Chapter 2 Evaluation Before Anaesthesia

1.Purpose for preanesthetic evaluation (page 8)

Preanesthetic evaluation has specific objectives including :
 Establishing a doctor-patient relationship (alleviate many of the fears
the patient may have and foster trust);
 Becoming familiar with the surgical illness and coexisting medical
conditions;
 Developing a management strategy for perioperative anesthetic care;
 Obtaining informed consent for the anesthetic plan. This involves
discussing the anesthetic plan, alternatives, and potential
complications in terms understandable to the layperson.
The overall goals of the preoperative assessment are to reduce perioperative
morbidity and mortality and to allay (alleviate) patient anxiety.

2. What information should be contained in the preoperative assessment?

REVIEW OF HISTORY
SYSTEMS GENERAL CONDITION

PREMEDICATION
INFORMATION
DRUGS CONTAINED IN
ALLERGIES
THE PREOP ASSESSMENT
ECG
LABORATORY
AND DRUG
FAMILY
STUDIES
REACTIONS
ANESTHETIC HISTORY
General
HISTORY
PHYSICAL
SOCIAL
conditions: the EXAM
HISTORY
anesthetist should AND
review the symptoms HABITS
of the present
surgical illness, diagnostic
studies performed, presumptive
diagnosis, initial treatment, and
responses. Vital signs should ne reviewed and fluid
balance estimated.
Coexisting illnesses: coexisting illnesses may complicate the surgical and
anesthetic course. These should be evaluated in a systemic approach with an
emphasis on recent changes in symptoms, signs, and treatment.

Drugs: medications used to treat present or coexisting illnesses, their dosages, and
schedules must be ascertained. Of special importance are antihypertensive,
antianginal, antiarrhythmic, anticoagulant, anticonvulsant, and specific endocrine
medications. The decision to continue medications during the preanesthetic period
depends on the severity of the underlying illness, the potential consequences of
discontinuing treatment, the medication’s half-life, and the likelihood of deleterious
interactions with proposed anesthetic agents.

Allergies and Drug Reactions: unusual, unexpected, or unpleasant reactions to

perioperative medications and non-allergic adverse reactions, side effects, and
drugg interactions are relatively common. True allergic reactions (any drug reaction
that (by direct observation, chart documentation, or description by the patient)
produced skin manifestations (pruritus with hives or flushing), facial or oral
swelling, shortness of breath, choking, wheezing, or vascular collapse) are relatively
uncommon.

Adverse reaction and side effects: preoperative medications can produce

memorable and unpleasant side effects (e.g., nausea, vomiting, and pruritus after
narcotic administration) in a conscious patient.

Anesthetic history: * response to sedative/analgesic premedications and

anesthetic agents.
 vascular access and invasive monitoring used, and if any difficulties were
encountered.
 *ease of mask ventilation, direct laryngoscopy, and size and type of
laryngoscope blade and endotracheal tube used.
 *perianesthetic complications such as adverse drug reactions, cephalgia
(headache), intraoperative awareness, dental injury, protrscted
postoperative nausea and vomiting, cardiorespiratory instability,
postoperative myocardial infarction or congestive heart failure, unexpected
admission to ICU or reintubation.

Family history: history of adverse anesthetic outcomes in family members should

be evaluated.

Social history and habits: smoking, drugs and alcohol

Review of systems: review of previous and present illnesses by systems which may
increase the risk or perioperative morbidity and mortality.
Physical Examination: special attention is directed toward evaluation of the
airway, heart, lungs, and neurologic status. When a regional anesthetic technique is
planned, there should be a detailed assessment of the extremities or back.

Lab studies: hematological studies, hematocrit/hemoglobin, platelet function,

coagulation studies, serum chemistry studies.

3. What is the ASA scale, please describe the 6 classes.

The ASA physical status classification system/ scale is a system for assessing the
fitness of patients before surgery. ASA (American Society of Anesthesiologists) has
adopted an evaluation scale for preoperative physical status, which helps to provide
an overall stratification of the patient’s risk for anesthetic morbidity and mortality.
Each patient’s ASA classification summarizes the patient’s degree of illness before
anesthesia and also assesses the increased risk inherent in unplanned, emergency
procedure. The scale is described in terms of classes below:
 Class 1: A healthy patient (no physiologic, physical or psychological
abnormalities).
 Class 2: A patient with mild systemic disease without limitation of daily
activities.
 Class 3: A patient with severe systemic disease that limits activity but is not
incapacitating.
 Class 4: A patient with incapacitating systemic disease that is a constant
threat to life.
 Class 5: A moribund (dying) patient not expected to survive 24 hours with or
without the operation.
 Class 6: A brain-dead patient whose organs are being removed for donor
purposes.
NOTE: If the procedure is performed as an emergency, an E is added o the
previously defined ASA physical status.
ASA Physical Status Classification

Class Definition

1 A normal healthy patient.

2 A patient with mild systemic disease and no functional limitation

3 A patient with moderate to severe systemic disease that results in some

functional limitation

4 A patient with severe systemic disease that is a constant threat to life and
functionally incapacitating

5 A moribund patient who is not expected to survive 24 hours with or without

surgery

6 Brain-dead organ donor

E If the procedure is an emergency, the physical status is followed by “E”

Chapter 3 General Anesthesia
1. Define “general anesthesia”.
I. General anesthesia is anesthesia that affects the whole body and
usually induces a loss of consciousness.
II. General anesthesia is the induction of a state of unconsciousness with
the absence of pain sensation over the entire body, through the
administration of anesthetic drugs.
2. What are the stages of general anesthesia?
 Amnesia - Stage I: This period begins with induction of anesthesia and
continues to loss of consciousness. The threshold of pain perception is
lowered during stage I.
 Delirium – Stage II: This period is characterized by uninhibited excitation and
potentially injurious responses to noxious stimuli, including vomiting,
laryngospasm, hypertension, tachycardia, and uncontrolled movement. The
pupils are often dilated, gaze may be divergent, respiration is frequently
irregular, and breath holding is common. Desirable induction drugs
accelerate transition through this stage.
 Surgical Anesthesia – Stage III: In this, target depth for anesthesia, the gaze is
central, pupils are constricted, and respirations are regular. Anesthesia is
considered sufficient when painful stimulation does not elicit somatic
reflexes or deleterious autonomic responses (e.g., hypertension, tachycardia)
 Over dosage – Stage IV: Commonly described as too deep, this stage is
marked by shallow or absent respirations, dilated pupils and nonreactive
pupils, and hypertension that may progress to circulatory failure. Anesthesia
should be lightened immediately.
The stages of planes of anesthesia were defined by Guedel after careful
observation of patient responses during induction with diethyl ether. Induction
with modern anesthetic agents is sufficiently rapid that these descriptions of
individual stages are often not applicable or appreciated. However, modification
of these categories still provides useful terminology to describe progression
from the awake to the anesthesized state.

 NOTE: when the patient is at increased risk of aspiration of gastric

contents. Drugs to neutralize gastric acid (the H2 receptor blockers:
cimetidine) and decrease gastric volume (the stomach tube placed) are
used. (recent meal, bowel obstruction, trauma, pregnancy, history of
gastric surgery, history of active reflux, Increased intra-abdominal
pressure)
3. Types of extubation.

