SPC: Anaesthetics & Perioperative Sung Yat Ng

Condition Pathology Signs & Symptoms Investigations Management

Airway Magnement Airway Maintenance Airway Adjuncts Cricothyroidotomy

• To prevent airway obstruction from the tongue: chin lift • Used to help secure an airways, and maintain it in an opened state • Used as an emergency surgical airway
or jaw thrust manoeuvres 1. Needle Cricothyroidotomy
• To maintain airway control: • Performed by passing a large IC canal into the
1. Holding a mask onto face cricothyroid membrane
2. Inserting a laryngeal mask airway • Only used in children
3. Intubation 2. Surgical Cricothyroidotomy
• Remove any obstruction with Magill’s forceps or • Similar to PCT but at cricothyroid cartilage
Yankauer sucker
Percutaenous Tracheostomy (PCT)
Basic Manoeuvres • Inserted subglotically through the neck tissues directly
• Head tilt and chin lift: standard technique to open into the trachea
airway where there are no risk of C-spine injury • Involves Seldinger technique and dilation of the trachea
• Jaw thrust in any trauma patient between cartilage rings before passing the
tracheostomy tube
Airway Adjuncts
• Used to help secure an airways, and maintain it in an PCT: Indications
opened state 1. Bypassing upper airway obstruction
2. Prolonged mechanical ventilation
Difficult Airways 3. Requirement for airway protection and need for
1. Obese frequent suctioning
2. Short neck
3. Impaired neck flexion and extension PCT: Advantage over ETT
4. Receding chin 1. Patient can communicate by phonation
5. Protruding teeth 2. Sedation is reduced as more comfortable than ETT
6. TMJ disorder 3. Nursing care is easier
7. Fractured mandible 4. Better for long-term ventilation

Management Pathway PCT: Complications

1. Bleeding, hypoxaemia, loss of airways, injury to
posterior trachea wall, pneumothorax
2. Dislodgement and obstruction of tube, trachea-
oesophageal fistula, stenosis of trachea and swallow
dysfunction
3. Air required humidification

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SPC: Anaesthetics & Perioperative Sung Yat Ng

Condition Pathology Signs & Symptoms Investigations Management

Ventilation Mouth-to-Mask Ventilation
1. Head tilt & chin lift: maintain neck in extended position
2. Apply mask to patient’s face, ensuring tight seal by
using 2 hands: thumbs and forefingers making a c-
shape on the mask, other fingers lifting the angle and
ramus of mandible
3. Blow a normal breath through the inspiratory valve
and watch for chest rise and fall
Bag-Valve-Mask Ventilation
• Used in pre-operative and emergency setting to
ventilate a patient no longer breathing on their own
• Prior to establishing a secure airway or secure airway
1. Apply mask to patient’s face, ensure tight seal by
using 2 hands
2. Gently seizure the bad by 2/3rd at rate of 10-12
breaths per minute
Non-Invasive Ventilation
• Application of ventilatory support without using an
invasive artificial airway
• Delivered via a sealed face-mask, nasal mask or helmet
• Indicated in HDU level support but not yet intimation
• Patient must be conscious to maintain airway
• Positive pressure is applied drive oxygen into the lungs:
Invasive Mechanical Ventilation
• Intubation is necessary
• Requires closed circuit between ventilator and lungs:
removes effect of thoracic cage
• Allows tight control of pressures in ventilation
Indications
1. Respiratory or cardiorespiratory arrest
2. NIV is failing to reduce PaCO2 or maintain SPO2
3. Surgical procedures requiring paralysis
4. Sedated patient in ITU setting that is not self-
ventilating

• Mechanical ventilation is titrated to give appropriate

inspiratory and expiratory airway pressures

Hypoxia: T1RF
• Hypoxia is determined by FiO2 and PEEP
• PEEP: positive end expiratory pressure and increased
by CPAP
• T1RF: CPAP is sufficient
• Start at 4cm H2O and increased to maximum 12cm H2O

