Table of Contents

Chapter 1
1
PRE-OPERATIVE EVALUATION
Chapter 2
11
AIRWAY MANAGEMENT
Chapter 3
18
INTRAOPERATIVE FLUID THERAPY
Chapter 4
33
ANESTHETIC MACHINE AND MONITORING
Chapter 5
41
ANESTHETIC TECHNIQUES
Chapter 6
43
GENERAL ANESTHESIA (GA)
Chapter 7
57
REGIONAL ANESTHESIA
Chapter 8
63
ANESTHESIA RISKS
Chapter 9
67
POSTOPERATIVE PAIN THERAPY
Chapter 10
73
ARTERIAL BLOOD GAS (ABG) ANALYSIS
Chapter 11
77
BASIC LIFE SUPPORT STEP-BY-STEP

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Chapter 1

PRE-OPERATIVE EVALUATION
The pre-operative evaluation is an opportunity to identify co-morbidities
that may lead to patient complications during the anesthetic, surgical, or post-
operative period.

Goals
 Allows the identification of patients who require additional preoperative
testing.
 Outline anesthetic risks and discuss the intended anesthetic plan including
options for postoperative analgesia.
 Facilitates the care of patients during the perioperative period while limiting
surgical cancellations resulting from patient-related issues.
 Obtain informed consent.
 Give instructions regarding nil per OS (NPO) guidelines.

Pre-Operative History
The pre-operative history follows the same structure as typical history taking,
with the addition of some anesthetic and surgery specific topics.

History of the Presenting Complaint

A brief history of why the patient first attended and what procedure they
have subsequently been scheduled for. One should also confirm the side on which
the procedure will be performed (if applicable)

Past Medical History

A full past medical history is required, with the following specifically asked about:
 Cardiovascular disease (including hypertension and exercise tolerance)
o The risk of an acute cardiac event is increased during anesthesia
 Respiratory disease, as adequate oxygenation and ventilation is essential in
reducing the risk of acute ischaemic events in the peri-operative period

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  Renal disease, as many features of renal disease (such as anaemia,
coagulopathy, biochemical disturbances) can increase the incidence of
surgical complications
 Endocrine disease, specifically diabetes mellitus and thyroid disease
o Many medications often require specific changes to be made in the peri-
operative period

Past Surgical History

Has the patient had any previous operations? If so, what, when, and why?
Past Anesthetic History
Has the patient had anesthesia before? If so, were there any issues? Were
they well intra- and post-operatively? Specifically, has the patient experienced to
any previous post-operative nausea and vomiting?
Drug History
A full drug history is required, as some medications require stopping or
altering prior to surgery. Ask about any known drug allergies.
Family History
An important condition to ask about is malignant hyperpyrexia* (also
known as malignant hyperthermia), yet any other adverse reactions in surgery of
immediate family members should also be documented.
*An autosomal dominant condition that characteristically leads initially to muscle
rigidity (despite neuromuscular blockade) followed by a rise in temperature.

Social History
Ensure to ask the patient about smoking history and alcohol intake and
their exercise tolerance.
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Pre-Operative Examination
Two distinct examinations are performed; the general examination (to
identify any underlying undiagnosed pathology present) and the airway
examination (to predict the difficulty of intubation). If appropriate, the area
relevant to the operation can also be examined.
In a full general examination, look closely for any obvious cardiovascular,
respiratory, or abdominal signs. Obtain baseline reading of heart rate, blood
pressure, temperature, and saturation on air/ oxygen. An anesthetic examination,
including an airway assessment, will also be performed by the anesthetist prior to
any surgery.

The ASA Physical Status Classification System

ASA is an abbreviation for the American society of anesthesiologists. The ASA
physical status classification system is a system for assessing the fitness of patients
before surgery. On all anesthetic charts, a patient will be given an ASA grade after
their pre-operative assessment. A patient’s ASA grade directly correlates with their
risk of post-operative complications and absolute mortality.

The ASA Physical Status

ASA
DESCRIPTION
CLASS
I A normal healthy patient in need of surgery for a localized condition.
A patient with mild to moderate systemic disease; examples include
II
controlled hypertension, mild asthma.
A patient with severe systemic disease; examples include complicated
III
diabetes, uncontrolled hypertension, stable angina.
A patient with life-threatening systemic disease; examples include renal
IV
failure or unstable angina.
A moribund patient who is not expected to survive 24 hours with or without
V the operation; examples include a patient with a ruptured abdominal aortic
aneurysm in profound hypovolemic shock.
A declared brain-dead patient whose organs are being removed for donor
VI
purposes.
The letter "E" is added in case of emergency surgery (e.g. ASA 2E).

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The Airway Examination
The airway examination will typically be covered during the anesthetist’s
assessment of the patient but is always good practice to assess during the
preoperative assessment.
1- Look at the face for any obvious facial abnormalities. Particularly, do they have
a receding mandible (retrognathia)? This could cause difficulties during airway
insertion.
2- Ask the patient to open their mouth and assess:
 Their degree of mouth opening (favourable if inter-incisor distance is above
3cm).
 Their teeth, mainly do they have teeth? If so, what is their dentition like? Are
any teeth loose?
 Their oropharynx. Ask the patient to maximally protrude their tongue. A
Modified Mallampati classification, which correlates with difficulty of
intubation, can be assessed.

‫٭‬Modified Mallampati classification

Is assessed while the patient is awake and sitting upright
with the head in the neutral position, mouth opened as
wide as possible and the tongue maximally protruded,
without phonation.

The higher the number, the more difficult the

intubation is expected to be.
Class I reveals the entire palate, uvula and tonsillar
pillars
Class II the tonsillar pillars cannot be seen
Class III the soft palate and the base of the uvula are
seen
Class IV the soft palate is not visible
The Modified Mallampati classification

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3- Assess the neck. Ask the patient to flex, extend and laterally flex the neck to see
their range of movement. Then ask the patient to maximally extend their neck and
measure the distance between the thyroid cartilage and chin (the thyromental
distance); if this is less than 6.5 cm (~3 finger breadths), it indicates that
intubation may be difficult

General risk predictors of difficult airway:

 Previous history of difficult endotracheal intubation
 Obesity and or obstructive sleep apnea
 Limited neck mobility and or short neck
 Narrow mouth opening/ absent teeth/buck teeth/ large tongue
 Maxillofacial abnormality
 Large kissing tonsils/ neck tumor/ goiter

Pre-Operative Investigations
The nature of the exact investigations required depends on a number of
factors, including co-morbidities, age, and the nature of the procedure.
I- Blood Tests
 Full Blood Count (FBC)
o Most patients will get a full blood count, predominantly used to assess
for any anaemia or thrombocytopenia, as this may require correction
pre-operatively to reduce the risk of cardiovascular events
 Urea & Electrolytes (U&Es)
o To assess the baseline renal function, which help inform any potential
IV fluid management intra- and post-operatively
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  Liver Function Tests (LFTs)
o Important in the assessing liver metabolism and synthesising
function, useful for peri-operative management; if there is suspicion of
liver impairment, LFTs may help direct medication choice and dosing
 Coagulation tests
o Any indication of deranged coagulation, such as iatrogenic causes (e.g.
warfarin), inherited coagulopathies (e.g haemophilia A/B), or liver
impairment, will need identifying and correcting before surgery
 Group and Save (G&S) +/- cross-matching
o A G&S is recommended if blood loss is not anticipated, but blood may
be required should there be greater blood loss than expected. It
determines the patient’s blood group (ABO and RhD) and screens the
blood for any atypical antibodies.
o A cross-match involves physically mixing the patient’s blood with the
donor’s blood, in order to see if any immune reaction takes places, and
should be done if blood loss is anticipated.

II- Imaging
Electrocardiogram (ECG)
An ECG is often performed in individuals with a history of cardiovascular
disease or for those undergoing major surgery.

N.B An echocardiogram (ECHO) may be considered if the person has (1) a heart
murmur (2) cardiac symptom(s) (3) signs or symptoms of heart failure.

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Chest X-ray
A plain film chest radiograph (CXR) should be used only when necessary
and should not be performed routinely. Indications may include:
 Respiratory illness
 New cardiorespiratory symptoms
 Significant smoking history
 Intermediate and high-risk surgeries, mainly intrathoracic and intra-abdominal
If a patient has a chronic lung condition, spirometry may be of use in
assessing current baseline and predicting post-operative pulmonary complications
in these patients.

Other Tests
Urinalysis
A urinalysis may be performed if any evidence or suspicion of ongoing
glycosuria or urinary tract infection yet should not be done routinely pre-
operatively.
NPO recommendations
NPO (nil per OS) means the restriction of oral intake for a period prior to
elective procedures, minimizing the volume, acidity, and solidity of stomach
contents. Such measures reduce both the risk of aspiration occurring and the
severity of pneumonitis, should an aspiration event occur.
Preoperative fasting in adult undergoing elective surgery:
o Clear liquids (e.g. water, fruit juices without pulp, carbonated beverages,
clear tea, and black coffee) ……………….. Stop 2 hours before procedure
o Light meal (toast and clear liquids)………… Stop 6 hours before procedure
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 o Solid food (including fried or fatty foods, or meat)…… Stop 8 or more hours
before procedure
Post-operative resumption of oral intake in healthy adults: patients should be
encouraged to drink when ready, provided that there are no contra-indications.
Preoperative fasting in children undergoing elective surgery (the 2-4-6 rule):
o Water and other clear fluids………. Stop 2 hours before procedure.
o Breast milk……………. Stop 4 hours before procedure.
o Formula milk, cow's milk or solids……………. Stop 6 hours before procedure.
Oral fluids can be offered to children when they are fully awake after
anesthesia, provided that there are no contra-indications.

Emergency surgery, trauma, and vomiting and bowel obstruction: treat

as full stomach and use rapid sequence induction of anesthesia (RSI) if general
anesthetic is required.

Premedication
Premedication is used primarily to increase the general wellbeing of patients
and patient satisfaction after surgery.

Types: (1) Preoperative psychological preparation.

The following should be explained to patients before surgery:
 Planned anesthetic technique and its safety
 Magnitude of postoperative pain and methods of pain relief

(2) Preoperative pharmacological premedication.

Goals:
o To relieve anxiety
o To decrease the metabolic rate
o To decrease salivation and secretion, volume and acidity of gastric juice
o To prevent autonomic reflex responses during anesthesia
o To induce sedation, amnesia and analgesia
o Facilitation of smooth induction of anesthesia

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Various drugs are used to achieve these aims:
 Anxiolysis: Both psychological and pharmacological approaches are effective
in decreasing preoperative anxiety (e.g. personal interview with the
anesthetist, benzodiazepines, alpha 2 sympathomimetics)
 Sedation: benzodiazepines and alpha 2 sympathomimetics. Barbiturates are
no longer used.
 Anterograde amnesia: benzodiazepines
 Antiemetics: H1 antagonists, 5-HT3 antagonists (e.g. ondansetron)
 Decrease of volume and acidity of gastric content: prokinetics (e.g.
metoclopramide), and H2 blocker (e.g. ranitidine) respectively.
 Decrease of hypersalivation: parasympatholyticss (e.g. atropine)
 Analgesia: opioids

Drugs used for pharmacological premedication

Drug Route Effects Side effects

Benzodiazepines
Midazolam Oral ** Anxiolytic Over sedation
Diazepam Intramuscular Sedation Painful injection
Intravenous Amnesia diazepam

Opioids
Morphine Intramuscular Analgesia Respiratory
Mepeidine Intravenous depression
Nausea, vomiting

Anticholinergics *
Atropine Oral ** Antisialagouge Tachycardia
Glycopyrrolate Intramuscular Vagolytic Dry mouth
Hyoscine Intravenous Sedation Hyperthermia
(hyoscine)

* Anticholinergics are not used routinely in adults its use is recommended in children
** All adult patients and children prefer oral premedication

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 Perioperative Medication Management

References:
1. Tobias JD. Preoperative anesthesia evaluation. Semin Pediatr Surg. 2018 Apr; 27(2):67-74. doi: 10.1053/j.sempedsurg.2018.02.002. Epub 2018 Feb 7. PMID: 29548354.
2. Bock M, Fritsch G, Hepner DL. Preoperative laboratory testing. Anesthesiol Clin.2016;34:43–58.
3. Erin E. Hurwitz, Michelle Simon, Sandhya R. Vinta, Charles F. Zehm, Sarah M. Shabot, Abu Minhajuddin, Amr E. Abouleish; Adding Examples to the ASA-Physical Status Classification Improves Correct Assignment
to Patients. Anesthesiology 2017; 126:614–622.
4. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by
the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2017; 126:376–393
5. Association of Anaesthetists of Great Britain and Ireland, Pre-operative Assessment and Patient Preparation, The Role of the Anaesthetist, AAGBI, 2010, http://www.aagbi. org/sites/default/files/preop2010.pdf
6. Introduction to Anaesthesiology. J. Malek, A. Dvorak et al. English translation: J. Malek, A. Whitley. Videos: M. Jantac, TM Studio, Benesov u Prahy. Copyright, Third Faculty of Medicine, Charles University, 2019. Produced
by financial support of internal grant of Third Faculty of Medicine Project IPUK.
7. The Pre-Operative Assessment, http://teachmesurgery.com, April 12, 2021
8. ANESTHESIA For Medical Students. FIRST EDITION, Faculty of Medicine, Cairo University, 2000.

