Fundamental Concepts of Anesthesiology

Dr. Weiwei Liu

Department of Anesthesiology
The First People's Hospital of Jingzhou
The First Affiliated Hospital of Yangtze University
1. Respiratory physiology

2. Pulmonary function tests

3. Fluids and blood transfusion

 Respiratory physiology—anatomy of airways
It is the organ of voice extending from root of tongue to
trachea and lies opposite C3 to C6

Distance between teeth and vocal cords is 12 to 15 cms

Distance between vocal cords and carina is 10 to 15 cms

It consists of 3 paired cartilages :arytenoid

corniculate
cuneiform

And 3 unpaired cartilages:thyroid

larynx cricoid
epiglottis
Respiratory physiology—anatomy of airways
Respiratory physiology—anatomy of airways

Vocal cords
 Respiratory physiology—anatomy of airways
Length of the trachea is 10-12cms

It starts from cricoid ring (C6) and ends at

carina(T5).

It consist of 16-20 incomplete rings

The diameter of trachea is 1.2 cm

At carina trachea divides into right and left main

bronchus.

trachea Distance of carina from upper incisors is 28 to 30

Respiratory physiology--regulation of respiration

Mediated by:

 Pneumotaxic centre in upper pons

 Apneustic centre in lower pons
 Ventral group of neurons in medulla
(expiratory group)
 Dorsal group of neurons in medulla
(inspiratory group)
 Respiratory physiology--regulation of respiration
The factors effecting respiratory centres: pCO2
Body temperature
Hypoxia
Exercise
Pain
Hypothalamus
Cortex

Peripheral chemoreceptors:these are present in carotid body and aortic arch.they

are very sensitive to hypoxia.

All inhalational agents(except nitrous oxide and minimum with ether) have
depressant effect on ventilatory response to increased CO2 and hypoxia.
 Respiratory physiology—muscles of respiration

Inspiration Expiration

 Diaphragm is most important  Expiration is normally

muscle of inspiration passive. Forced expiration
is mediated by internal
 External intercostals ,pectoralis interccostals and abdominal
minor and scalene also assist in muscles.
normal inspiration.
 During anaesthesia with
 Pectoralis major ,latissimus dorsi inhalational agents expiration
and sternomastoids are needed is active,mediated by
during deep inspiration. abdominal muscles.
 Respiratory physiology—ventilation/prefusion(V/Q)

Ventilation is maximum at apex and minimum at base while perfusion is

maximum at base and minimum at apex.so V/Q ratio at apex is 2.1 and at
base it is 0.3(average V/Q ratio of lung is 0.8)

This ventilation perfusion mismatch is responsible for producing alveolar

dead space.

This V/Q mismatch creates alveolar to arterial oxygen difference [(A-a)pO2

difference]which is normally 3-5 mmHg.

This A-a difference is increased in lung pathologies affecting alveoli like

pulmonary edema, ARDS and interstitial lung disease.
 Respiratory physiology—dead space

Total dead space = anatomical dead space + alveolar dead space

Anatomical dead space : constituted by air which is not participating in

diffusion.therefore it is constituted by air present in nose,trachea and bronchial
tree (up to terminal bronchioles) .normally it is 30% of tidal volume or 2ml/kg
or 150ml.

Alveolar dead space : constituted by alveoli which are only ventilated but no
perfused .it is 60-80ml in standing position and zero in lying position (in lying
position perfusion is equal in all parts of lung).
 Respiratory physiology—dead space

Anatomical dead space is increased in: Anatomical dead space is decreased in:

1. Old age 1. Intubation

2. Neck extension 2. Tracheostomy
3. Jaw protrusion 3. Hyperventilation
4. Brochodilators 4. Neck flexion
5. Increasing lung volume 5. bronchoconstrictors
6. Atropine
7. Anesthesia mask,circuits
8. Intermittent positive pressure
ventilation(IPPV) and position
end expiratory pressure (PEEP)
 Respiratory physiology—dead space

Alveolar dead space is increased in:

