Surgery

Anesthesiology Part 1
Erwin Jessie Nercuit Taghoy, MD
August 11, 2020

OUTLINE o Based on the findings → it could be concluded by the

anesthesiologist if the patient is in optimal medical condition
PRE-OPERATIVE EVALUATION & PREPARATION OF THE ANESTHESIA to undergo elective surgery
PATIENT .......................................................................................................1
Phases of Anesthetic Management ....................................................................................1
o If findings show that patient is not in optimal med conditions,
Preoperative Phase ...............................................................................................................1 these findings and opinions are then discussed w/a patient’s
Preoperative Evaluation .......................................................................................................1
Preoperative Fasting.............................................................................................................3
primary physician/surgeon → surgery may be
delayed/cancelled until the patient’s medical condition is
LOCAL ANESTHETICS & REGIONAL ANESTHESIA ....................................3 further evaluated and optimized
Local Anesthetics ..................................................................................................................3
Regional Anesthesia .............................................................................................................3 - Past medical History = should include the ff:
o Surgical history
MANAGEMENT OF ACUTE & CHRONIC PAIN .............................................4
Definition ................................................................................................................................4 o Anesthetic history = patient’s previous exposure and
Characteristics ......................................................................................................................4 experience with anesthesia
Causes ....................................................................................................................................4
Pain: the 5th Vital Sign ...........................................................................................................4
▪ Any family history of problems with anesthesia
Management of Acute Pain ..................................................................................................5 o Allergies and drug reactions = history of atopy is an important
Management of Chronic Pain ..............................................................................................5
aspect of this eval
▪ May predispose patients to form antibodies against
antigens
PRE-OPERATIVE EVALUATION & PREPARATION OF THE o Review of systems = a review of the function of major organ
ANESTHESIA PATIENT systems
Phases of Anesthetic Management - Physical exam = targeted primarily at CNS, CVS, and lungs and
- There are 3 general phases: airway
o Preoperative phase - Lab testing = should be based on the patient’s condition and
o Intraoperative phase proposed procedure
o Postoperative phase o Healthy patients = usually do not need lab testings for minor
- Each phase has its own set of goals, targets, and standard of care procedures
- Ultimate goal of anesthesia: to provide amnesia, analgesia, and o Preop testing may be necessitate by findings on PE
relaxation to the surgical patient ▪ E.g., ECG obtained if there is an irreg heart rhythm noted
- Different medications anesthesiologists use in the operating theater
cater to these needs: ASA Physical Status Assessment
o Some drugs provide both analgesia and anesthesia in the form
of dissociative anesthesia (e.g., ketamine)
o Some meds provide only 1 of the 3 important needs during
anesthetic care
▪ E.g., ketorolac (for analgesic purposes), rocuronium
(non-depolarizing paralytic agents providing muscle
relaxation)
- Knowing the drugs’ clinical indication could help a GP use them in
other fields or help manage post-surgical patients who overdose or
with side effects of these drugs in the recovery room

Preoperative Phase
- Covers the time period wherein the patient consents to undergo
anesthetic care for surgery up to the last second before the
induction of anesthesia prior to surgery
- One of the goals: optimize the patient’s anatomic physiologic Figure 1. This table allows anesthesiologists to evaluate the medical status of the
mental and emotional conditioning to the effects that surgery and patient, develop a plan of anesthetic, and discuss this plan with the
patient/patient’s legal guardian. This is a classification used to risk stratify patients
anesthesia might cause on the human body
for anesthesia and surgery.
- Preparation in this phase of anesthetic care → key for a successful
and uneventful surgery - Patients undergoing emergent surgery = denoted with an “E” after
the ASA physical status classification
Preoperative Evaluation - Increasing ASA physical status = increasing mortality
- Includes an appropriately detailed medical history (history of o However, not shown to be higher for patients undergoing
present illness includes current medication / drug therapy (and emergency surgery
their adverse interactions with other agents) and past medical
history), appropriate physical exam, and review of lab and specific Airway Evaluation
testing results - Conduct of general anesthesia requires complete muscle paralysis
during surgery