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Chapter 2
AIRWAY MANAGEMENT
Airway management is the practice of evaluating, planning, and using a wide array
of medical procedures and devices for the purpose of maintaining or restoring a safe,
effective pathway for oxygenation and ventilation.

Airway Anatomy
The Upper Airway refers to:
 Nasal passages
 Oral cavity (teeth, tongue),
 Pharynx (tonsils, uvula, epiglottis)
 Larynx: the narrowest structure in the adult airway

The Lower Airway refers to:

 Trachea
 Bronchi
 Lung tissue: lobes and lobules
 Alveoli
 Pleura

Opening the airway:

Airway patency and protection must be always maintained.
Simple maneuvers to open airway are:
 Head tilt - Chin lift
 If cervical spine injury is suspected, we use Jaw Thrust instead
 In spontaneously breathing patients only: the recovery position (positioning
of the patient in a lateral decubitus position with slight neck extension)

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 Head tilt - Chin lift Jaw Thrust

Airway Adjuncts:
These are instruments used to open obstructed airway
1. Oropharyngeal Airway (OPA)
 Size is measured from the corner of the mouth (oral commissure) to the earlobe
or from the incisors to the angle of the mandible
 Sizes range from 00-6
 It holds the tongue away from the posterior pharynx, but does not isolate
the trachea
 The OPA is inserted with the curve towards the side/upper of the mouth
then rotated so that the curve of the OPA matches the curve of the tongue
 Contraindicated in conscious patient with an intact gag reflex

Proper size of OPA

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 Different sizes of OPA

2. Nasopharyngeal Airway (NPA)

 Rubber tube that is designed to pass just inferior to the base of the tongue
 Passed through one of the nares and can be used in patients with an intact
gag reflex
 Contraindicated in cases of suspected or possible facial fractures or basilar
skull fractures
 Measured from nostril to the ipsilateral tragus
 The nasal airway is lubricated with a water soluble lubricant
 The beveled tip is inserted directed towards the septum, with the NPA
directed perpendicular to the face
 If resistance is met, rotating the NPA may help, or the other nostril may be
used

Proper size of NPA

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 Different sizes of NPA

3. Laryngeal Mask Airway (LMA)

 It is inserted via the oropharynx to provide ventilation from above the glottis
 Available in different sizes
 Some types have a drain tube to aid in gastric suctioning or additional adaptations
to allow passage of an endotracheal tube (ETT) through it
 It is a first-line for short durations of anesthesia, and used as an alternative to ETT
if intubation has failed
 Contraindicated in conscious patients with an intact gag reflex
 Dose not offer complete protection against aspiration

LMA

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 Proper position of LMA

4. Endotracheal Tube (ETT)

 It is the preferred method of airway control
 It is placed below the vocal cords via direct laryngoscopy, video-assisted
laryngoscopy, or a flexible fiberoptic laryngoscope
 Most commonly placed orally (oro-tracheal intubation), although it may be
placed nasally (naso-tracheal intubation)
 Isolates the airway and allows for ventilation with 100 % oxygen
 Prevents gastric inflation and decreases the risk of aspiration
 Facilitates deep tracheal suctioning
 Additional route for drug administration
 Consider adjuncts to intubation or proceed to surgical airway management in
upper airway distortion, or limited mouth opening

Indications:
 Patient who is unable to protect his airway
 Patient with oxygenation problem requiring high concentrations of oxygen
 Patient with ventilatory impairment requiring invasive mechanical ventilation

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 ETT

Complications:
 Hypoxia (prolonged intubation attempts), bradycardia
 Trauma to the airway with resultant hemorrhage
 Esophageal intubation
 Vomiting, leading to aspiration
 Loose or broken teeth
 Injury to the vocal cords
 Laryngospasm, bronchospasm
 laryngo-tracheal stenosis, tracheomalacia (in long-term intubation)

Equipment used during ETT insertion:

 Different sizes of ETT
 Direct laryngoscope with different sized blades
 OPA
 Forceps Magill
 5-ml syringe to inflate the cuff
 Stethoscope
 Stylet
 Suction device
 Carbon dioxide (CO2) detector device
 Tape for tube fixation
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 Equipment used during ETT insertion

5. Surgical airway management

Surgical airway may be performed in an emergency, if endotracheal or nasal
intubation fails or may be placed for long-term mechanical ventilation
 Types:
1- Open cricothyroidotomy
2- Needle cricothyroidotomy with jet oxygenation
3- Percutaneous cricothyroidotomy using the Seldinger technique
4- Surgical tracheostomy

References
1- Airway management. AMBOSS. Last updated: May 17, 2021
2- Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
3- American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
4- Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
5- Stephens M, Montgomery J, Urquhart CS. Management of elective laryngectomy. BJA Educ. 2017; 17 (9): p.306-311. doi: 10.1093/bjaed/mkx014 . | Open in Read by QxMD
6- Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric Advanced Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010; 122 (18_suppl_3): p.S876-S908. doi: 10.1161/circulationaha.110.971101 . | Open in Read by QxMD
7- Kramer N, Lebowitz D, Walsh M, Ganti L. Rapid Sequence Intubation in Traumatic Brain-injured Adults. Cureus. 2018; 10 (4): p.e2530. doi: 10.7759/cureus.2530 . | Open in Read by QxMD
8- Aitkenhead AR, Thompson J, Rowbotham DJ, Moppett I. Smith and Aitkenhead's Textbook of Anaesthesia E-Book. Elsevier Health Sciences ; 2013
9- Sethi AK, Salhotra R, Chandra M, Mohta M, Bhatt S, Kayina CA. Confirmation of placement of endotracheal tube - A comparative observational pilot study of three ultrasound methods.. J Anaesthesiol Clin Pharmacol.
undefined; 35 (3): p.353-358. doi: 10.4103/joacp.JOACP_317_18 . | Open in Read by QxMD
10- Finucane BT, Santora A. Principles of Airway Management. Springer Science & Business Media ; 2006
11- Jannu A, Shekar A, Balakrishna R, Sudarshan H, Veena GC, Bhuvaneshwari S. Advantages, Disadvantages, Indications, Contraindications and Surgical Technique of Laryngeal Airway Mask. Arch Craniofac Surg. 2017; 18
(4): p.223. doi: 10.7181/acfs.2017.18.4.223 . | Open in Read by QxMD

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Chapter 3
INTRAOPERATIVE FLUID THERAPY
Body Fluid Compartments:
Males: Total Body Water = weight x 60%
Females: Total Body Water = weight x 50%
Total Body Water (TBW) components: 67% intracellular + 33% extracellular
(25% interstitial +7% intravascular (plasma) +1% transcellular).

Intraoperative Intravascular Assessment:

1- History:
• Previous limited intake, thirst, abnormal losses, comorbidities.

2- Vitals:
• Capillary refill time: normal average approximately 2 seconds.
Measurements of 5 seconds or more were regarded abnormal.
• Heart rate (HR) and blood pressure (BP) trends (not a single snapshot).
• Pulse Oximetry: waveform changes from baseline (assuming patient
normothermic and not in shock).
• Pulse pleth variability index (PVI): >12-16% volume responsive.

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3- Foley Catheter:
• Urine output (UOP): Urine output greater than 1.0 ml/kg/hr is a
reassuring indicator of adequate organ perfusion. Consider that
antidiuretic hormone (ADH) levels may be increased due to stress
response. UOP is a less reliable measure of volume status
intraoperative.

4- Arterial Line:
• Serial arterial blood gas (ABGs) (blood pH, hematocrit (HCT), electrolytes).
• Pulse Pressure Variation (PPV): indicator of preload responsiveness.
o PPV >10% suggests patient is volume responsive.
o Not reliable if not sinus rhythm, open chest, not on positive pressure
ventilation (PPV).

5- Central Venous Catheter:

• Absolute central venous pressure (CVP) unreliable measure of volume status,
though trend can be meaningful (still debated).

6- Pulmonary Artery Catheter (PAC):

• Most commonly used in right ventricle dysfunction, pulmonary hypertension,
valvular pathology (aortic stenosis, mitral regurge), left ventricle dysfunction.
• Consider risks/benefits of PAC placement.

7- Trans-esophageal Echocardiogram:
• Most commonly used in major cardiac surgeries and liver transplants.
• Trans-gastric view gives most accurate assessment of volume status.
• Valuable in narrowing differential of hemodynamic instability.

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TYPES OF INTRAVENOUS FLUIDS
- Crystalloids: solutions that contain small molecular weight solutes (e.g.,
minerals, dextrose).
- Colloids: solutions that contain larger molecular weight solutes (e.g., albumin
and starch).

- Crystalloids:
Osmolality Na+ K+ Cl- Ca2+
Buffer Glucose
(mOsm/l) (mEq/l) (mEq/L) (mEq/l) (mEq/l) (HCO3-) (g/L)
(mEq/l)
Normal
Saline 308 154 0 154 0 0 0
(0.9%)
Ringer's 28
273 130 4 109 3 0
lactate (lactate)
5%
253 0 0 0 0 0 50
Dextrose

Advantages Disadvantages
Normal Saline - Preferred in brain - In large volumes produces
(0.9%) injury/swelling hyperchloremic metabolic
(hyperosmolar) acidosis
- Preferred for diluting - Hyperchloremia→low
packed red blood cells glomerular filtration rate (GFR)
(pRBCs) and risk of acute kidney injury
(AKI)
Ringer's - More physiologic - Watch K+ in renal patients
lactate (balanced crystalloid) - Ca2+ may interfere with citrate's
- Lactate is converted to chelating properties of packed
HCO3- by liver red blood cells (pRBCs) (debated
if this is clinically relevant)

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- Colloids
Albumin (5% and 25%)
• Use 5% for hypovolemia, 25% for hypovolemia in patients with restricted
fluid and sodium intake.
• Minimal risk for viral infection (hepatitis or human immune deficiency (HIV)
virus).
• Expensive.

Hetastarch (6% hydroxyethyl starch, HES)

• Maximum dose: 15-20 ml/kg/day
• Side effects:
o Can increase partial Thromboplastin time (PTT) and clotting times
o Anaphylactoid reactions with wheezing and urticaria may occur
o May interfere with platelet function
• Contraindications: coagulopathy, heart failure, renal failure.

Which type is better?

Advantages Disadvantages
Crystalloid - Lower cost - Requires more volume for the
- Readily available same hemodynamic effect
- Non-allergic - Short intravascular half -life (IV t
1⁄ ) (20-30 min)
2
- Dilutes plasma proteins leading to
peripheral/pulmonary edema
Colloid - Restores IV volume and - Expensive
hemodynamics with less volume, - Coagulopathy
less time - Potential renal complications
- Longer IV t 1⁄2 (several hours to - May cause cerebral edema (in
days) areas of injured brain where blood
- Maintains plasma oncotic pressure brain barrier not intact)
- Less cerebral edema (in healthy - Risk of anaphylactic reactions
brain tissue)
- Less intestinal edema

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Classical Fluid Management:
Maintenance:
The maintenance fluid requirement per kg of weight in adults can be estimated
with one of the following:
 4-2-1 Rule:
First 10 kilograms (i.e. 0-10 kg): 4 ml/kg/hr
Next 10 kilograms (i.e. 11-20 kg): 2 ml/kg/hr
All remaining kilograms over 20 kg: 1 ml/kg/hr
 1–2 mL/kg/hour: Adjust according to risk factors for fluid overload.
 Rule of thumb: rate in mL/hour = (patient weight in kg) + 40

NB: Use ideal body weight (IBW) for fluid rate calculations in patients with
obesity

Pre-existing Fluid Deficits:

• Multiply maintenance requirement by number of fasting hours.
• Give 1/2 of maintenance requirement over 1st hour, 1/4 over 2nd hour, and
1/4 over 3rd hour.
• Patients no longer undergo bowel preparation, so deficit decreased
For example, a 60 kg woman fasting for 8 hours:
10 kg x 4 ml/kg/hr = 40 ml/hr
10 kg x 2 ml/kg/hr = 20 ml/hr
+ 40 kg x 1 ml/kg/hr = 40 ml/hr
= 100 ml/hr x 8 hr
= 800 ml
Therefore, the pre-operative deficit (excluding other losses) is 800 ml.

Ongoing Losses:
A- Evaporative and Interstitial Losses (capillary leak):
• Minimal tissue trauma (e.g. hernia repair) = 0-2 ml/kg/hr
• Moderate tissue trauma (e.g. cholecystectomy) = 2-4 ml/kg/hr
• Severe tissue trauma (e.g. bowel resection) = 4-8 ml/kg/hr
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B- Blood Loss:
• Estimated blood loss (EBL) = (suction canister - irrigation) + "laps" (100-
150 ml each) + 4x4 sponges (10 ml each) + field estimate (very approximate
estimation).
• Replace with pRBCs, colloid, or crystalloid.
C- Urine Output:
Be aware of losses from increased urine output (diuretics, etc.)
Because of the partitioning in the extracellular compartment, crystalloids
must be given in a 3-4:1 ratio to EBL. Colloids replace blood loss in a 1:1 ratio,
assuming normal membrane permeability.
The use of colloids is generally reserved for cases where greater than 20% of
the blood volume needs to be replaced or when the consequences of the interstitial
edema (which might occur with crystalloid administration) are serious (e.g.
cerebral edema).