1. Lung pathologies affecting diffusion at alveolar capillary membrane

2. General anaesthesia
3. IPPV
4. PEEP
5. Hypotension
 Respiratory physiology—dead space

Anaesthesia and dead space

 All anaesthesia circuits ,mask,humidifiers increase the anatomical dead

space
 Endotracheal tubes,tracheostomy decrease the anatomical dead space by
bypassing the upper airways
 All inhalational agents increase both anatomical and alveolar dead
space.anatomical dead space is increased beacause of hypotension produced
by these agents(V/Q mismatch).
 Positions during anaesthesia especially lateral position causes more
ventilation in upper lung and more blood flow in lower lung so increasing
the V/Q mismatch and hence alveolar dead space .other positions like
Trendelenburg,lithotomy also causes the V/Q mismatch
 Respiratory physiology—dead space

 Anaesthesia ventilation techniques like IPPV,PEEP increase both

anatomical and alveolar dead space .

Anatomical dead space is increased by increasing lung volume and alveolar

dead space is increased beacause of hypotension produced by IPPV and PEEP
(compression of venules in alveolar septae and interstitial tissue beacause of
dilated alveoli by PEEP and IPPV leads to deseased venous return and
compression of small arteries lead to decrease in pulmonary blood flow. Both
these factors finally decrease and cardiac output and thus causing
hypotension ).
Secondly, alveolar dead space is also increased by PEEP and IPPV because
normal alveoli are overdistended during PEEP,increasing V/Q mismatch.
Respiratory physiology—oxygen dissociation curve

shift of oxygen dissociation curve is seen with:

To left To right
Alkalosis Acidosis
Low pco2 High pco2
Decreased 2,3 DPG Increased 2,3 DPG
carbon monoxide Hyperthermia
poisoning Inhalational
Abnormal haemoglobins anaesthetics
Hypophosphatemia
Hypothermia
 Respiratory physiology—HPV

HPV:hypoxic pulmonary vasoconstriction.

This is a protective mechanism. Whenever there is hypoxia ,there

occurs vasocontriction in these hypoxic areas leading to shunting of
blood to well perfused area , decreasing the V/Q mismatch
 Pulmonary function tests— lung volumes

VT : tidal volume
IRV:inspiratory reserve volume
IC:inspiratory capacity
ERV:expiratory reserve volume
RV:residual volume
FRC:function residual capacity
VC:vital capacity
TLV:total lung volume

lung volumes
 Pulmonary function tests— pulmonary function test

Simple bed side test Spirometry Forced spirometry

 Breath holding  Tidal volume  Forced vital
time  Inspiratory capacity(FVC)
 Match test reserve volume  Forced expiratory
 Tracheal  Inspiratory volum(FEV)
auscultation capacity  FEV1/FVC
 Able to blow a  Expiratory reserve  Peak expiratory
balloon volume flow rate
 Vital capacity  Forced
midexpiratory flow
rate
 Pulmonary function tests— pulmonary function test
Fitness for surgery and pulmonary function
 Patients with FEV<20ml/kg and FEV1<15ml/kg require appropriate
preoperative preparation before surgery like chest
physiotherapy ,antibiotics, bronchodilators etc.
 Patient with FEV1<10ml/kg and history of dyspnea at rest or on
minimal activity should be subjected to only life saving operations.

Three most important criteria to indicate serve repiratory compromise are:

 Dyspnea at rest or on minimal activity
 FEV1<15ml/kg
 Po2<60mmHg on room air
 Fluids and blood transfusion