 Awake Extubation
Extubation of the airway usually occurs after the patient fully retains protective
reflexes. Awake extubation is indicated in patients at risk of aspiration of gastric
contents, patients who have difficult airways, and patients who have just
undergone tracheal or maxillofacial surgery.
Criteria: before extubation, the patient should be awake and
hemodynamically stable. The patient should have regained full muscle strength,
be able to follow simple verbal commands (e.g., life head), and breathe
spontaneously with acceptable oxygenation and ventilation.
Technique: the presence of an ETT may be irritating to patients emerging
from anesthesia. Lidocaine (0.5 to 1.0 mg/kg IV) can be given to suppress
coughing but may prolong emergence. The patient breathes 100% oxygen, and
the oropharynx is suctioned. Mild positive airway pressure (20cm H2O) is
applied via the ETT, the ETT cuff is deflated, and the tube is removed. Oxygen
(100%) administration is continued by facemask. The anesthetist’s attention
should remain focused on the patient until the patient’s ability to ventilate,
oxygenate, and protect the airway is confirmed. The extubated patient may
become unconscious again and lose protective airway reflexes when stimulation
decreases.
Removal of the ETT over a flexible stylette (e.g., ETT exchamger, jet stylette
fiberoptic bronchoscope) can be performed when the patency of the patient’s
airway is uncertain or reintubation may be difficult. The airway is first
anesthetized with lidocaine at 0.3 to 0.5 mg/kg administered via the ETT and the
patient is allowed to breathe spontaneously. A lubricated ETT exchanger is
passed into the trachea through the ETT, the ETT cuff is deflated, and the ETT
removed, leaving the exchange device in place until the anesthetist is certain hat
the patient’s airway is stable. If airway obstruction develops, oxygen can be
insufflated (to blow (air, gas or powder) into a body cavity) via the hollow
exchange device or an ETT can be inserted over the device, which acts as a guide.

Awake extubation: remain intubated postoperatively

 airway jeopardized: glottic edema
 difficult airways
 the risk of aspiration of gastric contents
 Tracheal or maxillofacial surgery

Extubation technology
o breathing 100% oxygen
o lidocaine given to supress coughing and bucking
o suction the oropharynx
o deflate the ETT cuff
o remove the tube
o continuous oxygen administration by face mask
o focused on the patient’s ventilation/oxygenation/the airway
reflexes/consciousness
The extubated patient may become unconscious again and lose protective
airway reflexes when stimulation decreases or absents, which is very
dangerous these symptoms and signs neglected

 Deep extubation
Stimulation of airway by the ETT during emergency can be avoided by
extubating the trachea while the patient is still deeply anesthetized (stage III).
This reduces the risk of laryngospasm and bronchospasm, making it a useful
technique for severely asthmatic patients. It also avoids coughing and straining
that may be undesirable after middle-ear surgery, open-eye procedures, and
abdominal or inguinal herniorrhaphy.
 Criteria: anesthetic depth must be sufficient to avoid responses to airway
stimulation. Anesthesia may be deepened with a short-acting IV anesthetic or
ventilation with a high concentration of a volatile agent.
Technique: all necessary airway equipment and medications should be
readily available for replacement of the ETT. Surgical positioning must allow
unrestricted access to the head for airway management. The oropharynx should
be suctioned, the ETT cuff deflated, and, if there is no response to cuff deflation,
the ETT is removed, inhalation anesthesia is continued by mask and emergency
is managed as described above.
Deep extubation
 The presence of an ETT may be irritating the airway reflexes during the
emerging from anesthesia
 When the patient is still deeply anesthetized, the tube is removed.
 decreased the risk of laryngospasm
 bronchospasm
 hypertension
 tachycardia
 coughing and bucking
 increased the risk of aspiration
 Increased the risk of surgery
 Increased the risk of anoxia

The technique of deep extubation

 Anesthetic depth must be sufficient to avoid responses to airway stimulation
(a short- acting IV anesthetic or ventilation with a high concentration of a
volatile agent.
 All necessary airway equipment and medications should be readily available.
 Easy to airway management *（no difficult airways: not suitable for deep
extubation)
 The oropharynx should be suctioned
 Avoided the hypoxia/hypercarbia/airway obstruction
 The patients’ monitoring of intravascular volume
Balanced salt solution replaces the blood loss, administered in a 3:1 ratio of volume
to estimated blood loss.
Colloid solutions (6% hydroxyethyl starch) may be used to replace blood loss in an
1:1 ratio of volume to estimated blood loss and restore intravascular volume. The
fluid deficits for fasting adults is estimated at 60ml/hour plus 1ml/kg/hour for each
kilogram greater than 20 kilogram (maintenance fluids).
In general, at least half of this deficit is corrected before induction; the remainder
may be corrected intraoperatively.

Chapter 4 Airway Evaluation and Management

1. Specific findings that may indicate difficult airway? (page 37)
Inability to open mouth
Poor cervical spine mobility
Receding chin
Large tongue
Prominent incisors
Short muscular neck
Morbid obesity
Injuries to the face, neck, or chest must be evaluated to assess their contribution
to airway compromise.
The Mallampati classification to predict difficult intubation is based on the
finding that visualization of the glottis is impaired when the base of the tongue is
disproportionately large. The modified classification includes the following four
categories:
Class I: faucial pllars, soft palate, and uvula are visible.
Class II: faucial pillars an soft palate may be seen, but the uvula is masked
by the base of the tongue.
Class III: obly soft palate is visible. Intubation is predicted to be difficult.
Class IV: soft palate is not visible. Intubation is predicted to be difficult.
Difficult Bag Mask Ventilation
• Incidence approx 5%
• MOANS
• M ask seal: cant approximate mask
• O besity: redundant tissues impede airflow
• A ge >55: loss of elasticity tissues
• N o teeth: mask doesn’t sit properly
• S tiff (lungs/body): need increased pressure

Identification Difficult Intubation

LEMON
 Look (External: *Facial trauma, *Unusual anatomy: Internal: Foreign
body, Obstructing mass; Sensitive but not specific)
 Evaluate 3-3-2
 Mallampati
 Obstruction/Obesity
 Neck mobility
2. Indications and contraindications of LMAs (page 41)
LMA: Abbreviation for laryngeal mask airway
The LMA is a reusable airway management device that can be used as an
alternative to both mask ventilation and endotracheal intubation in
appropriate patients. The LMA also plays an important role in management
of difficult airway.

 LMAs have three main components: mask, airway tube, and inflation
line. The mask has a bowl surrounded by an inflatable cuff, which is
designed to form an airtight and fluid-tight seal round the larynx.
 Large LMAs may increase the risk for sore throat postoperatively but
achieve a better seal.An LMA is inserted blindly and thus gentleness is
important. The “sniff” position is recommended for insertion of an LMA.

