIA MACHINE 59
Fig. 4.11: Vaporizers on back bar of anesthesia Fig. 4.12: Common gas outlet
machine
Fig. 4.15: Patient end of Bain circuit. Note inner Fig. 4.16: Jackson-Rees modification of
tube attached to outer by 3 spokes Ayres T piece
ends at the reservoir bag and incorporates an drag on the pediatric endotracheal tube. The
expiratory valve at the reservoir bag end. The FGF required to prevent rebreathing for
Bain circuit has many inherent advantages: spontaneous ventilation is 2-3 times the
1. It is lightweight and convenient to use. minute ventilation; that for controlled, 2 times
2. It is re-usable and easily sterilizable. the minute ventilation.
3. It can be used for both spontaneous and We discussed semiclosed systems till now
controlled ventilation without making any where provision of a designated FGF was
changes in connection, valves, etc. required to prevent rebreathing. With increasing
4. Exhaled gases in the outer tube warm the awareness to reduce theatre and atmospheric
inspired FGF. pollution by inhaled volatile anesthetics and for
5. Scavenging of exhaled gases is easy due to purposes of economy a circuit had to be devised
the expiratory valve being situated away which would absorb the exhaled carbon dioxide
from the patient.
and so enable recycling of unused oxygen and
Proper functioning of the Bain circuit should
volatile agent, thereby minimizing spill and
be ascertained by checking the integrity of the
wastage. The answer was the closed circuit
inner tube. If broken or kinked it leads to severe
(Fig. 4.17). The normal FGF used is 1litre. A
hypercarbia. For spontaneous ventilation, FGF
sterilizable canister packed with high-moisture
needed to prevent rebreathing is 2.5 times the
minute ventilation and for controlled ventilation soda lime (80% calcium hydroxide, 15% water,
it is 1-2 times the minute ventilation. 4% sodium hydroxide and 1% potassium
The Jackson-Rees modification of the hydroxide) is interposed in the circuit. The
Mapleson E circuit (Mapleson F, Fig. 4.16) is reaction that occurs in the sodalime canister is
widely used in pediatric anesthesia. You will as follows:
notice that it has no valves, which explains the CO2 + H2O H2CO3
low resistance it offers .It also has advantages
H2CO3 + 2NaOH Na2CO3 + 2H2O + Heat
of simplicity, allowing spontaneous or controlled
ventilation and is lightweight so that there is no Na2CO3 + Ca (OH)2 CaCO3 + 2NaOH
THE ANESTHESIA MACHINE 63
Use of the closed circuit results in economy, discussion of the circuit components is out of
prevention of theatre pollution and preven- the purview of this text. Compounds generated
tion of chronic exposure of personnel to due to the interaction of sodalime with
inhalational agents, and conservation of heat inhalational agents is detailed in the section on
and humidity in the inspired gases. A detailed inhalational agents.
Preoperative Evaluation of Patients
Anjolie Chhabra
taken jointly by the surgeon and anesthesio- scheduled, e.g. control of diabetes and
logist. hypertension.
Obtaining informed consent from the patient Saving of hospital and patient expenditure
after explaining the risks and benefits of the by shortening stay.
procedure, and the nonsurgical options Better utilization of hospital beds by faster
available. This is especially important where turnover.
major surgery (for example, in advanced Reduces patients anxiety regarding the
malignancy) is being contemplated, which procedure, especially after reassurance and
may involve life-threatening morbidity or discussion of postoperative pain manage-
disability without significantly prolonging ment. This has been shown to reduce
survival. Informed consent is also required tachycardia and stress in patients with IHD.
for procedures like tracheostomy and Enhances patient satisfaction about the
colostomy as these can adversely affect the quality of hospital care and the fact that his/
social lifestyle of the patient. Occasionally the her medical conditions have been adequately
patient may be aware of only the anticipated taken care of.
benefits of a procedure and not the risks
involved, and these should be explained by A Stepwise Approach to Preanesthetic
the surgeon or anesthesiologist who has the Evaluation
complete picture.
History
Planning appropriate anesthetic technique
and monitoring keeping in mind the length A. General:
and nature of surgery, positioning, the Previous anesthetic exposure and any
patients choice and feasibility and benefit untoward event: These could be a cardio-
of regional anesthetic techniques. Blood and vascular event, difficulty in intubation,
blood products are requisitioned if trans- anaphylaxis, reaction to blood or blood
fusion is anticipated. products. Check for documentation, similar
Ordering pharmacologic premedication history in close relative or sibling.
wherever necessary and appropriate. Any known systemic illness; whether on
Planning appropriate postoperative care medication; what are the current medica-
including analgesia and ventilatory support. tions?
Hospitalization in the last 2 years and need
What are the Benefits of Preoperative for ECG/X-ray in the last year.
Evaluation? Known drug allergies to local anesthetics,
Morbidity resulting from systemic illness is non-steroidal anti-inflammatory drugs
reduced or avoided by instituting specific (NSAIDs) radiological contrast/latex.
measures, e.g. reduction of postoperative History of mild chronic medication
pulmonary complications in a patient with (including nasal sprays, eye drops, metered
chronic bronchitis by chest physiotherapy dose inhalers)
and breathing exercises. Other examples are Possibility of neuromuscular disease,
cessation of smoking, immunization against especially muscular dystrophy in children.
pneumococcus and nutritional fortification. Possibility of pregnancy in pre menopausal
Unnecessary postponement of surgery is women
avoided, as co-morbid conditions are History of smoking and/or tobacco use in any
detected and treated before surgery is form.
66 A PRIMER OF ANESTHESIA
Pregnant patients for obstetric/non- anesthesia has obviated the need for long
obstetric procedures, owing to the acting drugs like morphine, meperidine
increased possibility of regurgitation (pethidine) and butorphanol. However, there
and aspiration with the use of general are some situations where narcotic
anesthesia. premedication is still indicated:
All obese patients, for the same reason. a. Patients with cardiac disease: Morphine
All patients with a difficult airway who administration shifts blood from the
are likely to experience multiple attempts central circulation to the periphery,
at intubation. reducing symptoms of pulmonary con-
Patients for emergency surgery after gestion and dyspnea. It also provides
trauma (e.g. fracture reduction who have sedation and euphoria, thus reducing
had a meal before injury). tachycardia caused by anxiety. Lastly it
(Patients with pheochromocytoma should reduces the pain caused by pre-induction
not be prescribed metoclopramide as it can procedures like intra venous cannulation.
precipitate a hypertensive crisis). The dose of morphine recommended for
3. Atropine: the routine use of this once pre-medication is 150-300 g/kg
ubiquitous drug is now questioned. Some administered through the intra-muscular
indications for its use still remain, however. route. Concomitant administration of a
They are: phenothiazine like promethazine
Infants (and most neonates) undergoing
(Phenergan) in a dose of 0.25-0.5 mg/
routine or emergency procedures under
kg is useful to counteract nausea induced
anesthesia, because of the high incidence
by morphine.
of bradycardia at induction and laryngo-
b. Patients with a painful condition like a
scopy. The intravenous (IV) dose used is
fracture where moving the patient is made
20g/kg.
less uncomfortable. Morphine 150-
Patients undergoing oral surgery and
dental procedures, to keep the operative 130 g/kg or meperidine (pethidine) in
field clear of saliva. Glycopyrrolate a dose of 1-1.5 mg/kg can be used, along
(10-20 g/kg), IV or IM is a better with promethazine.
choice for antisialagogue effect owing to 5. Concurrent medications: patients should take
the absence of cardiac effects. their routine morning dose of all drugs,
Side effects: Hyperpyrexia may occur after especially antihypertensives, beta blockers
intramuscular (or even topical application as and anti-anginal drugs. Exceptions are:
ophthalmic ointment) administration in (i) ACE- inhibitors, which may cause
children. Glaucoma can worsen or central profound hypotension with spinal anesthesia
anticholinergic syndrome may develop and should be discontinued; (ii) Diuretics,
in elderly adults. which can cause electrolyte imbalance and/
4. Narcotics are rarely used routinely for pre- or dehydration; (iii) Insulin and oral
medication. For example, in surgical hypoglycemic agents; (iv) Tricyclic anti-
procedures being performed on day-care depressants and MAO inhibitors.
basis, nausea and respiratory depression Systematic assessment is the most important
sedation may delay discharge. The availa- way by which we can detect abnormalities which
bility of potent, short acting narcotics like can adversely affect patient outcome, and this
alfentanil, remifentanil and fentanyl knowledge and preparedness are the strongest
combined with the judicious use of regional weapons which minimize morbidity.
72 A PRIMER OF ANESTHESIA
Renal: End stage renal disease is commoner Frequency and severity of hyperglycemic
in diabetics than non-diabetics. and/or hyperglycemic episodes.
Peripheral neuropathy: This is common in Neurological symptoms- stroke, tingling/
diabetics. Preoperative neural deficit should numbness, mononeuropathy, glove-and-
be identified and care should be taken to stocking paresthesia, etc.
protect the patient from nerve compression Diarrhea after meals, reflux esophagitis.
intraoperatively. After spinal or epidural Examination:
analgesia the patient is likely to associate any Weight, body habitus
new neurological deficit with the technique Blood pressure in sitting and standing
and not the disease and appropriate positions
explanation and consent are important. Prayer sign (Fig. 5.7)
Autonomic neuropathy: Manifests as resting Airway assessment
tachycardia, absent heart rate variability with Neurological examination to document
respiration (variability is normally 10-15 any deficit
beats per minute between inspiration and Anatomy of spine for feasibility of spinal
expiration). The other manifestations are anesthesia
orthostatic hypotension, gastrointestinal Relevant preoperative investigations
dysmotility and impotence. The hallmark of diabetes is a fasting blood
Absence of sympathetic nervous system sugar greater than 126 mg/dl or a random
response leads to absence of warning blood sugar of more than 200 mg/dl.
signs of hypoglycaemia, hypovolemia Glycosylated hemoglobin (Hb AIC) levels
and hypothermia (patients with autonomic reflect adequacy of control over the
neuropathy have a greater decrease in core preceding 1-3 months. Levels between
body temperature than non diabetics). 5-7% of total hemoglobin are normal
Undetected hypothermia may cause silent whereas more than 9% indicates poor
MI or sudden cardiac death in the periopera- long term glucose control.
tive period. Laboratory investigations include deter-
Airway problems: Abnormal glycosylation of mination of blood sugar, blood urea,
collagen in long- standing diabetes can result serum creatinine, serum electrolytes and
in limited joint mobility in the small joints of urine analysis for glucose, ketones and
the hand (Fig. 5.7) as well as the atlanto- proteins.
occipital joint resulting in limited neck Goals of optimization
extension and difficulty in intubation. To avoid hypoglycaemia as well as
Metabolic derangements: Inadequate blood hyperglycaemia and maintain blood
sugar control can lead to osmotic diuresis, sugar between 120-180 mg/dL.
hypovolemia, ketosis or keto acidosis. Identification of associated end-organ
disease and initiation of interventions to
Preoperative Assessment limit cardiovascular, renal and metabolic
Historyregarding complications.
Duration of the disease and drug therapy
the patient is receiving, i.e. oral hypo- Optimal Anesthetic Management
glycemic agents or insulin. Pre-anesthetic Instructions:
Adequacy of control of blood sugar. Ideally a diabetic patient should be
Symptoms suggestive of cardiovascular scheduled as the first case in the morning to
disease. minimize metabolic complications.
76 A PRIMER OF ANESTHESIA
Type I diabetics: Half the usual dose of short- hormones and thus protects against severe
acting insulin should be administered on the rise in blood sugar.
evening before surgery. Withold insulin on
Precautions
the morning of surgery; blood sugar levels,
1. In the presence of pre-existing peripheral
serum electrolytes as well as urine assay for
neuropathy local anesthetic requirement can
sugar and ketones is carried out on the
be significantly reduced and pre-existing
morning of surgery. A neutralizing drip
neurological loss should be recorded to avoid
(containing 8U regular insulin in 500 ml 5%
medicolegal claims.
dextrose) at the rate of 100-125 ml/hour is
2. In patients with autonomic neuropathy
then started. Alternately, separate infusions profound hypotension can occur after spinal
of dextrose at 100 ml/hour (5 g glucose in or epidural block.
an hour) and 1-2U insulin/hour are adminis-
tered. Blood sugar estimations are done General Anesthesia:
hourly to keep the level between 120-180 The airway should be secured with an
mg/100 ml. endotracheal tube as there is risk of
Type II diabetics: Patients with blood sugars regurgitation and aspiration because of
controlled on diet and oral hypoglycemic gastroparesis.
drugs should withold the oral hypoglycemic Premedication should include anti aspiration
agent with the exception of acarbose on the prophylaxis with metoclopramide and H2
morning of surgery. For minor procedures receptor blocker.
where the patient is likely to be allowed oral Choice of anesthetic agents is not very
intake a couple of hours postoperatively, important as long as maximal stress suppres-
blood sugar is monitored every 2 hours and sion achieved with good analgesia to prevent
the patient encouraged to restart oral intake counter- regulatory hormone- induced
as soon as possible and oral hypoglycemics hyperglycemia.
the next day. Precautions should be taken for cardio-
Type II diabetics undergoing major vascular stability and protection of peripheral
abdominal surgery will required to be nerves from injury. Careful perioperative
admitted at least 48 hours before surgery, hemodynamic and blood sugar monitoring
started on neutralizing drip with insulin or is important.
on separate insulin and glucose infusions as
described for type I diabetics. Valvular Heart Disease
Why should the anesthesiologist be concerned
Anesthetic Technique about valvular heart disease?
All types of valvular disease cause a burden
Regional anesthesia should be used whenever
to be imposed on the right ventricle, the left
feasible.
ventricle, the pulmonary or systemic circulation,
Advantages singly or in combination. All anesthetic agents
1. The patient can alert the anesthesiologist if as well as regional anesthetic techniques affect
he feels uneasy, and complications such as cardiac performance, pulmonary and systemic
hypoglycemia or myocardial ischemia may vascular resistance. Further, the stress of surgery
be diagnosed in time. or pregnancy adds additional burden on the
2. The use of spinal epidural or regional already precarious circulatory homeostasis in a
blockade decreases the stress response to patient with valvular disease. Thus, it is
surgery by modulating secretion of catabolic imperative that the anesthesiologist has a
PREOPERATIVE EVALUATION OF PATIENTS 77
Table 5.5: Classification of hypertension compliance with drug therapy and symptoms
Stages Systolic arterial Diastolic arterial of IHD.
pressure pressure
(mm Hg) (mm Hg) Investigations
Stage 1 (mild) 140-159 90-99 An EKG, a chest X-ray and an echocardio-
Stage 2 (moderate) 160-179 100-109 gram are desirable to evaluate the presence
and extent of myocardial ischemia, cardio-
Stage 3 (severe) > 180 > 110
megaly, left ventricular hypertrophy, to
estimate left ventricular function including
vascular resistance (SVR), cardiac output the presence of regional wall motion abnor-
increases. With a persistent increase in afterload, malities.
concentric left ventricular hypertrophy (LVH) Ophthalmoscopy can be done to ascertain
develops to maintain cardiac output at normal hypertensive retinal changes
levels. Auto-regulatory limits of perfusion of vital Renal function can be evaluated by serum
organs such as brain, heart, kidneys are reset creatinine, blood urea nitrogen levels and
to higher levels. Classification of hypertension serum electrolytes.
is shown in Table 5.5.
Accelerated hypertension is defined as a Premedication
recent progressive increase in BP above Antihypertensive medications should be
180/110 mmHg which may be associated with taken on the morning of surgery with a sip
renal dysfunction. of water. Diuretics may be omitted unless
Malignant hypertension is defined as a BP the patient is in congestive failure or fluid
reading greater than 220/114 mmHg associated overload.
with papilledema and encephalopathy. This is Anxiolysis with diazepam 0.2 mg/kg on the
a medical emergency. night before and 2 hours prior to surgery or
intravenous midazolam prior to surgery is
Preoperative Optimization helpful in reducing preoperative anxiety-
Ideally hypertensive patients scheduled for induced increase in blood pressure and is
elective surgery should have their BP controlled highly desirable in hypertensive patients.
with antihypertensive drugs. Mild hypertension
is usually controlled with a single drug (- Anesthetic Management
blockers, calcium channel blockers, ACE inhibi- The overall anesthetic plan for hypertensive
tors or diuretics). For moderate to severe hyper- patients is to maintain the pressures between
tension two or more drugs may be required. 10-20% of the pre-induction pressures.
The blood pressure should be measured in Any anesthetic drug is suitable for induction
both supine and standing position. It may except ketamine because of its propensity to
be necessary to keep a 6 or 8 hourly record cause tachycardia and hypertension. A
to see adequacy of control throughout the balanced anesthesia technique using opioid,
day in severe hypertensives or when inhalational agents and muscle relaxant can be
modifying treatment. The anesthesiologist routinely used intraoperatively. In- blocked
may want to see this chart. patients, concomitant use of fentanyl and
vecuronium may exaggerate bradycardic
Preoperative Evaluation response.
History to be elicited from a hypertensive To blunt the intubation response (i) intra-
patient include duration of hypertension, venous lignocaine 1.5 mg/kg IV 60-90
80 A PRIMER OF ANESTHESIA
seconds prior to intubation, (ii) fentanyl (the oxygen delivered to tissues per minute) is
2 g/kg or esmolol 150-300 g/kg/min can derived by the following formula:
be used. 1. Oxygen content = [(0.003 ml O2/100 ml
Intraoperatively, patients with poor anti- blood/mmHg) PO2] + [SaO2 Hb%
hypertensive control can have swings in 1.31 ml/100 ml blood]
blood pressure. A wide range of agents are = [0.003 100] + (0.975 15 1.31)
available for intraoperative control of blood = 19.5 ml/100 ml blood
pressure (Table 5.6). 2. 20 ml O2/100 ml blood 5000 ml/min
Regional anesthesia, especially graded (cardiac output)
epidural or combined spinal epidural block =1000 ml/min
are the anesthetic techniques of choice in That is, the normal oxygen content of
hypertensives if feasible for the surgery under arterial blood is 20 ml/100 ml only if the Hb is
consideration. These techniques not only 15 g%. Since arterio-venous oxygen difference
provide good intraoperative and post- is 4.7 ml/100 ml, the body normally consumes
operative analgesia but also avoid the hyper- only 25% of the oxygen carried in blood. If the
tensive response to intubation/extubation. hemoglobin is reduced by 50% (7.5 g%), the
Postoperative monitoring of blood pressure content drops to 10 ml/100 ml, but the
should be continued. extraction increases at tissue level to maintain
normal arterio-venous difference. Three more
Anemia changes help oxygen delivery in the anemic
Anemia continues to be a common problem in patient: (i) reduced hemoglobin reduces
developing countries. viscosity and improves microcirculation;
From the anesthesia point of view, reduc- (ii) levels of 2,3 diphospho glycerate DPG
tion in hemoglobin reduces the oxygen increase in the reticulocytes which reduce
carrying capacity of the blood. Oxygen flux affinity of hemoglobin for oxygen and help to
Table 5.6: Antihypertensive drugs which can be used for intraoperative blood pressure control
offload it in the tissues. This causes a rightward tation of parameters like heart rate, blood
shift of the oxygen dissociation curve; (iii) pressure, CVP and urine output are
cardiac output increases due to increase in important clinical guides for good patient
plasma volume and stroke output. outcome.
Important points regarding clinical manage- 6. Regional anesthesia is well tolerated by the
ment and optimization: anemic patient who is not in failure.
Adequate replacement of fluid or blood lost Supplemental oxygen should be given even
during surgery. during minor procedures, to fully saturate the
Stored RBCs take up to 24 hours to circulating hemoglobin.
regenerate 2,3 DPG; hence preoperative 7. For general anesthesia, all induction and
transfusion for an anemic patient should be inhalational agents are tolerated. The
given at least 24 hours prior to surgery. hyperdynamic circulation may hasten
Cyanosis is detectable clinically only when intravenous and inhalational induction.
deoxyhemoglobin level is 5 g%. Hence in Minimum alveolar concentration (MAC) of
severely anemic patients cyanosis is rarely inhalational agents therefore patients are
seen. induced at lower inspired concentrations of
inhalational agents has been seen to reduce
Anesthetic Technique, Monitoring and when the hematocrit reduces to < 10%.
Precautions in the Anemic Patient Agents causing tachycardia (pancuronium,
ketamine, atropine) can be avoided; if
1. Although 10 g% is the international norm
congestive cardiac failure is/was present, an
for minimum acceptable Hb levels for opioid-based technique (with morphine or
elective procedures, many authorities now fentanyl) is more suitable. Patients who have
accept a value of 8 g% in those who have had massive transfusion or major fluid shifts
no cardiac disease. pulmonary edema or are hypothermic may
2. Packed red cells should be cross-matched benefit with postoperative ventilation till fluid
and kept ready. compartments normalize.
3. Maximum allowable losses are kept at 10% 8. Postoperative care should include manda-
of estimated blood volume for the anemic tory oxygen therapy, checking and normali-
patient when considering replacement for zing the hematocrit and avoiding tachycardia
surgical losses. Tachycardia is a sensitive and pulmonary complications by judicious
guide and signals an attempt by the body to analgesia. Morphine is an excellent analgesic
increase cardiac output and maintain oxygen in this setting and may be given as IV bolus,
delivery. IV infusion, PCA or through the neuraxial
4. Standard monitoring suffices for minor route.
(cataract, surface biopsies) and moderate Many other conditions notably ischemic
(hernia repair, hysterectomy, gastrojejunos- heart disease, neuromuscular disease and
tomy) procedures where minimal blood loss hepatic and renal impairment affect anesthetic
is anticipated. management and require the anesthesiologist to
5. For major procedures involving fluid shifts be well versed in their diagnosis, presentation
and blood loss (abdomino-perineal resec- and interpretation of investigations to judge their
tion, Whipples procedure, major limb severity and to plan an appropriate anesthetic
disarticulation) CVP and invasive arterial technique. Thorough preoperative evaluation
pressure monitoring along with urine output reduces or eliminates avoidable perioperative
help to keep close track of volume status. morbidity, aids in perioperative planning and
Careful patient observation and interpre- improves outcome.
