A

Anesthesia and Peri-Operative Medicine

Alexander Huang. Lindsay MaclCenzie and Pamela Lau, chapter editors Alaina Garbens and Modupe Oyewumi, associate editors Adam Gladwish, EBM editor Dr. Isabella Devito and Dr. Ryan Mai, staff editors
Anesthesia Basics ....................... 2 Pre-Operative Assessment .. 2 History and Physical Pre-Operative Investigations Fasting Guidelines American Society of Anesthesiology (ASA) Classification Pre-Operative Optimization ............... 4 Medications Hypertension Coronary Artery Disease (CAD) Endocrine Disorders Respiratory Diseases Aspiration Monitoring ............................. 5 Induction Agents ........................ 6 Intravenous Agents Volatile lnhalational Agents Muscle Relaxants and Reversing Agents Airway Management .. 7 Airway Anatomy Review Tracheal Intubation Rapid Sequence Induction (RSI) Difficult Airway Intraoperative Management .............. 10 Oxygen Therapy Ventilation Temperature Heart Rate Blood Pressure Fluid Balance and Resuscitation IV Fluids Blood Products Extubation ............................ 17 Post-Operative Care . . . . . . . . . . . . . . . . . . . . 17 Pain Management . . . . . . . . . . . . . . . . . . . . . . 17 Regional Anesthesia .. 19 Definition of Regional Anesthesia Preparation for Regional Anesthesia Epidural and Spinal Anesthesia Peripheral Nerve Blocks Local Anesthesia ....................... 21 Local Anesthetic Agents Local Infiltration, Hematoma Blocks Topical Anesthetics Obstetrical Anesthesia .................. 22 Pediatric Anesthesia .................... 23 Uncommon Complications ............... 24 Malignant Hyperthermia (MH) Common Medications ................... 25 Intravenous Induction Agents Opioids Volatile lnhalational Agents Depolarizing Muscle Relaxants Non-Depolarizing Muscle Relaxants Reversal Agents for Non-Depolarizing Relaxants Local Anesthetic Agents References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Toronto Notes 2011

Anesthesia AI

A2 Anestheaia

Anestheaia Buies/Pre-Operative Assessment

Toronto Notes 2011

Anesthesia Basics
6 Ns of General Anesthesia
1. Anesthesia 2. Anxiolysis 3.Amnesia 4. Areflexia (muscle relaxation not always required) 5. Autonomic Stability 6. Analgesia
Types of Anesthesia

general
general anesthesia total IV anesthesia (TIVA)

regional
spinal, epidural peripheral nerve block IV regional local local inltration topical sedation monitored anesthesia care note that different types of anesthesia can be combined (e.g. general+ regional)

Pre-Operative Assessment
to identify the patient's medical and surgical issues; to allow for the arrangement of further investigations, consultations and treannents for patients not yet optimized; and to plan anesthetic techniques

History and Physical

History indication for surgery surgi.callanesthetic Hx: previous anesthetics/complications, previous intubations, medications, drug allergies PMHx CNS: seizures, stroke, raised intracranial pressure (ICP), spinal disease CVS: coronary artery disease (CAD), myocardial infarction (MI), congestive heart failure (CHF), hypertension (HTN), valvular disease, dysrhythmias, peripheral vascular disease (PVD), conditions requiring endocarditis prophylaxis, exercise tolerance, CCS class, NYHA class (see Cardiology and Cardiovascular C33 for NYHA classi1ication) respiratory: smoking, asthma, chronic obstructive pulmonary disease (COPD), recent upper respiratory tract infection (URTI), sleep apnea Gl: gastroesophageal reflux disease (GERD ), liver disease renal: insufficiency, dialysis, CKD hematologic: anemia, coagulopathies, blood dyscrasias MSK: conditions associated with difficult intubations - arthritides (e.g. rheumatoid arthritis), cervical tumours, cervical infections/abscess, trauma to cervical spine, Down syndrome, scleroderma, obesity, conditions affecting neuromuscular junction (e.g. myasthenia gravis) endocrine: diabetes, thyroid, adrenal disorders other: morbid obesity, pregnancy, ethanol/other drug use FHx: malignant hyperthermia. atypical cholinesterase (pseudocholinesterase), other abnormal drug/anesthetic reactions Physical Examination oropharynx and airway assessment to determine the likelihood of difficult intubation ability to assume "sniffing position" - upper cervical spine extension, lower cervical spine flexion (assesses likelihood of difficult intubation) no single test is specific or sensitive - all aid in determining the ease of intubation Mallampati Classification (Figure 1) thyromental distance (the distance of the lower mandible in the midline from the mentum to the thyroid notch) with the adult patient's neck fully extended, <3 finger breadths (<6 em) is associated with difficult intubation

'IbroDlo Nota 2011

mouth opening (<2 finger breadths is associated with difficult intubation) tongue size dentition, dental appliances/prosthetic caps - must inform patients of the rare possibility of

damage nasal passage patency (if planning nuotracheal intubation) bony landmarks and suitBbi1ity of anatomy for regional anesthesia (if relevant) fuCU&ed physical cum of the CNS. CVS, and respiratory systems general asseasment of nutrition. hydration, and mental status pre-aisting motor and sensory deftdts sites for IV, central venous pressure (CVP), and pulmonary artery (PA) catheters
II

Ill
CBC

UVIAl. (body lllld bus of

Tansilar prs

,\

, r=y
Tanlillrpillarll &tonsis (pwtill 'liiiWI

IV
nDt visibla

'
l'olt"Pi'myngeBIMI

._./

..#

i 0

Flgu.. 1. Malampltl Cllllllllcatlon of Upper Airway Vlulllzatlo

Pre-Operative Investigations
Tllllle 1. Suagested lmlcatlona far Specific lnweltlgllllonaln tile Pre-Operative PeiiDd
Major IIIIIBIV
!Jlql 1111 saaan or crass and

..............

lllltlllr
102l2):251-251 llalhllil.
.,...,.IIIIJIIIIiiod: r/ll&8.483 pll1iln

IDl or hapllic diSIIIIH;

known or sLIIf*l8d allllllia; blelding dialhasis or in patient less IIIII 1 year of age
ifacraan il politiva)

cll'llnic c:ardiii\IIISCUar, pumrxay,

l'6nll: 113!1111111111883 - - -

Genetically pradiBpoaad palin (hem:lglobil

..... l&lln.C.. """dellllll Pllim wilD lill8'llllliMd

pllillnl will

AnticDII(Iulant lhllliPY. blaeding diathasis. livtr diSIIIISa

Hypertanailn, rnl di1811a, diabalal, piluitllry or llhnll dis-.; lipil or diuretic tlmpy. cr athEr drug 11111nlpies alfac:lq slaclnllytas; age >SD

llalhllil.

Diabetes

day of SJ'lii!IYI

llilla'llllliMd Qlllllal"ll <led Milin Z4lwlns rll8C8i'lq IIMIIIaia. IBIInlill: Ginn!,.._ criDJtilal llalhllii1D IIII"Qi:ll
. . ..._camaarBI!wlhiiHIIIIInal

Woman d childbaaring age

ECG
HIBI disease, hypeltension, diabetes. ather carlile risk facltiiJ (mav include age), SJbnchnoid hemCI1heg&, f:<IA. haad'lnllml,age(llllle >40y.o. fanlla >50y.o.l

Ec:ooanl..-.
Qllt

DIF. cniclllyDpalhy, YIWJiar petllaiDgy, lilited c:ardiac rasiiM, slrok8 of urtnawn 8i?loll'f
Canlac cr pul11101111ry di1811a, lllllipncy, age >60

1111111: lha incidlncl of 24-lar posiDpniM dia1111111Jl8,..10,QI . . . . .!IIfliCI. U-l.!ilmllhein:iiiiDiala11111-D.5(15"1i O.ill.I).Anllthaia YnrlllgiiiiM rilkflmm 1IBIWVI8IIeCidlledwith I *-"d rilk Lf nalidly 11111111111ilyIMIII: . . dllct wit! pnlbD IIIII mrn.rtllion, ciac4tt IMiiiiMII

a.

lll8idlei.,_VIi1h chlveIIIHihlil.