Indications
 as an alternative to mask ventilation or endotracheal intubation for airway
management.
 The management of a known or unexpected difficult airway.
 In airway management during resuscitation.
Contraindications
 Patient at risk of aspiration of gastric contents.
 Patients with decreased respiratory system compliance.
 Patients in whom long-term mechanical ventilator support is anticipated.
 Patient with intact upper airway reflexes.
Adverse effects
 Most common: sore throat, with an estimation incidence rate of 10%, and is
most often related to over inflation of the LMA cuff.
 Primary major adverse effect: aspiration, which has been estimated to occur
at a comparable incidence as with mask or endotracheal anesthesia.
Assessment of Function of the LMA
 Observation of airway pressure and chest movement with a manual
ventilation
 Reservoir bag refill during expiration
 Capnograph
 Auscultation over the neck
 Cuff leak pressure
 Expired tidal volume and flow-volume loop
 Examination with a flexible fiberoptic laryngoscope

3. The difficult airway and emergency airway techniques. (page 44)

The difficult airway can be divided into the recognized difficult airway and
the unrecognized difficult airway; the Katter represents the greater challenge for
the anesthesiologist.
The ASA defines a difficult airway as failure to intubate with conventional
laryngoscopy after three attempts and/or more than 10 minutes.
The use of regional anesthesia is a way to avoid the known or anticipated
difficult airway. Regional anesthesia generally should not be elected for a patient
with a known difficult airway if the surgery cannot be terminated rapidly.
 The LMA is a prominent airway option.
 Percutaneous needle cricothyroidotomy involves placing a 14-gauage IV
catheter or 7.5 French introducer through the cricothyroid membrane into
the trachea. Oxygen can be administered by connecting the breathing
circuit.
 Rigid bronchoscopy may be necessary to support an airway partially
obstructed by a foreign body, traumatic disruption, stenosis, or mediastinal
mass. General anesthesia will usually be required for insertion. It is
important to have a range of bronchoscope sizes available. An inhalation
with spontaneous ventilation is most commonly used.
 Cricothyroidotomy is a rapid, effective method for relieving severe upper
airway obstruction. Tracheostomy may be performed under local
anesthesia before the induction of general anesthesia for a patient with a
particularly difficult airway.
 4. Indications for rapid sequence induction
Rapid sequence intubation (RSI) is a medical procedure involving a prompt
induction of general anesthesia and subsequent intubation of the trachea. RSI
is typically used in an emergency setting or for patients in the operating room.
Patients at risk for aspiration include those who:
 have full stomach
 pregnant patients
 bowel obstruction
 morbid obesity
 symptomatic reflux
The patient is preoxygenated using high flow rates of 100% oxygen for 3 to 5
minutes. Four vital capacity breaths of 100% oxygen achieve nearly the
same results. The neck is extended so the trachea is directly anterior to the
esophagus. After IV administration of an induction agent, followed
immediately by succinylcholine. There should be no attempt to ventilate the
patient by mask. Intubation can usually be performed within 30 to 60
seconds.

Indications
Failure to maintain airway tone

 Swelling of upper airway as in anaphylaxis or infection

 Facial or neck trauma with oropharyngeal bleeding or hematoma

Decreased consciousness and loss of airway reflexes

 Failure to protect airway against aspiration - Decreased consciousness that

leads to regurgitation of vomit, secretions, or blood

Failure to ventilate

 End result of failure to maintain and protect airway

 Prolonged respiratory effort that results in fatigue or failure, as in status
asthmaticus or severe COPD
Failure to oxygenate (ie, transport oxygen to pulmonary capillary blood)

 End result of failure to maintain and protect airway or failure to ventilate

 Diffuse pulmonary edema
 Acute respiratory distress syndrome
 Large pneumonia or air-space disease
 Pulmonary embolism
 Cyanide toxicity, carbon monoxide toxicity, methemoglobinemia

Anticipated clinical course or deterioration (eg, need for situation control, tests, procedures)

 Uncooperative trauma patient with life-threatening injuries who needs

procedures (eg, chest tube) or immediate CT scanning
 Stab wound to neck with expanding hematoma
 Septic shock with high minute-ventilation and poor peripheral perfusion
 Intracranial hemorrhage with altered mental status and need for close blood
pressure control
 Cervical spine fracture with concern for edema and loss of airway patency

5. Indications for awake intubation (page 45 )

Awake or nasal intubation should be considered when there is:
 A difficult intubation anticipated in a patient at risk for aspiration.
 Uncertainty about the ability to ventilate or intubate after induction of
general anesthesia.
 A need to assess neurologic function after intubation or positioning for
surgery.
Awake oral laryngoscopy often allows one to assess the airway. Sedatives such
as midazolam, propofol, and fentanyl may be used in addition to the nerve blocks.
Awake nasal intubation may be performed after adequate topical anesthesia
and regional airway blocks.
Successful intubation is noted when the patient is unable to phonate, breath
sounds and humidification within the ETT are noted with ventilation, and carbon
dioxide is noted on the capnograph.

In general, awake intubation should be preferred if:

 airway does not need to be immediately secured (i.e. sufficent time for
preparation)
 significant risk of a difficult airway
 low risk of vomiting
 compliant patient
 endotracheal intubation via the nasal or oral route is feasible

Chapter 5 Anesthesia Monitoring

1. Usage of ECG (page 47)
 To monitor the conduction of electrical impulses through the heart;
 To determine the heart rate and to detect and diagnose
dysrhythmias;
 To detect and diagnose myocardial ischemia;
 To view pacemaker function ;
 To detect and diagnose electrolyte abnormalities.

 Check the heart's electrical activity.

 Find the cause of unexplained chest pain or pressure. This could be caused by a
heart attack, inflammation of the sac surrounding the heart (pericarditis), or
angina.
 Find the cause of symptoms of heart disease. Symptoms include shortness of
breath, dizziness, fainting, and heartbeats that are rapid and irregular
(palpitations).
 Find out if the walls of the heart chambers are too thick.
 Check how well medicines are working and see if they are causing side effects
that affect the heart.
 Check how well mechanical devices that are implanted in the heart, such as
pacemakers, are working. These devices help to control the heartbeat.
 Check the health of the heart when other diseases or conditions are present.
These include high blood pressure, high cholesterol, cigarette smoking,
diabetes, and a family history of early heart disease.
2. Definitions (page 49)
SBP –Systolic Arterial Blood Pressure: The peak pressure generated during
systolic contraction. Systolic blood pressure is a measure of blood pressure
while the heart is beating.
DBP - Diastolic Arterial Blood Pressure: The trough pressure during diastolic
relaxation. Diastolic pressure is a measure of blood pressure while the heart is
relaxed.
MAP –Mean Arterial Pressure: The time-weighted average of arterial
pressures during a pulse cycle. The average arterial pressure during a single
cardiac cycle.
Pulse Pressure: The difference between the systolic and diastolic pressures.

3. Indications and Contraindications for Invasive Blood Pressure

Monitoring. (page 50-51)
Because intraarterial cannulation allows continuous, beat-to-beat blood pressure
measurement, it is considered the gold standard of blood pressure monitoring
techniques.
Indications
 Need for tight blood pressure control (e.g., induced hyper- or hypotension).
 Hemodynamically unstable patient.
 Frequent arterial blood sampling.
 Inability to utilize noninvasive blood pressure measurements.

Contraindications
If possible catheterization should be avoided in:
 Arteries without documented collateral blood flow;
 Extremities where there is a suspicion of preexisting vascular insufficiency
(e.g., Raynaud’s phenomenon).
Complications :
1.Hematoma
 2.Bleeding when the transducer tubing is not tightly affixed and
separates from the catheter hub.
3.Vasospasm
4.Arterial thrombosis.
5.Embolization of air bubbles or thrombi.
6.Necrosis of skin overlying the catheter, nerve damage, infection, loss of
digits, and so on.
Methods to decrease the risks of complications:
1. To choose smaller artery
2. Continuous infusing of heparinized saline at a rate of 2-3 ml/h
3. To pay meticulous attention to aseptic technique

4. Selection of Arteries for Cannulation (page 51-52)

The most common are radial, femoral and dorsalis.
 The radial artery: commonly cannulated because of its superficial location
and collateral flow. 5% of patients, however, have incomplete palmar arches
and lack adequate collateral blood flow. Allen’s test is a simple, but not very
reliable, method for determining the adequacy of ulnar collateral circulation.
In this test, the patient exsanguinates hos or her hand by making a fist.
While the operator occludes the radial and ulnar arteries with fingertip
pressure, the patient relaxes the blanched hand. Collateral blood flow
through the palmar arterial arch is confirmed by flushing of the thumb
within 5 seconds after pressure on the ulnar artery is released. Delayed
return of normal color (5-10s) indicates an equivocal test or insufficient
collateral circulation (>10s). alternatively, blood flow distal to the radial
artery occlusion can be detached by palpation, Doppler probe,
plethysomography, or pulse oximetry. Unlike Allen’s test, these methods of
determining the adequacy of collateral circulation do not require patient
cooperation.
  Ulnar artery: more difficult to catheterize because of its deeper and more
tortuous course (second choose). Because of the risk of compromising blood
flow to the hand, this would not normally be considered if the ipsilateral
radial artery has been punctured but unsuccessfully cannulated.