82 A PRIMER OF ANESTHESIA
MCQ
MCQss 4. A 55 years old male patient a known
asthmatic for the last 10 years is
1. The most important aim of preopera- scheduled for a laparoscopic chole-
tive evaluation of a patient prior to cystectomy. On preoperative evalu-
surgery is: ation the patient is found to have
a. To reassure the patient and his relatives. bilateral rhonchi. The following
b. To evaluate and optimize the co-existing should be immediately administered
medical disorders the patient may be to the patient:
suffering from. a. Steam inhalation and antibiotics.
c. To record vital signs and order sedation/ b. Nebulized 2 agonists and anti-
anxiolytics. cholinergic medications.
d. To ascertain the indication for the c. Intravenous aminophylline infusion.
surgery. d. Chest physiotherapy and incentive
2. A 25 years old student, a juvenile spirometry.
diabetic since the age of 12 years who 5. A 35 years old male is brought to the
is not eating regularly and also not casualty following a road traffic
taking insulin as prescribed due to accident. The patient is conscious but
examination stress is brought to the disoriented with a feeble pulse and
hospital casualty with acute pain unrecordable blood pressure. Blunt
abdomen. The following should be trauma to the abdomen is suspected.
done: The following should be done first:
a. The patient should be rushed first for a. A large bore I/V lines secured and
ultrasound abdomen. blood sent for cross match
b. Dextrose containing intravenous fluids b. Patient rushed to the OT for an emer-
should be administered. gency laparotomy.
c. Estimate the blood sugar and urine for c. The trachea should be immediately
sugar and ketones. secured with an endotracheal tube
d. Take up the patient for an emergency (ETT).
laparotomy. d. Large bore I/V lines secured and crystal-
loids rushed into the patient.
3. The following fasting guidelines are
acceptable for a 3 month old baby 6. A 28 years old primigravida with an
scheduled for a herniotomy under anticipated difficult intubation is
general anesthesia. scheduled to undergo an elective
a. Formula milk feed administered 4 LSCS. The anesthetic technique of
hours prior to surgery. choice would be:
b. Mothers milk administered 4 hours a. General anesthesia with an awake
prior to surgery. intubation.
c. Formula feed administered 2 hours b. Spinal anesthesia
prior to surgery. c. Epidural anesthesia
d. Mothers milk administered 6 hours d. General anesthesia combined with
prior to surgery. spinal anaesthesia.
PREOPERATIVE EVALUATION OF PATIENTS 83
7. An 80 kg, 55 years old female patient 11. All the following are features of
with a height of 5 ft is posted for difficult intubation except:
hemicolectomy under GA. The most a. Mallampatti grade III, IV oropharyngeal
preferred airway device to secure the view.
airway would be: b. Mento-hyoid distance of 1.5 cm
a. Proseal LMA (laryngeal mask airway) c. Thyromental distance of 6.5 cm
b. Classic LMA d. Restricted mouth opening with an inter-
c. LMA unique incision gap of 1.5 cm.
d. Endotracheal tube 12. Which of the following medicines is
8. The following condition is associated discontinued on the morning of
with a difficult intubation in a surgery even if the patient is otherwise
diabetic patient: taking them regularly?
a. Poorly controlled blood sugars a. Metoprolol
b. Orthostatic hypotension b. Insulin
c. Nifedipine
c. Inability to approximate the inter-
d. Pioglitazone
phalangeal joints of the fingers of the 2
hands held in apposition with the palm 13. A patient with history of unstable
facing inwards angina would be classified as:
d. Presence of diabetic retinopathy, a. ASA grade I
nephropathy. b. ASA grade II
c. ASA grade IV
9. During preoperative evaluation in a d. ASA grade V
patient of insulin dependent diabetes
mellitus, history of which of the 14. Which of the following drugs is not
following complaints is most signi- administered to a day care surgery
ficant: patient who is driving from home on
a. History of blood sugars going upto 200 the morning of surgery?
mg % occasionally. a. Diazepam
b. History of orthostatic hypotension and b. Ranitidine
dizziness. c. Metoclopromide
c. History of getting up several times at d. Metoprolol
night to empty bladder. 15. The minimum acceptable hemoglobin
d. History of low blood sugar during which concentration for a 21 year old
the patient feels dizzy. scheduled for herniorrhaphy is:
a. 10 g%
10. A 65 years old male patient, a chronic
b. 9 g%
smoker for the last 30 years with atrial c. 5 g%
fibrillation on oral anticoagulant is d. 7 g%
scheduled for left toe amputation due
to gangrene. The least indicated Answers
anaesthesia technique is:
a. General anaesthesia 1. b 2. c 3. b 4. b
b. Femoral and sciatic nerve block. 5. d 6. b 7. d 8. c
c. Combined spinal epidural anaesthesia. 9. d 10. c 11. c 12. b
d. Ankle block 13. c 14. a 15. d
Monitoring the Patient
Under Anesthesia
K Nirmala Devi, Rajeshwari Subramaniam
Importance of monitoring Wh
Whyy is Monitoring Necessary?
Noninvasive monitoring Strange as it may sound, although anesthesia is
ECG integral to any surgical procedure, it is still
Non-invasive blood pressure (NIBP) considered as incidental. Harvey Cushing, the
Pulse oximetry famous neurosurgeon realized that anesthesia
Capnography techniques were associated with labile hemo-
Invasive arterial pressure monitoring dynamics, and advocated monitoring of heart
Temperature monitoring rate and respiration by a precordial stethoscope.
Neuromuscular monitoring A risk management committee set up at
Selection of appropriate monitor Harvard to examine insurance claims for intra-
operative deaths from 1976-1985 found that
nearly 31% of these deaths were preventable,
What is a Monitor?
Monitor?
and occurred due to multiple reasons
A monitor is a device, which cautions, reminds, (unfamiliar equipment, lack of knowledge and
advises or admonishes. In anesthesia practice supervision, esophageal intubation, circuit
we refer to devices which record or follow a disconnect, kinked endotracheal tube, etc). Most
process/processes as monitors. Monitors serve of them occurred not in old or sick patients but
to act as extensions of our senses because the
previously healthy individuals. The common
physical principles they are based on enables
denominator was failure to detect low oxygen
them to detect physical quantities which are
levels or failure to detect absence of ventilation.
outside of the normal physiological range for
humans. A simple example is the estimation of This committee found that pulse oximetry and
arterial desaturation- the human eye can detect capnography could have probably prevented
a fall in SpO2 only when cyanosis occurs (PaO2 more than 90% of the mishaps. It also
< 80 mm Hg) whereas a monitor detects even recognized the fact that physicians were
a 1% fall. Thus they enhance our vigilance. responsible for the patients safety and well
Monitors are also used to collect specific data being.
which are important for morbidity profiling and Thus, monitoring in ASA-I-II (normal)
formulating treatment protocols. patients is necessary to:
88 A PRIMER OF ANESTHESIA
Chest leads V5 and V4 are useful for ischemia The non-invasive methods that can be used
detection. However, it is recommended to are as follows:
monitor both II and V as each provides unique - Palpation and auscultation: This is the least
information. A modified V5 can be monitored expensive method; however systolic
by re-arranging the limb leads. If the LA lead pressure may be underestimated. Mean
is placed at V5 and lead I is selected, a modified arterial pressure values are not obtainable.
V5 lead is displayed. Esophageal leads are sensi- Observer variability tends to be high.
tive for arrhythmia detection. Needle electrodes Auscultatory gap has to be kept in mind in
can be used in the extensively burnt patient. hypertensive patients. Korotkoff sounds
may be difficult to hear in the presence of
Non-invasive Blood Pressure (NIBP) electrocautery, in hypotension or
Monitoring vasoconstriction. Position of the BP
Blood pressure monitoring is mandatory no apparatus (Figs 6.2A and B) induces change
matter how short or trivial an anesthetic is. in reading- e.g. a difference of height of 20
Any of the techniques (see below) can be used; cm =14.7 mm Hg in pressure. Too small a
it is important to avoid placing cuffs on arms cuff gives erroneously high readings because
that have hemodialysis shunts, intra arterial or more pressure has to be applied on a small
intravenous lines. area to occlude the artery. Cuff width should
be 120-150% of the width of the upper arm
(Fig. 6.3).
- Doppler probe: A Doppler probe emits an
ultrasonic signal that is reflected by the
flowing blood. The probe has to be directly
over the artery and a coupling gel is applied
between the probe and skin. This technique
is sensitive for systolic pressures only.
- Oscillometric technique: This is the most
commonly used automated blood pressure
measurement technique. The principle is
based on the fact that when blood flow
A B C
Figs 6.5A to C: Appropriate cuff size
MONITORING THE PATIENT UNDER ANESTHESIA 91
Rajeshwari Subramaniam
Fig. 7.4A: The vein is made prominent Fig. 7.4D: Tip of cannula occluded
Fig. 7.4B: Blood enters the flash back chamber Fig. 7.4E: Dressing applied and IV fluid connected
TECHNIQUE OF ARTERIAL
CANNULATION
Arterial cannulation is performed (commonly
in either of the radial arteries) when continuous
monitoring of the blood pressure (BP) is vital
for a good outcome. Examples are mentioned
in Chapter 6. Arterial pressure is measured by
an electronic transducer and displayed on the
monitor.
The radial artery is normally chosen because
of its superficial location and ease of access, and
also the fact that the ulnar artery provides good
collateral flow to the hand. The modified Allens
Fig. 7.4C: Cannula slid over stylet test is performed to ensure good collateral
100 A PRIMER OF ANESTHESIA
Fig. 7.6B: Palpating the carotid artery Fig. 7.6E: Triple lumen catheter sutured in place
VASCULAR CANNULATION 101
AA D
D
BB E
E
Fig. 7.7A to E: Steps in cannulation of radial artery
Fig. 8.5: Two handed mask ventilation PROBLEMS WITH MASK VENTILATION
1. Airway obstruction: In spite of the head-
tilt and jaw thrust maneuvers, the airway
Mask Ventilation may still be obstructed due to a large tongue
This is one of the most important aspects of or obesity.
airway management. Ability to ventilate well How do you diagnose airway obstruction
with a mask even if one fails to accomplish if the patient is (i) making respiratory efforts
intubation ensures that the patient is safe (Table 8.1)?
and well oxygenated till help arrives or Paradoxical respiration is so termed
until other alternative techniques are being because the chest moves inward during
considered. On the other hand if mask inspiration instead of the common outward
ventilation is not easy or improperly performed movement, so that a rocking pattern is
it jeopardizes the patients safety if there is a seen. This is because the patient making an
delay in intubation or a failed intubation. effort to breathe generates a high negative
Mask ventilation can be performed with one intrathoracic pressure while trying to inspire
hand (Fig. 8.4) or both (Fig. 8.5). If the patient through an obstructed airway; this causes
is breathing spontaneously through the the chest wall to get sucked inwards. (ii) If
AIRWAY MANAGEMENT 105
Fig. 8.10A: Opening the mouth by Fig. 8.10.D: Introducing the endotracheal tube
depressing the jaw
108 A PRIMER OF ANESTHESIA
Adult males can be intubated with size 8.0 or In prolonged intubations (as in ICU patients) if
8.5 mm ID cuffed PVC endotracheal tubes. (A cuff pressure is consistently above capillary
description of various endotracheal tubes is pressure, deep ulcerations occur involving the
given in the section on Anesthesia Equipment). cartilage. Ultimately this heals by stricture
Cuffed endotracheal tubes of size 7.0 or 7.5 formation. The majority of patients of tracheal
mm ID are suitable for adult female patients. In stenosis have a history of prolonged intubation.
children it is important to be aware of the size The amount of air in the cuff is thus a matter
of the appropriate tube which is usually of concern. To regulate the amount injected into
calculated by age. The width of the small finger the cuff, a hand is kept over the sternal notch
of the hand is often used as a rough guide. Table where a gurgle is felt and heard as air leaks
8.2 lists the appropriate tube size for children. with every inspiration. Air is injected through
The endotracheal tube is held with the tips the one-way valve of the pilot balloon in
of the thumb, index and middle fingers of the increments till the leak is not felt or heard.
right hand and brought in an inclined manner In children up to 8 years of age non-cuffed
towards the mouth so that the vision of the tracheal tubes (Fig. 8.11) are preferred so that
glottis is not obscured (Fig. 8.10D). It is always there is no compromise on the maximal
inserted under vision. The tube should be seen external diameter possible that can be used. The
actually entering the larynx and the cuff resistance offered to breathing through a tube
positioned immediately below the vocal cords. is inversely proportional to the fourth power of
The black ring marked just above the cuff should the radius of cross section of the tube. Further,
be positioned at the level of the vocal cords. selection of the largest size that comfortably
Occasionally in an anteriorly placed larynx we passes through at the level of the cricoid
may have to shape the endotracheal tube with provides a circular seal as this is the narrowest
a malleable stylet (Figs 8.27 A and B). portion of a childs airway. The correct size in a
child should allow a gas leak at 15-20 cm H2O
Inflating the Cuff with Air pressure for a non-cuffed tube.
The blood supply to the tracheal mucosa and The tube is now checked for correct position.
cartilage is derived from the submucosa, which Even before one auscultates the chest, respi-
has a rich capillary network. If the intra-cuff ratory moisture is visible with every inspiration
pressure exceeds capillary pressure (19-25 mm in the tube. While ventilating manually, the chest
Hg), mucosal ischemia and ulceration results. is visually inspected for bilaterally equal
expansion, following which the apices and bases
of both lungs are auscultated sequentially to
Table 8.2: Approximate ETT size in children
check whether the intensity of breath sounds is
Age Weight (kg) Size
equal on both sides. The epigastrium is The Laryngeal Mask Airway (LMA)
auscultated to confirm absence of air entry. The laryngeal mask airway (LMA) is being
Obtaining a trace of exhaled carbon dioxide frequently used as an alternative to either the
(capnography) is the gold standard that confirms facemask or tracheal tube during anesthesia.
endotracheal placement of the tube.
This supraglottic airway device was designed by
The tube is then firmly secured in place with
Dr. Archie Brain of UK. Since the 1980s it has
a length of sticking tape. In infants and children
been replacing the endotracheal tube for most
it is prudent to make a note of the tube marking
routine procedures. It has proved to be
(in cm) at the angle of the mouth which can be
extremely useful in managing failed intubation
used as a reference if tube position needs to be
re checked. It is also common practice to cut situations. It can be described as a device
off extra length of the tube in infants and small intermediate to the facemask and endotracheal
children to prevent drag on the circuit. In head tube. There are now five versions of the LMA
and neck, ophthalmic and neurosurgical available (Figs 8.12A to D): the classic, the
procedures, the importance of fixing the tube flexible, the intubating LMA ( ILMA or LMA-
correctly and securely cannot be over empha- Fastrach), the Proseal LMA and the LMA-C
sized; dislodgement or displacement of the tube Trach which has a camera at the observer end
in a patient where access to it is not possible which helps to visualize the laryngeal inlet in
spells disaster. difficult airways. The LMA can be used in all
Fig. 8.12A: The LMA classic Fig. 8.12B: The flexible LMA
Fig. 8.12C: The intubating (Fastrach) LMA Fig. 8.12D: The Proseal LMA
110 A PRIMER OF ANESTHESIA
situations except those where it is contra- The head is extended at the atlanto-occipital
indicated (see below). The advantages of the joint and the mouth opened with the left hand.
LMA over the endotracheal tube are: The cuff should be fully deflated and not have
1. Can be inserted without the use of muscle any folds. The LMA is held like a pencil with
relaxants the concavity (bowl) facing the tongue. The right
2. Does not need laryngoscopy index finger is insinuated into the groove
3. High success rate after 10 insertions; can be between the stem and the cuff and the LMA
taught to paramedics and students inserted into the mouth. It is advanced by
4. Does not elicit tachycardia and hypertension pressing against the hard palate; the index finger
during/after insertion travels down all the way in a smooth, single,
5. Permits the use of light planes of anesthesia fluid movement behind the tongue till the LMA
especially when a regional block is used encounters resistance below the hypopharynx.
concomitantly The left hand then steadies the LMA and the
6. Does not produce cough/breath-holding
right index finger withdrawn. The requisite
during emergence. This smooth emergence
amount of air is then injected into the cuff; the
is of great value after ophthalmic procedures
LMA is seen to rise and occupy its position in
and tonsillectomy
the hypopharynx. An ideally placed LMA is
7. Can be retained in small children and elderly
bordered superiorly by the base of the tongue,
till they are fully awake, thus increasing
airway safety laterally by the pyriform sinuses and inferiorly
8. Useful in cannot intubate, cannot ventilate by the upper esophageal sphincter. If the
situations as a rescue airway device esophagus lies within the cuff the stomach will
9. Can be used as a conduit for the fibreoptic be insufflated.
bronchoscope to guide an endotracheal Correct placement of an LMA is confirmed
tube into the trachea in patients with difficult by the presence of all of the following findings:
intubation. a. expansion of the chest
b. absence of gastric inflation
Disadvantages of the LMA: c. a square wave capnogram which touches
may get displaced (usually in very small the baseline
children, edentulous adults)
d. maintenance of normal saturation
gastric insufflation always a possibility
e. airway pressures below 20 cm H2O
does not guarantee against aspiration
f. in the case of LMA Proseal (Fig. 8.11D),
positive pressure ventilation may be difficult
the gastric drainage tube should be easily
if high airway pressures are required
the large epiglottis of a child may get folded inserted in the stomach.
and result in obstruction to expiration The recommended sizes and cuff inflation
may provoke regurgitation. volumes for laryngeal mask are shown in
Table 8.3.
Technique of insertion (Figs 8.13A to C): It is Contraindications to the use of the LMA
important to ensure that the jaw is adequately These relate to patient factors or surgical
relaxed. Propofol is an ideal agent for LMA conditions.
placement due to its depressant effect on the
respiration and airway reflexes. The LMA can Patient factors:
also be placed under inhalational anesthesia Morbid obesity: the LMA may not withstand
(with halothane or sevoflurane), or after the high airway pressures needed to ventilate
thiopentone-relaxant sequence. these patients.
AIRWAY MANAGEMENT 111
Table 8.3: LMA sizes and volume of air to patient, it is important to secure a definitive
inflate cuff airway by fibreoptic intubation or tracheo-
Size Size of patient Cuff inflation stomy before proceeding with surgery.
volume Gastroesophageal reflux disorders.
Neonates and small infants for major
1 Neonates, infants upto 5 kg Up to 4 ml procedures: the LMA might get dislodged
11/2 Infants 5-10 kg Up to 7 ml or malpositioned and it is very difficult to
2 Infants/Children 10-20 kg Up to 10 ml access these small patients under the surgical
21/2 Children 20-30 kg Up to 14 ml
drapes.
3 Paediatric 30-50 kg Up to 20 ml
4 Adult50-70 kg Up to 30 ml Surgical factors:
5 Adult70-100 kg Up to 40 ml Oral surgery; major head and neck pro-
6 Large adult >100 kg Up to 50 ml cedures
Microlaryngeal surgery
Full stomach(see below) patients: the LMA Surgery in prone position
does not guarantee against aspiration. Procedures where the patient is likely to
Difficult airway: although the LMA may be require postoperative intubation/ventilatory
used as an interim device to oxygenate the support
112 A PRIMER OF ANESTHESIA
maneuver and continue to mask ventilate till Assistant to have scalpel + tube ready
the return of spontaneous ventilation, wake up Consider paralysis if not already paralysed
the patient and reschedule the procedure. Make one attempt at intubation under
The importance of timely recognition of vision
airway obstruction in an anesthetized patient 9. If you cannot intubate
cannot be over emphasized. There is every Consider LMA
chance of severe morbidity or mortality once 10. If this fails, emergency cricothyrotomy
hypoxemia sets in. Most deaths under anesthesia is indicated.
have been a consequence of failure to Needle cricothyrotomy can be performed
oxygenate. Corrective action must be initiated through a 12 or 14G cannula inserted through
ideally well before onset of hypoxemia. Signs the cricothyroid membrane (Fig.8.15).
of airway obstruction include noisy, poor or Oxygenation can be maintained for 10 minutes.
absent ventilation, paradoxical chest and/or However ventilation to remove CO 2 is not
abdominal movements and inability to cause achieved and spontaneous ventilation is
chest expansion with a bag in an apneic patient. impossible through a cricothyrotomy. It is
This condition is an emergency and needs to therefore important to convert to a surgical
be managed by a planned sequence of actions cricothyrotomy or tracheostomy without further
or an algorithm to maximize success and delay.
minimize morbidity/mortality. Ventilate with 100% oxygen
The patient is then reviewed to exclude
DIFFICULT AIRWAY ALGORITHM pulmonary aspiration and post obstructive
1. Attempt to ventilate using only 100% pulmonary edema. The patient should be later
oxygen. Desaturation occurs in 65% cases
and hypoxemia is the cause of death.
2. Try chin lift and jaw thrust
3. Call for help immediately. Four people will
be required:
Person I holds mask and jaw with both
hands and intubates as soon as
conditions permit.
Person II holds emergency oxygen flush
valve and squeezes reservoir bag.
Person III ensures adequate anesthesia
and IV access.
Person IV finds and passes equipment
and helps others.
4. It should be strongly considered to wake
up the patient
5. If not so, try to visualize and clear
pharyngeal airway
6. Insert oral/nasal airway
7. Team mask IPPV/CPAP
8. If still cannot ventilate
Someone to feel pulse and call out SPO2 Fig. 8.15: Landmarks for cricothyrotomy
114 A PRIMER OF ANESTHESIA
explained about what happened, reassured and 3. A bite block which lies between the upper
advised to warn future anesthesiologists. and lower incisors.
AIRWAY EQUIPMENT Features
This small section will make you familiar with 1. Anatomically shaped.
the common equipment used to maintain an 2. Inserted through the mouth above the
open airway in an unconscious patient. tongue in to the oropharynx.