Fasting Guidelines
Fasting Guidelines Prior to Surgery (Canadian Anesthesiologists' Society) 8 houn after a meal that includes meat, fried or fatty fuods 6 houn after a light meal (such as toast, crackers and dear fluid) or after ingestion of infant furmula or nonhuman milk 4 houn after ingestion ofbreast milk or jello 2 houn after dear fluid& (water, black coffee. tea. carbonated beverages, juice without pulp)

11MIIII al nuda . . . . . 1111 paRi!laniM

A4 Anestheaia

Pre-Operative Assessment/Pre-Operative Optimhation

Toronto Notes 2011

American Society of Anesthesiology (ASA) Classification

common classification of physical status at the time of surgery a gross predictor of overall outcome, NOT used as stratification for anesthetic risk (mortality rates) ASA 1: a healthy, fit patient ASA 2: a patient with mild systemic disease, e.g. controlled '!YPe 2 diabetes, controlled essential HTN, obesity, smoker ASA 3: a patient with severe systemic disease that limits activity, e.g. stable CAD, COPD, DM, obesity ASA 4: a patient with incapacitating disease that is a constant threat to life, e.g. unstable CAD, renal failure, acute respiratory failure ASA 5: a moribund patient not expected to survive 24 hours without surgery, e.g. ruptured abdominal aortic aneurysm (AAA), head trauma with increased ICP for emergency operations, add the letter E after classification (e.g. ASA 3E)

.....

,,

Pre-Operative Optimization
in general, any fluid and/or electrolyte imbalance should be corrected prior to elective surgery

lli8kAa_..... 1. Reconcile patient factors with 11r9icel

needs 111d devise safe and ellective llllllllhstic plan 2. Optimiz co-morbidities

Medications
pay particular attention to cardiac and respiratory meds, narcotics and drugs with many side effects and interactions pre-operative medications to start prophylaxis risk of GE reflux: sodium citrate 30 mL PO or ranitidine 150-300 mg PO 30 min to 1 hour pre-op risk of infective endocarditis, GI/GU interventions: antibiotics risk of adrenal suppression: steroid coverage risk ofDVT: heparin SC consider oral benzodiazepines for the anxious patient optimization of co-existing disease: bronchodilators (COPD, asthma), nitroglycerin and beta-blockers (CAD risk factors) pre-operative medications to stop oral hypoglycemics: stop on morning of surgery antidepressants (tricyclics, MAOis): stop on morning of surgery pre-operative medication to adjust insulin, prednisone, cownadin, bronchodilators

ElhiD If Elllndllll .....lllprillll

Hypertension
mild to moderate HTN is not an independent risk factor for peri-operative cardiovascular complications (LBrlllllf .J. Ann. Sury. 19i2; 216:192-2041 target sBP <180 mmHg, dBP <110 mmHg assess for absence/presence of end-organ damage and treat accordingly

S...., IPOISE111111: A......... tantnhd

t.w21l08; 371:113H7 ...,._To iiMStiglle1he mleli bell-blacb!i (llillllplilll PIMPalltiwly ia pllillilllwitl knuwii mculr undi!Pv1IDIH:Inlilc IIJllll'f, 11-..: PQnls from 180 ci!Qs in 23 counlrilll wnllligllll >45, ll"lllllgoira nancmlilc lllllll'f llllwere knuwii til hM lignilic:lnt VIICIB lillna. l'ltianiJWIII rulomisad til eidler 1he metupmlol gnq, ar pllcebo.l'llqlnls I'IIC8ivad rnalpilllal (or pllcaboll 00 II'G" 2-4 hlln betare ugety liid again 6 hlln iller lllllll'f 1111 lollll"lilg 1lllt 200 mg daily for 30 days, 11111 prinlly IIM!poilt- CIII1ICISII rl ClldiiNIIaUr dnd!. non-llllllilfDCIIIdill iArctiaillllll111111.fllll caAilc 111111. Anltjln- by irDn1ion 1011111. a-111: 8351 ]JitierG were ido 1he 8331 the 30dlycaLn8. sigliicdy reduce lhl rilk rl caniavlscul11 dath, non.filii Ml or non-11111 canlilc 1111151vs. placeba (llizlid IIIia 0.114, p<0.051 bit ..., incl8llld 11111111 rl llrol:ajlanjratio2.17,p<O.OIIIIIIOVI!IIrisk lidlllh (hmnl ratio 1.33, P<0.05). Ciliilbia1: U. rl piliopmtivl b111-bDcbr1 (rnulapalall in prilli1ll with kamvucullr chilli pmida bGih risks and banlfiiJ, and 111111 -be caftlidnd fur 8ldl pllient indM!llll-

Trill

dis-.

Coronary Artery Disease (CAD)

ACC/.AHA Guidelines (2007) recommend postponing elective surgery 4-6 weeks following an MI

this period carries an increased risk of reinfarction/death

<3 months after MI - 37% patients may reinfarct 3-6 months after MI -15% >6 months after MI - risk remains constant at 5% if operative procedure is essential, and cannot be delayed, invasive intra and post-operative ICU monitoring reduces the risk to 6%, 2% and 1% respectively for the above time periods mortality with peri-operative MI is 20-50% initiation of peri-operative beta-blockade in patients with increased risk of CVA beta-blockade should be continued if already started initiate beta-blockade if inducible ischemia, CAD or multiple cardiac risk factors and undergoing high risk surgery consider initiating beta-blockade if CAD or multiple cardiac risk factors and undergoing intermediate risk surgery treatment with beta-blockers should be optimized well in advance of any surgery

Toronto Notes 2011

Pre-Operative OptimizationJMonitoring

Anesthesia AS

Endocrine Disorders
diabetes mellitus hypoglycemia caused by drugs and surgical stresses and masked by anesthesia prevent with dextrose/insulin infusion and blood glucose monitoring end organ damage: be aware of damage to CVS, renal and nervous systems, including autonomic neuropathy hyperthyroidism can experience sudden release of thyroid hormone (thyroid storm) treatment: beta-blockers + pre-op prophylaxis adrenocortical insufficiency e.g. Addison's, exogenous steroid use steroid coverage suggested if steroid use of> 1 week in past 6 months

Respiratory Diseases
asthma bronchospasm from intubation, delivery of inhaled anesthetics pre-op inhaled salbutamol may mitigate risk avoid non-selective beta-blockers, caution with beta2 specific cancel/delay elective surgery for poorly controlled asthma smoking adverse effects: altered mucus secretion and clearance, decreased small airway caliber and altered immune response abstain at least 8 weeks pre-op, if possible if unable, abstaining even 24 hours pre-op has shown benefit
COPD

anesthesia, surgery and analgesia predispose to atelectasis, bronchospasm, pneumonia, prolonged mechanical ventilation and respiratory failure cancel/delay elective surgery for acute exacerbation optimize with bronchodilators ;1; inhaled corticosteroids ;1; antibiotics

Aspiration
risk of aspiration in gastroesophageal (GE) sphincter incompetency, GERD or hiatus hernia avoid inhibiting airway reflexes; reduce gastric volume and acidity employ rapid sequence induction if increased risk (see RSI, A9) increased risk with laryngeal mask (instead of ETT)

Monitoring
Canadian Guidelines to the Practice of Anesthesia and Patient Monitoring an anesthetist present: "the only indispensable monitor" a completed pre-anesthetic checklist: including ASA class, NPO policy, Hx and investigations a peri-operative anesthetic record: HR. and BP qSmin, dose and route of drugs and fluids continuous monitoring: m.ygenation ventilation circulation temperature Routine Monitors for All Cases BP cuff, telemetry, pulse oximeter (02 saturation), stethoscope, temperature probe, gas analyzer, capnometer (end tidal C02 to assess adequacy of ventilation) Elements to Monitor (Figure 2) anesthetic depth inadequate: blink reflex present when eyelashes lightly touched, HTN, tachycardia, tearing or sweating excessive: hypotension, bradycardia oxygenation: pulse oximetry, inspired 0 2 concentration (FiOz) ventilation: verification of correctly positioned ETT, chest excursions, breath sounds, end tidal C02 analysis, end tidal inhaled anesthesia analysis circulation: pulse, heart sounds, BP, telemetry, oximetry, central venous pressure (CVP), pulmonary capillary wedge pressure temperature: temperature probe
It'