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 Surgery | Anesthesiology Part 1
o Management of the airway = one of the most critical steps in
the conduct of anesthesia
- Most airway examination can identify most patients in whom
management of the airway and endotracheal intubation may be
difficult
o Recognize such patient before administering meds that induce
apnea
- Mallampati classification = based on the structures visualized with
maximal mouth opening and tongue protrusion in the sitting position
o Higher classification + other airway abnormalities = difficult to
intubate
o Other predictors of difficult intubation:
▪ Short neck
▪ Immobility of the neck
▪ Large overbite
▪ Small mandible
▪ Inability to shift the lower incisors in front of the upper
incisors
▪ Decrease thyromental distance (<6 cm)
• This is the distance from the thyroid cartilage to the
tip of the chin)
▪ Obesity
▪ Neck circumference = also assoc with difficult mask
ventilation
Figure 2. The Mallampati Classification.
Cardiovascular Disease
- Widely regarded as the most important risk associated with
anesthesia and surgery
Figure 3. A simplified version of the ACC/AHA Guidelines for evaluation for
noncardiac surgery. These guidelines have minimized the role of routine
screening.
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- This guideline stresses the importance of functional status in
determining need for further evaluation
o patients with good functional status can typically proceed to
surgery without additional evaluation
- Functional capacity (METs):
o in patients unable to attain 4 METs = poor functional status
o Activities representing 4 METs includes:
▪ walking up a flight of stairs
▪ climbing a hill
▪ walking on level ground at 3 to 4 miles per hour
- Preoperative electrocardiograms and stress testing: unnecessary
for asymptomatic patients undergoing low-risk surgery
- Special attention is required for patients with coronary stents
o The ACC/AHA guidelines recommend delaying elective
surgery for 30 days after bare metal stent placement and
for 1 year after drug eluting stent placement
- Dual antiplatelet therapy = should be continued for urgent or
emergent procedures that take place before the minimum
recommended waiting period
- Recommendations: beta-blockers and statins should be continued
in patients who are on them chronically
o Recent large randomized trials have demonstrated excess risk
of mortality and stroke simultaneously with decreased risk
of myocardial events in moderate- and high-risk patients
who are newly treated with β-blockers in the periprocedural
setting
- Implanted cardiac devices (e.g., pacemakers, implantable
cardioverter-defibrillators) = also have important perioperative
implications
- A 2011 ASA practice advisory stressed the importance of
determining whether electromagnetic interference is likely to
occur during the planned procedure
o This will determine the following:
▪ current function and necessity of the implanted device
▪ whether reprogramming or temporary disabling of the
device is advantageous
▪ having alternative therapy available for the time that the
device is unavailable
▪ restoring device function in the postoperative period
Pulmonary Disease
- Chronic pulmonary disease: an increasingly recognized cause of
morbidity and mortality in surgical patients
- For patients with asthma or chronic obstructive pulmonary
disease, the following should be evaluated:
o Exercise tolerance
o the frequency and severity of exacerbations
- A focused history should be obtained
o Include prior admissions and intubations for exacerbations
- Treatment with bronchodilators in the perioperative setting is
appropriate
o Most inhaled anesthetics act as bronchodilators.
▪ Desflurane can be an airway irritant, and it is often
avoided in patients with reactive airway disease.
- For patients with obstructive sleep apnea