3. Maintains patency of the upper airway.
The Oropharyngeal (Guedel s) Airway 4. Can cause trauma and injury to oral
This anatomically shaped airway (Fig. 8.16A) structures.
is inserted through the mouth into the 5. Risk of stimulation of gag reflex and
oropharynx above the tongue (Fig. 8.16B) to vomiting.
maintain the patency of the upper airway. It is
important to select the right size so that the The Nasopharyngeal Airway
tongue is not pushed back against the posterior (Figs 8.17A and B)
pharyngeal wall. 1. Inserted through the nose into the naso-
Components pharynx by rotating so that concavity faces
1. A curved body
2. A flange which lies outside the mouth
Fig. 8.16B: Oropharyngeal airway inserted Fig. 8.17 B: Correct insertion of nasopharyngeal
appropriately airway
AIRWAY MANAGEMENT 115
pressure cuffs. In these cuffs the intra cuff accepts 100 ml of air and the smaller distal cuff,
pressure is distributed over a smaller area, which 15 ml. In between the two cuffs the blue tube
means that a given volume of air will exert more has many perforations. The blue end of the tube
pressure on the tracheal mucosa in a red rubber after blind placement enters the esophagus in
tube compared to a PVC tube. These tubes are 95% of instances. After gentle, blind placement
almost obsolete now. connecting the self-inflating bag or anesthesia
circuit end to the blue end results in oxygen
Parts escaping from perforations in the pharyngeal
Bevel part and entering the trachea (Fig. 8.22). If this
Left facing and oval in shape end has inadvertently entered the trachea, the
Murphy eye- hole just above and opposite circuit is connected to the clear adaptor and
the bevel the distal cuff used as an endotracheal tube cuff
(Fig. 8.23).
Cuff
Other supraglottic devices are the COPA
When inflated, provides an airtight seal (Fig. 8.24) and the Laryngeal Tube (Fig. 8.25)
between the tube and the tracheal wall. which enjoy limited use as they are not widely
Cuffs can either be high pressure, low available.
volume or low pressure, high volume type.
Connectors
Connect the tracheal tubes to the breathing
system.
Also known as universal connectors; all
sizes have 15 mm internal diameter.
MCQ
MCQss
blade hinged on a handle, which houses two
batteries. The blade has a bulb midway along 1. Which of the following is a contra-
its length. When the blade is opened out on indication for using a laryngeal mask
the handle to 90 o, electrical connection is airway?
established and the bulb glows. The laryngo- a. When inhalational anaesthesia is
scope illuminates the oropharynx and enables required
b. Large obstructive lesion in the upper
visualization of the trachea. Many varieties of
airway
blade have been designed, each with its unique c. Maintaining airway during difficult
use or advantage. The one most commonly intubation
used is the curved Macintosh blade (named d. Emergency management of airway
after Sir Robert Macintosh) available in 4 sizes. during resuscitation
The straight blade, useful in infants to directly
2. In children:
lift up a large epiglottis, is the Miller blade. a. The larynx is at a lower level than in an
Other special blades are the McCoy and Polio adult
blades. b. The epiglottis is relatively large and
floppy when compared to that of an
The Malleable Stylet (Figs 8.28A and B) adult
This long, flexible length of copper or steel wire c. The narrowest part of the airway is at
encased in a plastic sheath is useful for bending the cords
the endotracheal tube to the desired shape if d. The larynx is less susceptible to oedema
AIRWAY MANAGEMENT 119
When injected into infected tissue (which dressing (Tegaderm). The dose recommen-
is acidic) more LA is ionized, explaining ded is 1-2 g/10 cm2 of skin area with a
lack of efficacy. maximum application area of 2000 cm2 in
Commercially available LA solutions the adult and not to exceed 100 cm2 in
have a pH of 6-7. Since epinephrine is children weighing less than 10 kg.
unstable in alkaline environments, LA Contraindications to use of EMLA include
preparations containing epinephrine are infants less than 1 month old, broken skin,
made even more acidic (pH 4-5). It is mucous membranes and in patients with a
therefore recommended to add predilection to methemoglobinemia.
epinephrine to LA solution immediately After injection: The rate of absorption is
before use. Commercial epinephrine- proportional to firstly, the vascularity of the
containing solutions have a prolonged site. If we count out intravenous injection,
onset of action. the order of decreasing absorption is
Tachyphylaxis: Decreasing efficacy of tracheal> intercostal> caudal> para-
repeated doses-can also be explained by cervical> epidural> brachial> sciatic>
the fact that the acidic LA solution subcutaneous. Secondly, addition of
consumes the available extracellular epinephrine causes vasoconstriction and
buffering capacity. delays absorption. This effect is most
Addition of 8.4% sodium bicarbonate apparent with shorter acting LA agents.
solution (1 ml/10 ml of 1% lidocaine):
Metabolism of LA agents
Also known as carbonation, hastens
Esters: These are predominantly meta-
onset of block, prolongs action (the CO2
bolized by plasma cholinesterase (pseu-
released from sodium bicarbonate
docholinesterase). One of the by products
diffuses into the cell, causes acidosis and
ionization of the LA molecule, trapping of ester metabolism is p-aminobenzoic acid
it inside the cell. Intracellularly, it is the (PABA) which may be responsible for allergic
ionized cation which is responsible for manifestations to esters. Pseudocholin-
blocking the sodium channels). Carbo- esterase deficiency can lead to prolonged
nation also reduces pain on subcutaneous action and vulnerability to toxic effects. As
infiltration. the CSF lacks cholinesterase enzyme,
Absorption termination of intrathecally administered
After topical application: Most LA agents esters depends on absorption by the
can cross conjunctiva or buccal mucous bloodstream. In contrast to other esters,
membrane and provide topical anesthesia cocaine undergoes partial metabolism in the
(2%lidocaine for the eye, benzocaine liver and is partly excreted unchanged.
lozenges for painful oral ulcers). EMLA Amides: All amide anesthetics are meta-
[Eutectic (easily melted) Mixture of Local bolized by hepatic microsomes. Prilocaine
Anesthetic] is an oil-in-water emulsion of 5% undergoes the most rapid metabolism
lidocaine and 5% prilocaine mixed in a 1:1 followed by lidocaine and bupivacaine.
ratio. This provides adequate topical Patients with reduced hepatic blood flow
analgesia for IV line insertion, laser removal (congestive cardiac failure) or reduced
of port-wine stains, skin graft harvesting and hepatic function (cirrhotics) are very
circumcision. The depth of penetration is susceptible to amide overdose toxicity. O-
reported as 3-5 mm. The contact time should toluidene derivatives are metabolites of
be at least an hour under an occlusive prilocaine which accumulate if prilocaine
126 A PRIMER OF ANESTHESIA
which has since been replaced with a and autonomic fibers, physiological effects
derivative of EDTA. observed are related to block of conduction in
Severe back pain after epidural has also these fibers.
been reported after chloroprocaine; the
possible causes could be (i) large volumes Somatic Blockade
of chloroprocaine, (ii) low pH, (iii)EDTA 1. Epidural and spinal blocks interrupt
preservative and (iv) local infiltration with transmission of impulses both in the dorsal
chloroprocaine. Recently a preservative- root (which carries somatic and visceral
free formulation of chloroprocaine has afferents) and the ventral root (which carries
been prepared. motor and autonomic efferents).
Cauda equina syndrome refers to perma- 2. Spinal roots contain fibers which vary in size
nent damage to the fibres of the cauda and myelination; as a rule, thinner,
equina reported with the repeated myelinated fibers get blocked earlier.
injection of 5% lidocaine and 0.5% 3. There is complete absence of pain perception
tetracaine through spinal microcatheters. and profound skeletal relaxation, which
Transient neurologic symptoms (TNS) produces excellent operating conditions.
consist of dysesthesia, burning pain, and 4. The phenomenon of differential
aching in the buttocks and lower extre- blockade is seen with respect to somatic
mities after apparently uneventful spinal blockade whereby sympathetic blockade is
anesthesia with a variety of agents. Risk two to six segments higher than sensory
factors appear to be lidocaine, obesity, block, which in turn is two segments higher
lithotomy position and outpatient status. than motor block.
5. Motor and proprioceptive fibres are blocked
Drug interactions the last and need high concentration of LA;
Since succinylcholine and ester LA are sympathetic and nociceptive fibres (Pain,
both metabolized by pseudocholine- temperature) are the most vulnerable.
sterase, concomitant administration
potentiates the effects of both agents. Autonomic Blockade
Nondepolarizing neuromuscular block is
1. Cardiovascular signs: Spinal and epidural
potentiated by LA agents.
blocks produce hypotension in proportion
Dibucaine, an amide anesthetic, inhibits to the number of segments blocked (height
pseudocholinesterase and can be used to of block). Vasomotor tone is determined by
detect genetically abnormal enzyme in the sympathetic outflow from T5-L1.
suspected pseudocholinesterase defi- Sympathetic blockade results in dilatation of
ciency. the capacitance vessels(the large veins in the
Fentanyl, morphine, epinephrine and pelvis and IVC), pooling of blood and
clonidine potentiate analgesia produced reduced venous return to the heart, resulting
by LA agents. in reduced cardiac output. Some arteriolar
dilatation may also occur. If the block extends
PHYSIOLOGICAL EFFECTS OF up to and above T4, block of cardiac
NEURAXIAL BLOCKADE accelerator fibres leads to severe bradycardia
The site of action of local anesthetic solution in and also compromises compensatory
the epidural or subarachnoid space is the nerve vasoconstriction which usually occurs above
root. As the nerve root carries somatic, visceral the block. The drastic reduction in cardiac
128 A PRIMER OF ANESTHESIA
output may lead to cardiac arrest. All these 3. Gastrointestinal effects: Since a major part
effects are exaggerated in the pregnant or of the thoracolumbar sympathetic outflow
grossly obese patient or patients with large is blocked, there is parasympathetic
intra-abdominal tumors or tense ascites, predominance evidenced by a contracted,
which further reduce venous return by ribbon-like small bowel. This greatly facilita-
compressing the inferior vena cava. Hypo- tes abdominal and pelvic surgery and also
tension can be prevented by preloading the results in earlier return of bowel function.
patient with 10-20 ml/kg of a crystalloid Neuraxial block does not block the vagus.
solution (Ringers lactate) before adminis- 4. Urinary tract: Neuraxial block interrupts
tering the block and left uterine displace- both sympathetic and parasympathetic
ment in the pregnant patient. Hypotension control of bladder function and results in
should be treated aggressively with 5-10 mg urinary retention till the block wears off. This
boluses of ephedrine or mephentermine. is especially seen in elderly patients with
prostatic enlargement. The shortest acting
Oxygen should be given through facemask.
agent commensurate with the procedure
If bradycardia is also present, atropine 0.3-
must be used. Other factors promoting
0.6 mg should be given. Phenylephrine bolus
retention are use of neuraxial opiates and
(25-50 g) is another option. If hypotension
surgery on the urethra or bladder.
persists in spite of these vasopressors,
epinephrine should be administered. Contraindications to Neuraxial Blockade
2. Pulmonary manifestations: Properly
Absolute contraindications are:
performed spinal and epidural blocks do not - Patient refusal
affect the respiratory system. Normally - Coagulopathy
attained levels up to T6 which paralyze the - Infection at proposed site of injection
external oblique are not seen to produce any - Severe hypovolemia
distress in patients who do not have - Raised intracranial pressure
respiratory disease. Even with accidental - Severe aortic or mitral stenosis.
injections of large volumes of LA into the Relative contraindications are:
subarachnoid space, phrenic nerve (C3-C5) - Sepsis
block rarely occurs probably because the LA - Pre-existing neurologic deficit
gets diluted by CSF and is unable to block - Progressive neurological disease (demye-
the large fibers of the phrenic nerve. linating disorders)
However, clinical implications of respiratory - Deformity of spine at proposed site of
muscle involvement with spinal blockade are injection.
seen in patients with significant respiratory
disease like emphysema, who rely on active PREOPERATIVE PREPARATION OF THE
expiration for carbon dioxide elimination. PATIENT PRIOR TO NEURAXIAL BLOCK
A block involving the accessory muscles of Preoperative preparation should fulfill all criteria
expiration can prevent effective breathing, as for GA and neither the patient, surgeon or
coughing and clearing of secretions and can physician should regard it as a short cut to safety,
cause significant distress and panic to the especially in high-risk patients.
patient and may even lead to respiratory
failure. Thus, spinal anesthesia is not Psychological Preparation
without its dangers in a patient with - The patient will have many doubts and
severe lung disease. questions regarding the plan of neuraxial
NEURAXIAL (SPINAL AND EPIDURAL) BLOCKADE 129
block and the preoperative period is the time Shaving may produce scratches or cuts
to clarify them. which can harbor infection.
- After completing the preanesthetic assess-
ment and ensuring that major contraindica- OPERATION THEATER MANAGEMENT-
tions are absent, the patient is provided with PREPARATION AND MONITORING
full explanation covering the conduct of the - Check the anesthesia machine and connect
block and management of his comfort during a simple tube attached to a facemask at the
surgery. common gas outlet. Check the Bain circuit
- It is important to let the patient understand and keep it handy.
that he/she will be kept comfortable at all - Check laryngoscope, endotracheal tube.
costs. The patient should be given the choice - Check functioning suction.
of whether to remain fully awake or receive - Check table tilt and the anesthesia monitor
intravenous sedation during the procedure. connections.
- The patient should be explained that he/she - Staff in the operating theatre should be made
may be able to appreciate deep pressure or aware of the impact their conversation and
position changes, specially if an epidural is noise are likely to have on the patient.
being planned (as the large diameter pro- - The area where the block is being given
prioceptive fibers may not be blocked). should be well lighted.
- The advantages neuraxial blockade has over - Prepare (i) Atropine 0.1 mg/ml, (ii) Ephedrine
GA can be explained to the patient to 5 mg/ml, (iii) Mephentermine 6 mg/ml, and
increase acceptance. (iv) Midazolam 1 mg/ml. Check that thio-
- In spite of all explanations there may be a pentone and succinylcholine are readily
patient who refuses to accept neuraxial block. available.
In that case, the refusal should be documen- - Ability to administer GA rapidly if need
ted in the case sheet. arises, should be checked.
- Attach the desired monitors. For straight-
Physical Preparation forward procedures in ASA-I-II patients,
- Making the patient assume the position to EKG, pulse oximetry and non-invasive blood
be used the next day for the block (sitting up pressure (NIBP) suffice. For patients who are
or lateral decubitus position) is very helpful. sick (ASA-III and above) the level of
In obese patients the sitting position helps to monitoring will be decided by the gravity of
identify the midline more accurately than the the procedure. For patients undergoing major
lateral decubitus position. The full term surgery under combined epidural anesthesia
pregnant patient scheduled for labor and GA, monitoring will be planned
epidural would probably be more comfor- according to the needs of the procedure
table sitting. (CVP, invasive arterial pressure, urine output,
- This has the advantage of checking out any etc.).
difficulty (e.g. patient may be unable to lie - Set up an IV infusion of Ringers lactate or
on the side planned) and also letting the normal saline. Give the patient 500ml-1l
patient know that this is the position expected while the block is being given.
from him prior to the block. - Position the patient as previously planned.
- There should be no infection at the planned If the patient is unduly anxious, midazolam
site and the space should be well felt. 1-1.5 mg may be administered. (Children
- If there is a lot of hair instructions may be and adolescents may require GA for
given to apply epilator cream at night. placement of the block). The patient in the
130 A PRIMER OF ANESTHESIA
EPIDURAL ANESTHESIA
Epidural anesthesia offers a wide range of
applications and can be performed at the
lumbar, thoracic or cervical levels. Sacral
epidural block is also known as caudal block.
Epidural block is slower in onset than and not
as dense as spinal anesthesia. This characteristic
confers several advantages on epidural
Fig. 9.9: Tendency of LA to track in different
directions
analgesia: (i) differential block is pronounced,
so dilute LA solutions combined with an opiate
needle in the center of the desired interspace can be used to block pain and sympathetic fibers,
(Fig. 9.11). The needle is withdrawn and the and avoiding motor blockade in patients
point of entry marked with the hub of the receiving labor analgesia; (ii) it is possible to
same needle. This simple maneuver ensures produce segmental analgesia which is a well
that the point of insertion of the spinal or defined band-like area of analgesia by placing
epidural is exactly at the same site as the the catheter in the appropriate spinal interspace.
LA. (iii) If the catheter is only to be used for
132 A PRIMER OF ANESTHESIA
Fig. 9.14: (L) Epidural needle in subcutaneous tissue; (R) engaged in ligamentous layer
conversation with the patient (see complica- the hub of the needle tells us the direction.
tions), till the appropriate effect is achieved. Normally, 5-7 cm of the catheter is inserted
In adults depending on the position of the in the epidural space. The catheter left
catheter, volumes from 6-15 ml may be externally is taped to the back by adhesive
needed (Table 9.2). (Fig. 9.16). This can be easily calculated by
adding this length to the depth of the
- If a catheter is to be inserted, the needle is epidural space. The test dose and subse-
rotated so that the bevel faces cephalad or quent complete dose may be given through
caudad to insert the catheter. The notch on the catheter.
134 A PRIMER OF ANESTHESIA
beneficial for surgery as the field is quiet and Tingling, pins and needles
intense relaxation facilitates surgery, For motor block, see if the patient can
especially lower intra-abdominal proce- flex the ankle joint or the knees
dures. The patient has to be specially - Observe
informed that no ambulation will be possible Vasodilatation and engorgement of the
for at least 4-6 hours. veins over the penis.
- With epidural blockade, presence of motor Even an elderly, arthritic patient can be
blockade depends on the concentration and easily placed in lithotomy position with
volume of local anesthetic. the thighs abducted.
- Motor blockade can be achieved using full In very thin patients, pulsations of the
concentrations (2% lignocaine, 0.5% femoral artery, abdominal aorta and
bupivacaine) of LA. Dilute LA solutions bowel peristalsis may be observed.
(0.125% bupivacaine, 0.5% lignocaine) can - Testing the level and effectiveness
be provided to patients without hampering With an alcohol swab start from the area
which is blocked and go up dermatome
motor activity, which is important in, for
by dermatome till the patient can
example patients receiving neuraxial
appreciate the cold swab.
analgesia for cancer pain and obstetric
Ask the surgeon to gently hold the
patients for labor analgesia(walking
proposed site of skin incision with a non-
epidural). toothed forceps and shake it from side
- Possibility of toxic effects of dose is more with to side. Keep your eyes on the patients
epidural because of the large volume of drug face to observe any grimacing or
used. reaction.
- Onset of cardiovascular effects like
bradycardia and hypotension is rapid and SEDATION
sometimes precipitous in subarachnoid
Sedation should be individualized
block. On the other hand, these are more
The elderly already have reduced input to
gradual with epidural and usually not severe,
the reticular formation (due to ageing of the
and allow for some time for correction. sensory organs) and start sleeping as soon
as afferent input falls further.
ASSESSMENT OF EFFECTIVENESS OF Excessive sedation will defeat the purpose
SPINAL/EPIDURAL BLOCK of sparing GA in patients with pulmonary
- Asking the patient disease
The patient can be asked for heaviness Midazolam in 0.5 mg2 mg increments can
in the legs be used.
138 A PRIMER OF ANESTHESIA
PRECAUTION
PRECAUTIONSS can carry infection if aseptic technique is not
Hypothermia-especially in the elderly. followed. This is especially important considering
Shivering should be prevented and aggre- the proximity of the sacral hiatus to the peri
ssively treated with radiant heat, blankets, anal region.
small doses of pethidine (10-15 mg) The pediatric patient is placed in the lateral
Keep verbal contact with the patient decubitus position. The jack-knife position is
Occasionally sudden severe bradycardia preferred for adults. A small child can be tucked
may occur due to unopposed vagal action into position by an assistant (Fig. 9.19) after
and visceral manipulation (especially elderly anesthesia is induced and the airway maintained
on beta blockers): Atropine is given in doses by a facemask or LMA. After cleaning and
of 0.3-0.6 mg. draping the area the sacral hiatus is palpated.
The two posterior superior iliac spines and the
CAUDAL ANESTHESIA (TABLE 9.4) sacral hiatus form the vertices of an equilateral
triangle (Fig. 9.20). The hiatus is felt as a
There is less effect on cardiovascular, respiratory depression between the two sacral cornua and
and bowel function as caudal block is limited to
usually admits the pulp of the index finger. The
the sacral and lumbar nerves. Motor blockade
skin over the center of the hiatus is infiltrated
is limited to the legs. Autonomic dysfunction is
with 1% lidocaine injected through a 26-G
limited to bladder and anorectal sphincter. needle after informing the patient.
Indications of caudal anesthesia are outlined In adults 20 ml volume is sufficient for
in Table 9.4. perineal and urethral procedures. For groin and
other sub-umbilical procedures (supra pubic
Technique
cystostomy), a volume of 25-30 ml is required.
There is a tendency to treat the caudal approach In pre-adolescent children the Armitage formula
with less respect than lumbar epidural technique given in the Table 9.5 is useful to calculate the
as it appears to be very easy and quick. It must volume of local anesthetic needed.
be remembered that the sacral hiatus is also a Needle size: In children 23-G needles and
portal of entry to the epidural space and thus in adults 22-G serve the purpose.