Pre-Anesthetic Checklist

SAMMM Suction - connected and working

Airways- IIIIYIIIIOSCOP8 lll1d blades, ETT. syringa. stylet. Dnll and nual 111pe, bag and mask

Machin a - connactad, pressum okay, all meters functioning, vaporizen run Monilo!'ll - available, connected and wolking Mediclllions -IV fluids and kit ready, emerqancy medicines in correct location and accessible

A6 Anesthetia

ToroDio

2011

Syslemlc Amrlll

AI1Brill Una

BPfrml

CepnllfiPII
lnlpil'll4'

Ellpired 1111111101'1118 1%1

N,O Can:enlllllion

I
0

J
E

F"111r1 2. TypiC;JI Anllllllli1 Monitor

Induction Agents
Induction may be achl.eved with intravenous agents, volatile agents or both

Intravenous Agents
Table ll,A25 the IV induction agents include a selection of non-opioid drugs used to provide amnesia e.nd blunt reflexes. These are initially used to draw the patient into the maintenance phase ofgeneral anesthesia. rapidly, smoothly, and with little adverse effects e.g. propofol, sodium thiopental or ketamine propofol and ketamine are also used for the maintenance phase ofGA

.... ,
Dltlrni.-dl rA of llnlat of VDIIthAnedldCI I. loUIIIIy: d -.ollflilily, ilci'IIISII 11118 Ill induction

s.-

Volatile lnhalational Agents

Table 13, A26 general concepts ofvolatile agents are diacussed below e.g. sevo8urane, desflurane, lsoflurane, enflurane, halothane and nitrous ande

z. c:.&c GIIIIU (COl: as CO iu:reasa,

daCI'IIISIIS.. thus delaying indi!Ciion 3. Putl.. lllllilre..:a

111111111: incnllllll dacnla8 11118 Ill inducticn 4. llllplred Ga CGnnntr.a.:
ilci'IIISII lllpilld cunC8Illl'llion. ilcra. 11118 Ill induction 5. Venlldln: ilcrtllll llvaDI!r vsnllldian, inC1111118 I'Btll Df

......._...........
induction

upllie to blo!MI and lllvllolar gn conC8Illl'llion

......... a. Efhct: whlll z11818'

the first ga (e.g. Nz(l) incnauaslhl lllvlolr conclllllrltian Df lhlseccnd

are admirintr11d 1ogelher. 11Jc8 Df

gn (a.g. dllllllurana), i'IC1111118 1'11111 of rdlcticn

......._---------------, ,
Salllility rA lflllllll
bllllhlllb In L...amUIIIa lllallt .......

MAC (minimum alveolar concentration) definition: the alwolar concentration ofan agent at one atmosphere (atm) of pressure that will prevent movement in 5096 of patients in response to a surgical stimulus (e.g. abdominal incision) often 1.2-1.3 times MAC will ablate response in the general population potency ofinhalational agents is compared using MAC MAC values are roughly additive when mixing N20 with another volatile agent (Le. 0.5 MAC ofa potent agent + 0.5 MAC ofN20 = 1 MAC ofpotent agent; however, this only applies to movement, not other effects sucll as blood presrure changes and does not hold over the entire N20 dose nmge) MAC-intubation: the MAC ofanesthetic that will inhibit movement and coughing during endotracheal intubation, generally 1.3 MAC MAC-block adrenergic response (MAC-BAR): the MAC necessary to blunt the sympathetic response to ruW.oua stimuli, generally 1.5 MAC MAC-awake: the MAC ofa given volatile anesthetic at which a patient will open their eyes to command, usually 0.3-0.4 of the uaual MAC value

NilrDunxide < dHIIIHIIB < MVOflurane < itolllrena < hlllothana

'IbroDlo Nota 2011

Induction Apnb/Airway M8D&Fl1lent

Anfstbala A7

Muscle Relaxants and Reversing Agents

depolarizing muscle relaxants: sw.:dnyk.hollne (SCh) non-depollll'Wng: rocurontum, mivacurium, vercuronium specific muscle relaxants are described in Tables 14 and 15

Blllli..Eii11

AChE

Po8t synaptic mulda maninna

Na

Higher [Na1

ACh recepblr
I. Action potanlial arrivas

Z. Rei- af ACh i1ta cleft 3. ACh bilds to ACh receptor.

ion chlnnal1 opan

4. Changa in membrana pamnlllbility 5. AChE ltyG'olyz8s ACh

B. At:tion potlnlilltpreads across

muscle membrane

Figun 3. Anatomy and

Df th1

JuactiDn (NMJ)

Muscle Relaxants muscle relaxation produces the following desired effects: 1. :filcilitates intubation 2. assists with mechanical ventilation 3. prevents muacle stretch rdlc:x and decreases IDUJicle tone 4. allows lla:e8S to the slll'gical. field (intracavitary surgery)
never use without adequate preparation and equipment to maintain airway and ventilation blocks nicotinic chollnergl.c receptors in NMJ provides skeletal muscle paralysis, including the diaphragm. but spares involuntary muscles such as the heart and smooth muscle nerve stimulator is used intraoperatively to assess the degree of nerve block; no twitch response seen with complete neuromuscular blockade

P111111 CHIIIIt8rMe
Ill liver and metabolia; SCII. Qblr
P111ma chclin881e1'118 is produc:ed by
hal ..llllhstics, lll'ld miwciDn. A prolonged dlftlion of blocklde by SCh

(a) dacra.ad

chDiinaslar'M8, a.g. livar disaM,

JliBtFI'"C'f, malijpncy, mlllrUritian.

(b) abnlliTIIII quality of plu'n

cholilllllenl88, i.e.

but

Reversing Agents for Non-Depolarizing Muscle Relaxants (e.g. neostigmine, pyrldostlgmlna, adrophonlum) reversal agents are acetylcholinesterase inhibitors inhibits enzymatic degradation of ACh; 1ncreases amount of ACh at nicotinic and muscarinic receptors, displacing non-depolarJ..zlng muscle relaxant anticholinergic agents, such as atropine or glytopyrrolate, are simultaneously administered to minimize muscarinic effect of reversal agents (i.e. bradycardia. salivation and increased bowel
peristalsis)

in.,aired IIC1iviLy of enzym11, gllfiBiically imarilad.

Airway Management
Airway Anatomy Review
normal airway: nares -+ nasal cavities -+ nasal pharynx -+ laryngeal pharynx -+ traceha resistancetoairfl.owtbroughnasalpassagesaccountsfurappromnattly2/3oftotalal.rwayreslstance pharyngeal mway extends from posterior aspect of the nose to cricoid cartilage the glottl.c opening (triangular space formed between the true vocal cords) 1s the narrowest segment of the laryngeal opening in adults when Intubating, the glottic opening is used as the space through which one vJ.sualizes proper placement of the endotracheal tube (ETT) the trachea begins at the level of the thyroid cartilB.ge at the level ofC6 the trachea bifurcates into the right and left main bronchi at the level ofTS

A8 Anesthetia

1'oroDio

2011

Tabl111 2. Matllllds of Suppurting tll111 AiiWIIJ

o
o

Basic Non-iMI&MI

Readily avalable

Easy 1D insert Lass airway lnl-rritllian lhlll ETT Frees up hands (vs. face mask) Primlliy uaad in spanblnaDIIIIIy
0
0

-n.s ,.