General Rules
Tailor management to patient, surgery, and clinical scenario
• Typically start with normal saline (NS) or ringer’s lactate.
• Be wary of using too much NS in hyperkalemic patients as the hyperchloremic
metabolic acidosis can increase serum potassium as well.
• Type and Cross for packed red blood cells (pRBCs) and other blood products
prior to surgery if anticipating significant blood loss (i.e. trauma,
coagulopathy)
• Consider that rapid volume resuscitation with only (pRBCs) RBS may still
create dilutional coagulopathy.
If receiving > 2 units (pRBCs) RBC, consider fresh frozen plasma (FFP) use.

Consequences of Volume Overload

• Increased mortality and length of intensive care unit (ICU)/hospital stay.
• Increased myocardial morbidity.
• Increased pulmonary, peri-orbital, and gut edema.
• Decreased hematocrit and albumin.
• Worsened wound healing/ increased anastomosis dehiscense due to edema.
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Restrictive (zero-balance) versus Liberal strategy:
A “restrictive” intraoperative fluid regimen aims to avoid hypovolemia but
limits infusion to the minimum necessary, initially to reduce major complications
after complex surgery.
Several protocols for restrictive fluid regimens have been described including
(1) replacement of blood loss with colloids on a “1 mL per 1 mL” basis, (2) non
replacement of intraoperative interstitial/third space loss or urine output, (3) non
fluid loading, and (4) administration of vasopressor agents (such as phenylephrine
or ephedrine) for correcting intraoperative hypotension.

Goal‑Directed Fluid Therapy:

Goal-directed fluid therapy (GDT) is a method of optimizing fluid and
hemodynamic status for at-risk patients, using monitors to predict which patients
will show hemodynamic improvement after fluid administration (fluid
responsiveness). It depends on individual intravascular volume optimization to get
a maximum cardiac stroke volume. It improves outcome compared with the fixed
volume (restrictive) regimens as it can offer a state of normovolemia.

Intraoperative Oliguria
Definition:
Oliguria is defined as a urine output that is less than 1 mL/kg/h in infants, less
than 0.5 mL/kg/h in children, and less than 400 mL daily in adults.

Causes:
Pre-renal (decreased renal perfusion)
• Hypovolemia
• Decreased cardiac output (LV dysfunction, valvular disease)
• Decreased mean blood pressure
• Perfusion is compromised with increased intra-abdominal pressure (e.g.
laparoscopy & pneumoperitoneum)
Post-renal (post-renal obstruction)
• Foley kinked, clogged, displaced, or disconnected
• Surgical manipulation of kidneys, ureters, bladder, or urethra
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Renal
• Neuroendocrine response to surgery (i.e. activation of renin-angiotensin-
aldosterone system with increased ADH), is age dependent
• Baroreceptor response to positive pressure ventilation also activates
neuroendocrine response

Treatments:
1. Relieve obstruction: check Foley; consider IV dyes (e.g. indigo carmine,
methylene blue) to check for patency of ureters (i.e. Urology cases)
2. Increase renal perfusion: fluids (bolus versus increased maintenance rate),
vasopressors/inotropes, or furosemide

Transfusion Therapy
Packed Red Blood Cells (pRBCs)
• Single donor; volume 250-300 ml with Hct ~70%
• 1 unit pRBCs: increases adult hemoglobin (Hgb) ~1 g/dl or Hct ~3%
• 10 ml/kg pRBCs increases Hct 10%
Platelets
Platelet Concentrate (PC)
• Platelets from one donated unit, vol = 50-70 ml; increases plt ~5,000-10,000
Apheresis Unit
• Platelets from a single donor; vol = 200-400 ml; increases plt ~50,000
• Document as 250 ml (no exact number written on unit)
Fresh Frozen Plasma (FFP)
• Fluid portion from whole blood
• Contains all coagulation factors (except platelets)
• 1 unit increases clotting factors 2-3%
Cryoprecipitate
- Fraction of plasma that precipitates when FFP is thawed
- Contains Factors I (fibrinogen), VIII, XIII and vWF
- 1 unit contains ~5X more fibrinogen than 1 unit FFP
- Use within 4-6 hours after thawed if you want to replace Factor VIII

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Massive Transfusion
Definition
 Administration of greater than 1 blood volume (~10 units) in 24 hours
 At Stanford, calling the blood bank for the Massive Transfusion Guideline
(MTG) will get you 6 pRBCs, 4 FFP, and 1 unit of platelets

Complications
1. Hypothermia
• Blood products are stored cold, this worsens coagulopathy

2. Coagulopathy
a. Dilutional thrombocytopenia
Platelet count likely <100,000 after ~10 units pRBCs
b. Dilutional coagulopathies
Decreased factors V & VIII (“labile factors”) in stored blood

3. Citrate Toxicity
• Citrate is in CPDA storage solution as a Ca2+ chelator
• Rapid transfusion (>65ml/min in a healthy adult with healthy liver) can cause
an acute hypocalcemia
• Citrate also binds magnesium causing hypomagnesemia

4. Transfusion reactions
I- Acute Transfusion Reactions:
- Mild allergic
- Anaphylactic
- Febrile non-hemolytic reaction: Fever, chills, urticaria
- Acute hemolytic reaction: Fever, chills, flank pain, unexplained hypotension
and tachycardia, hemoglobinuria and brown urine, microvascular bleeding,
diffuse oozing, disseminated intravascular coagulopathy (DIC)
- Transfusion Associated Circulatory Overload (TACO)

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 - Transfusion related acute lung injury (TRALI): Transfused serum versus
recipient white cells; Increased capillary permeability → non-cardiogenic
pulmonary edema and acute respiratory distress syndrome (ARDS) - type
picture.
- Infectious diseases: Hepatitis A, B, C; HIV, CMV
- Bacterial infection: Limit by transfusing over less than 4 hours

II- Delayed Transfusion Reactions:

- Delayed hemolytic reaction: More insidious, develops on day 2-21.
- Transfusion-associated graft-versus-host disease.

Treatment of acute transfusion reaction: Stop transfusion and start IV

fluids (Aggressive hydration is usually recommended with normal saline to
maintain a urine output at least 1 ml/kg/hr). Re-check blood with patient ID and
name on wrist band. Assess vital signs including temperature (If mild treat pyrexia
with paracetamol- Antihistamine for urticaria – Corticosteroids to reduce the
immune response- Recommence transfusion at slower rate). Maintain alkaline
urine output (by sodium bicarbonate, mannitol). Look for signs of respiratory
distress (dyspnea, tachypnea, wheeze, cyanosis), if sever maintain airway and give
100% oxygen. Treat hypotension. If evidence of multi-organ failure intubate and
transfer to intensive care unit (ICU).

5. Acid-Base Abnormalities
• At 21 days, stored blood has pH <7.0, due mostly to CO2 production, which
can be rapidly eliminated with respiration
• Acidosis more commonly occurs due to decrease tissue perfusion

6. Hyperkalemia
• K+ moves out of pRBCs during storage

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7. Impaired O2-Delivery Capacity
This decrease oxygen supply to tissues

References:
1. Barash, Paul G., et.al. Handbook of Clinical Anesthesia, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2013.
2. Butterworth JF, Mackey DC, and Wasnick JD. Fluid Management and Blood Component Therapy. In Morgan and Mikhail’s Clinical Anesthesiology, 5th ed. New York: McGraw-Hill Companies, Inc., 2013.
3. Holte K, Sharrock NE, and Kehlet H. 2002. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth, 89: 622-32.
4. Joshi GP. 2005. Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery. Anesth Analg, 101: 601-5.
5. Kaye AD and Kucera IJ. Intravascular fluid and electrolyte physiology. In Miller RD (ed), Miller's Anesthesia, 6th ed. Philadelphia: Elsevier Churchill Livingstone, 2005.
6. McKinlay MB and Gan TJ. Intraoperative fluid management and choice of fluids. In Schwartz AJ, Matjasko MJ, and Otto CW (eds), ASA Refresher Courses in Anesthesiology, 31: 127-37. Philadelphia: Lippincott Williams & Wilkins, 2003.
7. P. Panera, et al.. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010 Feb; 28(1):29-56.
Steven McGee MD, in Evidence-Based Physical Diagnosis (Fourth Edition), 2018
8. Kuca T, Butler MB, Erdogan M, Green RS. A comparison of balanced and unbalanced crystalloid solutions in surgery patient outcomes. Anaesth Crit Care Pain Med. 2017; 36 (6): p.371-376. doi: 10.1016/j.accpm.2016.10.001 . | Open
in Read by QxMD
9.Alves de Mattos A. Current indications for the use of albumin in the treatment of cirrhosis. Ann Hepatol. 2011; 10 Suppl 1: p.S15-20.
10.Bundgaard‑Nielsen M, Secher NH, Kehlet H. ‘Liberal’ vs. ‘restrictive’ perioperative fluid therapy – A critical assessment of the evidence. Acta Anaesthesiol Scand 2009;53:843‑51.
11.Wuethrich PY, Burkhard FC, Thalmann GN, Stueber F, Studer UE. Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and
hospitalization time: A randomized clinical trial. Anesthesiology 2014;120:36577.
12.Kang D, Yoo KY. Fluid management in perioperative and critically ill patients. Acute Crit Care. 2019 Nov;34(4):235-245. doi: 10.4266/acc.2019.00717. Epub 2019 Nov 29. PMID: 31795621; PMCID: PMC6895467.
13.Funk DJ, Moretti EW, Gan TJ. Minimally invasive cardiac output monitoring in the perioperative setting. Anesth Analg 2009;108:887‑97.
14.Phan TD, Ismail H, Heriot AG, Ho KM. Improving perioperative outcomes: Fluid optimization with the esophageal Doppler monitor, a metaanalysis and review. J Am Coll Surg 2008;207:935‑41.
15.Abbas SM, Hill AG. Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia 2008;63:44‑51.
16. Harewood J, Ramsey A, Master SR. Hemolytic Transfusion Reaction. [Updated 2020 Aug 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK448158/

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 VASCULAR AND INTRAOSSEOUS ACCESS

VASCULAR ACCESS is crucial for:

• Fluid or blood product resuscitation;
• Delivery of medication, which includes anesthetic drugs for induction and
infusions for anesthesia maintenance;
• Fluid maintenance.

Peripheral vein cannulation

"It is a standard procedure"

- Common site for insertion:

Back of hand, forearm and antecubital fossa.

- Others site for insertion:

1. Lower limbs (the dorsum of the foot and saphenous vein in the leg).
2. Scalp veins (in neonates or infants, if cannula insertion in limbs failed)

- Size of intravenous (IV) cannula:

Choose size according to type of surgery and age of patient; (generally, small
sizes for minor surgeries & pediatrics and vice versa)

Steps for peripheral intravenous access

1- Don your gloves and apron
2- Clean the puncture site with the chlorhexidine or alcohol swabs and allow to
air dry
3- Apply the tourniquet and do not re-palpate the cleaned skin.
4- Subcutaneous 1 % lidocaine [in awake patient can anesthetize their skin with
0.1 mL immediately adjacent to not over the vein] or topical EMLA cream
[eutectic mixture of local anesthetics (EMLA) cream;, applied in small children
to the intended site 30-45 min before insertion] may be used to numb the area
if policy allows.
5- Placing traction on the skin below the intended puncture site, insert the
cannula with the bevel up at an angle of 30o into the puncture site
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 6- Advance the cannula→ when you see a flash of blood, reduce the angle and
advance a tiny amount (1-2 mm)
7- Hold the needle introducer still whilst advancing the cannula forward, over
the needle and fully into the vein
8- Release the tourniquet, apply gentle pressure over the tip of the cannula to
prevent bleeding back, and dispose the needle into the sharps bin
9- Secure the cannula in place with the sterile dressing (ensure not to cover the
puncture site with the tape when securing down, as this can cover up any
possible phlebitis developing)
10- Flush the cannula with 5ml of saline
 No resistance should be felt,
 Check for any signs of extravasation / tissuing around the cannula site
(remove cannula if suspected)
11- Connect IV infusion set (primed and free of bubbles) and open to observe free
flow then slow down the administration as indicated by the patient's
condition
12- Remove your gloves and decontaminate your hands

Remember:
 Ideally, the cannula should be checked and flushed with saline 3 times a day
(to verify cannula is in the vein and to clean it), and should be removed after
72 hours.

Intravenous cannula insertion on back of the hand

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Things to consider:
1. Assess IV site insertion and extremity and document any abnormalities
2. Use the non-dominant hand
3. Avoid insertion close to a flexible joint where kinking is likely (e.g. wrist)
4. Seek a relatively straight vein without venous valves that may hinder its
cannulation
5. Palpate vein for good elasticity and filling
6. Finally, do not cannulate an arm that has been the target of an arteriovenous
shunt (as for dialysis); arm on side of a mastectomy/ axillary lymph node
dissection; and arm with diminished sensation or paralysis.

