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Hany El-Zahaby, MD
1. History -Current problem -Other known problems -Medical history (allergies, drug intolerance, present therapy, tobacco and alcohol intake) -Previous anesthetics, surgeries, deliveries -Family history -Review of organ systems -Last oral intake
2. Physical Examination -Vital signs -Airway (Thyromental distance, Malampati sign) -Heart -Lungs -Extremities -Neurological examination
glucose. creatinine: age >60 y ECG: age >40 y Chest radiograph: age >60 y Pregnancy test: fertile women .Preoperative Evaluation 3. anticipated significant blood loss S. age >60 y. Routine Laboratory evaluation (healthy asymptomatic) Hematocrite: All menstruating women.
08%) Mild systemic disease (0.8-4. not expected to live 24h (9.06-0.4%) Severe systemic D.8-23%) 5 6 Moribund.27-0.3%) Severe systemic D that is a constant threat to life (7.American Society of Anesthesiology Risk Classification ASA Class Description 1 2 3 4 Normal.4-51%) Care for organ donation . not incapacitating (1. healthy (0.
maintenance. relaxant) Regional (technique. positioning. induction. agents) Intraoperative management Monitoring.The Anesthetic Plan Premedication Type of anesthesia General (airway. fluids. ICU (ventilation. monitoring) . special techniques Postoperative management Pain control. MABL.
regional. local.Preoperative Evaluation Informed consent Gives the patient explanation of the options for anesthesia and its realistic risks (general. topical.g. consent must always be taken for GA if other techniques prove inadequate e. LA . intravenous sedation) Regardless of the technique chosen.
confusion. pain. paralysis. waking up during surgery.The Anesthetist-Patient relationship Is The Patient Scared? Surgery (cancer. headache) . death) Anesthesia (loss of control. not waking up. physical disfigurement. nausea.
Preoperative Evaluation 1-Unhurried. clear fluids up to 2-3 h unless GER) Time of surgery Premedication and other daily medications Tasks to occur on the day of surgery Postoperative recovery or ICU . organized interview 2-Calm reassurance and expression of interest in the patient’s well being 3-Informing about: NPO (no solids after m.n..
intense prolonged amnesia and sedation Midazolam (1-3 mg IV or IM) at the receiving area.5 mg/kg PO for pediatrics . unpredictable) Lorazepam (1-2 mg PO). 0. never IM (pain.Premedication Benzodiazepines: Diazepam (5-10 mg PO 1-2 hours before surgery).
2-0.Premedication Narcotics: painful fractures. planned extensive awake invasive monitoring devices Morphine 5-10 mg IM 60-90 min before surgery Anticholinergics (rare): Not Routine Glycopyrrolate 0.4 mg IV to reduce oral secretions (fibreoptic intubation) .
ileus. CNS depression H2 blockers (ranitidine. hiatal hernia. difficult airway.Premedication Prophylaxis for pulmonary aspiration: Pregnant. obesity. 150-300 mg PO before bedtime and early morning) Nonparticulate antacids (sodium citrate 30-60 ml) Metoclopramide (10 mg IV 1h before surgery to enhance gastric emptying) . GER.
neurologically obtunded. severe pulmonary or obstructive valvular disease . facilitate smooth induction Reduce the dose or withhold in elderly.Premedication Goals: Reduce anxiety. upper airway obstruction or trauma. debilitated. pain during vascular cannulation and regional blocks. central sleep apnea.
end-tidal carbon dioxide.Monitoring Standard monitoring for GA: ECG. inspired oxygen concentration Standard monitoring for regional anesthesia: ECG. respiratory rate. non-invasive BP. respiratory rate. oxygen saturation. non-invasive BP. oxygen saturation .
better under local anesthetic infiltration) .IV access IV access: (14-16 G if rapid fluid or blood transfusion or continuous drug infusions.
Components of GA Loss of consciousness Loss of reflexes (Movement to pain) Analgesia Amnesia Relaxation .
