MASTER REVISION CLASS OF ANAESTHESIA

 PAC CLINIC

1. Goal of pre-anaesthetic check up (PAC)

 To ensure, patients can safely tolerate anaesthesia for planned surgery.

 To reduce risk that is associated in preoperative period.

PAC includes

 Complete history
 Physical examination
 Systemic Examination
 Airway Examination
 Grade the patient
 Preoperative order.

- In case of any ambiguity, please talk to Anaesthesia Resident / Surgical

Resident before Rescheduling the case.

2. Demographic details
Name, age, sex, address & I.D no.

 Chief complaints
 Present history
 Past medical history – required to optimize the patient before surgery.
 Personal history
 Family history

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  Allergy history
 Past surgical history
 Menstrual history
 Immunization history

PBQ 1: Anaesthesia of choice in a pregnant patient coming for C-section?

(a) GA
(b) SA
(c) Caudal
(d) Epidural

Ans. C)

OPTIMIZATION OF PATIENT’S GENERAL CONDITION

 All the antihypertensive drugs should be continued till the day of surgery
except ACE inhibitors and ARB’s because they cause severe hypotension.
 Diabetes Mellitus has 3 acute complications
1) DKA (Diabetic Ketoacidosis)
2) HHS (Hyperglycemic Hyperosmolar state)
 Hypoglycemia
 Under anaesthesia, Hypoglycemia is dangerous
 Because, signs and symptoms of Hypoglycemia are masked under
anaesthesia.
 If Hypoglycemia is not corrected within minutes,

It can lead to permanent brain damage

 How to optimize Diabetes mellitus in a patient

 By oral Hypoglycemic agent or Insulin.

 Target level is 120-200mg/dl

 All oral Hypoglycemic agent & insulin should be stopped prior surgery

Because common side effect is Hypoglycemia

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  Long acting isulin dose should be reduced by 1/3rd or ½.

 To maintain blood sugar intraoperatively

Regular insulin (short acting) is given

o Onset : 30-60 minutes

o Peak : 1-2 hrs

o Activity : 5-7 hrs

To maintain blood sugar within the

range of 120-200 mg/dl

 In type I DM patients, on long acting insulin

Rather than skipping the dose, Reduce the dose to half

3. In type II DM

Dose reduced to one third

 Seizure:

1.If patients had 1st episode of seizure on the day of surgery

Should not do surgery

2. If patient is a known case of epilepsy and had last episode of seizure 5 years
back

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Surgery can be done. Because, patient is a known case

Must be taking AED’s (Anti Epileptic drugs)

3. Never stop AED before surgery

Because seizure episode can precipitated by

1) Hypoxia
2) Hypercarbia
3) Acidosis
seizure here will not stop,

It will lead to status epilepticus

4. All antiepileptic drugs should be continued till the day of surgery

5. Investigations that need to be done in a patient on AED’s before elective

surgery
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Liver function test (LFT)

 Thyroid Disorders

1. Hypothyroidism – reduced basal metabolic rate

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Metabolism of all anaesthetic drugs is decreased
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Results in very late / delayed recovery
So, continue all thyroxine supplementation

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2. Hyperthyroidism
. Continue all antithyroid medication
. Known Hyperthyroid patients for thyroid surgery
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Can precipitate Thyroid storm

3. How to optimize the patients

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Continue all thyroid related drugs

 Psychiatric Problems

- Patients on psychiatric medication

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Continue all antipsychotic medication
except MAO inhibitors

- Because older MAO inhibitors interact with synthetic opioids like meperidine
Fentanyl agents
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Resulting in increasing the catecholamine levels. Therefore, can precipitate
hypertensive crisis.

- So, older MAO inhibitors should be stopped

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3-4 weeks prior surgery

- Newer MAO inhibitors can be continued

- Lithium:

Li+, Mg+2 – interacts with muscle relaxants

So, should be stopped prior surgery. Lithium should be stopped 3-4 days prior
surgery

- With availability of newer drugs like

Atracurium / Cisatracurium / Mivacurium

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No need to stop

 If Patient is on oral contraceptive pills (Estrogen containing pills)

- There is increase chance of deep vein thrombosis (DVT)

- So, Estrogen containing pills are stopped 4 weeks prior surgery

- There is no such risk with progesterone only pills (POP’S)

 If patient is on steroid : Continue steroids

-Because abrupt stoppage of steroids causes disruption of HPA (Hypothalamo

pituitary adrenal) axis.