EmiRs aiway PabH;y Protacts llgailst apil'llian !Diet"

Allows Positive pni61IUf8 van111dian Allows suctionilg i.e. "PuumiiiiiiY

Arauta fur Pllarmacological acminiltretian

YIIITii-paliant

o
0

Ria ahapil'llian H LOC c.nt 811SW11airway

pa1lq.y

k&lily 1D dEliver precise tidaiYGiume

o

Riak. of glll!ic apil'llian PPV >20 em HzD needed Limed lMJ mability o C-apila cr Clltillga fracture
o

Clpntor fatigue

Illation Clll be dilfii'Ut fv\Jscla ralaxlln usualy needed may occur on failed ini!Man ar Bld:ubatian o SVmpatbaCic strass due to ini!Mon
o

Facillllnii'WII'( !l*ncy with jlrN t1rust llld din 1ft

o

pa1balogy or lor8ifll body Dues NOT prutect llgllinst

Cal

aspam ar (lllbic
apiraticll Sizilg (lliJIIIDX):
41}.50kg: 3 50.10kg: 4 70.100 kg: 5

aiway

Ausculbde Ill avoid !Riabranchill inbalion o Sizilg (approK): Male: 8.0-!I.D nrn Ftrral: 7.Q-8.0 IIIII Fedillbic: {8111(4) + 4 mm

Tracheallntubation
Equipment for Intubation oxygen source and self-inflating bag face mask (appropriate size and one size larger and smaller) oropharyngeal and nasopharyngeal airways endotracheal tubes (appropriate size and one size smaller)
tracheal stylet syringe for tube cuff infiation suction

laryngoscopes
A.
Oral 11Xi1 (OAI

Preparing for Intubation

failed attempts at intubation can make further attempts more difficult due to tissue trauma plan, prepare and assess fur potential difficulties (see Pre-operative Assessment, A2) ensure equipment is available and working (e.g. test ETT cuff, check. laryngoscope light.
machine check)

pre-caygenate/denitrogenate: patient breathes 100% O:!fur 3-5 min or for 4 vital capacity breaths may need to suction mouth and pharynx fim
Proper Pasitioning for Intubation "sniffing position: tlexion oflower C-spine (CS,6), ie. bow head forward and extension of upper C-spine at atlanto (Cl)-ocdpltalJoint, i.e. nose in the air aligns the three axes of mouth, pharynx and larynx to allow visuaiJzatl.on from the oral cavl.ty to

the glottis (Figure 5) proper position fur laryngoscope tip to visualize cords is in the epiglottic vallecula contraindicated in known/suspected C-spine fracture/instability
Tuba Insertion

F'11111111 5. Anatamic Considlrlltio111 il UfYIIIDSCDPJ

A. IIIUirBI polition, B. C"'Pin1 tlpion, C. C-lpi'la flllllicn "Mill atlanlo-accipital

ETT insertion can incite a signlfu:ant sympathetic response due to a -roreign body refleJ." in the trachea, including: tachycardia, dysrhythmias. myocardial ischemia, increaaed BP and coughing a malpositioned ETT is a potential hazard fur the intubated patient iftoo deep, may result In right endobronchial Intubation, which is associated with left-sided atelectasis and right-sided tension pneumothOIU iftoo shallow, may lead to accidental extubation, vocal cord trauma or laryngeal paralysis aa a result of pressure injury by the ETT cuff the tip ofETT should be located at the midpoint of the trachea at least 2 em above the carina and the proximal end of the cuffshould be placed at least 2 em below the vocal rords apprOJdmately 20-23 em mark at the right corner ofthe mouth for men and 19-21 em for

women

IDII:IIIIion.

Toronto Notes 2011

Confirmation of Tracheal Placement of ETT

Airway Management

Anesthesia A9

direct
visualization of ETT passing through cords bronchoscopic visualization ofETT in trachea indirect end-tidal C02 in exhaled gas measured by capnograph auscultate for equal breath sounds bilaterally and absent breath sounds over epigastrium chest movement and no abdominal distention feel the normal compliance oflungs when ventilating patient condensation of water vapour in ETT visible during exhalation refilling of reservoir bag during exhalation AP or lateral CXR: ETT tip at midpoint of thoracic inlet and carina (lateral CXR more sensitive and specific)
Complications During Laryngoscopy and Intubation o mechanical dental damage laceration (lips, gums, tongue, pharynx, esophagus) laryngeal trauma esophageal or endobronchial intubation accidental extubation insufficient cuff inflation or cuff laceration: results in leaking and aspiration
o

lntullation Tools
MD SOLES

Manitomg
Drug&

Suction

Oxygen

t.yngoscapes

Stylut, Syringa

It'

MNiAIIan tat Cllll Ml!'through lhl m

NAVEL

Naloxone A1ropine Vnmlin

Epinephrine

Udocaina

It'

systemic laryngospasm bronchospasm esophageal intubation suspected when zero or near zero on capnograph end-tidal abnormal sounds during assisted ventilation impairment of chest excursion hypoxia/cyanosis presence ofgastric contents in ETT distention of stomach/epigastrium with ventilation

DiffiNnlill Diagi!G8i of Poor Bil...ral Bruth Sounds .tt.r lnlullatlon

DOPE Displaced

Obstruction Pneumothorax Eaophag8111

Rapid Sequence Induction (RSI)

indicated when patient has "full ie. predisposed to regurgitation/aspiration: decrease levd of consciousness (LOC) trauma meal within 6 hours sphincter incompetence suspected (GERD, hiatus hernia, nasogastric tube) increased abdominal pressure (pregnancy, obesity, bowd obstruction, acute abdomen) pre-oxygenate/denitrogenate: patient breathes 100% 0 2 for 3-5 minutes or for 4 vital capacity breaths prior to induction of anesthesia (do NOT bag ventilate) assistant performs Sdlick's maneuver: pressure on cricoid cartilage to compress esophagus between cartilage and C6 to prevent reflux/aspiration administration of induction agent immediatdy followed by fast acting muscle relaxant (e.g. SCh) intubate shortly after administration of muscle relaxant (approxirn.atdy 45-60 seconds) with no bag-mask ventilation in between induction and intubation must use cuffed ETT to prevent aspiration of gastric contents inflate cuff, verify correct placement of ETT, rdease cricoid cartilage pressure ventilate when ETT in place and cuff inflated

............

,..... IIIIIUtbQ.......,....,
103:0l7

Difficult Airway
difficulties with bag-mask ventilation, supraglottic airway, endotracheal intubation, infraglottic airway or surgical airway 2004; 59:675) algorithms exist for difficult airways (e.g. Anssthesialogy 2003; 98:3273, pre-op assessment (history of previous difficult airway, airway examination) and pre-oxygenation are important preventative measures if difficult airway expected, consider: awake intubation intubating with bronchoscope, trachlight (lighted stylet), fibre-optic laryngoscope, glidescope, etc. if intubation unsuccessful after induction: 1. CALL FOR HELP 2. ventilate with 100% 0 2 via bag and mask 3. consider returning to spontaneous ventilation and/or waking patient

!Wililanl: defined lJUtt Cormac:k-l.ehw pie o/3 Jut IOtll8 adlm fiPO'IId 1hiNqUirlment of I specll 111chni1Jle, roolliple IIIU:CelllulllflnP Dr I CCIINinltion of 1111111 1hllllCIJIIId 1111ndlld far irtlbllion. 1111111: Thii1N81111 ilcidiiiC8 of dil&cut inllilltion - 5.8\ 195\ Cl. 4.S...7.51)1arlhe IMRI pltient ]liiiWiion. 6.2\IM C1. 4.r.-i.J\) far llOIII'III pllienls excUdilg obslltric IIIII obese pllierQ, 3.1\(MCl, 15.8\195\ Cl, 14.3-11.511 far obese pltilnls. SN: 4!11SP:II&\PLR:3.7 NLR:O.S, Thylomenlll diiUce: SP:M\ PUI:3.4IIJI:o.a Sllrnomml disllncl: SN:&Z\ SP:I2\ PLR:5.7 NL.II:O.S, t.billl 0J1811i'G: SN:Z2l SP:97\PLR: 4.0 ltJI:Q.B ,Wison rilk-UI: SN:4K SP:M PLR:5.8 NL.II:0.6, Combillllion Mdlqllli 111:1 SN::J&\ SP:mPUI:U NLR:0.6 Canlbinl: Acarmilllion a11111 Mllllmpltilllt and dislanca il Ills mOIIICaJIIIIII lllicUI iUib. The positiw lelihood lllio IU) is awrive allllulllt gliCid Jlllllm a1 diftiQJt inblbltian.
PUI: l'lllitM lblihood llliD; NUl: NigaM lblihood lllio; SN: S.iiM!y; SP: Spec:ificity

. . . .I[ Tabld!idllllts and Mlaly Ul8d ...,.ICDpiC IBdlniqull in 1t8 pradaon a1 dlliat imWons. l1udy: ........... ...... 35 AlfiesetlC:UQISiinq50,700 patilnll.