Induction of Anesthesia
The environment in OR should be warm with minimal noise and all attention focused on the patient Supine position with extremities in neutral position and head on firm pillow raised to ‘’sniff’’ position
Induction of Anesthesia
Techniques: 1- IV induction preceded by oxygen via face mask until loss of consciousness using thiopentone or propofol 2- Inhalational anesthetics either by low concentration with incremental increase every 3-4 breaths or by a single vital capacity breath technique using sevoflurane or halothane
3-5 mg/kg ----Slower onset, slower recovery Hypotension ++
2-2.5 mg/kg IVI 6-10 mg/kg/h
Painful injection Rapid induction, rapid clearheaded recovery Hypotension +++
Contraindicated in porphyria
Airway Management Face-mask with: Oro-pharyngeal airway Naso-pharyngeal airway LMA ETT with a muscle relaxant (depolarizing as succinyl choline or non-depolarizing as tracrium. rocuronium) . cistracrium.
e. causes depolarization of the motor end plate and muscle membrane but for longer time than Ach.Muscle Relaxants Depolarizing MR (succinylcholine) mimics the action of acetylcholine i. Used for rapid-sequence induction in patients with full stomach Non-depolarizing MR produce reversible competition with Ach at the motor end plate that produce relaxation for longer duration .
increase intracranial pressure. K+ level by 0.Succinylcholine Dose:1mg/kg produce relaxation in 1 min Side effects: Muscle pains. malignant hyperthermia .5-1 mEq/L. prolonged block due to decrease or inhibition or atypical plasma cholinesterase. increased intragastric pressure. increase intraoccular pressure. ganglionic stimulation. increase S.
hepatic metabolism (short duration) .5 mg/kg.15 mg/kg.Non-Depolarizing MR Atracurium: 0.1 mg/kg.5 mg/kg. less histamine release Vecuronium: 0. hepatic metabolism Rocuronium (Esmeron): 0. Hofmann elimination Cisatracurium (Nimbex): 0. Hofmann elemination.
Twitch Height After Succinyl Choline .
Twitch Height After Non-Depolarizing .
single twitch TOF response =1 TOF response =3 TOF ratio > 0. Possible extubation Normal VC . Surgical relaxation with inhalation anesth.75 TOF ratio = 1 Clinical correlate Good intubating condition Surgical relaxation without inhalation anesth.Clinical Assessment of the Blockade Evoked response 95% -.
opioids. inhalation anesthetics.Laryngoscopy and Intubation Profound sympathetic responses (hypertension. lidocaine. or beta blockers . tachycardia) can be attenuated by hypnotics.
5cm .5 2 Y: 4.ETT Size Premature: 2.5 Length (at mouth cm): 10+(age/4) ► 10 +(6/4) ►11.5-3 Full term: 3 6 M -1 y:3.5 Over 2y: 4+(age/4)► 4 +(6/4) ►5.
Positioning Movement of supine anesthetized patient into another position may cause hypotension due to lack of intact compensatory hemodynamic reflexes. Hyperextension or over-rotation of the neck and limbs must be avoided. . Patient’s head and limbs should be protected and padded.
Maintenance Depth of anesthesia (surgical anesthesia) +Muscle relaxation Signs of inadequate depth of anesthesia: Somatic responses (movement. changes of respiratory pattern) Autonomic responses (tachycardia. hypertension. tearing) . coughing. sweating. mydriasis.
no somatic or autonomic responses Depressed respiration. divergent gaze. constricted pupils. irregular breathing Central gaze. regular respiration. dilated pupils.Stages of General Anesthesia Stage I Amnesia Stage II Delirium Stage III Surgical anesthesia Stage IV Overdosage From induction to loss of consciousness. pain perception is maintained Exaggerated responses to noxious stimulus. marked hypotension . dilated fixed pupils.
nitrous oxide-opioidrelaxant with minimal inhalation anesthetic and controlled ventilation (Balanced anesthesia) TIVA: Continuous infusion of propofol-opioid + muscle relaxant (nothing through inhalation) . minimal opioids with nitrous oxide and inhalation anesthetic If muscle relaxation is needed.Maintenance If spontaneous breathing is needed.
Inhalation Anesthetics Blood-gas partition coefficient is inversely related to the rate of induction MAC: minimal alveolar concentration that prevent movement in response to a skin incision in 50% of patients .
0 .15 2.3 1.05 Desflurane 0.47 2.69 MAC 104 0.42 6.74 1.Inhalation Anesthetics Blood/gas PC Nitrous oxide Halothane Isoflurane Sevoflurane 0.4 0.