 If patients is on herbal medicine:

-LFT should be checked (most of them interact with liver)

-If LFT are normal, can proceed for surgery. Should stop 2 weeks prior to
surgery.

 If patient is on ATT (Anti Tubercular Therapy):

- Continue ATT
- But ATT drugs are enzyme inducers. So, LFT (liver function test)
should be checked.

 Past H/O MI and patient is on warfarin, Aspirin, clopidogrel

- Stop 5 days prior to surgery
- Low dose Aspirin can be continued.
- Ticlopidine (Congener of Clopidogrel) : Stop 14 days before surgery as
duration of action is 14 days
- Any regional anaesthesia procedure (for eg. Spinal | epidural |
Peribulbar block), there is risk of bleeding in closed cavity spaces.

So, spiral/ epidural will cause: permanent Paraplegia

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Peribulbar block will cause : complete blindness

- How to stop?
 Bridge the patient with LMWH to prevent another MI.
 Unfractionated Heparin should be stopped 6-8 hours prior to surgery.
 LMWH – should be stopped 10-12 hours prior
 Therapeutic dose of LMWH – 24 hours prior.
 Remove Epidural catheter after 10-12 hours only.
 Restart LMWH 2 hours after pulling out of catheter.

FAMILY HISTORY

 Malignant hyperthermia :
 Very rare disease
 Causes sustained contraction of muscles
 Presents as locked jaws (masseter spasm),
 Precipitating agent: All inhalational anaesthetics and succinylcholine
 Mutations in ryanodine receptor
 Family history of massive cardiac arrest and death on surgery table
 Because muscles are rapidly contracting: patient can go into
hyperkalemia, which leads to ventricular arrhythmias.
 Treatment:
(a) stop all anaesthetics
(b) Dantrolene sodium (2.5 mg/ kg) diluted in distilled water: repeat
every 15-30 minutes.
(c) calcium gluconate to stabilise the cardiac membrane as person is in
hyperkalemia.
(d) If patient is still in arrhythmia : ATLS protocol
(e) cool the temperature.

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PERSONAL HISTORY

 Smoking - ↑ chance of laryngospasm / bronchospasm during

anaesthesia
 Advice to stop smoking 6-8 weeks prior to surgery
 Alcohol consumption – an enzyme inducer
 Advice to stop 24 to 48 hours prior to surgery
 Tobacco chewing – Restricted mouth opening
o Submucosal fibrosis

o Difficulty in intubation

ALLERGIC HISTORY

(a) An Allergic drug – can cause anaphylactic shock

(b) M/C agent causing anaphylaxis/allergy is:- muscle relaxant > Latex
allergy > Antibiotics.
(c)
 First step of management – stop administering drugs
 DOC – injection Adrenaline – dose – 0.1 ml/kg 1: 10,000 dilution

(1 ampule = 1 ml = 1: 1000 concentration = 1 mg)

Or

Dilute 1 ml of adrenaline in 9ml of NS and give 1 ml depending on the

response as slow i.v.

(d) Incase of non-accessible i.v. line – give 0.5 ml 1 : 1000 s/c or I/M

ASA Grading

I. Normal healthy patient

II. Mild systemic disease with no functional limitations
Eg. HTN, DM, epilepsy – all under control
III. Moderate systemic disease with functional limitations

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 IV. Severe systemic disease which is constant threat to life

Eg unstable angina, MI

V. Moribund patient who is not expected to survive > 24 hrs

Eg. Mass RTA

VI. Brain dead patient

Advantages of grading:

 Can tailor the anaesthesia

 Can predict mortality and morbidity

PREMEDICATION IN ANESTHESIA

 Drugs given to smoothen the course of perioperative period: called

premedicant drugs.

Premedication

 To relieve Anxiety
- Reassurance
- By giving Benzodiazepine → increases cl- conductance
Hyperpolarizes the membrane

 Antiemetics

 Antibiotics

 To reduce secretions : Anticholinergics

Eg: Atropine

Glycopyrrolote

 Analgesics: Preemptive analgesia

 To decrease chances of aspiration