 The brachial artery: large and easily identifiable in the antecubital fossa. Its
proximity to the aorta provides less waveform distortion. However, being near
the elbow predisposes brachial artery catheters to kinking.

 The femoral artery: often provides an excellent access, but associated with an
increased incidence of infectious, complications and arterial thrombosis.

 The dorsalis pedis (in some special operation, aorta) and posterior tibial
arteries: are at the same distance from the aorta and therefore have the most
distorted waveforms. Modified allen’s test can be performed to document
adequate collateral flow around these arteries.

5. Complications of radial artery cannulation. (page 53-54)

HEMATOMA
EMBOLIZATION OF AIR
VASOSPASM BUBBLES OR THROMBI

NERVE DAMAGE COMPLICATIONS ARTERIAL

OF RADIAL THROMBOSIS
ARTERY
CANNULATION
NECROSIS OF SKIN BLEEDING (if the
OVERLYING THE transducer tubing is not
CATHETER tightly affixed and separates
from catheter hub)
Factors LOSS OF
DIGITS
associated (AMPUTATION) UNINTENTIONAL
INTRAARTERIAL
DRUG INJECTION
with an increased rate of complications include prolonged cannulation,
hyperlipidemia, repeated insertion attempts, female gender, extracorporeal
circulation, and the use of vasopressors. The risks are minimized when the ratio of
catheter to artery size is small, heparinized saline is continuously infused through
the catheter at a rate of 2-3 mL/h, flushing of the catheter is limited, ad meticulous
attention is paid to aspetic technique. Adequacy of perfusion can be continually
monitored during radial artery cannulation by placing a pulse oximeter on an
ipsilateral finger.

6. Indications for central venous pressure. (pages 54)

Central venous pressure (CVP) is usually monitored at the level of the right atrium,
and also the level of the vena cava. The transducer apparatus is usually placed at the
equal level of the coronary sinus. Normally 2-6 mmHg (approximates to right atrial
pressure), a major determinant of right ventricular end-diastolic volume.

Indications:
1. To assess intravascular volume and right ventricle function
2.Administrating drug to the central circulation
such as concertrated vasoactive drugs , hyperalimentation , chemotherapy, agents
irritating to peripheral veins, prolonged antibiotic therapy
3. Intravenous access for patients with poor peripheral access.
4.Rapid infusion of fluids
5.Sampling site for repeated blood testing
6.Indicator injection for cardiac output determination
7.Access for insertion of pulmonary artery catheter

Clinical considerations:
The shape of the central venous waveform corresponds to the events of cardiac
contraction, but how to read it ?
 a waves: these waves are from atrial contraction, and are absent in AF (atrial
fibrillation)
c waves: due to tricuspid valve elevation during early ventricular contraction
x and y descents : probably caused by the downward displacement of the tricuspid
during systole and tricuspid valve opening during diastole.

7. Complication of Central Venous Cannulation (pages 59-59)

 Dysrhythmias: caused by the guide wire or pulmonary artery catheter (PAC)
irritating the endocardium, they are temporary and resolved with withdrawal of
the catheter or wire.
 Arterial puncture: a complication that can occur at any point of catheter
placement and can cause significant vessel damage if the dilator or catheter is
placed into the artery. Before dilation, intravenous position should be verified by
color, blood gas, or pressure measurement through the finder needle, thin-
walled needle, or 18-gauge catheter. The guide wire should not feel tethered
with dilator placement, as this may signify venous damange or puncture. If an
artery is punctured before dilation, the needle should be removed and pressure
applied for at least 5 min (10 min in the case of coagulopathy) and a new site
chosen. If the catheter is placed in the artery, it should remain in place and a
vascular surgeon consulted.
 Pneumothorax, hemothorax, hydrothorax, chylothorax, or pericardial
tamponade may become evident with vita sign changes. They are in part ruled
out with chest radiography. The risk of pneumothorax is highest with subclavian
vein insertion.
 Infection and air embolism may occur at any time before removal of the
catheter. The risk of infection is highest with femoral venous placement. To
reduce the chance of air embolism upon catheter removal, the site is occluded
with the patient performing a Valsalva maneuver. The Trendelenberg (in the
Trendelenburg position, the body is laid flat on the back (supine position) with
the feet higher than the head by 15-30 degrees, in contrast to the reverse
 Trendelenburg position, where the body is tilted in the opposite direction.)
position helps to prevent air entrainment at neck and subclavian sites.

8. Indications for temperature monitoring. (page 65)

 Need to control temperature during induced hypothermia and rewarming (e.g.,
during cardiopulmonary bypass or vascular neurosurgery).
 Infants and small children are prone to thermal lability (easily altered) due to
their high surface area to volume ratio.
 Adults subjected to large evaporative losses or low ambient temperatures (as
occur with exposed body cavity, large volume transfusion of unwanted fluids, or
burns) are prone to hypothermia.
 Febrile patients need to be monitored because of the risk of hyper- or
hypothermia.
 Patients with autonomic dysfunction are unable to autoregulate their body
temperature.
 Malignant hyperthermia is always a possible complication, and temperature
monitoring should always be available.

9. Usual sites for temperature monitoring. (page 65-66)

 Skin/axilla as measured on the forehead, is normally 3° F to 4°F below core

temperature, and this gradient may increase with further cooling. The axilla
is a common site fo noninvasive temperature determination and is usually
1°F below body temperature. The probe needs to be placed at the axillary
artery with the arm adducted.
 Anus/rectal temperature changes lag behind those of core body
temperature. This phenomenon is often noted during rewarming after
hyperthermia and indicates the slower peripheral rewarming. The risk of
rectal perforation is a rare complication.
  Distal part of the esophagus temperature monitoring reflects the core
temperature well. The probe should be located at the lower third of the
esophagus ad rarely may be misplaced in the airway.
 Tympanic membrane temperature correlates well with core temperature
by measuring near the eardrum. Intervening cerumen may enlarge the
gradient with respect to core temperature.
 Nasopharyngeal temperature, measured at the posterior nasopharynx,
reflects the brain temperature. This measurement is performef by measuring
the distance from the external meatus of the ear to the external nare and
inserting the temperature probe to that distance. This method may be
associated with epistaxis in coagulopathic or pregnant patients or may result
in skin necrosis if the probe is allowed to press on the nare during longer
procedures. This method is discouraged in patients with head trauma or
cerebrospinal fluid rhinorrhea (cerebrospinal fluid (CSF) rhinorrhea is the
medical term for a rare condition in which the fluid that normally cushions
the brain and spinal cord, cerebrospinal fluid, runs from the nose.).
 Blood temperature measurements may be obtained with the thermistor of a
PAC.