Complications are uncommon:

Local infection, venous thrombophlebitis, extravasation of infused fluids into
surrounding tissues, arterial puncture, hematoma or bleeding, damage to the vein,
nerve damage, catheter occlusion and vasovagal reactions.

Central Vein cannulation

It is used for a long-term vein access and often performed in critical patients.

Indication:
1. Measuring of central venous pressure
2. Administration of concentrated and hyperosmotic solutions
3. Venous line for rapid fluid resuscitation
4. Inadequate peripheral veins
5. Parenteral nutrition support
6. Dialysis
7. Chemotherapy
8. Temporary pacemaker

The most common insertion veins:

1. Internal jugular vein
2. Subclavian vein

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Less frequent insertion vein:
1. Femoral vein (e.g. in patients with burns on the neck and chest)

Techniques for cannulation:

A. Anatomical guidance technique: Need expert doctor due to risk of
complications
B. Ultrasound guidance technique: Low risk of complications

Complications: Can be classified into three categories:

A. Mechanical :
(Hematoma, arterial puncture, pneumothorax, hemothorax, catheter
misplacement, and stenosis),
B. Infectious:
(Insertion site infection, central venous catheter colonization, and blood
stream infection)
C. Thrombotic:
(Deep vein thrombosis)

Intraoseal (IO) access

It is a provisional vascular access used mainly in emergency situations
[trauma or resuscitation scenario if intravascular (IV) access was too difficult or
failed]. It is a quick and effective methods for delivery of drugs, fluid and blood
product boluses directly into the marrow of a bone until IV access is successfully
achieved. The common site is the upper part of tibia. Infusions through IO access can
be very painful and need to be pressurized. It must be changed to standard venous
access within 24 hours, however, it may remain in situ for a maximum of 72 hours.

References:
O’Grady, N.; Alexander, M.; Dellinger, E.; Heard, S.; Maki, D.; Masur, H, et al. (2002). Guidelines for the prevention of intravascular catheter-related infections. American Journal of Infection Control, 30 (8), 476-489.
How To Do Peripheral Vein Cannulation. Yiju Teresa Liu, MD, David Geffen School of Medicine at UCLA Last full review/revision Oct 2020| Content last modified Oct 2020
Beheshti MV. A concise history of central venous access.Tech Vasc Interv Radiol 2011; 14 (4):184‑5.

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Chapter 4

ANESTHETIC MACHINE AND MONITORING

The Anesthesia Machine
The anesthetic machine delivers gases (oxygen, air and nitrous oxide) to the
patient in precise, known concentrations. It also delivers a precise concentration
of volatile anesthetic gases (e.g. sevoflurane and desflurane) that are contained in
liquid form in the vaporizers mounted on the machine.

The basic components of a modern anesthetic machine are:

 Inlet of anesthetic gases and oxygen. Anesthetic gases and oxygen are
supplied as:
- Gas cylinders
- Central pipe system

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  A meter for measuring flow of anesthetic gases and oxygen (FLOWMETER).
One flow-meter for each gas.
 A device to vaporize volatile anesthetic liquids and deliver controllable and
constant concentration (VAPORIZER)
NB: The gas mixture from the flow-meters flows through the vaporizer and the volatile
anesthetic is added to the mixture in gaseous form. The concentration of the volatile gas in
the final mixture is determined by a dial on or near the vaporizer. For safety reasons, only one
volatile agent can be delivered at a time.
 A common gas outlet
 A machine to push anesthetic vapours and oxygen into the lungs of
anesthetized patients receiving muscle relaxants through positive pressure
ventilation (MECHANICAL VENTILATOR). The ventilator can be set to
deliver a specific tidal volume or to achieve a certain peak inspiratory
pressure.
 A conduit to transfer anesthetic gases and oxygen mixture through the
common gas outlet to the patient airway and lungs (BREATHING CIRCUIT)
 Safety alarms and pressure gauges to ensure adequate oxygen supply
 Some anesthesia machines include monitoring equipment

NB: The majority of general anesthetics are delivered through a circle system. The circle
circuit has a CO2 absorber [a canister containing a hydroxide mixture (soda lime) that absorbs CO2].
The absorption of CO2 allows the expired gas to be recycled, thus minimizing the excessive cost and
pollution.

Monitoring
"The best single monitor is a vigilant anesthetist"

Monitoring in anesthesia means to observe and check the progress and

quality of anesthesia over a period of time. Basic anesthetic monitoring is one
component of anesthesia care; must be applied to every patient whether the
procedure is simple or invasive as anesthetic agents produce depression of central
and cardiorespiratory functions which is very serious because it occurs at
"therapeutic" anesthetic doses and it is life threatening. Monitoring is applied to all
general anesthetics, regional anesthetics and monitored anesthesia care.

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American Society of Anesthesiologist (ASA) Standards for Basic Anesthetic
Monitoring:
1. STANDARD I
Qualified anesthesia personnel shall be continuously present in the operating
room throughout the conduct of all general anesthetics, regional anesthetics and
monitored anesthesia care to monitor the patient and provide anesthesia care
because of the rapid changes in patient status during anesthesia.

2. STANDARD II
During all anesthetics, the patient’s oxygenation, ventilation, circulation and
temperature shall be continually evaluated.

1- OXYGENATION:
Objective:
To ensure adequate oxygen concentration in the inspired gas and the blood
during all anesthetics.

Methods:
Inspired gas: During every administration of general anesthesia using an
anesthesia machine, the concentration of oxygen in the patient breathing system
shall be measured by an oxygen analyzer with a low oxygen concentration limit
alarm in use.
Blood oxygenation: During all anesthetics, a continual quantitative method
of assessing oxygenation such as pulse oximetry with an audible variable pitch pulse
tone and a low threshold alarm shall be employed. Adequate illumination and
exposure of the patient are necessary to assess color.

Pulse oximetry:
Hypoxia of the brain first causes confusion, then coma, and eventually
irreversible brain damage. Other organs follow that pattern, even though most can
survive hypoxia longer than the brain. Thus, knowing whether arterial blood
carries oxygen to the organs assumes great importance.

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 Because oxyhemoglobin is red and reduced hemoglobin bluish, this color
difference can be exploited to assess the oxygenation of blood. Clinically, we
recognize cyanosis, but we cannot well grade the degree of bluishness.

The pulse oximeter is a probe sends red and infrared lights through a thin
piece of tissue e.g. finger nail bed, earlobe, nose, or toe and measures the relative
absorption of the two wavelengths. From this it calculates the functional oxygen
saturation, i.e. the proportion of oxy-hemoglobin to deoxyhemoglobin.

Some instruments estimate (not measure) the other species of hemoglobin in

blood (met-hemoglobin, carboxyhemoglobin) and compare the oxyhemoglobin as a
percentage of the sum of all known hemoglobins. This is called “fractional
saturation,” which will be a little lower than functional saturation.

The pulsatile change in tissue absorption is due to blood entering the

arterioles and thus the pulse oximeter measures arterial oxygen saturation SpO2%.
The p referring to the fact that the measurement is based on pulse oximetry rather
than on a direct in vitro measurement of oxygen saturation from an arterial blood
sample, which would be SaO2. A healthy person breathing room air at sea level
should have a SpO2 of about 98% +/− 2%. Here is a rough correlation of SpO2 to
arterial partial pressure of oxygen (PaO2):
SpO2 PaO2
100% 100 mmHg or higher
90% 60 mmHg
60% 30 mmHg

2- VENTILATION:
Objective:
To ensure adequate ventilation of the patient during all anesthetics.

Methods:
1. Every patient receiving general anesthesia shall have the adequacy of
ventilation continually evaluated. Qualitative clinical signs such as chest
excursion, observation of the reservoir breathing bag and auscultation of

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 breath sounds are useful. Continual monitoring for the presence of expired
carbon dioxide shall be performed unless invalidated by the nature of the
patient, procedure or equipment. Quantitative monitoring of the volume of
expired gas is strongly encouraged.
2. When an endotracheal tube or laryngeal mask is inserted, its correct
positioning must be verified by clinical assessment and by identification of
carbon dioxide in the expired gas. Continual end-tidal carbon dioxide
analysis, in use from the time of endotracheal tube/laryngeal mask
placement, until extubation/ removal or initiating transfer to a
postoperative care location, shall be performed using a quantitative method
such as capnography, capnometry or mass spectroscopy. When capnography
or capnometry is utilized, the end tidal CO2 alarm shall be audible to the
anesthesiologist or the anesthesia care team personnel.
3. When ventilation is controlled by a mechanical ventilator, there shall be in
continuous use a device that is capable of detecting disconnection of
components of the breathing system and giving an audible signal when its
alarm threshold is exceeded.
4. During regional anesthesia (with no sedation) or local anesthesia (with
no sedation), the adequacy of ventilation shall be evaluated by continual
observation of qualitative clinical signs. During moderate or deep
sedation the adequacy of ventilation shall be evaluated by continual
observation of qualitative clinical signs and monitoring for the presence of
exhaled carbon dioxide unless precluded or invalidated by the nature of the
patient, procedure, or equipment

Capnography:
Measures exhaled end-tidal CO2 (Et CO2) using the principle of infrared
absorption. When infrared light falls on a molecule, it enhances the molecule’s
vibrational energy and the infrared light is absorbed by the molecule. The amount
of infrared light absorbed at a specific wavelength is proportional to the amount of
carbon dioxide present in the gas mixture. During general anesthesia, absence of
Et CO2 wave on the monitor screen indicates that the patient stopped breathing or
a disconnection from anesthesia machine or ventilator had occurred.

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3- CIRCULATION:
Objective:
To ensure the adequacy of the patient’s circulatory function during all
anesthetics.
Methods:
1. Every patient receiving anesthesia shall have the electrocardiogram
continuously displayed from the beginning of anesthesia until preparing to
leave the anesthetizing location.
2. Every patient receiving anesthesia shall have arterial blood pressure and
heart rate determined and evaluated at least every five minutes.
3. Every patient receiving general anesthesia shall have, in addition to the
above, circulatory function continually evaluated by at least one of the
following: palpation of a pulse, auscultation of heart sounds, monitoring
of a tracing of intra-arterial pressure, ultrasound peripheral pulse
monitoring, or pulse plethysmography or oximetry.
Electrocardiogram (ECG):
ECG only monitors (1) Heart rate (2) Heart rhythm (3) Myocardial ischemia.
However, it tell nothing about the mechanical function of the heart or the state of
the circulation
Arterial blood pressure
There are two basic methods to measure arterial blood pressure:
 Indirect blood pressure measurement involves inflating a cuff around the
limb and monitoring the blood flow in a distal artery. Too small cuff gives
falsely HIGH values and too big cuff gives falsely LOW values.
Measurement can be:
- Manually using the mercury sphygmomanometer
- Automated non-invasive blood pressure measurements
 Direct (invasive) blood pressure measurement involves placing a catheter in
an artery and connecting it to a pressure transducer. This invasive form of
blood pressure measurement is more accurate and gives beat-to-beat
information of blood pressure. Direct blood pressure measurement should be
used in critically ill patients or major surgical procedure e.g. cardiac and intra-
cranial surgery.
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4- BODY TEMPERATURE:
Every patient receiving anesthesia shall have temperature monitored when
clinically significant changes in body temperature are intended, anticipated or
suspected.

Sites of temperature monitoring

o Pulmonary artery = “Core” temperature (gold standard)
o Tympanic membrane - correlates well with core.
o Nasopharyngeal - correlates well with core and brain temperature.
o Oropharynx – good estimate of core temperature.
o Esophagus - correlates well with core.
o Rectal - not accurate
o Axillary - inaccurate; varies by skin perfusion
Warming facilities (electric thermoblanket) should be available for
susceptible patients undergoing prolonged surgery.