Ventilation Spontaneous/assisted: All inhalation anesthetics depress respiration and moderately increase PaCO2 Can be affected by positioning. peritoneal insufflation. surgical packing and opioids . open chest.
If>30. RR=10-12/min. notice the PIP. decrease TV and increase RR A sudden drop in PIP → circuit leak A sudden increase in PIP → kink. endo-bronchial intubation. peritoneal insufflation .Ventilation Controlled Ventilation: Initial setting with TV=10-15 ml/kg.
IV Fluids Maintenance: first 10kg→ 4ml/kg/h Second 10 kg → 2ml/kg/h After 20 kg → 1 ml/kg/h Third-space loss: Tissue edema and evaporation. varies from 5-10 ml/kg/h Blood loss: Replaced in 1:3 with isotonic crystalloid. or 1:1 with blood .
IV Fluids (60 kg fit adult fasting for 6h) 1st h Fasting Maintenance (100ml/h) 3rd space Blood loss 300 100 5x60=300 -- 2nd h 150 100 5x60=300 -- 3rd h 150 100 5x60=300 -- Total 700 550 550 .
Estimated Allowable Blood Loss 70 kg. Hct 35 EABL = EBV X (Hctstart-Hctallowable) Hctstart EABL = 4900 X (35 – 27)= 980ml 35 .
with present Hct of 23 Volume=EBV X (Hctdesired .Estimating Volume of Blood to be Transfused 70 kg.Hctpresent) Hct transfused blood Volume=4900 X (30-23) =490ml 70 .
cannot aspirate and can be assessed neurologically Technique: withdraw anesthetics near the end of surgery. responsive with full muscle strength so he can maintain patent airway.4 mg/kg) .06 mg/kg) and atropine (0.2-0. reverse muscle relaxation with neostigmine (0.03-0.Emergence from GA Goals: awake.
avoid stimulation of the airway during stage II . tonsillectomy if full stomach Mask ventilation: 100% oxygen.Emergence from GA Environment: Warm and calm Positioning: Supine.
follow simple verbal commands.Emergence from GA Extubation: 1-Awake (desirable) with fully recovered protective reflexes. hernia repair) .Deep extubation (during stage III) reduce risk of laryngospasm and bronchospasm (in asthmatic) avoid coughing ( eye surgery. breathe spontaneously with good oxygenation and ventilation (lidocaine 1mg/kg IV) 2.
airway obstruction. fentanyl 25μg IV or morphine 2mg IV increments Delayed awakening: Continue ventilatory support and airway protection and reverse the etiology . Treated by treating the cause.Emergence from GA Agitation: due to hypoxia. full bladder. pain or sevoflurane and desflurane anesthesia. hypercarbia.
monitors. tools for re-intubation to PACU or ICU Anesthetist should give concise but thorough summary to PACU or ICU staff .Transport Stable patient can be transferred without oxygen or monitor to PACU Unstable patient should be transferred with oxygen.
acute postoperative pain management is now based on multimodal analgesia and opioid sparing .Acute postoperative pain management Optimal pain control is an integral component of accelerated recovery Although opioids are the most effective.
Acute postoperative pain management Psychological Preparation Assessing Pain (0-10 Verbal Analogue Scale is now the fifth vital sign to be recorded in the record) Preemptive Analgesia (peripheral injury ►central sensitization ►increase pain sensitivity .
1 gm/6h ..NSADs: Oral alone ► mild to moderate pain. expensive. can replace opioids Paracetamol (Perfalgan).Acute postoperative pain management Treatment Options: 1. gastric irritation. begin preop. coagulopathy. mask fever Oral with opioids ►reduce opioid intake Parentral ►keorolac 30 mg then 15-30 mg/6h.