Hypercapnia: T2RF
• Hypercapnia is determined by minute volume
(respiratory rate x tidal volume)
• Tidal volume is determined by pressure support
• T2RF: requires BiPAP
• Start at 12/4cm H2O and increased to maximum
20/12cm H2O

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SPC: Anaesthetics & Perioperative Sung Yat Ng

Condition Pathology Signs & Symptoms Investigations Management

Oxygen Therapy Defintion Nasal Cannulae Non-rebreathe Masks Indications

• Administration of oxygen at concentrations greater than
that in ambient air: with intent of treating or preventing
hypoxia
Saturations
• Referred to as SpO2 (peripheral) and SaO2 (arterial)
• When partial pressure of oxygen in blood is reduced:
hypoxaemia
• This can cause hypoxia: insufficient oxygen reaching
body tissues
Indications
• Widely used as comfortable and well tolerated
• Every extra L/min give 3-4% more oxygen above air
concentration
• Variable performance: inspired oxygen concentration is
dependent on rate/pattern/depth of breathing
• Simple face masks with reservoir bag attached
• Give fixed oxygen concentration
• Achieve high oxygen concentrations, with 60-90%
oxygen at a 10-15 L/min flow rate
• Not suitable for long term use as gas cannot be
humidified
Venturi Masks
• Fixed oxygen concentrations: high air flow oxygen
entrainment
• Generated 30L/min flow rate at different ratios of
entrained air and oxygen

Humidification
Simple Face Masks • Takes place in the upper airways
• 35-50% oxygen at flow rates of 5-10L/min • LTOT can dry out nasal mucosa leading to nose bleeds
• Attached to 100% oxygen: but extensive air entrainment and poor tracheobronchial clearance
through holes in the mask
• Bearable performance: inspired oxygen concentration is
dependent on rate/pattern/depth of breathing

Prescribing O2
• Healthy patients have oxygen saturations >94% and
peak inspiratory flow rate of 25-30L/min

Pulse Oximetry and Capnography Pulse Oximetry

• Over 90% of oxygen in the bloodstream is carried bound
to haemoglobin
• Each molecule of haemoglobin is 100% saturated when
carrying 4 molecules of oxygen
• Oxygen saturation: saturated haemoglobin/total
haemoglobin x100

Light Absorption
1. Saturated haemoglobin appears redder in colour as it
absorbs more high frequency blue light
2. Reduced haemoglobin absorbs more low frequency
red visible light and appears bluer in colour
3.

Post-operative Pain Management

Post-operative Nausea & Vomiting

Local Anaesthetics Mechanism of Action

• Prevent transmission of painful stimulus reaching the
CNS
• Achieved by inhibition of sodium influx through sodium-
specific voltage gated channels in the neuronal cell
membrane: prevents action potential generation and
conduction of nerve impulses

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SPC: Anaesthetics & Perioperative Sung Yat Ng

Condition Pathology Signs & Symptoms Investigations Management

Pre-operative Assessment for Anaesthesia ASA Score Medication • Investigations should be guided by age, history, Prophylactic Antibiotics
• Used to reflect the health of patient at the time of • Drugs that can be taken to take on the morning of examination and proposed surgery • GI surgery and joint replacement
surgery surgery • 15-60 minutes prior to surgery
1. ACEi Bloods • Regimens vary according to local guidelines:
2. Antibiotics 1. FBC
3. Beta-blockers 2. U&Es: diuretics, diabetes, burns, major trauma,
4. Digoxin hepatic or renal or TPN
5. Statins 3. Blood glucose
6. Bronchodilators 4. G&S + crossmatch
7. PPIs 5. LFTs: jaundice, malignancy or alcohol
8. Steroids 6. Clotting: liver disease, DIC, massive blood loss or use
9. Anticonvulsants of anticoagulants
7. Sickle-cell test
• Drugs that should not be taken on morning of surgery 8. TFTs