Advanced monitors:
1. Invasive Arterial Blood Pressure: real-time monitoring of blood pressure.
2. Processed electroencephalography (bi-spectral-index (BIS)) for
monitoring the depth of anesthesia (Awareness Monitoring).
3. Neuromuscular monitoring:
The degree of neuromuscular blockade can be assessed by stimulating a
motor nerve using a PERIPHERAL NERVE STIMULATOR (PNS) and
measuring the muscle contraction. With the use of full does of muscle
relaxants, the muscles will not contract in response to nerve stimulation.
During the course of anesthesia, as the effect of muscle relaxant wears off,
muscle contraction will gradually reappear and increases to normal levels.
In clinical practice, visual assessment of the amplitude of hand muscle
contractions in response to ulnar nerve simulation it commonly used to
evaluate the extent of neuromuscular blockade and recovery

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PNS can be used during general anesthesia to:
o Ensure full paralysis before endotracheal intubation
o Indicate the appropriate timing for the administration of
supplementary doses of muscle relaxant dung the course of surgery
o Ensure that the effects of the muscle relaxant have worn of and the
neuromuscular functions are adequately recovered at the end of
surgery
o Detect the appropriate location of a peripheral nerve during the conduct
of regional anesthesia
4. Trans esophageal echocardiography (TEE)
5. Pulmonary artery catheter (PAC)
6. Intracranial pressure (ICP) monitoring and Trans cranial Doppler
7. Other monitors with specific indications:
 Electromyography (EMG)
 Somatosensory evoked potentials (SSEP)
 Brainstem auditory evoked potentials (BAEP)
 Motor evoked potentials (MEP).
N.B: Continual: is defined as "repeated regularly and frequently in steady rapid succession".
Example: The patient's blood pressure shall be continually evaluated every 5 minutes.
Continuous: means "prolonged without any interruption at any time". Examples:
 Anesthesia personnel shall be continuously present during an anesthetic
 During mechanical ventilation continuous use of a device to detect disconnection shall be
used
 ECG monitoring shall be continuously displayed

References:
- ASA. Standards for basic anesthetic monitoring. http://www.asahq.org/publications AndServices/standards/02.pdf. 2015.
- Mark JB, and Slaughter TF. Cardiovascular monitoring. In Miller RD (ed), Miller’s Anesthesia, 6th ed. Philadelphia: Elsevier Churchill Livingstone, 2005.
- Moon RE, and Camporesi EM. Respiratory monitoring. In Miller RD (ed), Miller’s Anesthesia, 9th ed. Philadelphia: Elsevier Churchill Livingstone, 2019.
- Morgan GE, Mikhail MS, and Murray MJ. Clinical Anesthesiology, 6th ed. New York: McGraw-Hill Companies, Inc., 2018.
- Narang J, and Thys D. Electrocardiographic monitoring. In Ehrenwerth J, and Eisenkraft JB (eds), Anesthesia Equipment: Principles and Applications. St. Louis: Mosby, 1993.
- Euliano TY and Gravenstein J S. ESSENTIAL Anesthesia From Science to Practice. University of Florida, College of Medicine, Gainesville, Florida, USA. Published in the United States of America by Cambridge University Press, New
York www.cambridge.org. 2004.
ANESTHESIA For Medical Students. FIRST EDITION, Faculty of Medicine, Cairo University, 2000.

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Chapter 5

ANESTHETIC TECHNIQUES
Types of Anesthesia:
1. Sedation
2. Regional Anesthesia
3. General Anesthesia
Types of anesthesia may be employed alone or in combination depending on
the finding on pre-operative assessment, the nature of the surgery and the patient's
preference.

Sedation
Sedation involves the delivery of agents (usually intravenous) for the purpose
of achieving a calm, relaxed patient, able to protect his own airway and support his
own ventilation.

The range of physiologic effects of sedation is varied and is dependent on the

depth of sedation provided: minimal, moderate or deep.

Sedation may be used alone for minimally painful procedures such as

endoscopy. Often it is used in combination with regional anesthesia to provide a
more palatable experience for the patient.

In any case, the sedated patient must be monitored due to the depressant
effects of the agents used. Care must be taken to reduce the dose administered to
the frail, elderly or debilitated patient, in whom depressant effects may be
exaggerated.

Sedation may cause disinhibition, resulting in an uncooperative, agitated

patient.

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 The physiologic effects of level of sedation

Many different agents have been used for sedation. The term “neurolept
anesthesia” refers to the (now historical) use of high doses of droperidol (a
butyrophenone, in the same class as haloperidol) in combination with fentanyl (an
opioid). Side effects were prominent.

Currently, agents are chosen with specific effects in mind:

1. Opioids, such as fentanyl or remifentanil, may be given alone if analgesia is
the primary goal.
2. The short-acting benzodiazepine, midazolam, is a popular choice because it
provides amnesia as well as anxiolysis.
3. Propofol, an anesthetic induction agent, can be infused in sub-anesthetic doses
to produce a calm, euphoric patient.

References:

1. Understanding Anesthesia 1st EDITION AUTHOR Karen Raymer, MD, MSc, FRCP(C) McMaster University CONTRIBUTING EDITORS Karen Raymer, MD, MSc, FRCP(C) Richard Kolesar, MD, FRCP(C) TECHNICAL
PRODUCTION Eric E. Brown, HBSc Karen Raymer, MD, FRCP(C) A Learner's Handbook www.understandinganesthesia.ca.

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Chapter 6

GENERAL ANESTHESIA (GA)

Definition:
It is the induction of a balanced state of reversible unconsciousness,
accompanied by the absence of pain sensation and the paralysis of skeletal muscle
over the entire body.

Triad of GA:
1. Hypnosis: Pharmacological sleep, reversible unconsciousness
2. Analgesia: Pain relief
3. Muscle relaxation: Pharmacological reversible motionlessness
Plus
4. Amnesia: Loss of memories of perioperative period
5. Weakening of autonomic responses

Phases of GA:
A. Induction
B. Maintenance
C. Emergence

Conduct of GA:
TIVA Total Intra Venous Anesthesia
VIMA Volatile Induction and Maintain Anesthesia
But, usually GA is mixed of both conducts.

Anesthetic management
I- Induction of general anesthesia
Induction phase means getting the patient to sleep. It begins when the
anesthetic is administered and ends when the incision is made

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Things to be done before induction of anesthesia
1) Intravenous access for fluid and drug administration
2) Measure baseline vital signs e.g. heart rate, rhythm, arterial blood pressure,
and oxygen saturation before starting anesthesia.

Methods of induction
A. Intravenous
 In adults with normal airway
 Using one of intravenous induction agent and opioid
 Muscle relaxant when endotracheal intubation is required
B. Inhalational induction
 Children with difficult venous access
 Adults with difficult airway
 Using face mask and halothane or sevoflurane (pleasant odour)
C. Other methods (mainly in children)
 Intramuscular (IM) using ketamine
 Rectal using thiopental
What is required during induction?
 Smooth induction of unconsciousness and analgesia
 Maintaining patent and protected airway
 Minimal hemodynamic alterations

Airway management during induction:

1- Oral airway + manual support or laryngeal mask airway
With the use of this method of airway control note the following:
 The airway is patent but not protected
 Patient should be fasting
 Surgery should be of short duration
 Operation should be in the supine position
 Mechanical ventilation can not be used

-44-
2- Cuffed endotracheal tube (is the safest technique) when:
 Airway protection is required (e.g. full stomach, or bleeding near the airway
e.g. tonsillectomy)
 Mechanical ventilation is planned
 Frequent airway suction is required
 Operations performed in prone position

3- Rapid Sequence Induction:

Used for elective or emergency surgery in patients who are either not fasted or
where there is a risk of aspiration of gastric contents.
 Preparation – Trained staff, emergency drugs and equipment checked,
tipping trolley, suction on under pillow, aspiration of nasogastric tube
 Pre-oxygenate the patient with fraction of inspired oxygen 100% for 3-5
minutes regular breathing or five vital capacity breaths
 Induction

o Intravenous (thiopental, propofol, or ketamine), no co-induction opioid

o Succinylcholine (depolarizing muscle relaxant) to facilitate intubation
with cricoid pressure applied using the thumb and index finger to
provide downward pressure on the cricoid cartilage (Sellick,s maneuver)
by anesthetic assistant for compression of underlying esophagus
between the cricoid cartilage and the cervical vertebrae and prevention
of aspiration. A rapidly acting non-depolarizing agent (e.g. rocuronium)
is commonly used in a so-called "modified" rapid sequence induction.
o Oral intubation and confirmation of tube placement by visualization,
auscultation and capnography
o Start ventilation, and release of cricoid pressure
o Non-depolarizing muscle relaxant to maintain muscle relaxation
 Emergence
o Remove ETT when patient spontaneously breathing, regains airway
reflexes and wakes up. It is recommended that this is performed with the
patient in the left lateral position

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II- Maintenance of anesthesia
The maintenance phase means keeping the patient asleep during the
operation. It begins with the surgical incision and ends near the completion of the
procedure.
a) For short surgery e.g. abscess drainage: induction and airway
management may be all that is required
b) For longer operations: anesthesia is usually maintained
o O2 (minimum 30%) + inhalation anesthetics (nitrous oxide and/or
volatile anesthetic e.g. halothane or isoflurane)
o Additional doses of narcotics and muscle relaxants
o Mechanical ventilation of paralyzed patients
o Appropriate fluid therapy
o Close monitoring of vital functions

III- Emergence from anesthesia

The emergence phase means awaking the patient up at the end of the
procedure. It starts at the patient’s awakening and ends when the patient is
transferred to the post anesthesia care unit (PACU).
At the end of surgery, the anesthesiologist objectives are:
 To regain the patient's consciousness
 To restore protective airway reflexes
 To restore spontaneous adequate respiration
 To ensure patent airway after removal of endotracheal tube or laryngeal mask
airway

This is usually achieved by

 Discontinuation of inhalation anesthetic
 Discontinuation of mechanical ventilation
 Antagonism of muscle relaxants (neostigmine + atropine)
 Oropharyngeal suction

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When to remove the endotracheal tube "extubation"?
 Adequate spontaneous respiration
 Good protective cough reflex
 Good muscle tone to maintain the airway patent
 Patient is awake enough to obey commands

Criteria for transport the patient from the operating room?

 Patent airway (provided either by an awake patient, oral airway or
endotracheal tube).
 Adequate ventilation
 Stable hemodynamics
 Adequate pain control

Where to transfer patients at the end of surgery?

 Post Anesthesia Care Unit (PACU)
 Intensive Care Unit (ICU)

The Post Anesthesia Care Unit (PACU)

This is where every patient recovers from the effects of anesthesia. This unit
should be equipped with:
 Oxygen source
 Suction facilities
 Basic monitoring equipment
 Emergency drugs
 Experienced nurses and anesthesiologist

Criteria for discharge are stratified into:

1- Phase 1: which determines when the patient is able to be transferred from
the PACU to the ward.
2- Phase 2: which addresses home-readiness and only applies to those patients
having “same day surgery".
A scoring system (Aldrete score) has been developed that grades the
patient’s colour, respiration, circulation, consciousness and activity on a scale of
0-2.
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 A strong hand grip and the ability to lift the head off the bed for 5 seconds
reliably indicate the return of adequate muscular strength.
Patients are discharged from PACU after fulfilling the following criteria
(Phase 1 recovery):
 Fully awake
 Breathing adequately
 Good oxygen saturation (on room air)
 Stable hemodynamics
 No surgical site bleeding, no nausea, no vomiting
 Pain free
Most healthy patients undergoing routine surgery will meet the PACU
discharge criteria within 60 minutes.
For Phase 2 recovery, prior to being discharged home (from the same day
surgery unit), the patient must demonstrate the return of cognitive function,
ambulation and the ability to take oral liquids.

The Intensive Care Unit (ICU)

Indicated in critically ill patients requiring prolonged post-operative
ventilation or close hemodynamic monitoring as a result of:
 Complicated major surgery
 Serious medical illness
It is usually the anesthesiologist that looks after critically ill patients in ICU.
This unit should be equipped with mechanical ventilation facilities and invasive
hemodynamic monitoring.

DOCUMENTATION OF DATA
(Anesthesia record)
An important task in the practice of medicine in general and in anesthesia in
particular is to document all findings and interventions.
These data are collectively written in the anesthesia
record form and should include the following:
1. Patient data including age, sex, and body weight
2. Underlying diagnosis, site and type of proposed
surgery
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 3. Details of preoperative assessment and premedication
4. ASA physical status
5. The anesthetic technique used, the types, doses, and timing of all drugs given
intraoperatively
6. Details of fluid balance (input and output)
7. Intraoperative hemodynamic and ventilator parameters
8. Any adverse effects related to anesthesia e.g. difficult intubation or
succinylcholine apnea
9. Recovery room records of vital signs

Typical anesthetic regimen for an adult patient undergoing moderate elective

abdominal surgery
 Oral midazolam 60-90 minutes before surgery
 Intravenous access and baseline readings of vital signs
 Thiopental or propofol for induction of hypnosis
 Fentanyl, morphine, or meperidine for analgesia
 Atracurium or vecuronium for muscle relaxation
 Manual ventilation using mask oxygen for 2-3 minutes
 Endotracheal intubation using cuffed endotracheal tube
 Mechanical ventilation adjusted to maintain normocapnia (tidal volume 10
ml/kg and a respiratory rate of 10-12 / minute)
 Anesthesia is maintained with inhalation of:
o At least 30% O2
o Nitrous oxides 50-70% of the inspired gas mixture
o Isoflurane 0.5-1% concentration
 Incremental (top-up) doses of narcotics and muscle relaxant
 Minimum monitoring should include
o ECG, noninvasive blood pressure
o Pulse oximetry, end-tidal CO2
o Neuromuscular transmission using a peripheral nerve stimulator
 Replacement of fluid deficit and intraoperative losses
 At the end of surgery
o Switch off anesthetics
o Give 100% O2
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 o Antagonize residual muscle paralysis with neostigmine and atropine
o Oropharyngeal suction of secretions
o Extubate after recovery of cough reflex and muscle tone
 Send the patient to post anesthesia care unit
o Give supplemental oxygen by mask
o Observe vital signs
 Discharge to ward: fully conscious, stable vital signs, good oxygenation on
room air, and pain free

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 Anesthesia Agents

1. Inhalation anesthetics (volatile anesthetics)

- Gases : Nitrous oxide (N2O), xenon
- Liquids (vapors): Ether, halothane, enflurane,
isoflurane, desflurane, sevoflurane

2. Intravenous anesthetics
- Barbiturans : Thiopentone sodium
- Others : Propofol, ketamine, etomidate

3. Pain killers
- Opioids: Fentanyl, sufentanil, alfentanil, remifentanil, morphine, meperidine.
- Non Steroidal Anti-inflammatory drugs: Ketorolac, paracetamol

4. Muscle relaxants
- Depolarizing: Succinilcholine
- Non depolarizing: Atracurium, cis-atracurium, vecuronium, rocuronium

5. Adjuvants
- Benzodiazepines: Midazolam, diazepam

1) Inhalational anesthetics:
These are volatile liquids or gases that are given by inhalation to diffuse
rapidly from the lungs to the circulation and consequently produce reversible
central nervous system (CNS) depression and anesthesia. They are the most popular
agents used for maintenance of anesthesia. When intravenous access is difficult, e.g.
in children, some inhalation anesthetics have pleasant acceptable odour and can be
used for induction of anesthesia.
The concentration of a gas in the alveoli creates an alveolar partial pressure
of gas which in turn reflects its partial pressure in the active site (brain). Minimum
Alveolar Concentration (MAC) refers to the concentration of the inhaled agent in
alveolar gas necessary to prevent movement of 50% of patients when a standard
incision is made.
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FACTORS WHICH DECREASE MAC: advanced age, pregnancy, hypothermia, acute
alcohol intoxication, drugs: benzodiazepines, opioids, muscle relaxants, central-
acting antihypertensives.
FACTORS WHICH INCREASE MAC: childhood, hyperthyroidism, hyperthermia,
chronic alcohol use, drugs: amphetamine, cocaine.