AlO Aneat:heaia

Airway Management/Intraoperative Management

Toronto Notes 2011

if bag and mask ventilation inadequate: 1. CALL FOR HELP 2. attempt ventilation with oral airway 3. consider/attempt LMA 4. emergency invasive airway access (e.g. rigid bronchoscope, cricothyrotomy or tracheostomy)

Intraoperative Management
Oxygen Therapy
in general the goal of oxygen therapy is to maintain oxygen saturation >90% below an Sa02 of 90%, a small decrease in saturation corresponds to a large drop in (Figure 6) in intubated patients, oxygen is delivered via the endotracheal tube (ETT) in patients not intubated. there are many oxygen delivery systems available; the choice depends on oxygen requirements (FiO:z) and the degree to which precise control of delivery is needed cyanosis can be detected at Sa02 = 80%, frank cyanosis at Sa02 = 67%

Low Row Systems

10 0 10 20 30 40 50 BD 10 80 90 100

1'110.

Figure 6. Hb02 Sltllrltion Curve

.....

,
=
0 2 Ga Equnon PHzol- PaCOz

acceptable if tidal volume 300-700 ml, respiratory rate (RR) <25, consistent ventilation pattern provide 0 2 at flows between 0-8 Umin dilution ofoxygen with room air results in a decrease in the inspired oxygen concentration (Fi02 ) an increase in minute ventilation (tidal volume x RR) results in a decrease in the inspire oxygen concentration e.g. nasal canula (prong) well tolerated if flow rates <5-6 Umin, at high flows drying of nasal mucosa the nasopharynx acts as an anatomic reservoir that collects 0 2 the delivered oxygen concentration (Fi02 ) can be estimated by adding 4% for every additional litre of 0 2 delivered (e.g. at normal tidal volume and RR, flow rate of 1-6 Umin equate to Fi02 of24-44%)

....

,.----------------.

Altarial 02 Cant.nt Ca02 = (Sa0 2)[Hb)[1.34)+(Pa0 2)(0.003) = arlllrial 02 contant Sa02 = 'llo hamoglobin saturation Pa0 2 = artsrial p1111san

Reservoir Systems use a volume reservoir to accumulate oxygen during exhalation thus increasing the amount of oxygen available for the next breath simple face mask (Hudson face mask) covers patient's nose and mouth and provides an additional reservoir beyond nasopharynx fed by small bore 0 2 tubing at a rate of at least 6 Umin to ensure that exhaled C02 is flushed through the exhalation ports and not rebreathed of 55% can be achieved at 0 2 flow rates of 10 Umin non-rebreather mask reservoir bag and a series of one-way valves direct gas flow from the bag on inhalation and allow release of expired gases on exhalation, thus allowing for oxygen accumulation during intubation 0 2 flow rates of 10-15 Umin are needed to maintain the reservoir bag inflation and should deliver Fi02 >80% High Flow Systems generates tlows of up to 50-60 Umin meets/exceeds patient's inspiratory flow requirement delivers consistent and predictable concentration of 0 2 Venturi mask delivers specific percentages of oxygen by varying the size of air entrapment port determines the oxygen concentration (i.e. can vary to achieve 24%,28%,35%, 50%) enables control of gas humidity Puritan mask delivers the highest level of humidified oxygen

Ventilation
in patients given muscle relaxants, ventilation is maintained with positive pressure ventilation
(PPV)

if no muscle relaxant is given patients may have sufficient spontaneous respirations to maintain ventilation, or assisted/controlled ventilation can be used

Toronto Notes 2011

Intraoperative Management

Anesthesia All

other indications of mechanical ventilation: apnea hypoventilation intraoperative positioning limiting respiratory excursion (e.g. prone, Trendelenburg) required hyperventilation (to lower intracranial pressure) deliver positive end expiratory pressure (PEEP) increased intrathoracic pressure (e.g.laparoscopic procedure) complications of mechanical ventilation: decreased C02 due to hyperventilation decreased BP due to decreased venous return from increased intrathoracic pressure alkalemia with over correction of chronic hypercarbia nosocomial pneumonia/bronchitis see Re!ij!irology;. R27 for ventilatory modes

Sulpecldiffic-* vwnlhtion with:

BONES Beard
Obesity/Obstetrics
No 1&8tt1

Elderly
Sleep apnea

....

,.,.-----------------, ,

c - of lntrliOper.tivll Hypmdl
lnadequm axygan npply: e.g. bnletlling system disl:onnaction,

Tabla 3. Causaa af lntraopanllive Hypar- and Hypocapnaa

Hypocapnaa [..V COr} Hyperventilation Hypothermia Decreased blood flow to lungs Incorrect placement of sampling catheter sampling volume Incipient pulmonary edema Air ambolism HY!Iftapnaa [1' CD!) Hypoventilation Hyperthennia Improved blood flow to lungs after resuscitation or hypotension

obstructed or malpositioned ETT, leaks in 1118 11111111hlllic machillll, 1011 of oxyg111 supply.
llypownlilalian V.nlildon1Nirfpillll ........1-.: .g.lltiiiCinis, pnMIIIlllnia. pulmonary edema, pniUTIO!horu:. hdaction in oxygan carrying

Low bicarbonate

Anesthetic breathing cituit error Inadequate fresh gas flow Rebreathing, t.aulty circuit absorber valves Elchausllld 8oda lime
Water in Ci!pllDgraphy device

capacity: e.g. -mill, carbon monoxide poisoning, methemoglobi1111mill, hemoglobinoplllhy.

Llflwanlllift of dill h111qlalin OXJIIIII Mlumion c-: e.g. hypotharmia, decn111118d 2,3-DPG, allulloDi, hyp01:arbia. carbon monoxide poisoning.
llghMD-l.Bft canliR ....

Temperature
Causes of Hypothermia ( <36.00C)
intraoperative temperature losses are common (e.g. 90% of intraoperative heat loss is transcutaneous), due to: OR environment (cold room, IV fluids, instruments) open wound prevent with inflated warming blanket and warmed IV fluids (if giving platelet transfusion put through a line that does not go through warmer, warmer distorts viability of platelets)

llypathuml (3Z"-35.9"C) lm,.ct an Outcomu

Red- resimnce tD wound infections by impairing immune lunc:tion.

lncrt1-11he period of hospitalization by dallying healing.

Causes of Hyperthennia ( >37 .5-38.3C)

drugs (e.g. atropine) blood transfusion reaction infection/sepsis medical disorder (e.g. thyrotoxicosis) malignant hyperthermia (see Uncommon Complications, A24) over-zealous warming efforts

Red- plaiBI&t lunc:tion and impaiR activation of coagulation CISCide increasing blood loss and 1nlnsfusion rwquil'lllllllts. Triplell 1he incidence of '1-tach and
morbid cardiac aviiiiS.

Heart Rate
Causes of Intraoperative Tachycardia
confirm it is sinus tachycardia vs. other rhythms (e.g. atrial fibrillation/flutter, paroxysmal atrial tachycardia, accessory pathway syndromes, ventricular tachycardia) causes of sinus tachycardia: shock/hypovolemia/blood loss anxiety/pain/light anesthesia full bladder anemia febrile illness/sepsis drugs (e.g. atropine, cocaine, dopamine, epinephrine, ephedrine, isoflurane, isoproterenol, pancuronium) Addisonian crisis, hypoglycemia, transfusion reaction, malignant hyperthermia

._,...... the metabolism of llnNIImic aglllts prolonging portop recovery.