10.Reasons for neuromuscular blockade monitoring (pages 66-67)

Because of the variation in patient sensitivity to neuromuscular blocking agents, the
neuromuscular function of all patients receiving intermediate- or long-acting
neuromuscular blocking agents should be monitored.
Reasons for neuromuscular function monitoring:
 To facilitate timing of intubation
 To provide an objective measurement of relaxation during surgery and
degree of recovery before extubation
 To titrate dosage according to patient response
 To monitor for the development of phase II block
 To permit early recognition of patients with abnormal plasma cholinesterase
activity
11.Patterns of stimulation for neuromuscular blockade monitoring. (pages
67-70)
Single twitch

Double burst
stimulation Tetanic stimulus

Patterns of
stimulation for
neuromuscular
blockade

Posttetanic count Posttetanic single

twitch

 Single twitch is a supramaximal The TOF stimulus, typically

lasting 0.2 milliseconds at a frequency of 0.1Hz
(1 impulse every 10 secs). The height of the muscle twitch (its amplitude for a
given load and peak tension) is determined as a percentage of control. A
supramaximal stimulus ensures recruitment of all muscle fibers, and a short
duration prevents repetitive nerve firing. The stimulus frequency is important
because it affects twitch height and degree of fade. Single twitch is not a sensitive
measure of onset or recovery from blockade because 75% of recepors must be
blocked before twitch height begins to decrease and 75% may still be blocked
when it returns to control height.

 Tetanic stimulus frequencies vary from 50 to 200 Hz. All NMBDs (Neuromuscular
blocking drugs) reduce twitch height, but with non-depolarizing block and phase II

block tetanic fade is also demonstrated. This occurs when NMBDs bind to
presynaptic receptors and decrease mobilization of Ach during high-frequency
 stimulation. A tetanic stimulus at 50 Hz for 5 secs is clinically useful, because a
sustained tension at this frequency corresponds to that achieved with maximum
voluntary effort. However, tetanic stimuli are painful and can speed recovery in
the stimulated muscle, thus misleading the observer with respect to the degree of
recovery in important respiratory and upper airway muscles.

 Posttetanic Single Twitch is measured by single-twitch stimulation 6 to 10

seconds after a tetanic stimulus. An increase in this twitch is called PTP. This
transient reversal is due to partial increased mobilization and synthesis of Ach
during and after tetanic stimulation. Both nondepolarizing and phase II blockade
will cause PTP, but depolarizing blockade will not. Repeated tetanic stimuli can
change contractile function and may occasionally cause an artifactual PTP.

 The TOF (Train-of-Four Stimulation): Is four supramaximal stimuli given

every 0.5 second (2 Hz) .When used continuously, each set (train) of stimuli is
normally repeated every 10th to 20th second. Each stimulus in the train causes
the muscle to contract, and “fade” in the response provides the basis for
evaluation. That is, dividing the amplitude of the fourth response by the
amplitude of the first response provides the TOF ratio.TOF is a very useful
method for clinical monitoring, because it does not require a control
measurement, it is not as painful as tetanic stimulation (may be performed in an
awake patient to identify residual block), and it does not induce changes in
subsequent recovery.

• In the control response (the response obtained before the administration of

a muscle relaxant), all four responses are ideally the same: the TOF ratio is
1.0.
• During a partial nondepolarizing block, the ratio decreases (fades) and is
inversely proportional to the degree of blockade.
 • During a partial depolarizing block, no fade occurs in the TOF response;
ideally, the TOF ratio is approximately 1.0

 Posttetanic count is used to quantify deep levels of non-depolarizing block.

A 50-Hz tetanic stimulus is given for 5 seconds, followed 3 seconds later by
repeated single stimuli at 1.o Hz. The number of responses detectable
predicts the time for spontaneous recovery.

 Double burst stimulation uses a burst of two or three tetanic stimuli at 50

Hz followed 750 ms later by a second burst. A decrease in the second
response indicates residual curarization. It has been suggested that fade in
response to double burst stimulation is more easilt detected than fade in
response to TOF.
Chapter 6 - Breathing Function Monitoring and
Respiratory Care

Definitions:
SpO2:

SvO2: Venous Blood Oxygen Saturation

FIO2: Fraction of Inspired Oxygen - is the fraction or percentage of oxygen in the

space being measured. Medical patients experiencing difficulty breathing are
provided with oxygen-enriched air, which means a higher-than-atmospheric FiO2.
Natural air includes 20.9% oxygen, which is equivalent to FiO2 of 0.209. Oxygen-
enriched air has a higher FiO2 than 0.21, up to 1.00, which means 100% oxygen.

PEEP: Positive End Expiratory Pressure - is the pressure in the lungs (alveolar
pressure) above atmospheric pressure (the pressure outside of the body) that exists
at the end of expiration. The two types of PEEP are extrinsic PEEP (PEEP applied by
a ventilator) and intrinsic PEEP (PEEP caused by a non-complete exhalation).

PETCO2: Partial pressure of exhaled carbon dioxide. The carbon dioxide content
of an expired breath. In a patient with normal ventilation and perfusion, it should
exceed 40 mm Hg.

FEV1: Forced Expiratory Volume – the volume of air exhaled in the first second of
the FVC (forced vital capacity). It measures how much air a person can exhale
during a forced breath.

FVC: Forced vital capacity (FVC) is the total amount of air exhaled during the FEV
test.
Capnography: is the monitoring of the concentration or partial pressure of carbon
dioxide (CO2) in the respiratory gases. It is usually presented as a graph of
expiratory CO 2 (measured in millimeters of mercury, "mmHg") plotted against
time, or, less commonly, but more usefully, expired volume. Monitoring of the
concentration of exhaled carbon dioxide in order to assess physiologic status or
determine the adequacy of ventilation during anesthesia.
Chapter 7 – Local Anesthetics and Peripheral Nerve Block
1. Classification of local anesthetics. (pages 123-124) representative drug
and mechanism of action
Local anesthetics are weak bases whose structure consists of an aromatic moiety
connected to a substituted amine through an ester or amide linkage. Moiety
connected to a substituted amine through an ester or amide linkage. The pK a values
of local anesthetics are near physiologic pH; thus, n vivo, both charged and
uncharged form is more lipophilic and able to gain access to the axon. The clinical
differences between the ester and amide local anesthetics involve their potential for
producing adverse effects and the mechanisms by which they are metabolized.

Esters: procaine, cocaine, chloroprocaine, and tetracaine. The ester linkage is

cleaved by plasma cholinesterase. The half-ife of esters in the circulation is very
short (about 1 minute). The degradation product of ester metabolism is p-
aminobenzoic acid.

Amides: Lidocaine, mepivacaine, bupivacaine, etidocaine, and ropivacaine. The

amide linakge is cleaved through initial N-dealkylation followed by hydrolysis,
which occurs primarily in the liver. Patients with severe hepatic disease may be
more susceptible to adverse reactions from amide local anesthetics. The elimination
half-life for amide local anesthetics is 2 to 3 hours.

Mechanism of Action
 Local anesthetics block nerve conduction by impairing propagation of the
action potential in axons. They have no effect on the resting or threshold
potentials but decrease the rate of the action potential so that the threshold
potential is not reached.
 Local anesthetics interact directly with specific receptors on the Na+ ion
influx. The anesthetic molecule must transverse the cell membrane though
 passive nonionic diffusion in the uncharged state then binds to the sodium
channel in the charged state. In addition, recent data suggest that local
anesthetics may also act on K+ and Ca+ channels.

2. Sequence of Clinical Anesthesia. (page 126)

Neural blockade of peripheral nerves usually progresses in the following order:

Sympathetic block with peripheral vasodilation and skin temperature

elevation.

Loss of pain and temperature sensation.

Loss of proprioception.