Examples of inhalational anesthetics:

Criteria Nitrous oxide Halothane Isoflurane

Nature Gas Volatile liquid Volatile liquid

Analgesic effects Good analgesic Not analgesic Weak analgesic

Anesthetic effects Weak Potent Potent

Onset of action Very fast Moderate Fast

Rate of recovery Very fast Moderate Fast

Odour None Pleasant Pungent

Use for inhalation

Good Good Unacceptable
induction

Blood pressure May increase May decrease May decrease

Myocardial depression Minimal Significant Minimal

Arrhythmogenic effect None ++++ None

Vasodilatation None None +++

Hepatotoxicity None May occur Does not occur

Bronchodilatator None ++++ ++

Skeletal muscle relaxation No effect Minimal effect Potentiate

Cost Expensive Cheap Expensive

Sevoflurane has rapid onset and rapid offset, with pleasant odour, used for
induction & maintenance.

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2) Intravenous induction agents:
Intravenous anesthetics are mainly used to provide rapid smooth induction of
hypnosis. They may also be used as a continuous infusion to maintain anesthesia.
When used for maintenance of anesthesia, intravenous anesthetic agents should be
supplemented with analgesics and muscle relaxants as required.

The criteria of the three main intravenous induction agents used in clinical
practice:
Propofol
Criteria Thiopental Ketamine (Ketalar)
(Diprivan)
Chemistry Barbiturate Non-barbiturate Non-barbiturate
Route of injection Intravenous
Intravenous Intramuscular
Intravenous
Rectal Oral
Nasal drops
Duration Short Very short Moderate
Protective reflexes Suppressed Suppressed May be preserved
Quality of recovery Reasonable Excellent Poor
Analgesic effects None None Potent
Respiration Depressed Depressed Preserved
Blood pressure   
Intracranial tension   
Intraocular tension   
Hallucinations None None Common
Pain on injection None Common None
Nausea, vomiting May occur Antiemetic Common
Cost Cheap Expensive Cheap

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3) Pain Killers
1- Opioids:
These include morphine and its synthetic derivatives like fentanyl, sufentanil,
alfentanil, remifentanil and meperidine. This group of drugs act at the opiate
receptors present at multiple sites in the central nervous system. Opioid analgesics
may be used as:
 Intraoperative supplementation of general anesthesia.
 Postoperative pain killers
 As part of premedication
The two main side effects of all opioid analgesics are:
 Respiratory depression
 Nausea, vomiting and constipation

Intravenous opioid analgesics:

Onset Duration
Opioid Preparation Side effects
(min) (hours)
Morphine 10 mg Histamine release
5-10 4-8
20 mg Hypotension
Meperidine 50 mg Tachycardia
5-10 2-4
100 mg
Fentanyl 100 µg 2-5 1-2 Muscle rigidity (high dose)
10 mg Morphine = 100 mg Meperidine = 100 µg Fentanyl = 10 µg Sufentanil

2- Non Steroidal Anti-inflammatory drugs: Ketorolac, paracetamol

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4) Neuromuscular blockers (muscle relaxants):
Muscle relaxants act at the neuromuscular junction by blocking the binding of
acetylcholine to nicotinic acetylcholine receptors. Two mechanisms may inactivate
acetylcholine receptors:
1. Depolarizing the receptor continuously, which leads to initial stimulation
(fasciculation) followed by paralysis (depolarizing muscle relaxants).
2. Competitively antagonizing acetylcholine at the receptor sites without initial
stimulation (non-depolarizing muscle relaxants)
Muscle relaxants are used during general anesthesia to:
 Paralyze laryngeal muscles before endotracheal intubation.
 Improve surgical conditions e.g. paralyzing abdominal muscles during intra-
abdominal surgeries.
 If patient movement would be detrimental (e.g. neurosurgery, ophthalmic
surgery).
Muscle relaxants paralyze all skeletal muscles including those of respiration.
Therefore, after muscle relaxant injection, patients will stop breathing and
mechanical ventilation must be used.

Muscle relaxants in common use:

Muscle relaxant Onset Duration Metabolism Side effects
Depolarizing Muscle pains
Plasma Hyperkalemia*
Succinylcholine 60 sec 5-10 min
cholinesterase Hyperthermia
 IOP
Non depolarizing
Pancuronium 3 min 60-90 min Liver/kidney Tachycardia
Hypertension
Vecuronium 3 min 30-45 min Liver None
Atracurium 3 min 30-45 min Hoffman ** Histamine release
Cis-atracurium 1.5-3 min 40-75 min 77% Hoffman None
* Hyperkalemia with succinylcholine occurs in patients with recent burn
** Hoffman elimination is a form of spontaneous degradation at normal body temperature and pH.
It does not depend on kidney or liver functions
- IOP = Intraocular pressure

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Muscle relaxant antagonists:
Antagonism of non-depolarizing muscle relaxants is achieved by the
administration of one of the anticholinesterase drugs (sometimes termed "reversal
agent") such as neostigmine, edrophonium and pyridostigmine, with
NEOSTIGMINE being most commonly used. Neostigmine inhibits cholinesterase
enzyme at the neuromuscular junction. Consequently increased amounts of
acetylcholine will reverse the effects of muscle relaxants. An anticholinergic
(ATROPINE or glycopyrrolate) is given with neostigmine to prevent muscarinic
side effects e.g. bradycardia, bronchospasm, increased airway secretions, intestinal
spasm, increased bladder tone and pupillary constriction.

5) Adjuvants:
Benzodiazepines: midazolam and diazepam
They have anti-anxiety, amnesic, and sedative effects seen at low doses that
progress to stupor and unconsciousness at induction doses. They used in the
preoperative period to alleviate anxiety and can be used in the postoperative period
to manage postoperative agitations.

References:

2. European Board of Anaesthesiology (EBA),UEMS Anaesthesiology Section. Recommendations for minimal monitoring during anaesthesia and recovery 2012.
3. Miller’s Anesthesia 8th edition; Miller R.; Churchill Livingstone, 2014.
4. Clinical Anesthesia 6th Edition; Barash P., Cullen B., Stoelting R.; Lippincott Williams and Wilkins, 2011.
5. Shafer S, 2018. “Perioperative Use of Alfentanil, Meperidine, and Methadone,” presented at Stanford University Department of Anesthesia Grand Rounds, March 19, 2018.
6. Mohamed Naguib M, Lien CA. Chapter 29, Pharmacology of Muscle Relaxants and Their Antagonists in Miller’s Anesthesia (8th edition), 2015. Elsevier inc.
7. U.S. Pharmacopeia Staff. Consumer Reports Complete Drug Reference. Yonkers, NY: Consumer Reports Books, 2002.
8. ANESTHESIA For Medical Students. FIRST EDITION, Faculty of Medicine, Cairo University, 2000.
9. Understanding Anesthesia 1st EDITION AUTHOR Karen Raymer, MD, MSc, FRCP(C) McMaster University CONTRIBUTING EDITORS Karen Raymer, MD, MSc, FRCP(C) Richard Kolesar, MD, FRCP(C) TECHNICAL
PRODUCTION Eric E. Brown, HBSc Karen Raymer, MD, FRCP(C) A Learner's Handbook www.understandinganesthesia.ca.

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Chapter 7

REGIONAL ANESTHESIA
Goal of RA:
To produce loss of sensation and /or motor function in a specific extremity or
area of the body

Advantages:
1. Postoperative analgesia
2. Safe alternative to general anesthesia
3. May provide earlier discharge from post anesthesia care unit (PACU)
4. Patient satisfaction
Disadvantages:
1. Not practical for every surgical procedure
2. Need more training & expertise
3. Limited duration of action
4. Risk associated with complications as local anesthetic systemic toxicity
(LAST) & potential risk nerve injury
Classification of regional anesthesia:
A. Topical anesthesia
Applied directly on the skin and mucous membrane
B. Infiltration anesthesia
Local anesthetic is injected directly into the tissues to anesthetize nerve
ending
C. Intravenous regional anesthesia (Bier's block)
Local anesthetic is injected into the venous circulation of an upper or very
rarely lower extremity that has been isolated by means of a double cuff
tourniquet from central circulation.

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 D. Field block (anesthesia)
Local anesthetic is infiltrated to the subcutaneous area surrounding the
operative field
E. Conduction anesthesia
1. Peripheral conduction anesthesia
Local anesthetic is injected directly to
a specific peripheral nerve or nerve
group (plexus).
2. Neuroaxial or central conduction
anesthesia
Local anesthetic is injected to spinal nerve structures. According to the
site of administration can be classified as:
a) Subarachnoid (Spinal): Local anesthetic is injected into the
subarachnoid space
b) Epidural: Diluted concentration of local anesthetic is injected into
the epidural space
c) Combined subarachnoid and epidural anesthesia: to obtain the
advantages of both techniques

Contraindications to central neural blockade:

General Absolute Relative
Lack of consent Coagulopathy Evolving neurological deficit
Lack of resuscitative equipment Sepsis (systemic or at Obstructive cardiac lesion
site of injection) (e.g. aortic stenosis)
Lack of familiarity to technique Increased intracranial Spinal hardware
pressure (ICP)
Known or suspected allergy Shock

Preoperative evaluation and patient selection:

Pre‑anesthesia evaluation and preparation in the operative room are EXACTLY
the same as with general anesthesia GA (remember that your Regional can turn into
a General Anesthesia in a matter of seconds!!!). In addition to the above, a careful
examination of the back needs to be done to look for spinal deformities, scars or the
presence of inflammation or infection.
-58-
Subarachnoid (Spinal) Anesthesia:
Anesthesia is performed under strict asepsis.
The patient may be sitting or curled in the lateral
position. A special small-bore “spinal needle” is
used (22-27 Gauge). The spinal cord terminates in
adults at the level of vertebrae L1-L2 (in a child, it
terminates at the upper border of L3), so puncture
must be below these vertebral interspaces. The
needle is inserted at a lower lumber interspace (L3-
4 and L4-5) and is advanced through the dura
matter to inject medication into the subarachnoid
space.

Epidural Anesthesia:
A tiny plastic catheter is placed into the
epidural space, which is the anatomic space located
just superficial to the dura. An epidural catheter can
be placed at any point along the spinal column.
Epidural catheter placed for surgical anesthesia or
analgesia is most commonly used at the thoracic or
lumbar regions depending on the site of the surgery.
Epidural catheter

Caudal anesthesia: is a special type of epidural anesthesia. The local anesthetic is

applied epidurally via the hiatus canalis sacralis using a standard needle. It is used
mainly for perioperative analgesia in babies and children.

The following structures are pierced during placement of a spinal needle into
the subarachnoid space: skin, supraspinous ligament, interspinous ligament,
ligamentum flavum, epidural space, dura and arachnoid membrane, and
subarachnoid space. Epidural anesthesia involves detecting epidural needle tip
entry into the epidural space (just outside the dural sac) and passage of a fine
catheter into the space.

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Required dermatomal levels for various surgical procedures:
Surgical procedure Required level of block
Caesarian section T4
Inguinal hernia repair T10
Fractured hip repair L1
Total knee arthroplasty L2
Hemorrhoidectomy S4

Order of loss of function:

1. Sympathetic fibers (Vasodilation & decreased heart rate)
2. Sensory fibers (Loss of temperature discrimination, loss of pain perception
and loss of touch)
3. Motor fibers (Loss of movement and proprioception)
Order of return of function:
1. Motor (movement & proprioception)
2. Sensory (pressure discrimination, pressure & pain)
3. Sympathetic
Comparison between subarachnoid (spinal) & epidural anesthesia

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Minimum equipment for safe administering RA:
(1) Manual rescue bag, face masks and source of oxygen.
(2) Equipment for intubation.
(3) Suction.
(4) Intravenous (IV) cannulas, infusions (IV access should be always available
for case of emergency).
(5) Thiopental, diazepam.
(6) Atropine, ephedrine, adrenaline.