Causes of Intraoperative Bradycardia

increased parasympathetic tone vs. decreased sympathetic tone must rule out hypoxemia arrhythmias (see Cardiology and Cardiovascular Surgery, C12) baroreceptor reflex due to increased intracranial pressure or increased blood pressure vagal reflex (occulocardiac reflex, carotid sinus reflex, airway manipulation) drugs (e.g. succinylcholine, opioids, edrophonium, neostigmine, halothane, digoxin, beta-blockers) high spinal/epidural anesthesia

Al2 Anesthesia

Intraoperative Management

Toronto Notes 2011

Blood Pressure
ot'

Causes of Intraoperative Hypotension/Shock (sBP <90 mmHg or MAP <60 m.mHg}

a) hypovolemic/hemorrhagic shock see Infectious Diseases. ID24 most common form of shock, due to blood loss or dehydration class 1 hemorrhage: 0-15% of blood volume or <3% total body water (TBW) decreased peripheral perfusion of organs able to withstand prolonged ischemia (skin, fat, muscle. bone) patient feels cold, postural hypotension and tachycardia, cool/pale/moist skin, low JVP, decreased CVP, increased peripheral vascular resistance. concentrated urine treatment: rapidly infuse 1-2 L of balanced salt solutions (BSS), then maintenance fluids class 2 hemorrhage: 15-30% of blood volume or approximately 6% ofTBW thirst, supine hypotension and tachycardia, oliguria or anuria treatment: rapidly infuse 2 L of BSS then re-evaluate continued needs class 3 hemorrhage: 30-40% of blood volume mildly decreased perfusion to heart and brain marked tachypnea, tachycardia, decreased sBP, oliguria, confusion treatment: rapidly infuse 2 L of BSS replace blood losses with BSS (1:3) or PRBCs, colloid {1:1) maintain urine output >0.5 mUkg/hr class 4 hemorrhage: >40% of blood volume or approximately 9% ofTBW decreased perfusion ofheart and brain agitation, confusion, obtundation, supine hypotension and tachycardia, rapid deep breathing, anuria treatment: same as class 3 b) obstructive shock obstruction of blood into or out of the heart increased JVP, distended neck veins, increased systemic vascular resistance, insufficient cardiac output {CO) e.g. tension pneumothorax, cardiac tamponade, pulmonary embolism
myocardial dysfunction increased JVP, distended neck veins, increased systemic vascular resistance, decreased CO e.g. dysrhythmias, ischemia/infarct, cardiomyopathy; acute valvular dysfunction

lntropemiwl Shock SHOCKED

Sepsis or Spinal shock Hypovolemic/Hemorrhagic 0 bstructivll
Cardiogenic

-phylectiK Ext!Wother
Drugs

d) septic shod
bacterial, viral, fungal, endotoxins/mediators cause vasodilation and capillary leakage associated with contamination of open wounds, intestinal injury or penetrating trauma fever, decreased JVP, wide pulse pressure, increased cardiac output, increased HR, decreased systemic vascular resistance pressors initial treatment: antibiotics, volume expansion e) spinal/neurogenic shock decreased sympathetic tone hypotension without tachycardia or peripheral vasoconstriction (warm skin) f) anaphylactic shock see Emer&enc.y Medicine, ER30 acute/subacute generalized allergic reaction due to an inappropriate or excessive immune response (type I hypersensitivity) treatment - moderate reaction: generalized urticaria, angioedema, wheezing, tachycardia - epinephrine {1:1000) 0.3-0.5 mg SC - antihistamines: diphenhydramine (Benadryl) 25-50 mg IM - salbutamol {Ventolin) 1 cc via nebulizer - severe reaction/evolution: severe wheezing, laryngeal/pulmonary edema, shock - ABCs, may need ETT due to airway edema - epinephrine (1:1000) 0.1-0.3 mg IV (or via ETT if no IV access) to start, repeat as needed - antihistamines: Benadryl 50 mg IV (-1 mg!kg) - steroids: hydrocortisone (SolucortefW) 100 mg IV (-1.5 mg/kg) or methylprednisolone (Solumedrol) 1 mglkg IV q6h x 24h - large volumes of crystalloid may be required g) drup vasodilators, high spinal anesthetic interfering with sympathetic outflow h) other transfusion reaction, Addisonian crisis, thyrotoxicosis, hypothyroid, aortocaval syndrome

Toronto Notes 2011

Intraoperative Management

Anesthesia A13

Causes of Intraoperative Hypertension pain, anxiety due to inadequate anesthesia pre-existing essential hypertension, coarctation or pre-eclampsia hypoxemialhypercarbia hypervolemia drugs (e.g. ephedrine, epinephrine, cocaine, phenylephrine, ketamine) allergidanaphylactic reaction hypermetaholic states: malignant hyperthermia, neuroleptic malignant syndrome (see Ps.ychiatr.y, PS44), pheochromocytoma, thyroid storm (see Endocrinology. E35, E25)

Fluid Balance and Resuscitation

TOTAL REQUIREMENT =MAINTENANCE+ DEFICIT+ ONGOING LOSS in surgical settings this formula must take into account multiple factors including pre-operative fasting/decreased fluid intake, increased losses during or before surgery, fluid shifting during surgery, fluids given with blood products and medications

What is the Maintenance? average healthy adult requires approximately 2500 mL water/day 200 mL/day GI losses 800 mL/day insensible losses (respiration, perspiration) 1500 mL/day urine (beware of renal failure) increased requirements with fever, sweating, GI losses (vomiting, diarrhea, NG suction), adrenal insufficiency, hyperventilation, and polyuric renal disease decreased requirements with anuria/oliguria, SIADH, highly humidified atmospheres, and CHF 4:2:1 rule to calculate maintenance requirements (applies to crystalloids only) 4 mL/kg/hour first 10 kg 2 mL/kg/hour second 10 kg 1 mL/kg!hour for remaining weight >20 kg maintenance electrolytes Na: 3 mEq/kg/day K: 1 mEq/kg/day e.g. 50 kg patient maintenance requirements fluid= 40 + 20 + 30 = 90 mL/hour = 2160 mL/day Na = 150 mEq/day (therefore 66 mEq/L) K = 100 mEq/day (therefore 22 mEq/L) above patient's requirements roughly met with 2/3 D5W, 1/3 NS e.g. 2/3 + 1/3 @ 100 mL/hour with 20 mEq KCl per litre What is the Deficit? patients should be adequately hydrated prior to anesthesia TBW = 60% or 50% of total body weight for an adult male or female, respectively (e.g. for a 70 kg adult male TBW = 70 x 0.6 = 42 L) total Na content determines ECF volume, [Na] determines ICF volume hypovolemia due to volume contraction extra-renal Na loss Gl: vomiting, NG suction, drainage, fistulae, diarrhea skin/resp: insensible losses (fever), sweating, burns vascular: hemorrhage renal Na and H 2 0 loss +diuretics osmotic diuresis + hypoaldosteronism salt-wasting nephropathies renal H 20 loss diabetes insipidus (central or nephrogenic) hypovolemia with normal or expanded ECF volume decreased cardiac output redistribution - hypoalbuminemia: cirrhosis, nephrotic syndrome - capillary leakage: acute pancreatitis, rhabdomyolysls, ischemic bowel, sepsis, anaphylaxis replace water and electrolytes as determined by patient's needs with chronic hyponatremia correction must be done gradually over >48 hours to avoid CNS central pontine myelinolysis

2/3 ICF(28LI

TBW(42LI
I

ECF (14 L)

1/3

:V4 1/4 (1 0.5 Ll lmm.c:ul (3.5 Ll (Staing's lon:es manain bai111Cel

Figure 7. Total Body Water

Division in a 70 kg Adult

Al4 Anesthesia

Intraoperative Management

Toronto Notes 2011

Table 4. Signs and Symptoms of Dehydration

Fen:enlllge Ill Body Wiler Lass

Severity Mild
Modarata

Signs IIIII $Y1Jplllms

3%

Decreased skin

sunken eyes, dry mucous membranes, dry tongua. raduced swllilting

Oliguria, orthostlllic hypotension, tachycardia, low volunna pulse, cool extremities, raducad filing of peripheral wins and CVP. hamoconC811tration.

apalhy
Savara

Profound oliguria or anuria and compromised CNS function wi1h or wilhout alllrad sensorium

What are the Ongoing Loaaes7

tubes Foley catheter, NG, surgical drains third spacing (other than ECF, ICF) pleura, GI, retroperitoneal, peritoneal evaporation via exposed viscera. burns bloodloss ongoing loss due to surgical exposure and evaporative losses minor surgery 3 cc/kglhr e.g.laparoscopic surgery intermediate surgery 6 cclkglhr e.g. open cholecystectomy major surgery 9 cclkglhr e.g. abdominal aneurysm repair

IV Fluids
Colliii-Cyialailsfllr ltid ......... iiCrilcallriP--. Clldrw lblty 2009; ilu 3. .......:To tmbl81ba aftecll II culloidll compltld 1D cysldoidlfor luid IIUCilation, IIIJ8Cificattwflell u.ed in cri&:ltf il pllierQ. IIIIIIDU:A MS parfarmld laolq llllllldomilldccndldlrilll comiJI!i"G callid \'1. in IJI8 with pllliart Nquiring6Jid miDCitllion clle 1D tJunatic iqLIY [ilclucilg b!Jnl) or.,.tpgery. ....11111-lrld 1111111111111 were exduded. Prinlly autcome 1\U
- .l mafllllity.