Ringer lactate
Normal saline
crystalloids Glucose solution
Dextrose with normal saline preparations
Fluids Hypertonic saline
Dextrans
Albumin
colloids Gelatins
Hydroxyethyl starch
blood

crystalloids
1.May be isotonic (NS and dextrose),hypertonic
(DNS and hypertonic saline)
2.Intravascular half life 30 minutes so expands
plasma volume for less time
3.Cheap
4.Replaced in a ratio of 3-4 times of lost fluid
5.Can precipitate edema by easily diffusing to
interstitial compartment
6.Does not interfere with clotting
7.No such effect
8.Allergic reactions are rare
Fluids and blood transfusion
colloids
1.Hypertonic solutions
2.Expand plasma volume for 2-4hours
3.Expensive
4. Replaced in 1:1 ratio of lost fluid
5.Decrease cerebral edema and pulmonary
edema
6.Colloids in high doses can interfere with
clotting
7.Dextrans can cause rouleaux formation and
interfere with blood groups
8.Allergic reactions are common
 Fluids and blood transfusion
Fluid management
Maintenance fluids Intraoperative fluid replacement

Hourly maintence requirement is Maintenance fluids

calculated by formula of 4-2-1 Fasting deficit
Upto 0-10kg = 4ml/kg/hr 3rd space loss
10-20kg = 2ml/kg/hr Compensatory intravascular expansion
>20kg = 1ml/kg/hr
 Fluids and blood transfusion

Indications for transfusion

 In adult with normal haemoglobin and haematocrit blood losses more than
20% of their blood volume(or haematocrit falls below 30%) are to be replace
with blood.
 In children losses more than 10% of their blood volume should be replaced
with blood
 Minimum acceptable haemoglobin level for elective surgery is 10g% and
haematocrit 35%
 1 unit of blood raises the haemoglobin by 0.8g% in india while in western
countries by 1g% .
 Blood products should not be infused with 5% dextrose,ringer lactate and
haemaccel.
Fluids and blood transfusion

Group A can receive blood from :

group A and O

Group B can receive blood from :

group B and O

Group AB can receive blood

from : group AB,A,B and O

Group O can receive blood from :

group O
 Fluids and blood transfusion

Complications of blood transfusion:

 Transfusion reactions  Fluid overloading and pulmonary edema

 Haemolytic reactions  Metabolic
 Allergic reactions  Coagulation abnormalities
 Febrile reactions  Hypothermia
 Hepatitis  Immunosuppression
 Acquired immunodeficiency disease  Tissue hypoxia
 Other viral diseases  Endotoxermia and septicemia
 Bacterial infections  Adult respiratory distress syndrome
 Parasite  Disseminated intravascular coagulation
 Fluids and blood transfusion
Acute haemolytic reaction
It is usually due to ABO incompatibility.the most common cause of these
transfusion reactions is clerical error. There is intravascular haemolysis.

Clinical manifestations
As low as 10 ml of blood can produce haemolytic reaction.
The awake patient presents with pain and burning in vein,fever with chills and
rigors,nausea and vomiting,flushing,chest and flank pain,dyspnea.

In anaesthetized individual it is manifested as tachycardia,hypotension and

oozing from surgical site.

It is comfirmed by haemoglbinnuria.
 Fluids and blood transfusion

Management:
 Stop infusion
 Recheck the details of blood slip
 Send the remaining blood back to blood bank
 Maintain the urine output (1-2ml/kg/hr) by mannitol and fluid administration
 Dopamine in renal doses (2-5ml/kg/min) improves renal blood flow
 Alkalinize the urine
 Haemodialysis
 Assay yrine haemoglobin,platelet count,fibrinogen level and PTT and replace
with blood components accordingly.
 Fluids and blood transfusion

Delayed haemolytic reactions

 These are extravascular haemolytic reactions.

 These are ususlly due to Rh system or other systems like Kell,Duffy etc.
 These reactions are mild and seen after 2-21 days
 Diagnosed by Coombs test
 Treatment:only supportive.
 Fluids and blood transfusion
Massive blood transfusion
It is defined transfusion of blood more than patient’s blood volume (5 litres)in
less than 24 hours. It also implies transfusion of more than 10% of blood
volume in less than 10 minutes.

Complications:
 Hyperkalemia
 Hypocalcemia
 Hyperammonemia
 Hypothermia
 Metabolic alkalosis
 Dilutional coagulopathies and disseminated intravascular coagulation
 ARDS
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