Table 9.4: Indications of caudal anesthesia
Adult Pediatric
1. Surgery 1. Surgery on genitalia
Anorectal 2. Inguinal hernia repair
Gynecological 3. Orchidopexy
Orthopedic 4. To deliver neuraxial opioid for major abdominal and thoracic
surgery
Urethral 5. To thread an epidural catheter to provide for prolonged
postoperative analgesia especially after major vascular/orthopedic
lower limb procedures
2. Obstetric
Episiotomy suturing
Manual removal of placenta
3. Chronic pain
Coccydynia
Spinal manipulation
NEURAXIAL (SPINAL AND EPIDURAL) BLOCKADE 139
MCQ
MCQss
9. Hypobaric local anaesthetics have a 15. The LA whose pKa is closest to body
baricity less than pH is:
a. 1.000 a. Bupivacaine b. Mepivacaine
b. 1.0069 c. Ropivacainea d. Etidocaine
c. 0.0069
d. 0.0089 16. EMLA cream consists of
a. 1:1 mixture of 2% prilocaine and
10. The following factor will affect the lidocaine
height of subarachoid block b. 1:1 mixture of 4% prilocaine and 4%
a. Coughing lidocaine
b. Direction of needle level c. 2:1 mixture of 5% prilocaine and 5%
c. Gender lidocaine
d. Intra-abdominal pressure d. 1:1 mixture of 5% prilocaine and 5%
11. The fact not true about Ropiva caine lidocaine
is 17. The normal dose of EMLA recom-
a. Shorter acting than bupivacaine mended is:
b. Has vasoconstrictive property in a. 1-2 g/10 cm2 of skin
clinically used concentrations b. 3-4 g/10 cm2 of skin
c. Less cardiotoxic than bupivacaine c. 5-6 g/10 cm2 of skin
d. Better quality of motor block as d. 7-8 g/10 cm2 of skin
compared to bupivacaine
18. Fastest absorption of local anesthetic
12. Carbonation of local anesthetics after injection occurs from:
a. Increases the speed of onset of block a. Caudal epidural
b. Delays the speed of onset but gives b. Intercostal
better quality of block c. Tracheal
c. Delays the onset but prolongs the d. Subcutaneous
duration of block
d. Has no effect on onset of block 19. Allergic manifestation of ester local
anesthetics are due to:
13. In patients receiving LMWH (low
a. EDTA preservative
molecular weight heparin) neuraxial
b. Large volumes
blocks should
c. Sodium bisulphate
a. Never be performed
d. Para-amino benzoic acid
b. Should be delayed by 2 hours after
administration of drug 20. The amide anesthetic undergoing
c. Should be delayed by 12 hours after most rapid metabolism is:
administration of drug a. Lidocaine b. Prilocaine
d. Can be performed any time depending c. Etidocaine d. Benzocaine
on the dose of LMWH
21. Neonates born of mothers receiving
14. Side effects associated with sub- prilocaine for epidural anesthesia are
arachnoid block do not include more prone to develop:
a. Hypotension a. Hyperbilirubinemia
b. Tinnitus b. Hemolytic crisis
c. Tremors c. Myoglobinemia
d. Nausea d. Methemoglobinemia
142 A PRIMER OF ANESTHESIA
22. Methemoglobinemia after prilocaine 25. The agent of choice for treating
use can be due to all except: bupivacaine cardiotoxicity is:
a. Prilocaine dose > 10 mg/kg a. Lidocaine
b. Accumulation of ortho-toluidene b. Adenosine
derivatives c. Bretylium
c. Patients with cirrhosis d. Amiodarone
d. Patients with chronic renal failure
23. The only LA with intrinsic vaso- Answers
constrictive property is: 1. b 2. d 3. a 4. a
a. Bupivacaine b. Procaine 5. d 6. b 7. a 8. c
c. Cocaine d. Mepivacaine
9. a 10. d 11. d 12. a
24. The LA associated with hypertension 13. c 14. c 15. b 16. d
and ventricular dysrhythemia is: 17. a 18. c 19. d 20. b
a. Etidocaine b. Cocaine 21. d 22. d 23. c 24. b
c. Procaine d. Ropivacaine 25. c
Peripheral Nerve Blocks
Rengarajan Janakiraman
SUPRACLAVICULAR BLOCK
Supraclavicular block involves blocking the trunk
of the Brachial plexus (refer to Fig. 10.2). Place
the patient in supine position with the head
turned towards the opposite side and mark the
following landmarks (Fig. 10.5).
- 1 cm above the mid point of the clavicle or
- 1 cm above and posterior to Subclavian
artery pulsation.
Fig. 10.4: Technique of interscalene block
prevent the spread of local anesthetic from one epinephrine should not be used for digital block
quadrant to another. So it is important to block to avoid gangrene of the digits. Digital blocks
all the nerves separately. are useful for draining abscesses/suturing of
Axillary and infraclavicular block are not fingers, removing foreign bodies (glass), etc.
useful for shoulder surgeries.
LOWER LIMB ANATOMY
DIGITAL NERVE BLOCK
Gross Anatomy
Digital nerve block is the technique of blocking
The nerve supply of the lower limb is derived
the nerves of the digits to achieve anesthesia of
from the lumbar and sacral plexuses. The
the fingers. Each digit is supplied by a Palmar
lumbar plexus is formed from roots of L1-
and a Dorsal digital nerve. The Palmar digital
L4, while the sacral plexus is formed from L4,
nerves are derived from Median and Ulnar
L5, S1, S2 and S3. Arising from these plexuses
nerves. They run on the ventro lateral aspect of
are the five main nerves that innervate the lower
the finger. The Dorsal digital nerves are derived
limb. These five nerves are the femoral, sciatic,
from Radial and Ulnar nerves and run on the
and obturator nerves, as well as the lateral
dorso lateral aspect of the fingers (Fig. 10.8).
and posterior cutaneous nerves of the thigh.
The dominant nerve above the knee anteriorly
Technique
is the femoral nerve. The dominant nerve on
The hand is pronated and rested on a flat the posterior aspect of the leg above and below
surface. Skin wheals are raised at the dorsolateral the knee is the sciatic nerve.
borders of the proximal phalanx and the needle
is introduced at the dorsal surface of the lateral The Lumbar Plexus
border of the phalanx. Needle is advanced until This gives rise to the femoral nerve, obturator
it contacts bone.1 ml of Local anesthetic is nerve and lateral cutaneous nerve of the thigh.
injected after withdrawing the needle 1 mm from The femoral nerve stems from the anterior
the bone. An additional 1 ml is injected rami of L2-L4 and runs in the groove between
continuously as the needle is withdrawn. The
the psoas major and iliacus muscles, and is
same procedure is repeated on the other side of
covered by the fascia of these muscles. It enters
the base of the finger. Solutions containing
the thigh after passing deep to the inguinal
ligament, where it is lateral to the femoral artery.
The femoral nerve block is performed distal to
this point. The lateral cutaneous nerve of the
thigh and the obturator nerve both have
important sensory distributions to the lateral
thigh and medial side of the knee respectively.
foramen, and then passes along the midpoint about 2-4 cm from the midline, at the top of
between the greater trochanter (GT) and the the genital area.
ischial tuberosity (IT), lying just posterior to the
hip joint. It can be blocked at several points along Posterior Superior Iliac Spine (PSIS)
this course; parasacral, transgluteal, subgluteal The PSIS is the bony prominence at the posterior
or popliteal. On leaving the buttock area the end of the iliac crest. It is directly caudal to the
sciatic nerve runs distally down the thigh to the sacral dimple and is visible as a depression in
popliteal fossa between the biceps femoris and the skin just above (superior to) the buttocks
semimembranosus and semitendinosus muscles. close to the midline.
At the apex of the popliteal area, approxi-
mately 7-9 cm above the crease behind the knee, Greater Trochanter
the sciatic nerve splits into the tibial nerve This bony landmark is part of the lateral femur,
medially and the common peroneal nerve just below the hip joint. It is the most lateral bony
laterally. From its divergence from the sciatic point, and can be identified by internally and
nerve, the common peroneal nerve continues externally rotating the hip.
its path downward and descends along the head
and neck of the fibula. Its terminal branches are The Ischial Tuberosity
superficial and deep peroneal nerves. The tibial This is the part of the pelvic bone structure that
nerve is the larger of the two divisions of the can be felt on the medial side of the base of the
sciatic nerve. The tibial nerve continues its path buttock. It is the bony structure that we sit on.
vertically through the popliteal fossa. Its terminal
branches are the medial and lateral plantar FEMORAL NERVE BLOCK
nerves. Its collateral branches give rise to the
At the inguinal crease, the nerve is deep to the
cutaneous sural nerves, muscular branches to
fascia lata and covered by the fascia iliaca. It is
the muscles to the calf, and articular branches separated from the femoral artery and vein by
to the ankle joint. the femoral fascia sheath, a portion of the psoas
Surface Anatomy muscle and the ligamentum ileopectineum. It
may be useful to think of the mnemonic VAN
When performing the nerve blocks, it is essential (vein, artery, nerve) going from medial to lateral
to be able to locate the surface landmarks accu- in the femoral triangle (Fig. 10.9).
rately, since these form the reference points we After numbing the skin, the block needle,
use for determining the correct site for needle usually a 22 an insulated stimulating needle, is
insertion. introduced 1 cm lateral to the femoral artery
Anterior Superior Iliac Spine (ASIS) and 1 cm below the femoral crease (Fig.
10.10). It is advanced at 45o, and two distinct
If we follow the iliac crest (ridge of the pelvic pops can usually be felt as the needle penetrates
bones) from the flank forwards, it ends in an the fascia lata and fascia iliaca. Clear quadriceps
obvious bony prominence at the side of the contractions can be observed if the femoral
lower abdomen. This is the anterior superior iliac nerve is encountered with the stimulating
spine. needle. This should not be confused with
sartorius muscle motor response, which does not
Pubic Tubercle
cause the patella to move as seen with femoral
This is the bony prominence that can be felt at nerve stimulation. 20-40 ml of local anesthetic
the inner (medial) end of the groin crease. It is is injected through the needle.
PERIPHERAL NERVE BLOCKS 151
Fig. 10.9: Disposition of femoral view, artery and nerve Fig. 10.10: Landmarks for femoral nerve block
Before injecting the local anesthetic agent trochanter (GT) is palpated on the outside of
through the needle, a larger bore needle such the leg, and the ischial tuberosity (IT) is located,
as an 18-guage Tuohy needle may be used to as the main prominence at the base of the
thread a catheter through the needle for buttock. A line is drawn joining these two points
continuous nerve block and treatment of post- (Fig. 10.11). 2 cm below the midpoint between
operative pain. This can be done by placing the these two landmarks is the injection point (Fig.
catheter blindly through the needle, placing a 10.12). A definite groove will be palpable along
nerve stimulator on the proximal end of a stimu- the course of sciatic nerve at this point. Insert
lating catheter, or with the aid of ultrasound. the needle perpendicular to the skin. As the
Femoral nerve block is useful for providing needle is advanced, twitches of the gluteal
analgesia to a patient with fracture neck or shaft muscles are observed first. These twitches
of femur, especially to shift from the site of injury merely indicate that the needle position is still
to the trolley or bed. too shallow. Once the gluteal twitches disappear,
brisk response of the sciatic nerve to stimulation
is observed (plantar flexion or eversion of the
SCIATIC NERVE BLOCK ankle). This typically occurs at a depth of 5-8
Infragluteal Approach cm. After negative aspiration for blood, 15-20
mL of local anesthetic is slowly injected.
To perform this block, the patient lies on the
side with the side to be blocked uppermost. The ANKLE BLOCK
operator stands by the patients bed, on the side The ankle block is a safe and effective method
to be blocked. The hip is then flexed as much as for obtaining anesthesia and analgesia of the
possible with the knee bent. The greater foot.
152 A PRIMER OF ANESTHESIA
Fig. 10.11: Locating the sciatic nerve Fig. 10.13: Nerves supplying the foot
Fig. 10.14: Landmarks for posterior tibial nerve Fig. 10.15: Blocking the sural nerve
block
PENILE BLOCK
Anatomy (Fig. 10.18)
The penis is innervated by the left and right
Fig. 10.17: Anatomy of the inguinal canal
dorsal nerves, which are branches of the
PERIPHERAL NERVE BLOCKS 155
patients (where it is most needed). Just as the Right patient, Right surgery, Right technique
ultrasound does not replace x-rays in ortho- and Right equipment is emphasized. The
pedics, it is ultimately not likely to replace nerve technique should be custom made for the
stimulation for continuous nerve block. It is surgery and not vice versa. It should always kept
most likely to be a valuable addition to nerve in mind that
stimulation. A determined fool with a long needle can
cause all complications.
CONCLUSION
ACKNOWLEDGEMENT
Interest in Regional anesthesia has waxed and I sincerely thank Dr Andre Boezaart (who
waned since its introduction into clinical practice invented the Stimulating Catheters) and
over a century ago. The elegance, safety, and Dr. Robert Raw (who pioneered the Infra-
comfort of a successful peripheral nerve clavicular Superior approach technique) for
blockade are undeniable. However, a high their valuable guidance in crafting this chapter.
success rates depends on flawless understanding I extend my gratitude to Arunkumar J., V
of intricate anatomy. Technological advance- Amulya Ankanapalli and Corey Stotts for fine-
ments do not replace the basic anatomy tuning my chapter. I also appreciate Dr. Admir
knowledge required for Regional anesthesia. Hadzic (nysora.com) for helping me with
Throughout this chapter the golden rule of trouble shooting tabular columns.
Fluid Therapy and Transfusion
Anions
Cl 112.0 117.0 3
HCO3 25.8 27.1 7
Protiens 15.1 <0.1 45
Others 8.2 8.4 154
Total 161.1 152.5 209
40% of TBW is extracellular = 17L termed Definitions of Some Commonly used Terms
ECF. in Fluid Physics and Physiology
Interstitial fluid is 75% of ECF and equals 1. Osmolarity: Number of solute particles
13 L. Plasma constitutes 20% of ECF (3L) and per litre of solution. As volume of solvent
transcellular fluid accounts for 5% of ECF(1 L). can change with temperature (Boyles law),
Transcellular fluid is defined as fluid outside the temperature needs to be specified for
cells but separated from plasma and interstitial measurements.
fluid by membrane barriers, e.g. cerebrospinal 2. Osmolality: Number of solute particles
fluid, synovial fluid, mucus, pleural and per kg solvent. It is a better measure than
peritoneal fluid. Table 11.1 depicts the compo- osmolarity as mass, unlike volume, is
sition of these fluid compartments. unaffected by changes in temperature.
FLUID THERAPY AND TRANSFUSION 159
However, in practice, there is little difference result in movement of fluid out of cell, while
between osmolarity and osmolality. a hypotonic fluid (distilled water) will result
3. Osmole: Amount (in Moles) of solute that in diluting the plasma and cellular swelling.
exerts an osmotic pressure of 1 atmosphere 5. Osmosis: Movement of solvent particles
when placed in 22.4 litres of solution at 0 across a semipermiable membrane which
degrees centigrade. For a substance that does separates solutions of different solute
not dissociate in solution, e.g. glucose, 1 concentrations (tonicity).
mole = 1 Osmole. For a substance that 6. Osmotic pressure: If two solutions are
dissociates into two osmotically active separated by a semipermeable membrane,
particles, e.g. NaCl (Na+ + Cl-), 1 mole = 2 solvent particles will tend to move in the
osmoles. Therefore if 58 g of NaCl direction of higher solute concentration. If
(1g mol.wt) were dissolved in one litre of an arbitrary pressure is applied to the
water, it will be a 2 osmolar solution. If compartment of higher solute concentration,
58 mg of NaCl were dissolved in one litre which opposes this movement, that pressure
water, the concentration is 2 mOsm/l. If mean equals osmotic pressure of the solution
plasma osmolality were taken as 300 mOsm/ (Fig. 11.2).
l, [582] 300 = 8,700 mg or 8.7 g NaCl 7. Colloid osmotic pressure: Colloids are large
needs to be dissolved in one litre water. That gelatinous molecules with molecular weight
makes a concentration of 0.87% or roughly greater than 10,000 Da. Examples include
0.9%. Since dextrose does not dissociate, 1 plasma proteins like albumin and other
mOsm/l is generated when 180 mg is synthetic colloids like gelofusine. These
dissolved in one litre water. Therefore to molecules are unable to cross biological cell
generate 300 mOsmoles 180 300 = membranes due to their size, and hence exert
54,000 mg or 54 g/l or 5.4 g% of dextrose is their own pressure on the membrane called
needed. Thus 5% dextrose is isotonic with colloid osmotic pressure. Though this is
plasma.* It can be seen that it is not the kind significantly less that osmotic pressure exerted
on membrane by ions, it does become
of particle but the number of osmotically
important in conditions like liver failure and
active particles that is important when one
considers osmolality.
4. Tonicity: Molecules restricted to ECF by
selective permeability and charge of the cell
membrane (Na+ , Cl, HCO3) are important
in determining ECF volume and are said to
provide effective osmoles. The concen-
tration of these effective osmoles is
referred to as tonicity. Tonicity can also
be understood as relative osmolality. A
solution which is isotonic (for example
0.9% or normal saline, 5% dextrose) will not
result in net movement of molecules in and
out of the cell when given intravenously as it
does not result in a change in plasma
osmolality. Hypertonic saline (3-5%) will Fig. 11.2: Concept of osmotic pressure
burns, when plasma protein concentration (Na+)A (Cl) A = (Na+) B (Cl) B =>
deceases significantly, resulting in edema. 9Na+ 4Cl = 6 Na+ 6Cl
8. Oncotic pressure: this is the net osmotic
Hence, diffusion of ions down their chemical
pressure developed at a biologic membrane
concentration gradient is balanced by the
by molecules which are restricted to one side
electrostatic attraction of protein molecules
of the membrane, not just by virtue of size,
trapped in one compartment.
but also charge (See Gibbs Donnan effect
below). Intravenous fluids can be divided into
9. Gibbs-Donnan effect: This refers to the effect crystalloids and colloids.
of distribution of a large charged ion (like
albumin, which is negatively charged) which WHAT ARE CRYSTALLOIDS?
cannot diffuse across a biological membrane, These are solutions of ions (Na+, Cl-, HCO3,
on the distribution of smaller ions (like Na+ K+, etc.) and/or small sugars (eg. glucose) in
and Cl) which would otherwise diffuse much water. Crystalloids can be further classified into
more freely across the membrane and have (a) maintenance type and (b) replacement
different concentrations across membrane in type. Maintenance fluids are essentially low-
the absence of this larger ion (Figs 11.3A to sodium or sodium-free fluids used to replace
C). fluid loss due to fasting, urinary losses and
According to the law of mass action, the pro- evaporation. Examples are 5% glucose in water,
duct of ions on one side of the membrane should 0.45% saline in dextrose, 0.33% saline in dex-
equal the product of ions on the other side. trose, etc. Replacement fluids resemble plasma
(Cation)A (anion) A = (cation) B with respect to electrolyte composition (mainly
(anion) B sodium), i.e. contain 0.9% NaCl along with
FLUID THERAPY AND TRANSFUSION 161
Calculated
Osmolality
Examples are Ringers lactate and normal saline.
278
290
278
273
308
Salient Features
- Relatively cheap (compared to colloids).
(mmol/L)
- Most crystalloids are iso-osmotic with plasma
Glucose
0.1
and of a small molecular size. Hence the
-
-
-
molecules are able to pass freely through
microvascular endothelium and do not by
Table 11.2: Electrolyte concentration of normal serum and common crystalloid solutions
(as Lactate)
themselves, contribute to oncotic pressure.
(mmol/L)
HCO3
- When used to replace plasma loss for
28
29
26
-
example in trauma or burns, the volume
needed for replacement is three times plasma
volume lost. Therefore, if 500 ml of blood
Gluconate
(mmol/L)
loss is to be replaced with lactated Ringers
-
-
-
-
-
solution or normal saline, 3 times 500 or
1500 ml would be needed. This is because
1530 minutes after intravenous adminis-
tration crystalloids start to move out of the (mmol/L)
Ca2+
1.5
2.5
intravascular compartment under the
2
-
-
influence of Starling forces and get distributed
to the entire extracellular compartment,
which is approximately twice the volume of
(mmol/L)
Mg2+
-
-
-
-
4
-
-
below.
111
109
154
103
Cl
1. 5% Dextrose
This is essentially water. The glucose added
(mmol/L)
131
130
142
154
Ringers (US)
0.9% sodium
5% dextrose
Hartmanns
solution
Disadv antages
Disadvantages volume of intravascular compartment, crystal-
- As they contain calcium, these fluids are loids in the volume of three times the volume of
incompatible with stored blood (the citrate plasma lost have to be given to maintain
anticoagulant gets chelated and blood clots) intravascular volume. That is, for a 500 ml
- Due to the same reason, they are not ideal plasma loss, 3 500 = 1500 ml of crystalloid
drug diluents. (for example saline or Hartmanns solution) will
- Lactate present in these solutions gets be needed.
metabolised by liver to bicarbonate; in Approximate guidelines are provided to
patients with significant hepatic dysfunction, estimate fluid losses in various types of surgery
it can accumulate and cause lactic acidosis. according to the severity of trauma. Surface/
peripheral procedures like ocular/dental/
PERIOPERATIVE FLUID REPLACEMENT cystoscopy require maintenance + 2 ml/kg/hr.
GUIDELINES Procedures like inguinal hernia repair or
appendicectomy, most orthopedic limb proce-
How do we calculate the amount of intravenous dures require maintenance + 4-6 ml/
fluid needed to compensate for the duration kg/hr. Major body cavity procedures, surgery on
patients are fasting (Basal fluid requirement)? the spine, hepatic resection etc require 10-15
- Parameters needed body weight and ml/kg/hr and fluid replacement is guided by urine
duration of fasting output and central venous pressure.