replacement fluids include Cl}'litalloid and colloid solutions improves perfusion but NOT 0 2 carrying capacity of blood

Crystalloid Infusion
salt-containing solutions that distribute within ECF maintain euvolemia in patient with blood loss: 3 mL crystalloid infusion per 1 mL of blood loss fur volume replacement (ie. 3:1 replacement). Controversy surrounds this as an initial vs. maximal replacement target after 3 L crystalloid replacement. switch to pRBCs if large volumes are to be given, use balanced fluids such as Ringer's lactate or Plasmalyte, as too much normal saline (NS) may lead to hyperchloremic metabolic acidosis

0.741.151. .:..:.- Ther11 is no 8'lidllnl:e thd"" of culloids impnMIIlnMI in 11111111 pllilrlll, 11111 patieulli orpast-aperlllilie patirmts, when cornpnl .., CI'/SIIIIoid llllllions. Givan the i - d cost of I:Gioids 1$ 1D CI'/SIIIIoids,

Rids: I!Biullsn bnibn down bll8ll on 111J8Ciic culloid. For [or pllsrnl prul8in frdont the !Uiivl rill; IRRt Wll1.00 (95\ Cl 0.91 1.1 Of, II c:amplled llln:ll the IIAMS I.IB[Ma0.961.44f. r.bliliadgelltin 111111 RR 110.91195\a o.49 1.72tllllllleldnll '-1 111R II U4fMa 0.14 1.651. Ftr I:Gioidll nixld in 1 hy,.rtn: c:ryllllloid campued 'II iiOIDnic cryltlilid 1ba RR 1\U 0.88 115\ a

Colloid Infusion (see Blood Products, A15) collected from donor blood (fresh frozen plasma, albumin, RBCs) or synthetics [e.g. hydro.xyethel starch (HES) solutions] distributes within intravascular volume 1 :I ratio (infusion:blood loss) only in terms of replacing volume HES colloids remain in intravascular space (metabolized by plasma serum amylase and renally excreted), two avallable in Canada: Voluven and Pentaspan Table 5. Colloid HES Solutions Conc:enll'ltion Voluven
6%

Plllma Vo..me Exp1111ion

1:1 1:1.2-1.5

Duration lhl
4-6
18-24

Muimum Daily Dote

(mLtg)

chaice il these ]JitierD.

33-50 28

111%

Initial Distribution of IV Fluids

H 2 0 follows ions/molecules to their respective compartments

Table &. IV Fluid Solutions ECF

mEqn.
Na
K

lln1111r'a
Llctllll

O.INS
154

0.45NS 77

DSW

l/.1 + 113
51

Plumlllyta
140

142 4 4 3 103 27 28()..31 0

130 4 3

5
3

c.
Ma
Cl

109

154 308

77
407

51 253 269

98 27 294

HC01
m0sn111.
'CanwrtBd lrom lilc1lle

28*
273

Toronto Notes 2011

Intraoperative Management

Anesthesia A15

Blood Products
see Hematology. H50

Tabla 7. Blood Products Red Blood Cell1 (RBC.) (U = lllit)

o o o o

1URBCs = approx. 300 ml

....

1 U RBCs increeses Hb by appox. 10 wt in a 70 kg patient

RBCs may be !iluted
colloid/crystalloid to decrease viscosity Decision to transfuse based on initial blood volume, IJlllllOibid Hb 18V81. present volume s1illus, eJCpected further blood loss. patient health status

t-----------------,
Blood volume IBnn infant 80 miJitg 7D ml.ntg adult male adult female 60 ml,.\g Clllculate estimated blood volume (EBVI (e.g. in a 70 kg male, approx.
7DmlJkgl EBV = 7D kg x 7D mlJkg

C.k:ullling Acceptallll lllood La-

IABLI
o

o o

MASSIVE transfusion = > 1x blood volumr./24 hours of blood volume with one's own RBCs
o

o
o o o

May decrease CQmplications (infactious, febrile, ate.)

Alternative to homologous transfusion il elective procewres, but l'reo(]p phlebotomy prior to elective surgery (up to 4 U collected

if adequate Hb and no infection

= 49DD ml

>1 week before surgery)

ntraoperative salvage and filtration (cell saver); contraindicated in dirty cases

NoHIBC l'rllduca

Fresh lruzen plasma (FFPJ

1 1

Decide on a transfusion 1rigger, i.e. the Hb I&Vel at which yuu WDUid begin transfusion, (e.g. 7D Gil for a pmon with Hb(il = 150 g/1..] Hb(lj = 7D g/1..

Contains all plasma clotting factors llld fibrinogen dose to nonnal plasma levels To p1'8V8111/ba1t bleeding due to coagulation factor daplatiO!Vdaliciancies, liver

Calculate
ABL

Cryoprecipillrle 1 Contains Factors VIII and XIIL WIF, fibrinogen

Platelets 1 Usad in thrormocytopania, massive transfusions,
Albumin 1 Selective intravascular volume expander Elythropoiatin 1 Can be used pre-operatively to s1inllate erythropoiesis platelet function

Hb(il = l.5ll..::.lll X 49DD

= Hbfi!
150

Hblfl

x EBV

= 2613ml

Therefore in order to keep 1he Hb lavalllbove 7D ll'l, RBCs would hlva to tJ. givan alter approximmly 2.6 L of blood hu been lost.

Transfusion Reactions Immunosuppression

some studies show associations between peri-operative transfusion and post-operative infection, earlier cancer recurrence, and poorer outcome

Nonimmune
infectious risks: HIY, hepatitis B/C, Epstein-Barr virus (EBV), cytomegalovirus (CMV), brucellosis, malaria, salmonellosis, measles, syphilis hypervolemia electrolyte changes: increased K in stored blood dilutional coagulopathy dilutional thrombocytopenia hypothermia citrate toxicity hypocalcemia iron overload

Al6 Anesthesia
AlUi. . . "--onized. r:..l'-1 Cllir:ll

Intraoperative Management Teble 8. Immune Tr1nsfusion Reections

lllu:lion
Nan-ll1111111ytic: F*ie

Toronto Notes 2011

lillllflnnlluliln .......... il r.tlillll C. Nf.JM11111;340:G417 ..,....: To dlnnawhldlllamtricliw st1111gy al RBC IAnlfusion and a lbenillllllegy proclJctltiwlmt JIUts in crD:IIr I p!lliiRII. llldr.RIIIdomillld canfnilld trill v.ntll60 illy flllluw-up. Pllilnll: 838 c:ri1icatf I patierD v.ntll inilill bellrnllnl who 1-.d Hb al Ins thin Ill wt IWhin 7Z haursllfllr lldniaian to 1lla ICIJ. Mlln lljll57.5yuus. &2.5\1111118. lnllmnllan: l'llim Wlttlllldomly llligned Ill eik I restrictive strlllgf al1rlnsNsln, inl'ltich ABC -111n1Ued f lhl Hb dropped <10 111d Hb CCIIICI1Ibltian wn1nlintllined bllween JG.tO or111alllerll mllgy, in which Rlslulilas were ltlall'lllen111e Hb dfOIIPI!II <100 wt and Hb CIIIICIIIIIIIil-ll'llinllinad IIIIYMn 100.120w\.. lllllin o.am.: AI CIUI811'1111Dlyflt8lll 30 and 60 days, monalty llfll dlling 'dlliltly iiiCU and hospilllllltian, times dlling 11111 first30 dlys, and 111H II OJVIIIIIIWn and clysM1cticll. lids: 3Ckllymar111ty-limilt illhl 1wo Pill' 1be Illes were significlnl IDMr Mh lila ras1riciM 1lllllfulian 1tr111gy amang patilntl wf1a MlllniiiCIIIIIy il lll\ VL 1&.1') and wlloweraiBll tlwl55 yean al ega (5.7\ vs. 137.), but 1111 amang pGilniJ IWh clinically signiic:ant c:arGic Thlllllr111ty 1111 during lloi!Oiilltianlowar in 1lla llltrictiwltllllgy gruup (22.2\ VI. 28.1 '). e.t.Qna: Altllric:!Ne 11r1tagy al RBC 1nrlslulila ilatlllllulfiiii:IM and paaihly Slperiar 1D. alllnllllmlusion ltllllgy in W:ally I pllim. with the possilila:aption al petiants v.ntilllabl Ml and lllllllble .