Opioids: PO (chronic pain) IM ( morphine 0. max 10-15mg) IVI ( morphine 10. unreliable IV-bolus (morphine 2mg every 5 min. pethidine 1mg/kg) painful.Acute postoperative pain management 2.1mg/kg.20 μg/kg/h) Monitor the respiratory rate .
start dose.PCA: Provide analgesic doses immediately based on patient needs using microcomputer-controlled infusion pumps which avoids extreme swings in plasma levels.Acute postoperative pain management 3. delay time. verbal response) . basal rate) and monitoring (pain level. Special order sheet is needed with detailed pump setting (demand dose. sedation level.
surgery Contraindications: patient refusal.Acute postoperative pain management 4. vascular & L. coagulopathy. LMWH. local infection 0. epidural hematoma or abcess . PDPH.1% Bupivacaine + 1-2 µg/ml Fentanyl ►5-10 ml/h ▼Bupivacaine if hypotension or motor block ▼Fentanyl if pruritis Complications: Inadequate analgesia.Epidural Analgesia Abdominal .L. bacteremia.
4 mg (Respiratory depression) 6.1-0. children) .Acute postoperative pain management 5.Neuraxial Morphine (preservative-free) Epidural: 1-4 mg Intrathecal: 0.Intraoperative Neural Blockade (esp.
Local Anesthetics Ester/ Amide Aromatic Ring Amine .
tetracaine (metabolised by plasma esterase. chloroprocaine. bupivacaine. ropivacaine (liver metabolism) . allergen) Amides: lidocaine.Local Anesthetics Esters: procaine.
Local Anesthetics Potency ►lipophilicity Duration ► protein binding Onset ► pKa (pH at which 50% are uncharged ions ► diffuse to nerve membrane) .
►proprioception ►touch & pressure ►motor Additives: Epinephrine 1:200. ▼surgical bleeding Sodium bicarbonate: 1 meq:10ml lidocaine. 0.Local Anesthetics Sequence of block: Sympathetic ►pain & temp.1meq:10 ml bupivacaine (avoid ppt)►fasten onset . ▲intensity of block. ▼systemic toxicity.000►prolong duration.
muscle twitching. Bupivacaine) Treatment: oxygen. cicumoral numbness. metallic taste..LA: Systemic Toxicity CNS Light-headedness. loss of consciousness Treatment: stop injection. VD ►collapse (esp. seizures.. midazolam 1-2 mg. visual disturbance. oxygen. vasopressors ►ACLS . tinnitus. volume. thiopentone 50-200 mg CVS ▼contract. ▼ conduct.
5% 2-3 mls .Local Anesthetics: Spinal Anesthesia Spinal Needle: 25G pencil point with 19G introducer Position: Sitting or lateral Level: L3-4. L4-5 Approach: Midline or paramedian Drugs: Bupivacaine (Heavy) 0.
caffeine 30mg. IV fluids.5-1L of LR before the block. ephedrine 5-10 mg boluses Bloody tap► if does not clear rapidly. withdraw & reinsert Nausea & vomiting ►treat hypotension Apnea (total spinal) ►support ventilation PDPH: bed rest. epidural blood patch .Local Anesthetics: Spinal Anesthesia Complications: Hypotension►0. analgesics.
25% 15-20 ml Techniques: Loss of resistance Hanging drop method Test dose: 3 ml lidocaine 1% with epinephrine 1:200.0.Local Anesthetics: Epidural Anesthesia Epidural Needle: 17G Tuohy needle Position: Sitting or lateral Level: L3-4.000 . L4-5 Approach: Midline or paramedian Drugs: Bupivacaine 0.125.
Local Anesthetics: Epidural Anesthesia Drugs: 1.5 ml/segment Decrease dose 50% in old age Decrease dose 30% in pregnancy Epinephrine increase duration Opioids (fentanyl 50-100 µ) improve the quality Sodium bicarbonate speeds the onset .
partial bevel insertion) Insertion into a vein (withdraw) Catheter break off (inform patient & leave it) .Local Anesthetics: Epidural Anesthesia Complications: Dural puncture 1% ► Convert to spinal ► Reinsert one space above Inability to thread the epidural catheter (too lateral.
Local Anesthetics: Combined Spinal-Epidural Anesthesia Combine advantages and avoid disadvantages of both techniques Rapid onset. less volume Longer time. more control on level . solid sacral block.
200.000 Epinephrine reach T6-8 level .Local Anesthetics: Caudal Epidural Through the sacrococcygeal membrane Can reach high level in children: 1 ml/kg Bupivacaine 0.25% with 1.2-0.
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