- For the 1st 10 Kg of body weight 4 ml/kg/
hr is needed REPLACEMENT FLUIDS COLLOIDS
- For the next 10 Kg of body weight 2 ml/
kg/hr Definition: colloids are solutions of molecules
- Thereafter 1 ml/Kg/hr with molecular weight greater than 10,000
For example Intravenous fluid required to daltons (Da), which contribute to the oncotic
correct fluid deficit due to fasting for a child pressure at the microvascular endothelium.
weighing 8 kg, who has been kept nil per mouth Use: Colloids are generally used for replacing
for surgery for 10 hours is 4 ml 8 kg 10 hrs plasma loss on an equal volume basis. For
= 320 ml. example if a patient has lost 500 ml of blood
The same needed for a 15 kg child would which is to be replaced with a colloid, then 500
be 4 ml/kg for the first 10 Kg body weight = 40 ml of colloid would be needed. Also colloids by
ml and 2 ml/kg for the next 5 kg or 10 ml. Hence virtue of their size are restricted to intravascular
40 + 10 = 50 ml/h for 10 hrs, which would be compartment for a significantly longer time than
500 ml. crystalloids (duration of action 2-12 hrs,
Similarly, the requirement for a 50 Kg adult compared with 30-60 minutes for crystalloids).
would be (10 4 +10 2+30 1) = Colloids cannot pass through vascular endo-
90 ml/ hr for 10 hrs or 900 ml. thelium due to a combination of greater size and
How is the volume of crystalloid needed to molecular weight and also the negative charge
replace ongoing plasma volume loss (replace- which is repelled by vascular endothelium.
ment) calculated? Hence their elimination is slow and dependent
Crystalloids solutions start moving out of the on kidneys or reticulo-endothelial system (see
intravascular space and get equally distributed below). If colloids are given rapidly or in large
throughout the extracellular compartment after volumes without close monitoring of patients
intravenous infusion. As the extracellular volume status they can result in fluid overload,
compartment is approximately three times the especially in patients with congestive cardiac
164 A PRIMER OF ANESTHESIA
Table 11.4: Composition of commonly used colloids and comparison with saline
Colloid Modified fluid Polygelines (0.9%)
gelatin (Gelofusine) (Haemaccel) Saline
transfusion should be based on the 3. Hemoglobin < 10 g/dl with major cardio-
individual patients risk for complications of respirator y disease (e.g. emphysema,
inadequate oxygenation. Hence patients ischemic heart disease).
who can possibly have a higher demand to 4. Hemoglobin <10 g/dl after autologous blood
supply ratio of oxygenated blood to end transfusion.
organs (for example patients with coronary 5. Hemoglobin< 12 g/dl in ventilated patients.
artery disease or peripheral vascular disease) The American College of Surgeons classified
should have a higher transfusion trigger acute haemorrhage depending on clinical signs
(explained on page 168) compared to and symptoms and indicated the type of fluid
normal healthy individuals. replacement justified in a given scenario
Other factors to be considered are the speed (Table 11.5).
of blood loss and ability of patient to Whole blood is rarely used nowadays for
compensate effectively. Hence very rapid blood transfusion. Whole blood is separated into
loss, for example secondary to polytrauma or various components (Fig. 11.4) to direct the
injury to a major vessel is more likely to require therapy towards individual deficiency.
rapid blood transfusion, especially in the elderly
or in a small child, who have limited capacity to 1. Packed Red Blood Cells (PRBC) are
compensate for such rapid blood loss, than in used for correction of anemia. The blood is
a healthy athlete. leukocyte depleted (irradiated) and trans-
The following guideline for transfusion is fused through a filter to minimize febrile non
based on the assumption that one unit of hemolytic reactions. Indications for use
packed RBC (PRBC) will increase the hemato- depend on the transfusion trigger as
crit value by 35% (increasing hemoglobin by explained.
1-2 g/dl), and should be transfused if: 2. Platelets for correction of bleeding
1. Blood loss is more than 20% of blood associated with inadequate platelet number
volume (normally 5 Liters in adults), i.e. (thrombocytopenia: when platelet count
>1000 ml. is less than 80,000 per ml, or platelet
2. Hemoglobin < 8 g/dl. dysfunction (thrombasthenia) congenital
or acquired, usually drug induced) exists. like warfarin immediately. The volume
One pool of platelets usually increases the transfused is usually 1520 ml/kg.The
platelet count by 10,000 per ml. Platelets duration of action of these clotting factors is
should never be refrigerated and need a usually 4 hours.
special filter set for transfusion as they would 4. Cryoprecipitate contains factor VIII, von
filter out if a normal blood giving set (with a Willebrand factor and fibrinogen and is
filter size 200 m) is used. therefore indicated in bleeding specifically
associated with the deficiencies of these
3. Fresh Frozen Plasma (FFP) It is rich in factors. This is a frequent finding in dissemi-
factor V(labile factor), factor VIII and plasma nated intravascular coagulation (DIC).
proteins. It is used to correct bleeding asso- Cryoprecipitate can be given without ABO
ciated with clotting factor deficiency and to compatibility as the concentration of
reverse the effects of anticoagulant drugs antibodies is very low.
Table 11.7: Estimated blood volume in various 1. Blood collected in suction drains
groups 2. Blood in swabs, which can either be weighed
Age Blood volume before and after use or a rough estimate, can
be judged by the size of the swab.
Premature Neonates 95 mL/kg
Full Term Neonates 85 mL/kg A standard 4 4 sponge holds ~ 1020
Infants 80 mL/kg ml blood. Lap sponges (large sponges) ~ 30
Adult Men 75 mL/kg 100 ml blood
Adult Women 65 mL/kg These are only estimates, and ideally
patients hemoglobin and hematocrit should be
Which are the donor blood groups that a checked before commencing blood transfusion.
patient can receive and donate to? The management schema of a patient who
is actively bleeding is given in Figure 11.5.
Table 11.6 provides the answer to this question.
How do we calculate the Transfusion What are the Complications of Blood
Trigger or the amount of blood loss that can Transfusion?
be allowed before ordering for a transfusion
1. Changes in oxygen transport (Valtis
during surgery?
Kennedy Effect). This refers to the leftward
Parameters needed: patients weight, hemo- shift of the oxyhemoglobin dissociation curve
globin (g%), acceptable hemoglobin before of stored blood and is mainly due to lowered
commencing transfusion (transfusion trigger) levels of 2, 3 DPG in stored blood. This
and estimated blood volume (EBV). The implies that hemoglobin of stored blood has
estimated blood volume (EBV) for various age a much higher affinity for oxygen than
groups is given in Table 11.7. normal blood and would offload oxygen with
The formula used is
difficulty.Thus transfused blood becomes
Allowable blood loss = [EBV wt (Initial functional only after 24 hours.
Hb transfusion trigger)] Initial Hb 2. Coagulopathy. This is mainly seen after
massive transfusion, which is defined as
For example, if a patient undergoing major
transfusion of one blood volume in 24 hours
orthopedic surgery has an initial Hb of 14 g/dl
and a transfusion trigger of 10 g/ dl is considered or less. The main contributing factors to
appropriate, assuming a weight of 70 kg, his coagulation abnormality seen after blood
allowable blood loss will be [75 70(1410)] transfusion are:
14 = 1500 ml. a. Volume of blood given and duration
Hence blood loss up to 1500 ml in this of hypotension: It has been shown that
patient can (and should) be safely replaced by patients who have been hypotensive for
either crystalloids (3 1500 = 4500 ml) or less than one hour have a better chance
colloids (1 1500 = 1500 ml) or both. The of not developing coagulopathy after
patients hemoglobin is expected to be multiple transfusions.
approximately 10 g/dl after losing 1500 ml. If b. Thrombocytopenia: At 4C, which is
this loss is replaced by non blood containing the temperature of stored blood, platelet
fluids, he should remain hemodynamically stable activity decreases very rapidly and is only
as long as intravascular volume is maintained. 510% after 24 hours of storage. Trans-
Blood loss during surgery can be judged by fusion of large volumes of banked blood
taking into account can result in thrombocytopenia.
FLUID THERAPY AND TRANSFUSION 169
c. Low factors V and VIII: most factors directly or indirectly through some toxins
are stable in stored blood except factors and activate the extrinsic pathway of
V and VIII which decrease to 15 and 50% coagulation. The rapid coagulation in the
of normal after 13 days of storage. microcirculation leads to microthrombi,
d. Disseminated intravascular coagu- further hypoxic damage and consump-
lation (DIC): the specific reason for DIC tion of fibrin and platelets which leads to
seen after massive transfusion is not clear. activation of fibrinolysis (secondary
However, it seems that hypoxic, acidotic fibrinolysis) and further loss of fibrin. The
tissues with stagnant blood flow drugs useful in this scenario have been
probably release tissue thomboplastin enumerated in Figure 11.6.
170 A PRIMER OF ANESTHESIA
* CPD-A1 is Citrate-Phosphate-Dextrose with Adenine, the solution used to preserve banked blood.
FLUID THERAPY AND TRANSFUSION 171
survive for 221 days before being pulmonary edema after transfusion. Though
hemolysed. The level of antibody at the the clinical picture is similar to ARDS and
time of transfusion is presumably too low warrants similar management, the mortality
to elicit a reaction, but as the levels rate is much lower (<10%) compared to that
gradually increase after secondary seen in ARDS.
stimulus (anamnestic response) the cells 7. Immunosuppression: Blood transfusion
get lysed. This mainly presents as jaundice has been associated with non-specific
and hemoglobinuria. Management is immune suppression. This has been asso-
symptomatic. ciated with tumour recurrence or reduced
c. Nonhemolytic transfusion reac- survival in cancer patients. It is therefore,
tions: These reactions are usually not recommended that cancer patients should
serious and are either febrile or allergic be given packed RBCs instead of whole
in nature. The main reason is bacterial blood. The mechanism has been related to
contamination and hence these are most increased synthesis of PGE and Interleukin-
commonly seen in relation to transfusion 2 in stored blood.
of platelets which need to be stored at
room temperature. DIAGNOSIS AND CORRECTION OF SOME
4. Infection: Infections commonly associated COMMON ELECTROLYTE ABNORMALITIES
with blood transfusion are hepatitis B, Use of large amounts of crystalloids in the peri
hepatitis C, HIV, HTLV, Cytomegalovirus, operative period can occasionally cause
Yersinia enterocolitica, syphilis and malaria. disturbances in the extra- and intra cellular
Others repor ted are Leishmaniasis, electrolyte balance and also with total body
Brucellosis, Salmonellosis, measles, Filariasis water and its distribution. These imbalances can
and typhus. profoundly affect cardiovascular, neurological
5. Transfusion associated Graft-versus and neuromuscular function and can even cause
Host Disease: Donor lymphocytes from mortality. In this section we will discuss about:
transfused blood products engraft in the - Effect of different fluid loads on extra-cellular
recipient initiating an immune reaction. This and intra-cellular water content
can be prevented by using appropriate filters - Causes and management of disorders of
and irradiating blood components. sodium homeostasis
6. Transfusion related acute lung injury - Management of potassium disorders
(TRALI): This manifests as noncardiogenic - Management of calcium disorders.
172 A PRIMER OF ANESTHESIA
As you saw earlier in this chapter, the C. When a hypertonic load of e.g. 600 mEq
intracellular and extracellular solutes maintain NaCl is administered (no water):
equal osmolality on either side of the cell - Total body solute = 11,760 + 600 =
membrane, which separates the ICF from the 12,360 mOsm/kg
ECF. The normal ECF and ICF osmolar load is - New body osmolality = 12,360 42 =
calculated as follows: 294 mOsm/kg
- Total body solute (280 mOsm/kg - New extracellular solute = 600 + 3920
= 4520 mOsm
TBW) = 280 42 = 11,760 mOsm
- New extracellular volume = 4520 294
- Intracellular solute = 280 mOsm/kg
= 15.4 L (Gain of 1.4 L)
28 kg = 7840 mOsm
- New intracellular volume = 42-15.4 =
- Extracellular solute = 280 mOsm/kg 26.6 L (Loss of 1.4L)
14 kg = 3920 mOsm - New extracellular sodium = 294 2 =
- Extracellular sodium concentration = 147 mEq/L
280 2 = 140 mEq/L Thus, there is a net movement of 1.4 L water
from the ICF to the ECF and the [Na+] increases.
Effect of Infusion of 2 L Crystalloid Load on
TBW and its Distribution in a 70 kg Adult HYPERNATREMIA AND ITS MANAGEMENT
A. When 2 L of normal saline is infused Hypernatremia occurs either due to hypotonic
(isotonic load): Isotonic saline stays mainly losses (i.e. more water lost than sodium) or due
extracellularly and its osmolality is nearly to sodium retention. Thirst and water intake
equal to that of plasma.Therefore the usually prevent hypernatremia secondary to
changes that are expected are as follows: sodium retention, but this mechanism cannot
- Total body solute = 280 mOsm/kg operate in the debilitated or unconscious patient.
44 kg = 12,320 mOsm Hyperosmolality is an inevitable consequence
- Intracellular solute = 280 mOsm/kg of hypernatremia.
28 kg = 7840 mOsm The major causes of hypernatremia are:
- Extracellular solute = 280 mOsm/kg I. Impaired thirst perception:
16 = 4480 mOsm - Coma
- No change in osmolality; water gain of 2 - Essential hypernatremia
kg in ECF space II. Excessive water loss:
- Sweating
B. When 2 L of water or 5% dextrose is
- Neurogenic diabetes insipidus
infused: (dextrose is metabolised quickly,
- Nephrogenic diabetes insipidus
leaving behind a water load).
III. Solute diuresis:
- New TBW = 42 + 2 =44 kg - Osmotic diuresis as seen in diabetic
- New body osmolality = 11,760 44 = ketoacidosis, mannitol administration
267 mOsm/kg IV. Combined causes:
- New intracellular volume = 7,840 267 - Coma and hypertonic enteral feeding
= 29 L Signs and symptoms of hypernatremia
- New extracellular sodium concentration depend on whether the patient is conscious,
= 267 2 = 133 mEq/L when the overpowering symptom is intense
Thus the osmolality is reduced and the fluid thirst, progressing to unconsciousness and
has distributed itself into both ECF and ICF. death. Small children are especially prone to
FLUID THERAPY AND TRANSFUSION 173
- Potassium intake should be stopped. into the cell with each glucose molecule
- Calcium supplementation (calcium gluconate transported. This mechanism takes 1
10%, preferably through a central venous hour for peak effect.
catheter as the calcium may cause phlebitis) - When metabolic acidosis is present, IV
does not lower potassium but decreases sodium bicarbonate (1-2 mEq/kg) can
myocardial excitability, protecting against life decrease plasma K+ in 15 min.
threatening arrhythmias. - Polystyrene sulfonate (Calcium Resonium,
- Nebulised or intravenous salbutamol is a Kayexalate) is a binding resin that binds K
rapidly acting catecholamine. Catechola- within the gut and removes it from the body
mines promote movement of K into cells, in feces. Calcium Resonium (15 g three
lowering the blood levels. times a day in water) can be given by mouth.
- -agonists may be useful in acute hyper- Kayexelate can be given by mouth or as an
kalemia associated with massive transfusion, enema. In both cases, the resin absorbs K
and will also provide inotropic support. Low within the gut and carries it out of the body.
dose epinephrine (0.52 mg/min) is used for - Refractory or very severe cases may need
this purpose. dialysis to remove the potassium from the
- Insulin and dextrose (e.g. 20 Units of insulin circulation.
and 50 ml 50% dextrose) act similarly, - When mineralocorticoid deficiency is res-
leading to a shift of potassium ions into the ponsible, high dose hydrocortisone and
intracellular compartment. Some of the intravenous saline solution may be all that
glucose transport mechanisms bring a K ion is necessary.
FLUID THERAPY AND TRANSFUSION 181
HYPERCALCEMIA AN
ANDD HYPOCALCEMIA
Hypercalcemia- causes, Treatment and
Anesthetic Implications
Normal plasma calcium is 8.510.5 mg/dl (2.1 Fig. 11.14: Short Q-T interval in hypercalcemia
2.8 mmol/L). Ionised calcium is normally 4.75
5.3 mg/dl (1-1.3 mmol/L). Levels of ionised coma. Patient may have concomitant pan-
calcium is affected by plasma albumin (each creatitis, peptic ulcer disease or renal stones/
increase or decrease of albumin by 1g/dl renal failure. Terminal hypotension is preceded
increases or decreases total calcium by 0.81 by hypertension. A short ST segment and
mg/dl), or by pH (each decrease of 0.1 unit shortened QT (Fig. 11.14) interval are the
pH increases ionised calcium by 0.36 mmol/L). salient ECG findings. Hypercalcemia sensitises
Ionised calcium fraction is the physiologically the myocardium to digoxin.
active calcium.
Treatment
Causes of Hypercalcemia (Table 11.12)
Symptomatic hypercalcemia requires aggressive
The commonest cause is hyperparathyroidism treatment. The most important initial treatment
which may be primary or secondary to renal is rapid hydration with normal saline and
failure. Patients are usually extremely debilitated administration of a loop diuretic to ensure brisk
and bedridden. They may have multiple diuresis. The management plan can be followed
fractures or renal stones (which is how the on the flow chart (Fig. 11.15). Rarely emer-
condition is usually diagnosed). They may have gency parathyroidectomy may be indicated if
poor intravenous access (due to fractures and conservative measures fail to reduce serum
casts) and may not be able to sit up on account calcium levels.
of debility or vertebral fractures. These factors
increase their perioperative morbidity and Anesthetic Considerations for
mortality. Hypercalcemia
Fig. 11.19: Management strategy for hypocalcemia (serum Ca2+< 88.5 mg/dl or 2 mmol/l)
FLUID THERAPY AND TRANSFUSION 187
Preethy Mathew
analgesic doses and thus improves titration of What are the Possible Respiratory
analgesia. NSAIDs, though not as potent as Complications?
narcotics, are useful adjuncts to opioids. The majority of complications in PACU are
Narcotics administered in the epidural space
related to the respiratory system and include
have the advantages of effective and prolonged
airway obstruction, hypoxemia and hypoventi-
analgesia.
lation. The risk factors for these complications
The patients are observed until they are fit
following general anesthesia are age older than
to be discharged to the surgical ward. The
60 years, obesity, emergency surgery, prolonged
recovering patient is fit for the ward when awake
and extubated, is arousable and can respond surgical procedures and heavy opioid or sedative
appropriately, can lift the head on command, medications.
is breathing quietly and comfortably, is not i. Airway obstruction: The most common
hypoxic and has satisfactory pulse and blood cause of postoperative airway obstruction
pressure. Complications related to the is pharyngeal obstruction caused by the
procedure should be ruled out, ensuring that tongue falling back on the posterior
tubes, drains and catheters are functioning pharyngeal wall. Laryngeal obstruction
properly. Patients who receive regional may occur due to laryngospasm, direct
anesthesia should be able to move and perceive airway injury or vocal cord paralysis.
touch in the blocked extremities. L aryngospasm is more common in
The steps of management of a patient children, in light planes of anesthesia and
recovering from general anesthesia are sum- in the presence of blood or secretions in
marized in Table 12.1. the pharynx. Direct airway injury results
from multiple intubation attempts or
COMPLICATIONS prolonged intubation and is more common
24-30% of the patients observed may develop in children. Edema of the upper airways
a complication in the postoperative phase. may present as sore throat and hoarseness
Greater ASA physical status tends to have a progressing to respiratory stridor and
higher incidence of complications. The compli- dyspnea. Intrinsic compression, as from a
cations may be grouped as: respiratory, rapidly expanding wound hematoma after
circulatory, failure to regain consciousness, thryoid surgery gives rise to life threatening
nausea and vomiting, hypothermia and airway obstruction.
shivering, and miscellaneous issues. ii. Hypoxemia: Measurement of arterial
Table 12.1: Steps in management of patient after oxygen saturation with the pulse oximeter
general anesthesia provides early and reliable detection of
hypoxemia and is now the standard of care
1. Administration of oxygen in postoperative period.
2. Position-Propped-up, if awake The common causes of hypoxemia can be
Head down and lateral, if drowsy severe airway obstruction, atelectasis (i.e.
collapse of entire lung or lobe or segment),
3. Record of vital parameters- heart rate, blood
pressure, respiratory rate and pattern, oxygen bronchial obstruction with secretions, or
saturation pneumothorax. Other important causes of
4. Intravenous fluid administration hypoxemia are pulmonary edema and
pulmonary embolism. Postoperative
5. Ensure adequate pain relief
shivering increases oxygen consumption by
6. Look for surgical bleeding, drain output, etc. 300500% and contributes to hypoxemia.
194 A PRIMER OF ANESTHESIA
Table 12.2: Causes of postoperative hypoventilation (2.25%). Some experts recommend the use of
1. Inadequate central respiratory drive corticosteroids. Laryngeal spasm may be
Inhalational induced relieved by continuous positive airway pressure
Narcotic induced (CPAP) or a small dose (0.2 mg/kg) of
2. Inadequate function of respiratory muscles suxamethonium and assisted ventilation till
Inadequate reversal of neuromuscular blocking spontaneous ventilation results.
agents Management of airway obstruction secon-
Inadequate analgesia resulting in respiratory
splinting
dary to external compression of larynx or
Obesity trachea by a tense hematoma (e.g. following
Tight dressings/ Body casts thyroidectomy, cervical dissection) is a surgical
3. Intrinsic lung disease emergency and demands urgent evacuation of
4. Increased CO2 production the hematoma under local infiltration
Hyperthermia, Thyrotoxic crisis. anesthesia.
In the event of hypoxemia and hypo-
iii. Hypoventilation: Hypoventilation is ventilation without airway obstruction, evaluate
defined as reduced alveolar ventilation and treat the cause. Chest auscultation, a
resulting in an increase in arterial CO2 portable chest roentgenogram (X-ray) and
tension (Pa CO2). The causes are listed in arterial blood gases are valuable tools.
Table 12.2. Hypoxemia due to atelectasis may be managed
by humidifying inspired gases and encouraging
How do you Manage a Patient with the patient to cough with the help of chest
Respiratory Compromise? physiotherapy, deep breathing and incentive
Prompt recognition and management of these spirometry. If hypoxemia persists (PaO2 < 60
life-threatening situations are crucial. All patients mmHg) despite maximal oxygen therapy
with any form of respiratory complication should (FiO2=1.0), tracheal intubation and assisted
receive oxygen by facemask. Prop-up the ventilation may be required.
patient to alter the ventilation-perfusion ratio The treatment of pneumothorax depends
favorably. on the size of the pneumothorax and the
Airway obstruction is initially managed with patients condition. A 1020% pneumothorax
a combination of backward tilt of the head in a spontaneously breathing patient can be
(head extension) and anterior displacement of observed for any increase or clinical deterio-
the mandible (jaw thrust). If the obstruction is ration. A pneumothorax of >20% in a
not immediately reversible, a nasal or oral airway spontaneously breathing patient or any
should be inserted. If the airway cannot be pneumothorax in a mechanically ventilated
opened by simple maneuvres, positive-pressure patient should be treated by insertion of an
ventilation with a bag, mask, and 100% oxygen intercostal drainage. Tension pneumothorax
is indicated. During management of airway with circulatory compromise should be relieved
obstruction using any maneuvre, one must immediately using a large gauge needle until a
target for regular and good chest excursions. If chest tube is inserted.
a bag and mask are used to supplement oxygen, Narcotic induced respiratory depression can
then bag movement is a good indicator of be reversed with naloxone. Pain management
airway patency. Orotracheal intubation is with nerve block or epidural analgesia prevents
necessary if these measures fail. respiratory embarrassment due to surgical pain.