Loss of touch and pressure sensation.

Motor paralysis.

3.Local anesthetics Toxicity causes. (pages 130-131)

Local anesthetic toxicity is related to high plasma levels of local anesthetics found in:
 Drug overdose
 Direct intravascular injection
 Rapid absorption/injection into a highly vascular area, e.g., intercostal
 Continuous infusion of local anesthetic
 Cumulative effect of multiple injection or continuous infusion.
Recommended maximum doses as quoted by manufacturers’ data sheets are a
guide only. Equally important are:
 The site of injection with relation to vascularity and absorption
 Metabolic status: acidosis, hypoxia, and hypercarbia all potentiate the
negative inotropic/chronotropic effects of local anesthetics
  Whenever possible, keep within the maximum dosing reccommendations,
aspirate carefully before injection, and divide large-volume injections into
smaller aliquots.

Maximum recommended doses of common agents

Agent Maximum Recommended Maximum Recommended
Doses mg/kg Doses with
Vasoconstrictor m/kg
Bupivacaine 2 2
Levobupivacaine 2 (insufficient info)
Ropivacaine 3 (insufficient info)
Lidocaine (Lignocaine) 3 6
Prilocaine 6 8
Cocaine 3

3. Treatment of local anesthetics toxicity

 Stop injection or infusion as appropriate
 ABC/CAB:
 Mild symptoms may be best treated by oxygen, plus judicious doses of
midazolam (1-4 mg) to increase the convulsant threshold.
 For moderate to severe toxicity, cardiovascular collapse is normally
preceded by convulsions and is related to drug overdose in the presence of
hypoxia.
 The first priority is, therefore, to prevent convulsions and maintain
oxygenation.
 If the conscious level is deteriorating or there are convulsions, intubate (use
thiopental/suxamethonium for preference as this will decrease/stop
convulsions, but propofol or midazolam are suitable alternatives) and
ventilate with 100% oxygen.
 If the cardiovascular collapse ensues begin CPR.
4. Indications and Contraindications for Peripheral Nerve Block (page 132)

Indications:
The choice of anesthesia is determined by *patient comorbidities and by obtaining
and by obtaining an informed consent that includes understanding all available
options and their risks and benefits. Important considerations in discussing
anesthetic choices include the suitability of the technique for the type of surgery, the
surgeon’s preference, the experience of the anesthesiologist, and the physiological and
mental state of the patient.

Contraindications:
Uncooperative patients
Bleeding diathesis
Infection
Local anesthetic toxicity
Peripheral neuropathy (Contralateral phrenic nerve palsy, Ipsilateral
interscalene block, etc.

5. Complications following peripheral nerve block

Complications of local anesthetics include intravascular injection, overdose, and
allergic response. Test doses and intermittent aspiration during injection may help
identify intravascular injection. Benzodiazepine premedication increases the seizure
threshold and may decrease the central nervous system toxicity of local anesthetics
as well as the level of patient anxiety.
 Complications:
– Intravascular injection
– Overdose
– Allergic responses.

 Treatments:
 – Test doses and intermittent aspiration during injection may help
identify intravascular injection.
– Benzodiazepine premedication.

Chapter 8 Spinal, Epidural, and Caudal Anesthesia

1. Complications of spinal Anesthesia. (pages 177-180)

Neurologic
Nerve injury is infrequent but can be a serious problem. Several types of nerve
injury may occur.
 DIRECT NERVE INURY related to needle or catheter placement. Pain during
insertion of the catheter or injection of the drug is a warning sign for
potential nerve injury resulting from needle or catheter placement and
requires repositioning of the needle or catheter. Transient paresthesias (an
abnormal sensation such as tingling, tickling, pricking, numbness or burning
of a person's skin with no apparent physical cause), which can occur during
placement of neuraxial blocks, are often without any long-term sequelae.
 BLOODY TAP – puncture of an epidural vein during needle insertion may
result in either blood or a mixture of blood and CSF emerging from the spinal
needle. If the fluid does not rapidly clear, the needle should be withdrawn
and reinserted.
 SPINAL HEMATOMA rare 1/150,000 incidence rate. Signs and symptoms of
severe back pain and persistent neurologic deficit usually present within 48
hours. Risk is higher among patients who are coagulopathic or
anticoagulated. Bloody taps are not generally thought to cause a spinal
hematoma in patients with normal coagulation. A bloody tap may be a risk
factor for spinal hematoma in patients who undergo subsequent
anticoagulation, but there are no data to support the mandatory cancellation
of a case under these circumstances. Diagnosis usually made with MRI, and
treatment is via emergent hematoma evacuation. Because catheter removal
as well as needle placement may cause spinal hematoma, anesthesiologists
need to check a patient’s coagulation status and use of anticoagulants not
only at the time of needle placement but also at the time of catheter removal.

Cardiovascular
  HYPOTENSION. The incidence of hypotension may be reduced by IV
administration of 500 to 1,000mL of Ringer lactate solution before
performing the block. Patients with decreased cardiac function require care
in administering large volumes of IV fluid, because translocation of fluid from
the peripheral to the central circulation during recession of the block and
return of systemic vascular tone could produce volume overload and
pulmonary edema. Treatment of hypotention includes increasing venous
return and treating severe bradycardia. Trendelenberg position (the body is
laid flat on the back (supine position) with the feet higher than the head by
15-30 degrees), fluid administration, or the use of vasopressors, such as
ephedrine (5 to 10 mg IV bolus) or phenylephrine (40 to 100ug IV bolus, 10
to 150 ug/min IV infusion) may be necessary. Oxygen should be available.
 BRADYCARDIA. This can be treated with atropine (0.4 to 0.8 mg IV) or
glycopyrrolate (0.2 to 0.4 mg). if bradycardia is severe and accompanied by
hypotension, ephedrine or epinephrine may be used.

Respiratory
 DYSPNEA is a common complaint with high spinal levels. It is caused by
proprioceptive blockade of afferent fibers fro, abdominal and chest wall
muscles. Reassuring the patient may be all that is required, although
adequate ventilation must be ensured.
 APNEA can be caused by reduced medullary blood flow accompanying severe
hypotension or from direct blockade of C-3 to C-5 (total spinal, inhibiting
phrenic nerve output). Immediate ventilator support is required.
Visceral
 URINARY RETENTION may outlast the sensory and motor blockade. This
effect may be problematic, particularly if the patient has pre-existing urinary
obstructive symptoms or if large volumes of IV fluids have been administered
during surgery. A urinary catheter should be placed if anesthesia or analgesia
is maintained for a prolonged period.
  NAUSEA AND VOMITING are usually caused by hypotension or unopposed
vagal stimulation. Treatment involves restoring BP, administering oxygen
and IV atropine.
Infection after spinal anesthesia is exceedingly rare. Nevertheless, meningitis,
arachnoiditis, and epidural abscess can occur. Possible etiologies include chemical
contamination and viral or bacterial infection. Consultation and prompt diagnosis
and treatment are essential.