Local anesthetics
Local anesthetic drugs produce anesthesia by inhibiting excitation of nerve
endings or by blocking conduction in peripheral nerves. They achieve this by
reversible binding to and inactivating sodium channels.

Physiologic activity of local anesthetics is a function of their lipid solubility,

diffusibility, affinity for protein binding, percent ionization at physiologic pH, and
vasodilating properties.

Local anesthetics are classified into ester & amide groups. Lidocaine and
bupivacaine are two of the most frequent used local anesthetics.

Differences between Esters and Amides local anesthetics:

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Local anesthetic systemic toxicity (LAST):
Rare in spinal anesthesia, due to the smaller doses given, epidural blockade
has the potential systemic toxicity through an accidental administration of local
anesthetic into an epidural vein. This will produce immediate systemic toxicity,
seizures and cardiovascular collapse. The best treatment is prevention, the use of
test dose will minimize accidental intravascular injections and if it does occur, the
treatment is symptomatic &supportive (cardiovascular, respiratory and central
nervous system CNS).

Combined Anesthesia: Combination of general and regional anesthesia is

used for better analgesia and decreasing the dose of general anesthesia and systemic
opioids. Combined anesthesia results in a greater suppression of the stress reaction
to surgery and allows analgesia to be prolonged into the postoperative period.

Reference:
9. Understanding Anesthesia 1ST EDITION AUTHOR Karen Raymer, MD, MSc, FRCP(C) McMaster University CONTRIBUTING EDITORS Karen Raymer, MD, MSc, FRCP(C) Richard Kolesar, MD, FRCP(C) TECHNICAL
PRODUCTION Eric E. Brown, HBSc Karen Raymer, MD, FRCP(C) A Learner's Handbook www.understandinganesthesia.ca
10. Introduction to Anaesthesiology. J. Malek, A. Dvorak et al. English translation: J. Malek, A. Whitley. Videos: M. Jantac, TM Studio, Benesov u Prahy. Copyright, Third Faculty of Medicine, Charles University, 2019.
Produced by financial support of internal grant of Third Faculty of Medicine Project IPUK.

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Chapter 8
ANESTHESIA RISKS

Overall, anesthesia is very safe. Even particularly ill patients can be safely
anesthetized. It is the surgical procedure itself which offers the most risk.
However, older adults and those undergoing lengthy procedures are most at risk of
negative outcomes.

Factors increase the risk of anesthesia:

1. Allergies to anesthesia or a history of adverse reactions to anesthesia
2. Diabetes, Obesity, Stroke
3. Heart, lung, kidney diseases
4. High blood pressure
5. Obstructive sleep apnea, a condition where individuals stop breathing while
asleep
6. Seizures or other neurological disorders
7. Smoking, or drinking two or more alcoholic beverages a day
8. Medications that can increase bleeding e.g. aspirin

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Recommendations may help to reduce the incidence of perioperative
complications:
1. Preoperative: Pre-assessment Clinic, Fitness and risk assessment, Correct
diagnosis and treatment of comorbidities, Continue/ stop relevant drugs
2. Intraoperative: Correct and timely antibiotics, Cardiovascular optimization,
Specific drugs (e.g. antiemetics), Check the equipment to be used and make sure
that backup facilities are available, Close patient monitoring
3. Postoperative: Enhanced recovery programmes, Good analgesia, Early
mobilization, Postoperative intensive care, Regular postoperative ward rounds,
Local postoperative outcome data collection

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Complications of Anesthesia
Problematic Potential clinical
Category Contributory factors
events consequences
Dental trauma
Difficulty in tracheal Difficult airway
Airway Soft tissue trauma
intubation Inexperience Urgency
Hypoxia
Hypoxia
Difficult airway
Airway trauma
Cannot intubate, Inexperience
Surgical airway
cannot oxygenate Poor airway
Abandoned surgery
assessment
Death
Inadequate muscle
High airway Pulmonary barotrauma relaxation, Obesity
Respiratory
pressures Pneumothorax Bronchospasm
Pneumoperitoneum
Inexperience
Endobronchial
Hypoxia Failure to auscultate
intubation
chest
Light anesthesia
Laryngospasm Hypoxia Secretions on vocal
cords
Asthmatics, Carinal
stimulate with ETT,
Bronchospasm Hypoxia
Histamine release,
Anaphylactic reaction
Pneumonitis Unfasted patient
Aspiration
Prolonged ventilation Reflux
Residual anesthetics,
Metabolic, Central, Pain,
Hypoventilation Hypoxia
High blockade after
neuraxial anesthesia
Difficult central line
Needle injury to
Pneumothorax insertion
lung
Inexperience
Myocardial ischaemia,
Bleeding Sepsis
Cardiac arrest
Cardiovascular Hypotension Neuraxial block
Brain injury
Hypovolaemia
Bleeding
Stroke Light anaesthetic
Hypertension Vascular accidents such as Inadequate analgesia
anastamosis or aneurysm Awareness
rupture

-65-
 Drugs, Metabolic, Heart
Dysrhythmias, Life-threatening
disease
cardiac arrest
Peripheral Peripheral nerve injury, Incorrect positioning of
Intraneural
nervous system Weakness, patient, Inexperience
injection
Pain
Central nervous Difficult epidural or
Dural puncture Postural headache
system spinal Inexperience
Difficult procedure
Misplaced epidural
Intra- or postoperative pain Long surgery
catheter
Inexperience
Anticoagulation
Damage to epidural Epidural haematoma,
Coagulopathy
vessel Paraplegia
Bleeding disorder
High-risk surgery
Failure to turn on Awareness
Comorbid patient
vapouriser Psychological trauma
Distraction
Patient factors,
long-term memory and
Delirium Comorbid disease,
learning problems
Medication, Metabolic
Patient factors, Surgery
Nausea, Vomiting, Aspiration, Suture
Gastrointestinal factors, Anesthetic
Ileus dehiscence
factors
Patient factors
Allergic drug
Drug related Anaphylaxis Inadequate history
reaction
taking
Patient factors
Idiosyncratic drug
Malignant hyperthermia Inadequate history
reaction
taking
Suxamethonium apnea
Various unintended effects,
Inadequate labelling
for example, hypertension,
Drug administration Inattention
neuromuscular blockade,
error Distraction
awareness
Difficult IV access
Lack of drug effect IV line in situ from the
Tissued intravenous
Compartment syndrome ward
(IV) line
Tissue necrosis

References
What to know about general anesthesia. Medically reviewed by Deborah Weatherspoon, Ph.D., R.N., CRNA — Written by Tim Newman on January 5, 2018
Merry AF, Mitchell SJ. Complications of anaesthesia. Anaesthesia. 2018 Jan;73 Suppl 1:7-11. doi: 10.1111/anae.14135. PMID: 293139
A Nicholls, I Wilson, 2000. Perioperative medicine managing surgical patients with medical problems. New York: Oxford University Press

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Chapter 9
POSTOPERATIVE PAIN THERAPY
Postoperative pain is a typical example of acute pain. The availability of good
postoperative analgesia is not only necessary, but also a fundamental right of every
patient suffering from pain and a basic duty of any health care facility that treats
these patients. Good analgesia is associated with reduced morbidity, more rapid
recovery and discharge of the patient from hospital.

Physiologic consequences of poor postoperative pain control:

1- Pulmonary:
Difficulty in coughing leads to atelectasis and pulmonary infection.

2- Cardiovascular:
Sympathetic stimulation leads to increased myocardial oxygen demand and
ischemia.

3- Endocrine/ Metabolic:
Catabolic hormone release leads to sodium and water retention and
hyperglycemia.

4- Thromboembolic:
Restricted mobility, combined with activation of acute phase proteins, leads
to increased risk of deep venous thrombosis and pulmonary embolism.

5- Gastrointestinal:
Pain decreases gastric motility and intestinal function and leads to
postoperative ileus.

6- Immunologic:
Pain can reduce immune system function, leading to increased risk of
infection.

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7- Psychologic/ Central nervous system:
Unrelieved pain causes sleep deprivation, anxiety and fatigue. Severe
prolonged acute pain can lead to chronic pain.

Assessing Acute Pain:

There are many methods used to assess pain intensity. The most reliable and
valid method to quantitatively assess pain in adults is Numeric Rating Scale (NRS)
where patients express their pain as a score from 0 to 10, where 0 = no pain; 1-3 =
mild pain; 4-6 = moderate pain, and 7-10 = severe pain. Other scales such as the
Visual Analogue Scale (VAS) and Simple Verbal Descriptive Scale can also be used.
More importantly pain should be assessed regularly, with a consistent
approach and treatment should be quick with adequate doses of analgesics once the
assessment is finished.
Types of Pain: (1) Somatic (2) Visceral (3) Neuropathic

The World Health Organization (WHO) Analgesic Ladder:

It is currently applied for managing cancer pain and also acute and chronic non-
cancer painful conditions.

The revised WHO analgesic ladder. Contributed by Marco Cascella, MD

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Postoperative Pain Management:
I- Non-pharmacological methods:
These methods (psychologic intervention, hypnosis, cooling, immobilization,
massage, acupuncture and transcutaneous electrical nerve stimulation (TENS)) are
used as an adjuvant of pharmacotherapy. They have little contraindications and side
effects, but little efficacy.
II- Pharmacological methods:
1) Oral, Intravenous, Rectal, Intramuscular, Subcutaneous, Transdermal
2) Patient-controlled analgesia (PCA): Allows patients to administer
analgesics (opioids) themselves most commonly in the vein or epidural
space.
3) Regional administration of analgesics: Provide better analgesia, more
invasive, by a single-injection or catheter technique.
4) Combination of systemic and regional analgesia: Effects of regional
analgesia are potentiated by systemic non-opioid analgesia and pain is
suppressed in areas that the local anesthetic dose not reach.
5) Multimodal analgesia: It combines analgesic drugs from different classes
and employs analgesic techniques that target different mechanisms of
pain. It maximizes pain relief at lower analgesic doses and reduces
adverse drug effects.

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Pharmacological management of acute pain symptoms in children (aged >1–15 years)

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Pharmacological management of acute pain symptoms – adults

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 Advantages and disadvantages of regional analgesic techniques

Technique Advantages Disadvantages

Epidural Reduced pain and requirement for co-analgesics Technique-related: backache, postdural puncture
Improved respiratory function headache, neurological injury, epidural haematoma,
Reduced pulmonary, thromboembolic, cardiovascular, failure
ileus and surgical stress response Epidural local anesthetic-related: hypotension,
Can be continued after operation sensory deficits, motor weakness, urinary retention,
toxicity
Epidural opioids: nausea, vomiting, pruritus, respiratory
depression
Attachment to drug delivery equipment

Intrathecal (spinal) Reduced pain and systemic opioid requirements Nausea and vomiting
Pruritus and respiratory depression if opioids used

Peripheral trunk blocks Reduced pain and systemic opioid requirements in the Fails to address visceral pain,
(e.g. transversus immediate postoperative period Local anaesthetic toxicity
abdominis plane and Catheter insertion allows continued block in Risk of perforation of the peritoneum with possible
rectus sheath) postoperative phase damage to visceral structures on insertion

Paravertebral Reduced pain and systemic opioid requirements Lower Hypotension possible
risk of pulmonary complications for patients Vascular or pleural puncture on insertion
undergoing thoracotomy
Catheter insertion allows continued block in
postoperative phase
Levels of analgesia comparable to those of epidural
analgesia, with reduced incidence of hypotension

Wound infiltration Reduced pain and systemic opioid requirements in Short-term efficacy
immediate postoperative phase
Easily administered

Adapted from Wick et al.

References:
1. Introduction to Anaesthesiology. J. Malek, A. Dvorak et al. English translation: J. Malek, A. Whitley. Videos: M. Jantac, TM Studio, Benesov u Prahy. Copyright, Third Faculty of Medicine, Charles University, 2019.
Produced by financial support of internal grant of Third Faculty of Medicine Project IPUK.
2. Registered Nurses Association of Ontario (2013). Assessment and Management of Pain, 3rd Edition. Toronto.
3. Niazi A, Matava C. Anesthesia for medical students. A Concise Clerkship Manual for Medical Students. Third Edition.
4. Wick EC,GrantMC,WuCL.Postoperative multimodal analgesiapainmanagementwithnonopioidanalgesicsand techniques.JAMA Surg 2017;152:691–697.
5. Aabha A. Anekar; Marco Cascella. WHO Analgesic Ladder. Copyright © 2021, StatPearls Publishing LLC .
6. Small C, Laycock H. Acute postoperative pain management. Br J Surg. 2020 Jan;107(2):e70-e80. doi: 10.1002/bjs.11477. PMID: 31903595.
7. Guidelines for the management of acute pain in emergency situations. Website: www.eusem.org ©European Society of Emergency Medicine (EUSEM) 2020.