Airway edema secondary to trauma Inadequate reversal of neuromuscular blockade
responds to aerosolized racemic adrenaline can be prevented by ensuring adequate neuro-
POST-ANESTHESIA CARE 195
13. Which of the following physiological 15. Propped up position is not advised in
alterations is present in hypothermia? the following situations except:
a. Generalized vasodilatation a. Risk of bleeding into the airway
b. Systemic vasoconstriction b. Obese patient
c. Hypotension c. Excessively drowsy patient
d. Metabolic alkalosis. d. After subarachnoid block.
14. Oxygen administration to the patient Answers
is not indicated after:
a. Inguinal hernia repair in a 30-year-old 1. a 2. b 3. d 4. c
b. Inguinal hernia repair in a 3-year-old 5. b 6. b 7. d 8. c
c. Laparoscopic cholecystectomy 9. d 10. c 11. d 12. a
d. Mastoidectomy. 13. b 14. a 15. b
Oxygen Therapy
A patient on an oxygen mask or receiving oxygen Clinical Situations which may be Associated
through a nasal cannula is a common sight in with Hypoxemia
hospital wards. This chapter aims at enumerating Postoperative patient
goals of oxygen therapy, various devices to CO poisoning
provide it with their function, advantages and Shock
limitations. Further, it can guide selection of Trauma
appropriate mode of therapy. Sepsis
Acute myocardial infarction (AMI).
Objectives of Oxygen Therapy
To correct acute hypoxemia (due to any Laboratory and Bedside Measurements to
cause) Diagnose Hypoxemia
To provide symptom relief in chronic
a. Adults, children and infants>28 days of age:
hypoxemia by
PaO2<60 mm Hg or SpO2<90%
reduction of dyspnea
b. Neonates: PaO2< 50 mm Hg, SpO2<85%
improving mental alertness
reducing angina
Oxygen Delivery Systems
reducing fatigue
To reduce cardiopulmonary workload by These are classified based on the basic design:
reduction in work of breathing I. Low- flow systems
reduction in myocardial work II. Reservoir systems (This category also
reduction in pulmonary vasoconstriction includes hoods and tents)
reduction in right ventricular strain. III. High-flow systems
OXYGEN THERAPY 201
How ccan
an you Estimate the FiO2 Provided by
Low Flow Systems?
Each litre of supplemental oxygen increases FiO2
by 4% in a patient with normal tidal volume
and respiratory rate; therefore a patient receiving
3l/min through a nasal cannula is receiving
(21+12) = 33% oxygen.
RESERVOIR SYSTEMS
These systems collect and store oxygen between
Fig. 13.2: Nasal catheter breaths. During the next breath the patient draws
upon this reservoir when the inspiratory flow
Disadvantage: It can cause gagging or aspiration exceeds oxygen inflow. Thus dilution with air is
if high flows are used. Frequent change is reduced and the FiO2 provided is higher than
required (68 hourly) as it promotes production low flow systems. They are of two varieties:
of secretions and gets blocked. reservoir cannula and reservoir mask.
B. Reservoir Masks
These are the most commonly used reservoir
systems. The simple mask is an important item
of postoperative recovery room equipment.
The simple face mask (Fig. 13.4) is a
disposable plastic device which covers the nose
and mouth and has a securing elastic strap.
There are multiple holes through which the
patient can exhale and also draw air during
inspiration. FiO2 is variable. Flows of 5-12l can
be used. Flows less than 5l/min may result in
CO2 retention.
To improve the performance of this mask, a
Fig. 13.5: A partial rebreathing mask
flexible reservoir bag of 11 can be attached to
the mask at the oxygen inlet. This partial
rebreathing mask (Fig. 13.5) has expiratory
ports but no unidirectional valves. The patient
partly exhales the anatomical dead space gas
into the bag. The last 2/3rds of the exhaled gas
high in CO2 escapes through the ports. As long
as enough O2 flows to prevent the bag from
collapsing during inspiration, re breathing is
negligible. A leak-free non-rebreathing mask
fitted with competent unidirectional valves
C. Oxygen Tent
This consists of a canopy into which cooled and
oxygen-enriched air is circulated. It can provide
a maximum of 4050% O2. Frequent opening
causes large swings in FiO2 even with flows of
Fig. 13.4: A simple face mask 12-15l/min.
204 A PRIMER OF ANESTHESIA
to make up, thus reducing the calculated FiO2. need hyperbaric oxygen therapy). Those
The total flow has to be at least 60 l/min if the patients are usually intubated and on
FiO2 has to remain stable. assisted ventilation. The ventilators are
However, if a nebuliser entrainment device capable of providing 100% oxygen. High
is set to deliver 40% for the above patient, the FiO2 levels can be achieved with blending
total flow would be = sum of ratio parts (3+1) systems which provide high flows thus
15 = 60 l/min which would provide a preventing dilution. For a critically ill adult
consistent FiO2 of 40%. In the first scenario, patient with moderate to severe
extra oxygen can be bled into the patients hypoxemia, who is able to breathe
mask through a cannula to increase FiO2. Thus spontaneously, a reservoir or a high-flow
air entrainment devices behave as high flow and system capable of providing at least 60%
fixed output devices at lower FiO2 values. oxygen should be used. These patients
Practically, to determine whether the total are carefully monitored and if hypoxemia
flow from a nebuliser is sufficient, the mist remains uncorrected, they should be
escaping from the orifices of the mask is intubated and receive mechanical
observed. If it is seen throughout inspiration it ventilation with FiO2 > 0.6, and possibly,
indicates that the flow is sufficient and that the PEEP. For adult patients in more stable
set FiO2 is being delivered. condition (acute MI, postoperative
hypoxemia) a system capable of low to
B. Blenders moderate oxygen concentration can be
When air entrainment devices cannot provide used, e.g. a nasal cannula or air entrain-
high enough oxygen concentration or flow, ment device. Adult patients with COPD
blending systems are the next step. Here and acute-on-chronic hypoxemia need
pressurized oxygen and air are separately careful oxygen augmentation so that their
delivered into a mixing chamber where hypoxic drive is not suppressed. In these
blending is done by manual adjustment or patients, low flow nasal oxygen or a
mechanically by a proportioning device. 2428% entrainment device can be
Special, calibrated high-flow flow meters are used.
used. Blenders can be used to fill non b. Presence of adequate respiratory effort:
rebreathing reservoir bag circuits to provide a If a patient is generating a good tidal
full range (21100%) oxygen. volume (evident by chest excursions) and
How to select the ideal oxygen delivery has a resonable respiratory rate, oxygen
system? can be supplemented by any of the
One examines (i) the objectives, (ii) patient means listed in Table 13.2.
factors and (iii) equipment performance and c. Degree of consciousness and alertness:
limitations. An unconsious patient who is also
I. The primary objective/purpose is to correct hypoxemic needs to the intubated and
arterial hypoxemia. Secondary benefits then given appropriate FiO2 to correct the
follow. hypoxemia. If respiration and sensorium
II. Patient factors to be considered: do not improve, mechanical ventilation
a. Severity and cause of hypoxemia: An is required. Similarly even if an alert
FiO2 of 100% should be provided in cases patient is unable to maintain PaO2 of 60
of cardiac arrest, severe trauma, shock, mm Hg while breathing 60% oxygen,
CO or cyanide poisoning (the latter may needs respiratory support.
OXYGEN THERAPY 207
2. The following bedside tests are useful 6. Unwanted effects of oxygen commonly
in monitoring hypoxia seen are
a. Colour of lips a. Dryness of mouth and nose
b. Saturation of fingers or toes b. Fire hazards
c. Respiratory rate c. Formation of new retinal blood vessels
d. Arterial blood gases d. Respiratory distress syndrome
208 A PRIMER OF ANESTHESIA
7. The following facts are correct in 12. Dramatic hypoxia may be features of
oxygen therapy with high flow systems a. Tension pneumothorax
a. Entrainment of air from surrounding b. Flail chest
atmosphere c. Amniotic fluid embolism
b. Flows higher than peak expiratory flow d. Marathon race
is delivered
13. Choose the correct statements
c. Blenders provide accurate FiO 2 by
a. Oxygen is an anesthetic gas
mixing pressurized oxygen and nitrogen
b. Commercial preparation of oxygen is
d. Ventimask is a common example
by fractional distillation of liquid air
8. Optimising oxygen therapy may c. No harm would come to the patient
include from receiving oxygen
a. Controlling fever d. Molecular weight of oxygen is 16
b. Good nutrition
14. Perioperative patients are given
c. Treating heart failure
oxygen for the following reasons
d. Appropriate antibiotics for chest
a. At the start of GA 100% oxygen is given
infection
to replace air from the FRC
9. Useful parameters to monitor in a b. After prolonged GA with N2O, oxygen
patient who is given oxygen must be given to avoid diffusion hypoxia
a. Respiratiory rate c. Pain causes increase respiratory rate and
b. Temperature and humidity of the hence better oxygenation
inspired air d. Massive blood transfusion of bank blood
c. Blood pressure interferes with oxygen delivery
d. Glasgow coma scale
15. The following maneuvres would
10. Oxygen reaches the tissues from the complement oxygen therapy
heart in the following ways a. Sitting position rather than supine
a. Carried by normal haemoglobin b. CPAP (Continuous Positive Airway
b. Dissolved in the plasma Pressure)
c. As carboxyhemoglobin c. Bronchodilators in asthmatics
d. By diffusion from higher towards lower d. Tracheostomy
partial pressure
Answers
11. Common sources of oxygen supply in
large hospitals are 1. FFFT 2. TTTF 3. TTTF
a. Liquid oxygen tanks 4. TTFT 5. TTFF 6. TTTT
b. Cylinders 7. TFFT 8. TFTT 9. TTTT
c. Green oxygen tubings 10. TTFT 11. TTFT 12. TTTF
d. Oxygen concentrators 13. TTFF 14. TTFT 15. TTTF
Infection and the Anesthesiologist
Ashish Malik
Fig. 14.2: The hepatitis B virus Fig. 14.3: The hepatitis C virus
Fig. 14.4: Causes of injury at the workplace Fig. 14.5: Effective hand washing
9. What are the precautions taken to 13. PEP for HIV infection includes :
prevent needle stick injuries called: a. Zidovudine
a. Transmission based precaution b. Zidovudine + Lamivudline
b. Universal Precaution c. Lamivudine
c. Double standard precautions d. Zidovudine + Lamivudine + indinavir
d. Prevention 14. Anti-Hbs titre for long term protection
10. Transmission based precautions are should be more than
used in which of the following a. > 10 mIu/ml
b. 1-9 mIu/ml
disease:
c. 0.1-1 mIu/ml
a. Herpes simplex b. HIV
d. 1 mIu/ml
c. Hepatitis d. Conjunctivitis
15. Dose of HBIG following exposure to
11. Infected sharps should be kept in:
hepatitis B is
a. 0.02% bleach a. 0.08 ml/kg b. 0.06 ml/kg
b. 0.1 % bleach c. 0.05 ml/kg d. 1 ml/kg
c. 10 % bleach
d. 5% bleach Answers
12. If large volume contact occurs through 1. c 2. c 3. c 4. d
compromised skin it is referred to as 5. a 6. b 7. b 8. a
a. EC1 b. EC2 9. b 10. a 11. b 12. b
c. EC3 d. EC4 13. d 14. a 15. b
Care of the Patient in the ICU
Sumesh Arora
MONITORIN
MONITORINGG IN THE INTENSIVE CARE
UNIT
Respiratory system monitoring: Most of the
patients in the ICU will be on ventilatory support.
Adequacy of oxygenation is monitored conti-
nuously by pulse oximetry; while adequacy of
ventilation is monitored by end tidal CO2. The
shape of the end tidal CO2 curve may provide
additional information about position of the
endotracheal tube after intubation, discon-
nection, expiratory airway obstruction and
breathing efforts made by a paralyzed patient.
Modern ventilators are equipped with a monitor
Fig. 15.1: A hemofiltration unit
that displays information about airway pressure,
flow rate, tidal volumes and dynamic relations
Critically ill patients generally have limited
like flow-volume curve and pressure-volume
mobility, require multiple drugs and undergo
curves. These curves give information about
multiple procedures (Fig. 15.1). The need for
airway resistance and compliance of the
adequate number of trained nursing staff cannot
respiratory system.
be overemphasized. Ideally, one nurse should
care for one patient, but this generally depends Cardiovascular monitoring: Lead II and a chest
upon the available nursing resources. lead are generally monitored continuously. Lead
An ICU with technical staff like respiratory II is generally most helpful for the diagnosis of
technicians who look after ventilator manage- arrhythmia. The ST segment may be monitored
ment, weaning protocols etc. may improve for diagnosis of ischemia. Measurement of blood
outcome. The administrative staff looks after the pressure may be done non-invasively or
records, research work and other administrative invasively using intra-arterial catheter. Beat to
needs of the unit. The ancillary staff consists of beat intra-arterial blood pressure is measured
social workers, equipment in- charge, cleaners, for patients who are hemodynamically unstable,
wards persons etc. They are also important are on vasopressors, or if non-invasive blood
components of the ICU team. pressure measurement is likely to be inaccurate
[e.g. in the very obese, or at very low blood
ADMISSION TO INTENSIVE CARE UNIT pressure]. Pulse pressure variation with respira-
Patients may be admitted to Intensive care unit tion on intra-arterial blood pressure trace may
from the emergency department, operation give additional information about the intra-
suite, any hospital ward or from another hospital. vascular volume status.
Appropriate patient selection is important to Central Venous Pressure [CVP] is the
derive maximum benefit out of the available intravascular pressure in the great thoracic veins.
(and usually limited) resources. Patients who It is the equivalent of right atrial pressure and in
only need monitoring may be managed in a high the absence of tricuspid valve disease is a
dependency unit (HDU). Critically ill patients for measure of right ventricular preload. It is
whom intensive care is likely to be futile [e.g. measured at the level of fifth intercostal space
with advanced metastatic malignancy] should in the mid-axillary line [Phlebostatic axis;
not be admitted to ICU. Fig. 15.2]. Most of the patients in the ICU have
CARE OF THE PATIENT IN THE ICU 221
water. It hands are not visibly soiled, alcohol critically ill patients are considered to be full
based hand rubs may be used. Provision of stomach. Rapid sequence intubation with
alcoholic hand rubs at the bedside ensures better cricoid pressure is usually performed. Facilities
compliance with hand hygiene compared to for suction, hemodynamic resuscitation and a
hand washing. difficult airway cart should be available at the
Gloves should be worn for anticipated time of intubation. The position of the endo-
contact with blood, mucus membrane or tracheal tube should be confirmed by capno-
contaminated items. The use of gloves does not graphy. Patients are often hemodynamically
obviate the need for hand wash, and hands unstable at the time of intubation. If conventional
should be washed before wearing and after dose of anesthetic drugs are used severe
removing gloves. hypotension may result. Positive pressure
Sterile precautions should be used for ICU ventilation in hypovolemic patients decreases
procedures like CVC insertion. venous return to the heart and can cause severe
Urinary tract infection is the most common hypotension. Large volume of fluids or
nosocomial infection in ICU. Indwelling catheters vasopressors may be required for resuscitation
should be removed at the earliest possible. soon after intubation. An experienced intensivist
Patients on ventilator are at risk of develop- should be present at the time of intubation.
ment of ventilator associated pneumonia [VAP].
The risk increases with increased duration of POSITIVE PRESSURE VENTILATION [PPV]
mechanical ventilation. Risk of VAP can be PPV may be delivered through an endotracheal
reduced by raising the head end of the bed by tube or a tight fitting mask. The latter is known
15-30, minimizing the number of discon- as non-invasive ventilation [NIV]. The best way
nections of ventilator circuit, avoiding routine to learn the working of a mechanical ventilator
change of ventilator circuit, use of heat and is to stand at the bedside and watch the monitor
moisture exchange [HME] filter between ET tube of the ventilator and the breathing pattern of
- circuit connection and compliance with hand the patient. The following section discusses the
wash guidelines. basic components of mechanical ventilation.
Infection control in ICU requires compliance
of all the members of the health care team. Even Initiation of the mechanical breath: The
one noncompliant staff member may spread ventilator, or patient, may initiate the breath.
infection. Inadequate staffing particularly at For patients who cannot initiate a breath, the
night-time and overcrowding in ICU are ventilator is set to deliver timed breaths. Such a
associated with poor compliance with infection mode of ventilation is called control mode
control practices in ICU. Regular teaching of the ventilation. In control mode ventilation, the
ICU staff and audit of infection control practices ventilator controls the rate and rhythm of
helps to evaluate and improve the ICU perfor- breathing.
mance. When the spontaneously breathing patient
makes a breathing effort, the ventilator circuit
RESPIRATORY ISSUES IN ICU senses a decrease in pressure in the circuit. The
ventilator then delivers a positive pressure
Most of the patients admitted to ICU require
breath. Such a mode of ventilation is called
intubation and mechanical ventilation. support mode. Pressure support ventilation
Airway: Indications of intubation are: (i) [PSV] is an example of this mode of ventilation.
protection of airway from collapse or aspiration In support mode ventilation, the patient controls
and (ii) positive pressure ventilation. Most the rate and rhythm of breathing.
CARE OF THE PATIENT IN THE ICU 225
In synchronized modes of ventilation, the expiration. This pressure is called positive end
ventilator synchronizes with the patient effort. If expiratory pressure [PEEP]. PEEP improves
the patient fails to initiate a breath, the ventilator oxygenation by keeping alveoli open during
delivers a timed breath. This mode combines expiration. In healthy lungs, 5 cm H 2O is
the characteristics of control mode and support generally sufficient to prevent alveolar collapse.
mode ventilation. In acute respiratory distress syndrome [ARDS],
high PEEP is generally required.
Depth of breathing: The depth of breathing
[Limit of breath] can be set in different ways. In Respiratory rate and minute ventilation: Minute
the volume control or volume support modes, ventilation is the product of tidal volume and
the tidal volume is set. Generally, tidal volume respiratory rate. CO2 removal is a function of
of 68 ml/kg body weight is used. In these the minute ventilation. Respiratory rate is set to
modes, the ventilator will deliver each breath to achieve adequate minute ventilation and CO2
a preset volume, regardless of the pressure removal.
required to reach the volumes.
The other way to set the depth of ventilation Alarm settings: The following alarms are
is to deliver a breath to preset peak inspiratory commonly set on ventilator:
pressure. Pressure control ventilation [PCV] and 1. High airway pressure: To avoid injury to
pressure support ventilation [PSV] are such alveoli form high pressure [Barotrauma]. It
modes. The tidal volume delivered in these is generally set at 3035 mm H2O. It is
modes varies from breath to breath but the peak particularly important when ventilating with
inspiratory pressure remains constant. a volume limited ventilation mode.
2. Low airway pressure: To detect accidental
End of inspiration: Cycling from inspiration to disconnection or leak from circuit and
expiration can be set in different ways. At the hypoventilation because of leak. It is
end of inspiration, the inspiratory valve of generally set at just below PEEP.
ventilator closes and the expiratory valve open, 3. High minute ventilation.
allowing the patient to exhale passively. 4. Low minute ventilation: It is particularly
Ventilator modes may be time or flow cycled. important when ventilating with pressure
In the time-cycled modes, inspiratory time is set. limited mode.
At the end of inspiratory time, the inspiratory 5. High and low respiratory rate.
valve closes and the expiratory valve open. In
the flow-cycled modes, [e.g. PSV] after the Side effects of PPV: Mechanical ventilation
inspiratory flow reaches a particular fraction of is uncomfor table. Patients on PPV need
the peak inspiratory flow [1030%], the sedation. It reduces mobility and makes patients
ventilator changes from inspiration to expiration. dependent for their most basic needs. It increases
In obstructive air way disease [asthma, nursing requirements. PPV may cause injury to
emphysema] adequate time should be given for the lung by excess pressure in the alveoli
expiration because of predominantly expiratory [Barotrauma] or excess stretching of the alveoli
airflow obstruction. [Volutrauma]. Barotrauma may present
suddenly as tension pneumothorax. Repeated
Positive end expiratory pressure (PEEP): During opening and closure of alveoli may also injure
expiration, the alveoli have a tendency to the alveoli [Atelectrauma] which manifests as
collapse. Collapsed alveoli do not participate in acute lung injury and worsening of oxygenation.
gas exchange. To keep the alveoli open, positive PPV leads to release of inflammatory mediators
pressure is applied to the airways during from the lung that may cause systemic
226 A PRIMER OF ANESTHESIA
inflammatory response syndrome [Biotrauma]. may be delivered outside the ICU in ward or
By increasing intrathoracic pressure, PPV may high dependence unit. It is discontinuous and
reduce venous return to the heart. In hypo- allows patient periodic breaks from ventilation.
volemic patients, it may lead to hypotension. The patient retains the ability to speak and
The endotracheal tube bypasses the defense of cough. Risk of infection is less compared to
the upper respiratory tract and makes the patient invasive ventilation. NIV instituted in time may
more prone to respiratory tract infection avoid intubation and invasive ventilation. For
[Ventilator Associated Pneumonia or VAP]. patients who have refused intubation, NIV may
be used as a ceiling of therapy.
Weaning from mechanical ventilation: Weaning
refers to transition from ventilator support to Contraindications to NIV: Patients who are
spontaneous breathing without support. unable to protect their airway from aspiration
Weaning is started when the reasons for initiation or maintain a patent airway are inappropriate
of mechanical ventilation have stabilized, candidates for NIV. Similarly patients who are
oxygenation and hemodynamics are stable and profoundly hypoxic, who require high PEEP to
spontaneous breathing efforts are present. maintain oxygenation cannot be managed on
Patients on PPV should be assessed for weaning NIV. Recent esophageal or upper GI surgery are
every day. There is no single method of weaning. contraindications for NIV.