o should not be extubated until they are completely awake
o they should be treated with non-invasive positive pressure
ventilation in the post-operative period
Renal Disease
- Renal considerations in anesthetic patients:
o Focused on:
▪ Perioperative fluid management
▪ Acid-base electrolyte homeostasis
o Doses of drugs are also adjusted / contraindicated in patients
with chronic renal insufficiency
 Surgery | Anesthesiology Part 1
Hepatic Disease LOCAL ANESTHETICS & REGIONAL ANESTHESIA
- Anatomic and physiologic pathologies in the liver may affect drug Local Anesthetics
choices, anesthetic technique, and monitoring modality in surgical - These are the drug of choice for anesthesiologists when they do
patients regional anesthesia
- Increase intragastric pressure brought about by ascites may also - Act on sodium channels to block transmission of neural impulses
affect airway management of these patients - Divided into 2 groups based on their chemical structure:
- Coagulation factor deficiency and thrombocytopenia → may be o Amides & esters
hepatic-related
o Thus, subarachnoid block and epidural anesthesia/several Amides Esters
other anesthetic techniques may be contraindicated in - Metabolized in the liver - Metabolized by plasma
patients presenting w/bleeding abnormalities - Less allergenic cholinesterase
- Hepatic considerations: - Include: - More allergenic
o Hepatic dysfunction o Lidocaine - Include:
o Hypoalbuminemia o Bupivacaine o Cocaine
o Ascites and increased abdominal pressure o Mepivacaine o Procaine
o Hepatocellular dysfunction o Prilocaine o Chloroprocaine
o Portal hypertension o Ropivacaine o Tetracaine
o Thrombocytopenia o Benzocaine
o Coagulation factor deficiency
- Metabolites from esters have a slightly higher allergic potential
compared to an amide
Endocrine Diseases
- Differentiation of a local anesthetic
- Periop management of diabetic patients can be especially
o presence of “i" in the name of the drug:
challenging
▪ 2 “i" → amide
- DM2
▪ 1 “i" → esters
o Lower risk of hypoglycemia
o Duration of action:
o Higher blood glucose at baseline
▪ Lidocaine = lasts for appx 30 mins
o May tolerate higher serum glucose
▪ Bupivacaine = lasts for about 90 mins when given as
- DM1
spinal anesthesia
o More risk to hypoglycemia
- Lidocaine = a local anesthetic commonly used for local infiltration,
o More insulin requiring
nerve blocks, or epidural infusions
o Prone to ketoacidosis if hyperglycemic
- Hga1c = required prior to surgery
Toxicity
o This must always be obtained if a recent level is not available
o as an increased A1c level is associated with an increase in - When used in large quantities over a short period of time,
perioperative complications including wound infections these can rise in the blood and cause central
- The most important thing for a practitioner to know and remember is nervous system (CNS) toxicity and cardiovascular toxicity.
that the difference between type 1 and type 2 diabetes - CNS toxicity:
o these two different diseases require different approaches to o Restlessness
their management o Tinnitus
o slurred speech
o can progress to seizures and coma
Preoperative Fasting
o Lidocaine for CNS toxicity
- Cardiovascular toxicity: may manifest as:
o Hypotension
o Conduction abnormalities leading to heart block
o ventricular arrhythmias
o may lead to cardiac arrest
- The type of local anesthetic used affects the risk of developing
toxicity
o Bupivacaine = most often associated with cardiovascular
toxicity
- Other risk factors for local anesthetic systemic toxicity include the
ff:
o Cumulative dose
o site of injection
o preexisting renal, hepatic, or cardiac disease in the patient
- In addition to treating symptomatology, local anesthetic systemic
Figure 4. Specific guideline from ASA for pre-op fasting to mitigate the risk of
toxicity can be treated with intravenous administration of lipid
aspiration of gastric contents. emulsion