Further Investigations
1. Spirometry
2. CXR
3. ECG
4. Echocardiogram
5. Lateral C-spine x-ray
6. MRSA swabs

Fasting
• No food intake for up to 6h before operation
• No clear fluid 2h before operation
• Chewing gum and boiled sweets up to 2h before
operation

Venous Thromboembolism Prophylaxis

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SPC: Anaesthetics & Perioperative Sung Yat Ng

Condition Pathology Signs & Symptoms Investigations Management

Principle of General Anaesthesia Introduction Induction Inhalation Induction N 2O & O 2

• Unable to create response to pain IV Induction • Most commonly used: sevoflurane in oxygen or nitrous • Volatile anaesthetic agents are usually combined with
• No movement • Rapid loss of consciousness and relatively predictable oxide nitrous oxide and oxygen as this can be used to spare
• No dreaming (as dependent on passive pharmacokinetic processes the amount of anaesthetic required to maintain
• Respiratory depression unlike inhaled induction) Indications anaesthesia
• Reduced swallowing and cannot maintain airway 1. Difficult veins
2. Difficult airways N 2O
Components of GA 3. Needle-phobic • Colourless odourless gas with analgesic properties (blue
1. Lack of awareness (Hypnosis) bottles)
2. Prevention of movement (Muscle relaxation) Advantages • Diffuses into air spaces and cause then to enlarge: can
3. Analgesia and no response to noxious stimuli 1. Slower onset of hypnotic effects lead to adverse effects
• GA prevents pain generated peripherally from 2. More control over cardiovascular and respiratory side • Entonox (gas & air): 50/50 mix of N2O & O2 used for
being interpreted as pain by CNS effects analgesia
• Does not stop transmission of painful stimuli from • Avoid in pneumothorax (as diffuse into airspace and
source of pain Disadvantages enlarge)
• Induced slowly if the patient is unwell of elderly 1. Need for patient cooperation and skilled practitioners
Balanced Anaesthesia 2. Speed of action dependent on Sevoflurane
• The components of anaesthesia are achieved by using Pharmacokinetics
• Drug solubility • Fluorinated methyl-isopropyl ether
a combination of drugs: balanced anaesthesia • IV anaesthetics have a rapid onset
• Respiratory rate and depth • Widely used
• Combination of • However, redistribution of the drug into fat also very
• Cardiac output • Yellow bottle
1. Anaesthetic rapid • MAC: 2% (not veery potent)
2. Analgesic • Redistribution lowers plasma concentration of the drug Rapid Sequence Induction • Very insoluble therefore produces a rapid indiction (but
3. Muscle relaxant to “wake-up” concentration very quickly Indications wears off very quickly)
• Single anaesthesia can achieve all components but • Clearance of the drug through liver and kidney is very • Risk of aspiration is high • Non-irritant and cardiovascularly stable
risks respiratory and cardiac depression slow 1. No fasting
• Balanced anaesthesia reduces side effects as the dose 2. GORD Desflurane
of each component is lower Propofol 3. Pregnancy • Low potency fluorinated methyl-ethyl ether
• Most common • Light blue bottle
Drug Routes • GABA receptor agonist Methods • MAC: 6%
• Induction and maintenance of anaesthesia can be with • Insoluble in water: suspended in white soybean egg • Involves pre-oxygenation and cricoid pressure followed • Irritant: unpleasant for patients
IV or inhaled agents phosphatide emulsion by an IV induction and administration of a muscle • Rapid onset
• Rapid wake-up and does not accumulate relaxant then immediate ET intubation and release of