Trials of spontaneous breathing without
ventilator support or gradual reduction of PSV CARDIOVASCULAR ISSUES IN ICU
are established methods of weaning. Many Critically ill patients are frequently in a state of
patients are difficult to wean. Poor gas exchange, shock and require fluid resuscitation, vasopres-
poor respiratory muscle strength or inability to sors and invasive hemodynamic monitoring.
clear respiratory secretions are the most obvious
causes of weaning failure. Cardiac failure, Choice of vascular access site: For resuscitation,
peripheral IV catheter [PIVC] is quick and easy
malnutrition, excessive sedation, fluid overload
to insert. The resistance to flow through a
and sepsis are other common causes of failure
catheter is directly proportional to the length of
to wean. In difficult to wean patients, the
catheter. Therefore, for the same caliber of the
potential causes should be looked for and
catheter, faster fluids can be given through the
treated. For patients who have been on ventilator
PIVC. Attempts to insert CVC during resusci-
for a long time [>2 weeks] or who are likely to
tation wastes precious time without any benefit.
require mechanical ventilation for a prolonged
The PIVC should be changed every 4872 hours
period, tracheostomy may reduce the duration
to reduce infectious complications. PIVCs
of mechanical ventilation and possibly improve
inserted in pre-hospital care or emergency
outcome. Protocol based weaning and daily
department are associated with higher risk of
interruption of sedation may help in early
infectious complications and should be removed
weaning.
as soon as possible, preferably within the first
Non-invasive ventilation [NIV]: NIV refers to 24 hours.
delivery of PPV using a tight fitting mask. The A CVC generally has 34 lumens to allow
mask may fit over the whole face or over the multiple infusions. A CVC is inserted when the
nose or over nose and mouth. It avoids intuba- patient is more stable. The common sites for
tion and the risks associated with it. NIV offers CVC insertion are the internal jugular, subclavian
many advantages over invasive ventilation. It or femoral veins. CVCs in the subclavian vein
CARE OF THE PATIENT IN THE ICU 227
are the most comfortable, easy to nurse and IV. Distributive shock: It occurs because of
have the least incidence of infectious complica- maldistribution of the cardiac output.
tions. However, it is associated with maximum Cardiac output is frequently normal or
rate of serious complications at the time of even elevated in distributive shock but the
insertion [pneumothorax and hemothorax from blood is shunted away from vital organs as
subclavian artery puncture]. The risk of brain and kidneys. Septic shock is the
complication is inversely related to the most common form of distributive shock
experience of the physician. Nowadays CVCs seen in intensive care setting, but it also
are inserted using ultrasound guidance which occurs in neurogenic shock [loss of
minimises or prevents complication like arterial sympathetic vascular tone] and anaphylaxis
puncture. CVCs can be kept in situ for longer [Release of vasodilator mediators e.g.
duration than PIVCs. histamine and platelet activating factor].
Assessment and Management of Shock State
Septic Shock
Patients admitted to ICU are frequently
hypotensive or in a state of shock. Shock results Septic shock affects 10% to 15% of ICU patients
from failure to deliver adequate oxygen to the and has a high mortality [5060%]. Invasion
tissues. The causes are circulatory failure, severe of blood stream by microorganisms or their
hypoxia from pulmonary disease or failure to products triggers a complex host response
utilize oxygen. characterized by activation of inflammatory and
anti-inflammatory pathways, coagulation and
Classification of shock anticoagulation pathways and initiation of
I. Hypovolemic shock: It occurs because of endothelial dysfunction. Systemic inflammatory
reduced circulating blood volume. Loss of response syndrome [SIRS] is a term used to
volume may occur from hemorrhage, third describe systemic response to a variety of insults.
space loss of intravascular volume, The presence of two or more of the following
diarrhea, vomiting, excessive sweating or clinical features defines SIRS:
reduced fluid intake. Shifting of fluid from I. Temperature > 38 C or < 36 C.
one compartment to other may also II. Heart rate > 90 beats per minute.
manifest as hypovolemia; for example in III. Tachypnea > 20 breaths/min.
peritonitis, fluid shifts to peritoneal space IV. Leucocytosis > 12000/mm3 or leucopenia
and the patient manifests signs of hypo- < 4000/mm3 or more than 10% immature
volemia. neutrophils.
II. Cardiogenic shock: It occurs because of Sepsis is defined as SIRS due to proven or
impaired cardiac pump function. The suspected infection. Severe sepsis is sepsis with
causes include myocardial infarction, end organ dysfunction [e.g. respiratory failure].
valvular heart disease as aortic stenosis, Septic shock is severe sepsis with hypotension
acute aortic regurgitation, cardiac arrhy- despite adequate fluid resuscitation.
thmias, cardiomyopathy, etc.
III. Obstructive shock: It results from Pathophysiology of septic shock: Both pro-
mechanical obstruction to the cardiac inflammatory and anti-inflammatory pathways
output. Tension pneumothorax, cardiac are activated in sepsis leading to vasodilatation
tamponade and air embolism are examples and increased vascular permeability leading to
of obstructive shock. reduced blood pressure. Activation of both
228 A PRIMER OF ANESTHESIA
procoagulant and anticoagulant pathways leads The choice of ideal fluid is controversial.
to microvascular thrombosis and a disseminated If the patient is significantly anemic,
intravascular coagulation (DIC)-like picture. [Hemoglobin < 7 g/dl], packed red blood
Endothelial dysfunction leads to release of nitric cells should be transfused both to treat
oxide which causes vasodilatation and anemia and as part of fluid resuscitation.
hypotension. Relative adrenal and vasopressin Crystalloids [e.g. 0.9% saline, Ringers
insufficiency may also contribute to Lactate] are solutions of small molecules in
hypotension. Vasodilatation reduces the water. Crystalloids freely cross the
systemic vascular resistance and patient may endothelium. They distribute in both the
have raised cardiac output despite shock. intravascular and extravascular extracellular
Increased capillary permeability leads to loss of (interstitial) space. Colloids [e.g. dextran,
intravascular volume into the third space and starch, and albumin] are solutions of large
therefore intravascular hypovolemia. molecules that do not freely cross the semi-
permeable membrane. Theoretically, colloids
Treatment of septic shock: The treatment of remain in the intravascular space whereas
severe sepsis and septic shock is based on crystalloids distribute in both intravascular
following principles. and extravascular space. Colloids seem to
1. Early source control: Without early control be an attractive choice because less fluid may
of the source of sepsis, any therapy is unlikely be required to correct intravascular hypo-
to be effective. For example drainage of volemia. However, because of increased
abscess, laparotomy for resection of capillary permeability in septic shock, colloids
gangrenous gut are essential for treatment also diffuse out of the intravascular space.
of sepsis. Colloids have not been shown to reduce
2. Early antibiotic therapy: Early antibiotic mortality in sepsis. They are also significantly
therapy reduces mortality in sepsis. If more expensive than crystalloids and may
possible, appropriate specimens should be cause anaphylactic reaction. The choice of
collected for culture before antibiotics are resuscitation fluid is influenced by individual
administered. However, this should not physicians understanding of literature,
cause undue delay in the administration of existing practice in the ICU and availability
antibiotics. Initial antibiotic therapy is or resources. At present crystalloids may
empirical and broad spectrum based on local represent cheaper and equally effective fluids
flora and sensitivity patterns. Later, antibiotic for resuscitation compared to colloids.
therapy is modified depending upon the 4. Vasopressors: Patients may need vaso-
results of culture. pressors to maintain blood pressure while
3. Fluid resuscitation: Most patients with septic fluid resuscitation is under way or if
shock are hypovolemic and require large hypotension persists even after adequate
amount of fluid for resuscitation. Fluid fluid resuscitation. The choice of vasopressor
requirements are frequently underestimated agent is controversial. Recently several
and patients often under-resuscitated. The studies have shown that noradrenaline may
importance of adequate fluid resuscitation be the vasopressor of choice in sepsis.
cannot be overemphasized. Vasopressors Dopamine is no longer considered to be
may transiently improve blood pressure but vasopressor of choice in septic shock. There
that does not cure shock. Cardiac output is some evidence that its use may actually
remains low and organs remain hypoper- be associated with increase in mortality. Low
fused without adequate fluid resuscitation. dose dopamine [13 g/kg/min] has been
CARE OF THE PATIENT IN THE ICU 229
used for many years to preserve renal mortality in ICU patients. Hypoglycemia may
function in septic patients but is no longer occur in an attempt to maintain blood sugar
recommended. level with in target range. The benefits of
Vasopressin [or anti-diuretic hormone] tight glycemic control should be weighed
is secreted by the pituitary gland. It acts on against risks of hypoglycemia. Tight blood
V-1 receptors in the vasculature and cause sugar control should be attempted only if
vasoconstriction. Vasopressin increases nursing resources are available to monitor
vascular responsiveness to catecholamines. for hypoglycemia.
Septic patients may become deficient in 8. Activated Protein C [APC]: Protein C is a
vasopressin. Low dose vasopressin [0.01 natural anticoagulant. In sepsis, the proc-
0.04 units/min] increases in mean arterial oagulant pathways are activated, which leads
pressure and reduces catecholamine require- to disseminated intravascular coagulation
ments. It is not recommended as initial [DIC] that causes organ dysfunction. APC
vasopressor. High dose of vasopressin prevents this DIC like picture and has been
can cause intense vasoconstriction and shown to reduce mortality in severe sepsis.
ischemia of intestine, digits or other It is associated with risk of bleeding and the
organs. benefits should be weighed against risks. At
5. Mechanical ventilation: Mechanical ventila- present, APC is an extremely expensive drug.
tion in sepsis should follow the principles as Considering that the reduction in mortality
outlined in the previous section on respiratory is only modest, its high cost has limited its
support. widespread use in severe sepsis.
6. Steroids: Patients in septic shock may have
relative adrenal insufficiency. Low dose Acute Heart Failure in ICU
hydrocortisone [200300 mg/day] may Pulmonary edema is common in the ICU. It
reduce the duration of shock and may reduce may be cardiogenic or non-cardiogenic [e.g.
mortality in septic shock. Steroids should not ARDS] in origin. Ischemic heart disease is the
be used in sepsis in the absence of shock. most common cardiogenic cause of pulmonary
High dose steroids are not recommended. edema. The diagnosis of pulmonary edema is
7. Normoglycemia: Hyperglycemia is common not always straightforward. It may be confused
even in non-diabetic ICU patients. Hyper- with acute severe asthma or exacerbation of
glycemia causes osmotic diuresis, chronic obstructive pulmonary disease or
increases risk of infection, slows pneumonia. Non-cardiogenic pulmonary edema
wound healing and increases mortality. may occur in acute lung injury and ARDS. The
Hyperglycemia should be prevented or distinction between cardiogenic and non-
treated with insulin. Oral hypoglycemic cardiogenic pulmonary edema may be difficult.
agents may have unpredictable pharma- In a patient with respiratory failure, when the
cokinetics and drug interactions. Metformin cause of respiratory failure is not apparent,
may cause lactic acidosis in patients with assessment of Brain Natriuretic Peptide [BNP]
severe hepatic or renal impairment. may be useful. BNP is secreted by the ventricular
Short acting plain insulin as an intra- myocardium and the levels increase when
venous infusion is the most predictable way myocardium is stretched. BNP levels below 100
of insulin delivery. The target blood sugar pg/ml rule out cardiogenic pulmonary edema.
level is controversial. Blood sugar level of If BNP is above 500 pg/ml, cardiogenic
80110 mg/dl has been shown to reduce pulmonary edema is very likely. The usefulness
230 A PRIMER OF ANESTHESIA
of BNP measurement in critically ill patients in intubation. Intubation may be necessary for
ICU is however limited because levels may be patients who cannot be managed with non-
elevated even in the absence of heart failure. invasive ventilation. PPV may cause hypo-
Severe sepsis, pulmonary hypertension and tension necessitating the use of inotropes.
pulmonary thrombo-embolism are other 8. Intra-aortic balloon pump may be used
conditions where the BNP levels may be very particularly in the setting of acute MI.
high and BNP cannot be used to differentiate 9. Revascularization/surgery may be necessary,
these conditions from congestive cardiac failure. e.g. after acute MI or acute valvular regurgi-
Cardiogenic pulmonary edema may be tation.
distinguished from non-cardiogenic pulmonary
Other cardiovascular problems in ICU: Both
edema on chest X-ray by the presence of an
supraventricular and ventricular arrhythmias are
enlarged heart, redistribution of pulmonary
common in ICU. ICU medical and nursing staff
blood flow to upper lung zones, peribronchial
should be experienced in arrhythmia recognition
cuffing, Kerley B lines, pleural effusion and
and treatment.
central distribution of pulmonary edema.
After acute MI, coronary angioplasty or
Treatment of acute cardiogenic pulmonary coronary artery bypass, many patients may be
edema: on mechanical cardiac support. Intra aortic
1. Sit the patient upright. balloon pump [IABP] is a catheter with an
2. Provide supplemental oxygen to maintain inflatable balloon that is inserted into the aorta
SpO2 above 95%. from the femoral artery. The balloon inflates in
3. Diuretics: Generally loop diuretics, e.g. diastole and deflates in systole. When it inflates
frusemide 40 mg IV in the average adult. in diastole, it increases the diastolic blood
Patients previously on diuretics may require pressure and increases coronary perfusion.
a higher dose. There is a risk of dehydration When the balloon deflates in systole, it leaves
and pre-renal azotemia with high doses or the aorta relatively empty and thus reduces
repeated doses of diuretics. cardiac afterload. Balloon inflation may be
4. Nitroglycerine infusion: At a dose range synchronized with the R wave on ECG or the
5-100 g/min, it reduces cardiac preload and dicrotic notch on the arterial pressure trace, or
reduces pulmonary edema. Tachyphylaxis the ventricular spike of pacemaker. If the position
occurs after prolonged administration of the balloon is too high in the aorta, it may
[beyond 24 hours]. cause ischemia of the left arm by occluding the
5. Nesiritide: It is a BNP analogue. It causes left subclavian artery. The position of the tip
vasodilatation and reduces cardiac preload. should be checked on daily chest X-ray. It should
It is given as IV bolus [2 g/kg] followed by be in descending thoracic aorta below the origin
infusion 0.010.03 g/kg/min]. It may be as of left subclavian artery.
efficacious as nitroglycerine for acute A Ventricular Assist Device [VAD] is used in
pulmonary edema. It is a new drug and its patients with severe ventricular dysfunction. The
role in management of acute heart failure is VAD may be used in the waiting period prior to
yet to be firmly established. heart transplant or as a permanent measure.
6. Inotropes may be necessary in hypotensive ICU patients may have implanted permanent
patients. pacemakers or Automated Implanted
7. Mechanical ventilation: Non-invasive Cardioverter Defibrillator [AICD]. Electrocautery
ventilation may be used. CPAP improves or MRI may cause pacemaker malfunction and
oxygenation and may reduce the need for ICU personnel should be aware of such devices
CARE OF THE PATIENT IN THE ICU 231
in the patient. Most of the modern pacemakers/ Reduced metabolic function of kidneys [e.g.
AICDs are not affected by mobile phones. anemia from reduced erythropoietin,
Pacemakers may be changed from the demand reduced vitamin D synthesis].
mode (Pacemaker senses the heart rhythm and Reduced drug clearance.
paces if required) to asynchronous mode Side effects of renal replacement therapy.
(Pacemaker paces at a fixed rate) by application Reduced immune response.
of external magnet if electrocautery is to be used.
Temporary pacing may be done in the ICU Prevention of ARF in ICU: The various strategies
transvenously (By inserting pacemaker wires into for prevention of ARF in ICU are as follows:
the right ventricle) or transcutaneously. Most 1. Adequate hydration: Maintaining intra-
modern defibrillators are equipped with vascular fluid volume will provide adequate
capability for transcutaneous pacing using the blood flow to the kidneys. In certain
same pads as are used for defibrillation. situations like trauma and rhabdomyolysis,
aggressive fluid resuscitation may have
RENAL PROBLEMS IN ICU salutary effect on preserving renal function.
Acute renal failure [ARF] affects approximately Diuretics should not be given to hypovole-
5% of hospitalized patients and 15% of ICU mic, oliguric patients.
patients. ARF in patients with multiorgan failure 2. Adequate mean arterial pressure: At very low
approximately doubles the mortality. mean arterial pressures, renal blood flow
Hypertension, diabetes mellitus and chronic decreases and ischemic Acute Tubular
compensated renal insufficiency are risk factors Necrosis (ATN) can occur. Hypertensive
for development of ARF in ICU. The most patients require higher mean arterial pres-
common causes of ARF in ICU are prolonged sures to maintain adequate renal perfusion.
hypotension, sepsis, drug toxicity, and radio- 3. Avoid nephrotoxin exposure: Many drugs
contrast dye. Acute tubular necrosis is the most used in ICU are nephrotoxic. Therapeutic
common pathological finding. plasma level monitoring may prevent toxic
The pathogenesis of ARF in sepsis still levels. Drug level is commonly monitored for
remains to be elucidated. Intra renal vaso- aminoglycosides and vancomycin. In
constriction may occur because of inflammatory patients with renal dysfunction, drug dose
mediators and down regulation of nitric oxide or dose interval should be adjusted.
synthesis within the kidney. Formation of micro Aminoglycosides are taken up actively by the
thrombi may cause renal ischemia. Oxidative renal tubular epithelium. They are released
damage may occur from free radicals. Some
slowly as the plasma levels fall, to very low
recent data suggest that apoptosis [Programmed
levels. Dosing aminoglycosides once daily
cell death] may be the predominant pathogenic
allows adequate time for excretion of the
mechanism responsible for ARF in sepsis.
drug from renal tubular epithelium and is
The physiologic consequences of acute renal therefore more effective and less nephrotoxic
failure are because of following. than divided dose regimes.
Accumulation of uremic toxins. 4. Prevention of Contrast nephropathy: ICU
Disorders of water balance [Fluid overload], patients frequently require imaging studies
and electrolyte balance [Hyponatremia or with intravenous contrast. Intravenous
hypernatremia, hyperkalemia, hyper- contrast can cause renal dysfunction by direct
magnesemia, hyperphosphatemia and toxic damage to renal tubules and ischemia
hypocalcemia]. due to renal vasoconstriction. Patients with
232 A PRIMER OF ANESTHESIA
Most of the times a benzodiazepine or When a patient is critically ill and likely to
propofol is used in combination with an opioid. die, decisions may have to be taken for several
Clonidine is useful for its sedative, analgesic and end-of-life issues. For example, if the patient
antihypertensive properties. suffers a cardiac arrest, should CPR be done or
Administration of protocol-based sedation not; or, if the patient has respiratory failure,
with a well-defined target is associated with should mechanical ventilation be offered or not.
reduced sedation requirements and reduced ICU Patient autonomy is liberty to follow ones
length of stay. Daily interruption of sedation will, and implies personal freedom. It means that
reduces the duration of mechanical ventilation, the patient should be able to choose the course
ICU length of stay and number of investigations of his/her therapy and the physician, who shares
done for altered mental status. this knowledge with the patient, acts as a guide.
Medical paternalism refers to the practice that
Thromboprophylaxis in ICU: Patients in ICU
allows the physician to make the decision for
are at high risk for development of deep venous
the patient. Neither of the two approaches is
thrombosis [DVT] and pulmonary thrombo-
perfect. In most circumstances, decision-making
embolism [PTE]. All patients admitted to ICU
is shared between the patient or his surrogate
should receive thromboprophylaxis. Mechanical and the physician.
methods include pressure stockings and Mentally competent patients may participate
pneumatic calf compressors. The pneumatic calf in decision making themselves. Many patients
compressors is tied around the calf and thigh. It may have advance directives that guide the
inflates at periodic intervals to pump blood in physician to make decisions when they fall ill. A
the deep veins of lower limbs. Pharmacological living will is the most common form of advance
methods are subcutaneous heparin or low directive by which a person may express his
molecular weight heparin. Low molecular weight desire to receive or refuse treatment should he
heparin [e.g. enoxaparin] has a long half-life and become critically ill and incapable of making a
more predictable pharmacokinetics. Unlike decision. Patients may also nominate a surrogate
heparin, low molecular weight heparins do not decision maker who will make decisions on their
increase APTT. Their effect can be monitored behalf when they are unable to make decisions
by measuring activated factor Xa level. The half themselves. If no such individual has been desig-
life of low molecular weight heparin may be nated, an appropriate family member is sought.
prolonged in renal failure. Because of these The common hierarchy is from spouse to elder
reasons, heparin may be better in ICU patients. adult child to parent to adult sibling, in that order.
Warfarin also prevents DVT or PTE. Warfarin is Limiting therapy in ICU may take the form
not a practical drug to use in ICU patients of a)withholding treatment [e.g. not offering
because its effect cannot be reversed at short mechanical ventilation to a patient who is in
notice, e.g. in an ICU patient urgently requiring respiratory failure] to b)withdrawal of treatment
CVC insertion. [ e.g. extubating a patient who needs mechanical
ventilation for respiratory failure] to c) Do Not
ETHICAL ISSUES IN ICU resuscitate order [i.e. not to do CPR in the event
Many ICU patients will die. Patients, family and of cardio-respiratory arrest].
ICU physicians view death from different Before making a decision to limit therapy,
perspectives. The approach towards end of life the physician should have a clear understanding
is influenced by cultural and social background. of the patients diagnosis, physiologic and
Not infrequently, the opinions of the patient and functional status. The other members of the
family differ from that of the treating physician. health care team should agree to the decision.
236 A PRIMER OF ANESTHESIA
Informed consent should then be sought from process and do not contribute to patient
the legally competent patients or their surrogate. comfort. They should be provided only if a
The primary referring physician should be positive contribution to patient comfort is
involved in the decision making as well. obvious. The decision is also influenced by the
beliefs of the patient, family and physician and
Care of the Dying Patient should be taken as a shared decision. Other
As the decision to forgo further life prolonging drugs may or may not be given depending upon
therapy is made, the patient, family and the the situation. For example, fever may be
clinical team should be prepared for further uncomfortable and antipyretics may be
management. The clinical team may be familiar indicated. Patients should know that their
with such a situation, but for the patient, this is cultural beliefs are understood and cultural and
a singular event in his/her life. It may also be religious expectations should be met [e.g. a visit
the first such experience for the family. by a priest].