- rapid sequence induction and intubation should be Regional Anesthesia

considered in patients who are at higher risk for aspiration
- A multitude of new techniques that only anesthetize certain regions
o e.g., very symptomatic gastroesophageal reflux
of the body
o achalasia
- Can focus on an area as big as the entire abdomen extending down
o gastroparesis
to both extremities, or can only involve 1 limb, or a small as an area
o dysmotility, regardless of fasting status of 1 finger or the area surrounding the wound
- Allows for selective blockage
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 Surgery | Anesthesiology Part 1
- Technique of choice for several surgical techniques o Pectoral nerve block
o E.g., neuraxial blockade o Serratus anterior plane block
o Spinal and epidural anesthetics - These are usually done under US guidance with local anesthetic
o Peripheral nerve and tranquil blocks injected in the appropriate plane
o Neuraxial block
- Can also provide excellent post-operative pain control MANAGEMENT OF ACUTE & CHRONIC PAIN
Definition
- An unpleasant sensory and emotional experience assoc with, or
resembling that assoc with, actual or potential tissue damage
- A localized or generalized unpleasant bodily sensation or complex of
sensations that causes mild to severe physical discomfort and
emotional distress and typically results from bodily disorder (e.g.,
injury or disease)

Characteristics
Acute Chronic
- Short duration - Lasts longer than 3 months
- Well-defined cause - May not have defined cause
- Decreases with healing - Begins gradually and persists
Figure 5. Anatomic markers in performing neuraxial block - Is reversible - Exhausting and useless
- Ranges from mild to severe - Ranges from mild to severe
Spinal Anesthetics - May be accompanied by - May be accompanied by
- Refer to a subarachnoid block restlessness and anxiety depression, fatigue,
- Used for lower extremity, lower abdomen, pelvic, urologic, and decreased functionality
gynecologic procedures
- Acute pain: usually comes on suddenly and is caused by something
- How performed:
specific
o A small caliber needle typically gauge 25 or smaller is inserted
o Has a sharp quality
into the intrathecal space in the cauda equina below the conus
o Usually does not last longer than 6 months
medullaris
o It goes away when there is no longer underlying cause for the
o A small volume of local anesthetic is injected
pain
- Duration & level of the block in the spinal cord is affected by the
- Chronic pain: pain that is ongoing and usually lasts longer than 6
anesthetic used, dose employed, and the baricity of solution injected
months
o This continue even after the injury or illness that caused it has
Epidural Anesthesia
healed / gone away
- Used as a primary anesthetic for a procedure o Pain signals remain active in the nervous system for weeks,
- Can also be placed preop and used in conjunction with a general months, or years
anesthetic for post-op pain control o Some people suffer from chronic pain even when there is no
- How performed: past injury / apparent body damage
o Epidural catheters can be placed in the thoracic / lumbar spine ▪ They can have physical effects that are stressful on the
o Can remain in place for days after surgery body, includes:
• Dense muscles
One should have thorough knowledge of the aforementioned • Limited ability to move around
techniques and be able to ID the differences & similarities in their • Lack of energy
techniques, instrument used, and their effects and complications. • Appetite changes
o Also have emotional effects, including:
▪ Depression, anger, and anxiety
Peripheral Nerve Blockade
▪ Fear of reinjury
- Used to provide surgical anesthesia and post-op analgesia
• This might limit a person’s ability to return to their
particularly for the surgeries of the upper or lower extremities regular work / leisure activities
- Nerve / plexus of interest = located with ultrasound and/or
peripheral nerve stimulator
Causes
- How performed:
o The local anesthetic is injected around the nerve Acute Pain Chronic Pain
- Surgery - Headache
- Broken bones - Arthritis
Learn the difference between single shot nerve blocks vs blocks with - Dental work - Cancer
flexible catheters inserted. - Bruns or cuts - Nerve pain
- Labor and childbirth - Back pain
- Local anesthetic toxicity = the most complication of a nerve block - Fibromyalgia pain

Truncal Blocks Pain: the 5th Vital Sign

- Have become a more commonly and widely used for treatment of - Pain is a subjective sensation. However, it can be used in the clinical
post-op pain setting to assess the patient’s current clinical condition
- Include the following:
o transversus abdominus plane → top block
o Rectal sheath block

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 Surgery | Anesthesiology Part 1

Figure 6. These are the most common pain intensity scaling used in the clinical
setting. The most common technique is allowing the patient to rate his pain
intensity from a scale of 0 to 10.

- Usually, a patient’s pain of 4/10 warrants immediate pain relief

- Since there are 2 major different types of pain, there are also 2
approaches in the management of pain:
o Acute pain = usually treated in a step-ladder-down approach
usually starting with the most potent analgesic first, then
tapering down once pain is relieved
o Chronic pain = goes the other way:
▪ Starting with the weakest analgesics (e.g., non-opioids &
NSAIDS) first, and then increasing in doses or steps up
into a more potent drugs to achieve pain relief
▪ Rationale: avoid complications arising from the chronic
use of these analgesic meds

Management of Acute Pain

Figure 7. Approach to different levels of pain.

- Acute pain can also be best managed via a multimodal approach

- Its approach is the rationale of using different techniques / meds in
treating acute pain
- Target: maximizing effect with the least dose for possible for side
effects
- This can also be categorized based on the level of injury sustained
- Preemptive analgesia = giving of pain meds prior to onset of pain
o This is usually done in the surgical patient whose post-op pain
quality can be predicted by the surgical procedure

Management of Chronic Pain

- WHO step-ladder approach to chronic pain: the standard in the
management of chronic pain
- Pain is managed initially with low dose / weak analgesics to achieve
tolerable levels / levels equivalent to less than 3 on the pain score
- Breakthrough pain meds = put on standby for unanticipated surges
in pain severity

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