Premedication • Anti-emetic cricoid pressure Enflurane & Isoflurane
• Used to decrease anxiety and pain • Pain on injection: add lidocaine • Minimises air entering the stomach and hence • Fluorinated ethers
• Induce amnesia without loss of consciousness • Not good for patients with heart problems: leads to regurgitation • Enflurane MAC: 1.68%
• Given 30min to 2h prior to surgery (not universal) depressed myocardial function/hypotension • Isoflurane MAC: 1.15%
1. Anxiolytic/amnesia • CI: <17, very elderly, egg or soya bean allergy Muscle Relaxants • Both irritant and cause vasodilation
2. Analgesia • Max 4mg/kg/hr 1. Suxamethonium • Rarely used: risk of epileptic activity and renal damage
3. Antiemetics 2. Atracurium
4. Antacids Etomidate Halothane
5. Anti-sialogogues • Less commonly used as infusion can lead to adrenal Maintenance • Halogenated hydrocarbon
6. Antibiotics prophylaxis suppression and myoclonus • Maintenance of anaesthesia most common done by • MAC: 0.75%
• Imidazole ester dissolved in propylene glycol inhalational techniques • Not stable in light
Conscious Sedation • Does not accumulate • Non-irritant
• A form of semi-hypnosis: patient is rousable and can talk • Higher rates of post-op vomiting Ideal Properties • No longer used due to risk of halothane hepatitis
but no memory of events • Max 40mg 1. Non-flammable
• Useful in non-surgical procedures 2. Pleasant to inhale (non-irritant) Inhaled Anaesthetic Agents Side Effects
• Benzodiazepines (midazolam) are used Thiopentone 3. Fast onset (low blood; gas solubility) 1. Myocardial depression
• Used in obstetrics 4. High potency (high lipid:water solubility) 2. Malignant hyperthermia
• Very long half life and take several days to clear 5. Minimal effects on other systems or metabolism
• Works rapidly: used for rapid sequence intubation Monitorting
• Preserves laryngeal reflexes: Laryngospasm Potency: MAC 1. Rate and depth of respiration
• Best anti-epileptic GA • Anaesthetic should be potent and fast acting 2. HR and arterial oxygen saturation via pulse oximeter
• Measure of anaesthetic potency is MAC: minimal 3. Temperature
Ketamine alveolar concentration: the concentration of 4. BP: may be intra-arterial in difficult cases
• Phencyclidine that antagonises the NMDA receptor anaesthetic in the alveoli required to produce 5. ECG
• IV or IM preparation immobility in 50% of patients 6. Central venous pressure
• Allows partial maintenance of airway • MAC is therefore an inverse indicator of anaesthetic 7. Capnography
• SE: vivid dissociated nightmares, disorientation, potency 8. Urine output
hallucination • Doses given are higher than MAC as potency differs 9. Neuromuscular status
• Has little myocardial depression bases upon sex, height, weight, other genetic factors
• Suitable for haemodynamically unstable patients End of Anaesthesia
MAC & Lipid Solubility 1. Change inspired gasses to 100% oxygen only
• MAC is inversely proportional to lipid solubility: the more 2. Discontinuation of any infusion of anaesthetic drugs
lipid soluble the anaesthetic: the lower the dose that has 3. Use peripheral nerve simulator to ensure spontaneous
to be given reversal has occurred and reverse any residual
• Lipid solubility is the main determinant of anaesthetic muscle paralysis with neostigmine and an anti-
potency cholinergic
• MAC is measured in exhaled air: virtually equal to brain 4. Remove ET once spontaneously breathing and
tensions of the agent administer oxygen via facemask

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SPC: Anaesthetics & Perioperative Sung Yat Ng