Decision to withhold life prolonging The needs of the family should not be
treatment does not mean withdrawal of care. overlooked. Unrestricted visiting time should be
Patients are still cared for. All patients have the allowed. Regular updates about the changing
right to be treated with respect and die with condition of the dying patient should be
dignity. This decision only means that the focus provided. They should be assured of the
of therapy has changed from intended cure to patients comfort and that their decisions were
palliation.
right. Many family members would have reached
If possible, the patient should be transferred
a level of exhaustion by this time and need to
to a separate room. (Transferring the patient out
be comforted, rested and fed.
of the ICU to a ward may give an impression
In addition to medical knowledge, the
that the care is withdrawn; the family should be
importance of communication skills to put these
reassured that this is not the reason). There is
principles before the patients and their family
often a pressure to admit more patients in ICU.
cannot be overemphasized. When discussing
Often the family may itself desire to transfer the
patient to a quieter environment. The family end of life issues, simple words should be used
should be allowed unrestricted time to be with that are easily understood by the patient or the
the patient. The monitors should be turned off family. Unfamiliar words [e.g. CPR, ventricular
and the cables should be disconnected. fibrillation, etc.] should be avoided. Whenever
Catheters may be removed if they are interfering possible, the news of death should be delivered
with comfort. in person. When delivering the news of death,
Control of pain is one of the most important ambiguous words as passed away etc. should
aspects of care of the dying. Generous doses of be avoided, and the physician should not
analgesics should be prescribed as dictated by hesitate to use the word death.
the severity of pain. Nausea and vomiting should
Predicting the Outcome
be controlled using anti-emetics.
Hydration and feeding are controversial Intensivists are frequently questioned about
issues in management of dying patients. prognosis. Unfortunately, there is no definitive
Traditional view is that feeding and hydration answer to this question. Various scoring systems
contribute to patient comfort and it should be have been devised to predict outcome of
continued until death. The current thinking is critically ill patients. They may be useful when
that loss of hunger and thirst are normal to dying predicting the outcome of a group of patients,
process. Feed and hydration prolong the dying but cannot be used for the individual patient.
CARE OF THE PATIENT IN THE ICU 237
Examples of such scoring systems include Acute 3. Which of the following is not an
Physiology and Chronic Health Evaluation indication for invasive [intra-arterial]
[APACHE II and III] scores, Trauma Severity monitoring of blood pressure?
score [TSS], Simplified Acute Physiology Score a. Need for vasopressors
[SAPS], etc. b. Need to take repeated arterial blood gas
These scoring systems take into account the samples
patient data [e.g. age, sex], physiological c. Difficult measurement, e.g. obese
parameters [e.g. blood pressure], principal patients
diagnosis and comorbidities to calculate the d. Pregnant patients in ICU.
score. It may be emphasized that scoring systems 4. All of the following can be used to
are generally not helpful in guiding therapy in measure cardiac output except:
individual patient. The major applications of a. Pulmonary artery catheter
severity of illness scores are for performance b. Microdialysis catheter
assessment [e.g. comparing different ICUs], c. Transpulmonary thermodilution
predicting and planning resource utilization, and d. Esophageal Doppler.
research.
5. Which of the following is the most
Critical care offers hope of life to many
effective in preventing spread of
critically ill patients and to those after major
nosocomial infections?
surgery, who, a few decades ago would not have a. Hand wash
survived, ICUs are integral to most tertiary b. Use of gloves
medical centers. c. Gowning before invasive procedures
d. Avoiding use of Foleys urinary drainage
MCQ
MCQss catheters
1. Which of the following statements is 6. Which of the following statements is
not true about ICU? not true?
a. In open ICU, there are no isolation beds a. Positive end expiratory pressure [PEEP]
for patients infected with multiresistant is applied to prevent collapse of alveoli
organisms during expiration
b. Ideally, one nurse should look after one b. Tidal volume of 6-8 ml/kg body weight
patient is usually sufficient while on mechanical
c. There should be designated areas for ventilator
holding family discussions c. Ventilator can sense breathing effort
d. Closed intensive care units may lead to made by the patient and synchronize
better implementation of protocols and mechanical breath with patient effort
may improve efficiency and outcome. d. Ventilators help in expiration by
applying negative pressure during
2. Which of the following monitoring
expiration.
technique can provide information
about accidental disconnection of a 7. Which of the following is not a side
ventilator from patient? effect of positive pressure ventilation?
a. Pulse oxymeter a. Ventilator associated pneumonia
b. End tidal CO2 b. Barotrauma
c. Lithium dilution technique c. Esophagitis
d. Mixed venous oxygen saturation d. Atelectrauma
238 A PRIMER OF ANESTHESIA
1. The lay rescuer does not check for the chest compressions improves oxygen
pulse in an unresponsive victim but delivery to the myocardium, making
straightaway provides two rescue breaths success of subsequent shocks more likely.
to an unresponsive victim. 10. Emphasis on importance of ventilation and
2. All breaths (whether given mouth-to- de-emphasis on the use of high concen-
mouth or mouth-to-device) are to be given trations of oxygen for resuscitation of the
over 1 second with sufficient volume to newborn.
achieve visible chest expansion. 11. Administration of intravenous fibrinolytics
3. A universal compression-to-ventilation to patients with acute ischemic stroke by a
ratio of 30:2 is to be provided by single knowledgeable team and institutional
rescuers for victims of all ages except commitment to stroke care.
newborn infants.
4. Definition of pediatric victim in the case of Components of Adult BLS Sequence (Fig. 16.1)
a health care provider (HCP) includes up Make sure it is safe to approach the patient.
to the pre-adolescent age; in the case of a Move patient only if absolutely necessary, e.g.
lay person it remains 18 years. burning building, middle of busy road.
5. Emphasis on quality of chest compressions:
Push hard, push fast (100 compressions / Check for Response (Box 1)
min), allow complete chest recoil, and Assess responsiveness by tapping on the shoulder
minimize interruptions in chest compres- and calling. If injured but responsive and needs
sions. assistance, leave to phone, return quickly to check
condition.
6. EMS (Emergency Medical Service)
providers should provide 5 cycles or 2
Activate EMS (Box 2)
minutes of CPR pending arrival of a
Lone lay rescuer finds unresponsive adult-activate
defibrillator especially when the interval
EMS, get AED (automatic electrical defibrillator)
from the call to arrival is expected to be (if available), return to provide CPR and defibril-
more than 45 minutes. lation if needed.
7. In pulseless arrest, CPR should be resumed If 2 rescuers available, one activates EMS and other
immediately after shock delivery and check starts CPR.
If occurs in hospital, notify emergency system.
for return of pulse made after 5 cycles (or
Lone healthcare provider (HCP) witnesses sudden
2 minutes) of CPR. collapse-phone EMS, ask for AED, returns to
8. All rescue interventions (e.g. insertion of provide CPR.
airway devices, administration of medica- Lone HCP aids asphyxial arrest (drowning): 5
tions and re-assessment of patient) should cycles/2 minutes of CPR before activating EMS.
be done in a way as to minimize interrup- Open the Airway and Check
tions in chest compressions. Breathing (Box 3)
9. Only 1 shock is recommended followed
Lay rescuer should open airway using head tilt
immediately by CPR (beginning with chest chin lift manoeuvres (Fig. 16.2) for both injured
compressions) instead of 3 stacked shocks. and non-injured personnel. The jaw-thrust is no
This recommendation is based on the high more recommended as it is (a) difficult to learn,
first-shock success rate of new defibrillators (b) often not effective and (c) may result in spinal
and the fact that immediate resumption of movement.
CARDIOPULMONARY RESUSCITATION 241
HCP provider also uses head-tilt and chin-lift Give Rescue Breathing (Box 4)
techniques; however if c-spine injury is suspected
The following points are emphasized:
(2% victims of blunt trauma, 6% blunt trauma with
craniofacial injuries or with GCS < 8 or both), Rescue breaths are not as important as chest
uses jaw thrust Priority is patent airway, compressions in the first few minute of Ventricular
ventilation and oxygenation and if jaw thrust Fibrillation (VF) or Sudden Cardiac Arrest (SCA),
does not open the airway should use head tilt- as the oxygen level in the blood is still high an
chin lift. myocardial and cerebral oxygen delivery is limited
Check breathing: while maintaining an open more by an impairment of blood flow.
airway look, listen and feel for a breath (Fig. 16.3). Both ventilation and compressions become
Gasping, agonal movements should be important in prolonged arrest where hypoxemia
differentiated from breaths and the patient given
is invariable, e.g. asphyxial arrest due to drowning.
rescue breaths and CPR.
242 A PRIMER OF ANESTHESIA
Fig. 16.2: Head tilt-chin lift Fig. 16.3: Listening and feeling for breathing
(A) (B)
Figs 16.4A and B: Mouth-to-mouth breathing
Since blood flow to the lungs is substantially The delivered volume should produce a visible
reduced during CPR, use of lower tidal volumes chest rise.
(500700 ml; 67 ml/kg) is recommended to Avoid rapid and forceful breaths.
maintain ventilation-perfusion ratio. Mouth-to-mouth breathing: Open the airway,
Excessive ventilations are not only unnecessary,
pinch the victims nose and create an airtight
but (i) increase intrathoracic pressure and impair
mouth-to-mouth seal (Fig. 16.4A). Give one
venous return; reduced venous return causes a
breath over 1 second, take a regular (NOT a deep)
fall in cardiac output and coronary and cerebral
perfusion; (ii) may cause gastric inflation which breath and give a second breath over 1 second. If
might result in regurgitation and aspiration and the chest does not rise with the first breath, perform
(iii) reduce respiratory compliance by elevating the head tilt-chin lift and give the second rescue
the diaphragm. breath (Fig. 16.4B).
CARDIOPULMONARY RESUSCITATION 243
Fig. 16.5: Bag-mask ventilation with one person (L) and 2 persons (R)
Defib rillation
Defibrillation
(A) This is described in the following section on
advanced cardiac life support.
paddle at the infero-lateral left chest lateral to tibia; in the latter situation the needle is
the left breast. Other acceptable positions are inserted at a 45 degree angle, 23 cm below
the bi-axillary position and the standard left the tibial tuberosity and directed away from
paddle position along with the sternal paddle the epiphyseal plate. The advantages of this
placed on the back. The paddles should not be route are ease, rapid rates of infusion
placed on any medication patch as they may (including colloids and blood) and an alter-
cause a burn. native route for antibiotics, inotropes and
other agents. Displacement of the cannula,
Access for Medications osteomyelitis and compartment syndrome
Central line access is NOT required in most are important considerations in using this
resuscitation attempts. A large peripheral line route. Intraosseous cannulation is accepted
is desirable. Drugs take 12 minutes to reach in children and adults. If spontaneous
the central circulation; each drug should be circulation does not return after defibrillation
followed by a bolus of 20 ml saline and and peripheral/IO drug administration,
elevation of the limb. Peripheral intravenous central cannulation may be indicated.
(IV) line placement does not interrupt CPR If IV/IO access cannot be established some
while placement of a central line certainly drugs can be administered through the
will. A femoral central venous access is endotracheal route. These include lidocaine,
perfectly acceptable and can be performed epinephrine, atropine, naloxone and
without interrupting cardiac compressions. vasopressin. Sodium bicarbonate should not
The advantages of having central venous be administered through this route. The
access include rapid onset of drug action and main disadvantage is that drug concen-
a route for pacemaker wire insertion. trations achieved are lower than with IV/IO
Intraosseous (IO) route (Fig. 16.7) can routes. The drug dose required is usually
provide emergency vascular access in 2.53 times the IV dose. It should be diluted
children. A rigid 18-G cannula with a stylet in 510 ml of saline or water (latter
is inserted into the distal femur or proximal preferred) and directly injected into the
endotracheal tube.
dynamic monitoring as well as tracking and Transport the prehospital cardiac arrest
correcting acid-base abnormalities. patient to the hospital emergency depart-
ment and then to an appropriately equipped
Arrhythmia recognition: This is the cornerstone
critical care unit.
of ACLS as further treatment actions and specific
Provide cardiorespiratory support to
maneuvres depend on the rhythm, or dysrhy-
optimize tissue perfusion especially to the
thmia that is noted. These can be shockable
brain and maximize neurological recovery.
like VF or VT; or unshockable, like pulseless
Attempt to identify the precipitating causes
electrical activity (PEA) or asystole. The various
of the arrest.
treatment algorithms can be accessed on the
Institute measures such as antiarrhythmic
AHA website, or you can access the Circulation
therapy to prevent recurrence.
2005 issue (supplement), vol.112, p 2554.
A good way to acquire familiarity with CPR
DRUGS is to familiarize oneself with the contents of the
emergency trolley: Airway equipment (Fig.
The indications, doses and mode of action of 16.11), and vascular equipment (Fig. 16.12),
drugs commonly used in CPR are listed at the and the location and working of the defibrillators
end of the chapter. Newer the guidelines in each ward. Airway equipment should be kept
regarding use of some drugs, which, till recently, on the trolley in a tray. Syringes and emergency
were administered routinely during CPR, drugs should also be on the same cart so that
should be followed. For instance, calcium salts only a single trolley is needed in an emergency.
are indicated only with documented hypocalce- In addition, the wall oxygen outlets and vacuum
mia or hyperkalemia. Examples are massive points should be regularly checked and serviced.
transfusion, calcium channel blocker overdose This gives every one a sense of security and
or hypomagnesemia. Sodium bicarbonate highlights the importance of equipment
reacts with metabolic acids forming carbonic maintenance and preparedness in ancillary
acid and raises plasma pH; however carbonic hospital staff.
acid dissociates to form carbon dioxide which Practicing CPR in a simulator or in a course
readily crosses the blood-brain barrier leading environment (specifically designed ACLS
to intracellular acidosis. Increased intramyo- Provider Course with mannequins) helps in
cardial carbon dioxide may reduce the familiarizing oneself with all the equipment,
possibility of successful resuscitation. Further, drugs and algorithms required for resuscitation.
sodium bicarbonate may shift the oxygen Practicing and training in CPR in a controlled
dissociation curve to the left, reducing oxygen environment has been shown to improve
delivery to the tissues. Sodium bicarbonate is response time and patient outcome.
thus indicated only in established metabolic Every effort should be made by all medical
acidosis, hyperkalemia, tricyclic antidepressant caregivers to enroll for these courses as CPR is
or barbiturate overdose. a core skill.
Dysrhythmia recognition, institution of
appropriate antiarrhythmic therapy, insertion of CPR FOR INFANTS AND CHILDREN
transvenous pacemaker and overdrive pacing The grouping of children for purposes of CPR
are some of the other important aspects of remains 18 years and above 8 years for the
ACLS. lay rescuer. It has been changed to pre-pubertal
and post-pubertal groups for the health care
Post-resuscitation Care provider (HCP). This makes it easy for the lay
The immediate goals of post-resuscitation care person to get involved immediately instead of
are to: worrying about the age.
CARDIOPULMONARY RESUSCITATION 249
Ambu self inflating bag Malleable stylet Cuffed and plain endotracheal tubes
Laryngeal mask airway Suction catheter Laryngoscope kit with batteries and
assortment of blades
Combitube
Syringes IV fluids
to palpate in hypotensive children. When 10. Epinephrine should be used for shockable
the pulse is felt, auscultation at the and unshockable arrhythmia (e.g. asystole)
precordium is carried out to determine the every 35 minutes.
rate, as ECC will have to continue if the 11. Fever should be immediately treated after
rate is 60/min or below, with signs of poor CPR. Core hypothermia may be beneficial.
perfusion. Active warming should not be performed
6. If foreign body obstruction is suspected, it on a child with temperature>32 C with
is recommended to look into the mouth stable circulation.
before starting CPR and also to perform 12. It is beneficial for the parent/s to stay during
sharper compressions. Back blows and CPR as they will know that all efforts were
chest thrusts are still recommended for made to revive their child, and also helps
infants while abdominal thrusts can be in the grieving process.
performed in older children. Details of pediatric and neonatal resuscita-
7. In ACLS, bag-mask ventilation is consi- tion are not covered in this text and will be
dered as effective as ventilation through a taught during paediatric rotation.You can refer
tracheal tube for a short period (10-15 to Circulation (2005,Supplement 13), vol.112,
minutes). However effective mask venti- for details on paediatric BLS and ACLS.
lation in infants needs to be taught and
learnt in the operating theatre. Although
the ERC recommends use of LMA where COMPLICATIONS OF BLS
providers experienced in its use are Potential complications of rescue breathing:
available, the AHA guidelines to use the Gastric distension
LMA in difficult intubations appears more Regurgitation
appropriate. A cuffed endotracheal tube Reduction in lung volumes by elevation of
should be used for older children. Uncuffed diaphragm
tubes are appropriate up to size Potential complications of cardiac compression:
5.5 mm ID. Fracture of ribs
8. Intraosseous and tracheal routes can be Fracture of sternum
used for drug administration when the Separation of ribs from sternum
intravenous route is not available. The Hemothorax
tracheal doses recommended by ERC are Pneumothorax
0.1 mg kg1 for adrenaline, 23 mg kg1 Lung contusions
for lidocaine and 0.03 mg kg1 for atropine. Laceration of liver and spleen
Fluid boluses of normal saline or lactated Fat embolism.
Ringers solution are recommended.
9. Infant paddles (4.5 cm) are recommended Drugs Used in CPR and their Doses
for infants <10 kg in weight. ERC Adenosine: 6 mg over 13 sec IV; flush with
recommends a 4J/kg single shock for saline; 12 mg after 12 min, twice; total dose
shockable rhythms. In case required to
30 mg.
be repeated, ERC recommends 2 minutes
of CPR in between shocks. AHA re- Amiodarone (VF/VT): 300 mg IV push (diluted
commends 2 J/kg initial shock; subsequent in 20 cc D5W)
are 4 J/kg. 5 cycles of CPR should be inter- Consider repeat 150 mg IV once in 35 min.
posed in between two shocks. Max dose: 2.2g in 24 hours
CARDIOPULMONARY RESUSCITATION 253
7. Which of the following is a false state- 12. Which of the following is true about
ment for bag-mask ventilation? epinephrine?
a. It consists of a self inflating bag and a a. Produces beneficial effects in patients
non-breathing valve attached to a face during cardiac arrest primarily because
mask of its b-adrenergic receptor-stimulating
b. Most commercially available adult bag- properties
mask units have a volume of approxi- b. Dose of epinephrine for tracheal
mately 1600 ml delivery is atleast 1015 times the
c. Self inflating bag-mask units are most peripheral IV dose
effective when 2 trained and c. The recommended dose of epinephrine
experienced rescuers work together is 1.0 mg administered IV every 3-5
d. If supplementary oxygen is available,
minutes during resuscitation
bag mask ventilation should be
d. Intracardiac administration of epine-
attempted to deliver 1012 ml/kg of
phrine should be done routinely.
tidal volume.
13. All of the following are potentially re-
8. All of the following are complications
of chest compression except: versible causes of adult cardiac arrest
a. Gas embolism except:
b. Fracture of the sternum a. Hypothermia
c. Hemothorax b. Metabolic acidosis
d. Fat embolism. c. Tension pneumothorax
d. Hypocalcemia.
9. ACLS includes all of the following
except: 14. All of the following steps are included
a. Basic life support in the ACLS algorithm except:
b. Blood transfusion a. Administration of calcium gluconate
c. Establishment and maintenance of b. BLS
intravenous access c. Defibrillation
d. Treatment of patients with suspected d. Administration of vasopressors.
acute coronary syndrome.
15. The dose of vasopressin administered
10. The percentage inspired oxygen during the management of adult
concentration delivered to the patient cardiac arrest is:
through ventilation using exhaled air: a. 20 U IV
a. 16-17% b. 20-22% b. 30 U IV
c. 22-24% d. 24-26% c. 40 U IV
11. Alternative airways recommended for d. 50 U IV.
the maintenance of airway during CPR
Answers
are all except:
a. Laryngeal mask airway (LMA) 1. d 2. c 3. a 4. b
b. Esophageal-tracheal combiture (ETC) 5. c 6. b 7. d 8. a
c. Pharyngotracheal lumen airway (PTC) 9. b 10. a 11. d 12. c
d. Cuffed oropharyngeal airway (COPA). 13. d 14. a 15. c
Index
A Arterial blood gas analysis 72 Colloid osmotic pressure 159
Arterial tonometry 90 Colloids 163
Acetylcholine (ACh) 34
Atracurium 32 dextrans 165
role of acetylcholinesterase
gelatins 164
34
B hydroxy ethyl starch 165
action of ACh on nicotinic
Combitube 116
receptors 34 Bag-mask-ventilation 243
Common gas outlet 60
Acute heart failure 229 Balanced salt solutions 162
Compressed oxygen outlet 60
Acute renal failure 231 Basal fluid requirement 163
Congenital myasthenic
Airway management 102 Blenders 206
syndromes 46
airway equipment 114 Blood transfusion 165
Cricothyrotomy 113
difficult airway algorithm complications 168
Crystalloids 160
113 components 166
balanced salt solutions
initial airway management cryoprecipitate 167
162
103 fresh frozen plasma 167
dextrose 161
problems with mask packed red blood cells
sodium chloride 162
ventilation 104 166
rapid sequence induction platelets 166
Bronchial asthma 72 D
and intubation 112
Airway obstruction 104, 193 Daltons law of partial pressures
Anemia 80 C 19
Anesthesia breathing circuits Capnography 92 Defibrillation 244
60 Cardiogenic shock 227 Demyelinating diseases 45
Anesthesia monitoring 87 Cardiopulmonary resuscitation Depolarizing block 36
appropriate monitoring 93 239 Depolarizing relaxants 37
common monitoring advanced cardiac life Desensitization block 36
techniques 88 support 244 Determination of exposure code
central venous pressure access for medications 213
monitoring 90 245 Diabetes mellitus 73
ECG monitoring 88 defibrillation 244 Dibucaine number 38
invasive (direct) arterial BLS algorithm 241 Differential blockade 127
pressure monitoring Complications of BLS 252 Disseminated intravascular
90 CPR for infants and coagulation 169
neuromuscular children 248 Distributive shock 227
monitoring 93 drugs 248 Double burst stimulation 48
non-invasive blood post-resuscitation care 248 Draw-over apparatus 53
pressure monitoring Caudal anesthesia 138 Dysrhythmias 195
89 Central pontine myelinolysis Dystrophies 45
temperature monitoring 176
Channelopathies 45 E
93
Anticholinesterase drugs 38 Chest compressions 244 Eaton Lambert syndrome 46
Anticoagulant therapy 78 Citrate intoxication 170 Electrical nerve stimulators
Antihypertensive drugs 80 Coagulopathy 168 143, 144
256 A PRIMER OF ANESTHESIA