Chapter 10 – Cardiopulmonary Cerebral Resuscitation

1. Aim of CPR, order of CPR, Three stages of CPR, High Quality CPR
AIM: Recovery of spontaneous circulation, breath and neurological function.
ORDER OF CPR: C CIRCULATION
A AIRWAY
B BREATHING

THREE STAGES OF CPR:

1. Basic life support, BLS: includes basic techniques taught to the general
public but applies equally to OP situations. A cardiac arrest should be
suspected in any person unexpectedly found unconscious. If the subject is
unarousable, the CABD method should be used after first calling for
assistance.
 Immediate recognition of sudden cardiac arrest(SCA)
 Activation of the emergency medical system(EMS)
 Earlier cardiopulmonary resuscitation(CPR)
 Rapid defibrillation with an external defibrillator(AED)
C begin cycle of 30 compressions
A open airway
B 2 breaths

2. Advanced cardiac life support, ACLS: including endotracheal intubation,

electrical defibrillation, and pharmacologic intervention, is the definitive
treatment for cardiac arrest.
 Advanced airway
 Ventilation strategies
 Pharmacotherapy
 Physiological monitoring
Advanced cardiovascular life support is a coordinated series of
interventions that augment the key BLS components of immediate
recognition and activation of the EMS, early CPR, and rapid defibrillation.
 3. Prolong life support, PLS

High Quality CPR

 Push hard、Push fast
 Rate at least 100/min
 Compression depth at least 2 inches(5cm)
 Allow complete chest recoil after each compression
 Minimize interruptions in chest compressions
 Avoid excessive ventilation (Hyperventilation can increase intrathoracic
pressure, which decreases coronary perfusion pressure in cardiac arrest
patients)

3. Cardiac arrest – how to diagnose, common causes

Diagnosis: the absence of a palpable pulse in a major peripheral artery (carotid,
radial, or femoral) in an unconscious, unmonitored patient is a diagnostic of a
cardiac arrest. An ECG may reveal asystole, ventricular fibrillation (VF), ventricular
tachycardia (VT), or even an organized rhythm (as in pulseless electrical activity).
 An unconscious patient and absence of breathing
 Dilated pupils
 Cyanosis(发绀）
 Appropriate ECG trace
 Ventricular fibrillation (VF)
 Asystole
 Pulseless Electrical Activity

Myocardial infarction Hypoxemia

Tension pneumothorax
Acid-base disturbances

Etiologies of
Pulmonary embolus Cardiac Arrest Hypovolemia
4. Atrial Defibrillation Electricity

Defibrillation Sequence
 Place electrode paste or normal saline
between the electrodes and the skin
 Turn the AED on
 Select 150J (biphasic), 360J (monophasic)
 Stand clear of the bed
 Shock
 Resume chest compressions immediately

5. Advanced airway management

In roughly increasing order of invasiveness are the use of supraglottic devices
such as oropharyngeal, nasopharyngeal and laryngeal mask airways; followed by
infraglottic techniques such as tracheal intubation and finally surgical methods.

 Endotracheal Intubation
 Supraglottic Airway

6. Drugs used during CPR

 Oxygen
 Adequate oxygen supply to the brain is at the core of CPR
 100% oxygen should be supported as soon as possible

 Intravenous fluids
 crystalloid (0.9% saline ,Ringer’s lactate)
 colloid solutions(Voluven, or gelatines )
 not to overload the patient with fluids

 Adrenaline
 Adrenaline is the top priority drug in cases of cardiac arrest, and should be
administered immediately and repeatedly if necessary.
 Can be administrated via the endotracheal tube if intravenous access has not
yet been established.
 The administration of adrenaline is followed by sequential cycles of 1
defibrillation 360 J (150 J biphasic). Once 3 cycles of adrenaline and
defibrillation have been administered, one can proceed to the use of other
medications
 The recommendations are that adrenaline 1.0 mg be administered every 3 to
5 minutes.

 Vasopressin
 Its chief function is increased water absorption from the kidneys.
 Increased coronary perfusion pressure and vital organ blood  flow.
 Increased ventricular  fibrillation median frequency.
 Increased cerebral oxygeon delivery.
 It may be used effectively in cases where adrenaline has no effect during
CPR.

 Lidocaine
 Lidocaine stabilizes cellular membranes and suppresses electrical activity by
blocking sodium channels.
 It is still the drug mostly used for the management of ventricular 
fibrillation resistant to defibrillation, ventricular tachycardia and ectopy.
 A bolus dose of 1.5 mg/kg should be administered, followed every 8 - 10
minutes by a dose of 0.5 mg/kg, up to a maximum of 3 mg/kg.

 Amiodarone
 It may be used in cases where lidocaine has no effect during CPR.
 150 mg administered over 10 minutes, dissolved in 20 ml dextrose water,
followed by 1 mg/min infusion for 6 hours, followed by 0.5 mg/min.
 maximum dosage:2 g per 24 hrs.

 Atropine
 Usually used for sinus bradycardia and AV block at the level of the AV node.
  Atropine is now also administered in cases of asystole and PEA with a pulse
rate of < 60 beats per minute.

 Magnesium sulphate
 Being used as an antidysrhythmic drug during cardiac arrest. It counteracts
the release of Ca2+, which originates during ischaemia of the brain.

 Sodium bicarbonate (NaHCO3)

 Only if laboratory tests reveal metabolic acidosis or hyperkalaemia before
the cardiac arrest, it may be used earlier.
 The formula is: weight (kg) x base excess x 0,3 = meq NaHCO3

 Calcium
 Dopamine hydrochloride
 Dobutamine hydrochloride
 Amrinone(氨力农）
 Potassium chloride

Chapter 11 – Pain Management

Definitions
Pain: An unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage. The pain system
provides information on noxious stimuli that allows the body to respond to the
injury (immediate, withdrawal from a noxious source; long-term, protection of the
injured part by guarding). Pain may be somatic, visceral, neuropathic or
systematically maintained.

Allodynia: Pain resulting from a stimulus that does not normally provoke pain.
Analgesia: Absence of pain in response to stimulation that normally would be
painful.

Anesthetic dolorosa: An anesthetic area that develops pain.

Central pain: Pain initiated or caused by a primary lesion or dysfunction in the

central nervous system.

Dysesthesia: An unpleasant abnormal sensation, whether spontaneous or evoked.

Hyperalgesia: An increased response to a stimulus that is normally painful.

Neuralgia: Pain in the distribution of a nerve or nerves.

Neuropathy: Pain initiated or caused by a primary lesion or dysfunction in the

peripheral nervous system.

Radiculopathy: Dysfunction of a nerve root leading to either motor manifestations

(weakness) or sensory manifestations (pain, numbness, paresthesias), or both,
along a dermatomal segment.

1. Classification of pain
ACUTE PAIN this follows injury to the body and generally disappears with wound
healing.

CHRONIC PAIN: while acute pain that normally occurs after trauma or surgery lasts
for a limited time, chronic pain persists for months or even years.
SOMATIC PAIN: is described as aching, gnawing, and/or sharp in quality. It is
generally well localized and initiated by nociceptor activation in cutaneous and deep
tissues. Eg. Acute postoperative pain and bone fractures.

VISCERAL PAIN is also associated with tissue injury, specifically infiltration,

compression, and distention of viscera. It is usually described as dull and aching in
quality and poorly localized, and it may be referred to other sites. Eg, abdominal
pain due to constipation.

INFLAMMATORY PAIN

NEUROPATHIC PAIN results from injury to the peripheral or central nervous

system. Shooting, electrical, or burning pain often is superimposed on a chronic
background of burning and aching sensations. E.g., postherpetic neuralgia (PHN)
and diabetic neuropathy.

2. Drugs used for postoperative pain management. (pages 217-220)

Nonopiod Analgesics
 Aspirin, acetaminophen, and NSAIDs are all useful in the management of
acute and chronic pain. These agents differ significantly from opioid
analgesics because the intensity of the analgesic effect is more limited; they
do not produce tolerance or physical dependence, and they are antipyretic.
Both ASA and the NSAIDs work by inhibiting the cyclooxygenase pathway,
which in turn stops the production of various prostaglandins that can
sensitize free nerve endings to painful stimuli. The mechanism of analgesia
produced by acetaminophen is not known. As a general rule, severe pain will
 require treatment with opioid analgesics, but most patients will do better if a
nonopioid agent is also administered as an adjuvant.