Condition Pathology Signs & Symptoms Investigations Management

Cardiac Disease Ischaemic Heart Disease
Respiratory Disease • Very common condition in surgical patients: reduction in
blood flow and oxygen delivery to cardiac muscle
IHD: Pre-op Investigations
1. Contractile function (echocardiogram)
2. Function of any stents or bypass grafts
3. Use of anti-platelet medications
4. Functional capacity assessment, ECG, exercise
testing
Effects of IHD on Anaesthesia
1. Slow circulation: reducing anaesthesia induction
speed
2. Pulmonary oedema: imparting respiratory function
3. Higher risk of arrhythmia
IHD: During & After
1. Avoidance of tachycardia and abnormal blood
pressures
2. Supplemental oxygen for up to 4 days
Atrial Fibrillation
• AF leads to ~15% reduction in cardiac output
• Slows the induction of anaesthesia
• Anticoagulation can have an impact on anaesthesia and
surgery: increased bleeding risk
Hypertension
Effects of HTN on Body Systems
1. Strain on the hart, coronary artery disease, cardiac
aneurysm
2. Vascular disease
3. Renal failure
4. Increased risk of stroke and other CNS bleeds
5. Retinopathy
Treatment
• Antihypertensive treatment should be continued
into preoperative period
• BP >180/110: investigations into associated cardiac or
renal damage before any elective surgery
Cardiac Valve Disease
• Patients likely to be taking anticoagulant medications
(Mitral valve diseases: warfarin)
• Antibiotic prophylaxis against spontaneous bacterial
endocarditis if abnormal valves
Congenital Heart Disease
• ASD and VSD
• Increased risk of endocarditis
• Antibiotic prophylaxis given prior to intubation
Pacemakers
• May be interfered with diathermy
• Bipolar diathermy reduces pacemaker interference
Asthma
• Small amounts of aspiration, laryngeal irritation and
painful stimuli: bronchospasm
Pre-Op
1. Peak flow or spirometry to assess severity
2. Preoperative doses of inhaled medication given via
nebulisers
3. Bronchospasm is reversible: therefore be managed
during surgery with oxygen driven nebulised
salbutamol at high doses
COPD
• Marked reduction in FEV1: less reversible than asthma
• Patients can be bronchodilator to a certain extent and
therefore managed same way as asthma in preoperative
period
• Inhalation anaesthesia (esp induction) is less effective in
COPD due to emphysematous dead space
Pre-Op
1. Pulmonary function tests
2. ABG
3. Assessment of infection status

Diabetes Key Aims Minor Surgery Regimen: NIDDM

1. Optimisation of glycemic control prior to surgery
2. Prevention of hypoglycaemia and ketoacidosis during
surgery: blood glucose measurement prior to induction
of anaesthesia
3. Maintenance of blood-sugar levels and recovery from
metabolic stress of surgery
1. Omission of oral hypoglycaemic agents on day of
surgery
2. Omission of metformin 28h prior to surgery
3. Restart medication when patient is eating
4. Restart metformin after 4 days

Considerations
1. Dipstick for proteinuria
2. Venous glucose
3. U&Es: K

Renal Disease
Liver Disease

Steroids
Anticoagulation

Malignant Hyperpyrexia Malignant hyperthermia (MH) is a rare, serious side effect

of volatile liquid anaesthetics (isoflurane, desflurane,
sevoflurane), which cause all skeletal muscle to rapidly
contract, including during a neuromuscular blockade. MH
is a genetic disorder, manifesting due to calcium overload
in the skeletal muscle causing sustained muscular
contraction and rhabdomyolysis, resulting in excess
anaerobic metabolism causing acidosis. End-tidal CO2
increases as a result, along with body temperature which
causes diaphoresis (excess sweating). This patient has
exhibited the typical signs described, directly after
administration of sevoflurane, making MH the correct
answer.

Types Description

CPAP • Continuous positive airway

pressure

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SPC: Anaesthetics & Perioperative Sung Yat Ng

Types Description

BiPAP • bi-level positive airway pressure

• Air pressure increased during
inspiration

Score Description

1 • Normal and healthy

2 • Mild systemic disease

• But no limitation of activity

3 • Severe systemic illness that limits activity

• Not incapacitating

4 • Incapacitating systemic disease which poses a

threat to life

5 • Moribund
• Not expected to survive 24h even with
operation

6 • Brain stem dead

• Organs harvested for donor purposes