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Chapter 10
Arterial Blood Gas (ABG) Analysis
Definition:
An ABG is a blood test that measures the acidity, or pH, and the levels
of oxygen (O2) and carbon dioxide (CO2) from an artery.

Uses:
An ABG can be used to assess respiratory compromise, status peri- or post-
cardiopulmonary arrest, and medical conditions that cause metabolic abnormalities
(such as sepsis, diabetic ketoacidosis, renal failure, toxic substance ingestion, drug
overdose, trauma or burns). An ABG can also be used to evaluate the effectiveness
of oxygen therapy, ventilatory support, fluid and electrolyte replacement, and
during perioperative care.

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Normal Arterial Values (At sea level)
Normal Values and Clinical Significance
Value Normal range Clinical significance
pH 7.35- The pH tells you if your patient is acidotic or alkalotic.
7.45 It is a measurement of the acid content or hydrogen
ions [H+] in the blood. Low pH indicates a higher
concentration of hydrogen ions (acidosis) while a
high pH indicates a lower concentration of hydrogen
ions (alkalosis).
PaCO2 35-45 mm Hg The PaCO2 level is the respiratory component of the
ABG. It is a measurement of carbon dioxide (CO2) in
the blood and is affected by CO2 removal in the lungs.
A higher PaCO2 level indicates acidosis while a lower
PaCO2 level indicates alkalosis.
PaO2 80-100 mm Hg The PaO2 level is a measurement of the amount of
oxygen dissolved in the blood. A PaO2 level less than
60% results in tissue hypoxia.
HCO3- 22-26 mEq/L
The HCO3 level is the metabolic component of the ABG.
It is a measurement of the bicarbonate content of
the blood and is affected by renal production of
bicarbonate. A lower HCO3 level indicates acidosis
while a higher HCO3 level indicates alkalosis.
BE -2 to +2 mmol/ L Base excess/ base deficit, represents an increase or
decrease in the amount of base compared with the
amount of acid present.

SaO2 95-100% SaO2, or arterial oxygen saturation, refers to the

number of hemoglobin binding sites that have oxygen
attached to them. How easily oxygen attaches to
hemoglobin can be affected by body temperature, pH,
2,3- di phosphoglycerate levels, and CO2 levels.

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Six Steps for ABG Analysis

Normal Values and Clinical Significance

Steps Clinical significance
Step 1: Analyze the pH Determine if the pH is within the normal range or
pH < 7.35 = acidosis reflects acidosis or alkalosis.
pH > 7.45 = alkalosis
Step 2: Analyze the PaCO2 Carbon dioxide is produced in the tissues of the
PaCO2 > 45 = acidosis body and eliminated in the lungs. Changes in the
PaCO2 level reflect lung (respiratory) function.
PaCO2 < 35 = alkalosis

Step 3: Analyze the HCO3- Bicarbonate is produced by the kidneys. Changes

HCO3- < 22 = acidosis in the HCO3- level reflect metabolic function of the
kidneys.
HCO3- > 26 = alkalosis
Step 4: Match the PaCO2 or HCO3- with pH:

If pH < 7.35 and PaCO2 > 45 and HCO3- level is Causes of respiratory acidosis include
normal, the patient has respiratory acidosis. hypoventilation, respiratory infection, severe
airflow obstruction as in chronic obstructive
pulmonary disease (COPD) or asthma,
neuromuscular disorders, massive pulmonary
edema, pneumothorax, central nervous
depression, spinal cord injury, and chest wall
injury.
Causes of metabolic acidosis include renal failure,
If pH < 7.35 and HCO3- < 22 and PaCO2 level is diabetic ketoacidosis (DKA), lactic acidosis, sepsis,
normal, the patient has metabolic acidosis. shock, diarrhea, drugs, and toxins such as ethylene
glycol and methanol.
If pH > 7.45 and PaCO2 < 35 and the HCO3- level is Causes of respiratory alkalosis include
normal, the patient has respiratory alkalosis. hyperventilation, pain, anxiety, early stages of
pneumonia or pulmonary embolism, hypoxia,
brainstem injury, severe anemia, and excessive
mechanical ventilation.
If pH is > 7.45 and HCO3- > 26 and the PaCO2 level Causes of metabolic alkalosis include diuretics,
is normal, the patient has metabolic alkalosis. corticosteroids, excessive vomiting, dehydration,
Cushing syndrome, liver failure, and hypokalemia.

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 Step 5: Assess for compensation by When a patient has an acid-base imbalance, the
determining whether the PaCO2 or the HCO3- respiratory and metabolic systems try to correct
go in the opposite direction of the pH. the imbalances the other system has produced.

If pH 7.35-7.40 (compensated acidosis), PaCO2 > To compensate for respiratory acidosis, the
45 (acidosis), and HCO3- > 26 (alkalosis), the kidneys excrete more hydrogen ions and elevate
patient has compensated respiratory acidosis. serum HCO3, in an effort to normalize the pH.

If pH 7.35-7.40 (compensated acidosis),PaCO2 <35 To compensate for metabolic acidosis, the

(alkalosis), and HCO3- < 22 (acidosis), the patient patient'srespiratory center is stimulated, and the
has compensated metabolic acidosis. patient hyperventilates to blow off more CO2,
raising the pH.

If pH 7.40-7.45 (compensated alkalosis), PaCO2 To compensate for respiratory alkalosis, the

<35 (alkalosis), and HCO3- < 22 (acidosis), the metabolic system is activated to retain hydrogen
patient has compensated respiratory alkalosis. ions and lower serum HCO3- , in an effort to raise
the pH.

If pH 7.40-7.45 (compensated alkalosis),PaCO2 > To compensate for metabolic alkalosis, the

45 (acidosis), and HCO3- > 26 (alkalosis), the patient’s respiratory center is suppressed;
patient has compensated metabolic alkalosis. decreased rate and depth of respiration causes
CO2 to be retained, lowering the pH.

Step 6: Analyze the PaO2 and SaO2 Causes of hypoxemia include COPD, acute
If PaO2 < 80 mm Hg or SaO2 < 95%, the patienthas respiratory distress syndrome (ARDS), certain
hypoxemia. medications, high altitudes, interstitial lung
disease, pneumothorax, pulmonary embolism,
pulmonary edema, pulmonary fibrosis, anemia,
heart disease, and sleep apnea.

Anion Gap (AG)

The anion gap is a measure of acid-based balance.
AG= Major cations – major anions = (sodium Na+ + potassium K+) - (chloride Cl- +
bicarbonate HCO3-)
The reference range for the anion gap is as follows:
 16 ± 4 mEq/L (if the calculation employs potassium)
 12 ± 4 mEq/L (if the calculation does not employ potassium)

References:
Lippincott NursingCenter (2020). Arterial Blood Gas (ABG) Analysis. www.nursingcenter.com
Lian, J. (2013). Using ABGs to optimize mechanical ventilation. Nursing2013, 43(6). doi: 10.1097/01.NURSE.0000423964.08400.95
Lian, J. (2010). Interpreting and using the arterial blood gas. Nursing2010 Critical Care, 5(3). doi: 10.1097/01.CCN.0000372212.89520.18
Woodruff, D. (2007). Six Steps to ABG Analysis. Nursing2007 Critical Care, 2(2). doi: 10.1097/01.CCN.0000264040.77759.bf

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 Chapter 11
BASIC LIFE SUPPORT STEP-BY-STEP
SEQUENCE/ACTION TECHNICAL DESCRIPTION
SAFETY
• Make sure that you, the victim and any bystanders are safe

RESPONSE
Check for a response Hello! • Shake the victim gently by the shoulders and ask loudly:
“Are you allright?"

AIRWAY
Open the airway • If there is no response, position the victim on their back
- Use the Head Tilt-Chin Lift maneuver: With your hand on the
forehead and your finger tips under the point of the chin, gently
tilt the victim’s head backwards, lifting the chin to open the airway
- Use the Jaw Thrust maneuver: When a cervical spine injury
cannot be ruled out. Place your fingers on the lower rami of the
jaw. Provide anterior pressure to advance the jaw forward.
BREATHING • Look, listen and feel for breathing for no more than 10
Look, listen and feel for seconds
breathing • A victim who is barely breathing, or taking infrequent, slow
and noisy gasps, is not breathing normally

ABSENT OR
ABNORMAL BREATHING • If breathing is absent or abnormal, ask a helper to call the
Alert emergency services emergency services or call them yourself
• Stay with the victim if possible
• Activate the speaker function or hands-free option on the
telephone so that you can start CPR whilst talking to the
dispatcher
SEND FOR AED • Send someone to find and bring back an AED if available
Send someone to get an AED • If you are on your own, DO NOT leave the victim, but start
CPR
CIRCULATION • Kneel by the side of the victim
Start chest compressions • Place the heel of one hand in the center of the victim’s chest
- this is the lower half of the victim’s breast bone (sternum)
• Place the heel of your other hand on top of the first hand and
interlock your fingers
• Keep your arms straight
• Position yourself vertically above the victim’s chest and press
down on the sternum at least 5 cm (but not more than 6 cm)
• After each compression, release all the pressure on the
chest without losing contact between your hands and the
sternum
• Repeat at a rate of 100-120 / min

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 SEQUENCE/ACTION
COMBINE RESCUE BREATHING WITH
CHEST COMPRESSIONS
COMPRESSION-ONLY CPR
WHEN AED ARRIVES
Switch on the AED and
attach the electrode
pads
FOLLOW THE SPOKEN/
VISUAL DIRECTIONS
TECHNICAL DESCRIPTION
• If you are trained to do so, after 30 compressions, open the
airway again, using head tilt and chin lift
• Pinch the soft part of the nose closed, using the index
finger and thumb of your hand on the forehead
• Allow the victim’s mouth to open, but maintain chin lift
• Take a normal breath and place your lips around the victim’s
mouth, making sure that you have an airtight seal
• Blow steadily into the mouth whilst watching for the chest to
rise, taking about 1 second as in normal breathing. This is an
effective rescue breath
• Maintaining head tilt and chin lift, take your mouth away
from the victim and watch for the chest to fall as air comes
out
• Take another normal breath and blow into the victim’s
mouth once more to achieve a total of two rescue breaths
• Do not interrupt compressions by more than 10 seconds
to deliver the two breaths even if one or both are not
effective
• Then return your hands without delay to the correct position
on the sternum and give a further 30 chest compressions
• Continue with chest compressions and rescue breaths in
a ratio of 30:2
• If you are untrained, or unable to give rescue breathes,
give chest-compression-only CPR (continuous compressions
at a rate of 100-120 / min)
• As soon as the AED arrives switch it on and attach the
electrode pads to the victim’s bare chest
• If more than one rescuer is present, CPR should be
continued whilst the electrode pads are being attached to
the chest
• Follow the spoken and visual directions given by the AED
• If a shock is advised, ensure that neither you nor anyone
else is touching the victim
• Push the shock button as directed
• Then immediately resume CPR and continue as directed
by the AED
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 SEQUENCE/ACTION TECHNICAL DESCRIPTION

IF NO SHOCK IS ADVISED
Continue CPR • If no shock is advised, immediately resume
CPR and continue as directed by the AED

IF NO AED IS AVAILABLE
Continue CPR • If no AED is available, OR whilst waiting for
one to arrive, continue CPR
• Do not interrupt resuscitation until:
• A health professional tells you to stop OR
• The victim is definitely waking up,
moving, opening eyes, and breathing
normally
• OR
• You become exhausted
• It is rare for CPR alone to restart the heart.
Unless you are certain that the victim has
recovered continue CPR
• Signs that the victim has recovered
• Waking-up
• Moving
• Opening eyes
• Breathing normally

IF UNRESPONSIVE BUT BREATHING

NORMALLY • If you are certain that the victim is breathing
Place in the Recovery Position normally but still unresponsive, place them
in the recovery position (only use the
recovery position if it is unlikely to
worsen patient injury)
• Be prepared to restart CPR immediately if the
victim becomes unresponsive, with absent or
abnormal breathing

CPR (Cardio-pulmonary resuscitation)

AED (Automated External Defibrillator)

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 Recovery Position (lateral recumbent or 3/4 prone position):
This position is used to maintain a patent airway in the unconscious person.
 Place the patient close to a true lateral position with the head dependent to allow fluid
to drain.
 Assure the position is stable.
 Avoid pressure of the chest that could impairs breathing.
 Position patient in such a way that it allows turning them onto their back easily.
 Take precautions to stabilize the neck in case of cervical spine injury.
Continue to assess and maintain access of airway.

References
- Olasveengen, Theresa M., Mancini, Mary E., Perkins, Gavin D., Avis, Suzanne, Brooks, Steven, CastrA©️n, Maaret, Chung, Sung Phil, Considine, Julie, Couper, Keith, Escalante, Raffo, Hatanaka, Tetsuo, Hu. Adult Basic Life
Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation. 2020; 142(suppl 1): S41–S91. DOI:
10.1161/CIR.0000000000000892
T.M. Olasveengen, et al., European Resuscitation Council Guidelines 2021: Basic Life Support, Resuscitation (2021), https://doi.org/10.1016/j.resuscitation.2021.

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