 COX II selective Inhibitors (coxibs): The only coxib that is still marketed in
the United States is celecoxib. It unquestionably produces fewer
gastrointestinal symptoms and bleeding than nonselective NSAIDs, but this
class definitely increases the risk of thrombosis, myocardial infarction, and
stroke. Coxibs and NSAIDs produce similar analgesic effects, so coxib use
should be restricted to those select patients in whom the risk of GI toxicity
offsets the cardiovascular risk.

Opioids: Systemic opioids have long been the treatment of choice for acute
postoperative pain and for severe chronic pain in combination with adjuvant
medications. There are several administration routes: oral, intramuscular, rectal, IV,
PCA (pain controlled analgesia), transderma, epidural.

Opioid Agonist-Antagonist: These include pentazocine, nalbuphine, and

butorphanol. Only pentazocine is available orally. There are less abusable than
morphine but may cause dysphoria (state of unease or generalized dissatisfaction
with life), so they are not commonly used. Nalbuphine (0.05 to 0.1 mg/kg IV/IM) is
an effective anatagonist for the management of opiod-related pruritus but may
reverse some analgesia.
OPIOIDS
 Analgesia for Labour
The most commonly employed ‘analgesics’ are transcutaneous electrical nerve
stimulation (TENS), inhaled nitrous oxide, opioids, and regional techniques.
Although some women find TENS helpful in labour, randomized studies show only
weak evidence of analgesia. Opioids in labour, although cheap and simple to
administer, act predominantly as sedatives and amnesicspain scores are minimally
changed. Entonox is more efficacious than pethidine, but complete analgesia is
never attained.
Regional analgesia provides the most effective pain relief. Provided hypotension is
avoided, fetal condition in the first stage of labour may be improve as maternal
sympathetic stimulation and hyperventilation are reduced. However, a degree of
maternal motor block is almost universal, and most randomized studies comparing
regional and parenteral analgesia demonstrate an association between epidural
analgesia and prolonged labour together with a higher incidence of instrumental
deliveries. Careful obstetric management of labour and appropriate anesthetic
management of analgesia may negate this effect.
Uterine pain is transmitted n sensory fibres which accompany sympathetic nerves
and end in the dorsal horns of T10-L1. Vaginal pain is transmitted via the S2-S4
nerve roots (the pudendal nerve). Spinal, combined spinal/epidural (CSE), and
epidural analgesia have largely replaced other regional techniques (paracervical,
pudendal, caudal block).

Acceptable analgesia must be provided, but minimizing the incidence of

hypotension and motor blockade is important. Reducing the degree of motor block
increases maternal satisfaction and may decrease the incidence of assisted delivery.
Motor block can be reduced by:
 Using synergistic agents such as opioids and the alpha2 agonist, clonidine, to
reduce the dose of local anaesthetic administered.
 Establishing regional analgesia with low-dose epidural local anesthetic and
opioid or low-dose intrathecal local anesthetic and opioid,
 Using patient-controlled epidural analgesia (PCEA) or intermittent topups to
maintain analgesia. In general, infusions deliver a greater total dose of local
anesthetic than intermittent top-ups, while PCEA delivers the smallest total
dose

Contraindications for Regional Labour Analgesia

 Maternal refusal.
 Allergy (true allergy to amide local anesthetics is rare so always take a careful
history).
 Local infection.
 Uncorrected hypervolemia.
 Coagulopathy. (guideline count platelet >80 x 109/litre and INR <1.4).

Relative Contraindications for Regional Labour Analgesia

 Expectation of significant hemorrhage.
  Untreated systemic infection (provided that systemic infection has been
treated with antibiotics, the risk of ‘seeding’ infection into the epidural space
with neuraxial procedure is minimal.
 Specific cardiac disease (e.g. severe valvular stenosis, Eisenmenger’s syndrome,
peripartum cardiomyopathy). Although regional analgesia has been used for
many of these conditions, extreme care must be taken to avoid any rapid
changes in blood pressure, preload, and afterload of the heart. Intrathecal
opioid without local anesthetic may be advantageous for these patients.
 Bad backs and previous back surgery do not contraindicate regional
analgesia/anesthesia, but scarring of the epidural space may limit the
effectiveness of epidural analgesia and increase the risk of inadvertent dural
puncture. Intrathecal techniques can be expected to work normally.

READ CANCER PAIN

Pharmacologic Therapy

WHO Guidelines
The barriers to effective pain control are multifold. As a result, clinicians have
traditionally undertreated cancer pain. A growing recognition of this health issue
has led to the development of numerous guidelines for treating cancer pain,
including most famously the WHO stepladder approach to treating cancer. Although
too simple to serve as a comprehensive treatment algorithm, the principle of
treating more resistant cancer-related pain with stronger doses of opioids is
generally sound.

Nonopioid Analgesics
The nonopioid class of analgesics includes both acetaminophen and NSAIDs.
Nonopiods are commonly used for mild cancer pain, as directed by the WHO
analgesic ladder. Even in the patient with advanced cancer, nonopioid analgesics
combined with opioid analgesics are effective in treating pain at both central and
peripheral sites. Nonopioids help to reduce the requirement for opioids, thus
decreasing the opioid-associated side effects of nausea, constipation, somnolence (is
a state of strong desire for sleep, or sleeping for unusually long periods (compare
hypersomnia).), and cognitive impairment. Nonopioid analgesics must be used with
caution, if at all, in cancer patients who are immunosuppressed. Both
acetaminophen and NSAIDs can suppress a fever response indicative of a mounting
infection in the immunocompromised patient.

Opioid Analgesics
Opioid analgesics are a mainstay for treatment of cancer pain. In the WHO three-
step analgesic ladder, “weak” opioids are recommended for treatment of moderate
cancer pain, whereas “strong” opioids are prescribed for severe cancer pain. The
“weak” opioids have less potency and fewer side effects. The “weak” opioids are
produced containing acetaminophen or aspirin. They are “weak” because of the
limitation of their ceiling dose of acetaminophen or aspirin, above which the patient
has a huger risk of renal and hepatotoxicity.
The “strong” opioids are more potent because they are made in pure form, without
addition of aspirin or acetaminophen. Thus, these opioids do not have a maximum
ceiling dose. However, with higher dosages of the “strong” opioids, the patient tends
to experience more significant side effects to nausea and vomiting, constipation,
pruritus, somnolence, and cognitive impairment.
Treatment of cancer pain is multifaceted and may require pharmacologic
intervention combined with counseling, nursing care, pastoral and social services,
nerve blockade, surgery, radiation therapy, chemotherapy, and hospice care. Cancer
pain often is a dynamic process with remissions and exacerbations paralleling the
disease course. Because of the terminal character of most chronic cancer pain,
narcotics are considered the mainstay of treatment. Long-acting continuous-release
preparations of opioids are useful in providing basal analgesia, and short-acting
preparations (immediate-release morphine, oral transmucosal fentanyl) can be used
to treat episodic pain. Often the side effects of the narcotics (especially constipation)
can start affecting quality of life, and these need to be treated aggressively. However,
in patients who cannot tolerate escalation of systemic opioids because of the side
effects, the following techniques can sometimes provide excellent control while
minimizing side effects.

 Intrathecal (occurring within or administered into the spinal theca) drug delivery
system
 Celiac Plexus block