Clu
Alloantibodies to WBC, platelet, or other donor plasma antigans

M1nq1ment
Mild fever <38"C or Rule out fever due to hemolytic rigors; may be >38"C reaction or bacterial contamination restlessnass and shiverilg Mild (<38"C): decrease irfusion l'illll Nausea. facial flushing. headache. and give antipyretics myalgias, hypotension, chest and Severe: stDp 1nlnslusion, give back pain antipyretics, antihistamines, and Occurs near corr1llalion Ill 1n1a1ment lnllsfusion or 2 houn 1 in 1DD

Alaq;c

Nan-ll1111111ytic:

Mild allergic reaction due Often have history of similar Mild: slow transfusion rate, IV to lgE aloantillodies to reactions antihistamines substances in donor plasma Abrupt onset pruritic erylhemlt/ Moderate to severe: stop transfusion, Mist calls activated with urticaria on arms and trunk, IV antihistamines, subcutanaous histamine ralease occasionally with fllvar epinephrine, hydrocortisone, IV fluids. Usually occurs in pre-exposed Less common: involvement of face, bronchodilators (e.g. multiple1nlnslusions, larynx and bronchioles Prophylactic: antihislamines 15-tiO multipa'Ous) 1 in 1 DD minutes prior to transfusion, washed or deglycerolizBd frozen RBC In lgA deficient patients with Rn, potentially lethal antibodies racBiving Apprehansion, urticarial eruptions, lgA-containing blood dyspnea. hypotEnsion, laryngeal lmroone complexes actiwte and airway edema, wheezing. mast cells, basophils, chest pain, shock, suddan death eosinophils, and ccrqli111111nt system = severe symptoms after transfusion of RBC, plasma, platelets, or other componentl with lgA CirculatoiY support with fluids, catecholamines (epinephrine), bronchodilators Respiratory assisbrlce as incicated Evalulllll for lgA deliciancy and ant). lgA antibodies Future transfusions must be free Ill lgA: washed'deglycerolized RBCs free ollgA, blood from lgA deficient donor

Nan-llemolytic: AniiPhylactuid

se.

T111nlfusion Fonm of noncardiogenic Relllld Aculll pumanary ed1111a Lunglnj.wv (TBAU) lmiTIIDOiogic cause; not due to fluid Dvelload or cardiac failure Binding of daner Ab against recipient WBC causing eytokine release leading to increased capilary penmeabilily

Occurs 2-4 hours post transfusion Usually resolves 48 hrs with Respiratory distrals: mild dyspnBB Oz. mechanical ventilation, supportive to Se\11!18 hypoxia traatment Chest x-ray: consistEnt with acute pulmonary edema, but artery and wedge pressures are not elevated 1 in 5DDD

HIIIIOiytiC AcutB [lnirlvlsculu

hemolysis)

Caused by donor Fever, chills, chest or back pain, Stop lnllsfusion incompatibility hypotension, tachycardia, nausea, Notify blood bank, confim or rule recipiant's blood flushing. dy&pnea, whellling, out diagnosis- clerical check, dnct Often due to clerical error hypoxemia. hemoglobiooria, diffuse Coorms', repeat grouping, Rh screen Antibody coated RBC is bleeding due to DIC, acute renal 111d crossmall:h, serum haptoglobin destroyed by lcliwtion of failure Manage hypotension with fluids, compl1111ent systam <: 1 in 250 ODD inotropes, other blood products ABO ilcCJ1111111:ibilily common Maintain urine output crystalloids, c111se, other RBC Ag-Ab furosemide, dopamine, alkalinize urine systems can be involved Component treatment DIC, repeat grouping. Rh screan and crossmatch, terwn haptoglobin Manage hypotension with fluids, inotropes, other blood products Componenttraatment (e.g. FFP. cryoprecipitate)

Hemolytic Delayed Caused by donor Occurs in recipiants sensitized to incompatibility RBC antigans by previous blood Dirac! Coonts, alliiiXIImination of hemolysis) recipient's blood trenfusion or pregnancy pretransfusion specimens from the Generally rrild, caused by Anemia, mild jaundice, fever 1 to patient and donor for diagnosis antibodies to Rh syst1111, Kell, 21 days post transfusion Duffy, or Kidd antigens The level of antibody at the tine of trenlusion is too low to be delected or to cause hemolysis, latllr the level of antibody is increased due to secondary stimulus

Toronto Notes 2011

Extubation/Post-Operative Care/Pain Manasement

Anesthesia A17

Extubation
perfunned by trained. experienced personnel because reintubation may be required criteria patient must no longer have intubation requirements patency: airway must be patent protection: patient must have intact airway reflexes patient must be oxygenating and ventilating spontaneously laryngospasm more likely in semiconscious patient; must ensure adequate LOC general guidelines ensure patient has normal neuromuscular function and hemodynamic status ensure patient is breathing spontaneously with adequate rate and tidal volume allow ventilation (spontaneous or controlled) with 100%02 for 3-5 minutes suction secretions from pharynx deflate cuff, remove ETT on inspiration (vocal cords abducted) ensure patient is breathing adequately after extubation ensure face mask for 0 2 delivery available proper positioning of patient during transfer to recovery room (e.g. lateral decubitus, head elevated)

Complications of Extubation
early aspiration laryngospasm late transient vocal cord incompetence edema (glottic, subglottic) pharyngitis, tracheitis

Post-Operative Care
pain management should be continuous from OR to post-anesthetic unit (PAU) to hospital ward and home pain service may assist with management of post-operative inpatients

.....

,"
.

Risk Faalors fur I'Mt-Oper.UV. lhaiN 1nd Yumiting (PONVJ 1. Younga11

Post-Operative Nausea and Vomiting (PONV)

hypotension and bradycardia must be ruled out pain and surgical manipulation also cause nausea often treated with dimenhydrinate (Gravot), metoclopramide (Maxenm) (not with bowel obstruction), prochlorperazine (Stemetil), ondansetron (Zofran), granisetron

2. Female
3. Hiltmy of PONY 4. Nan-smoker s. Type of surverv: aphtho. ENT,

(Kytril) Post-Operative Confusion and Agitation

ABCs first! - confusion or agitation can be caused by airway obstruction, hypercapnea, hypoxemia neurologic status (Glasgow Coma Scale, pupils}, residual paralysis from anesthetic pain, distended bowel/bladder fear/anxiety/separation from caregivers/language barriers metabolic disturbance (hypoglycemia, hypercalcemia, hyponatremia- especially post-TURP) intracranial cause (stroke, raised intracranial pressure) drug effect (ketamine, anticholinergics} elderly patients are more susceptible to post-operative delirium

.,... ,...a;

abdo/pelvic. plastics 6. Type of 1111111hlllic: NzO, apioids, valalil1 aglnls

lhl!f.-,._..

"-4,.......
Ill

Coclinlle Llnly 2001; laue 4. Towlultltt.lllliclcy af llllilrnatics in

It llndD!ri!ld amtmllld tri.

pltilnls. ...... Amnlysis WH]JIIIonmd laakilg

llllilrnlticto llllilmltic arpllc:lllo. Tri.IIIIUlg lldosiQ W/ar timing af nlllicltian .ni.mdion W8l8 '-' incUI&d. l'osloperiiMI ruea ar vomiting- Uled u the prinlly

illland

wtcarne. lllaltl: m ttlldils i1voMng 103m patiantJ.

OCCIW8IICII

Pain Management
Definitions
nociception: detection, transduction and transmission of noxious stimuli pain: perception of nociception which occurs in the brain

Acute Pain
pain of short duration (<6 weeks) usually associated with surgery, trauma or acute illness; often associated with inflammation usually limited to the area of damage/trauma and resolves with healing

fi posl-apmtiw IIIUIIIIAd vomiting. nemely: droprill, ndcil!M*'ide. ondlrlselran, tmpisetron, d!Utron, dBX111111bnone. t.lCIDle IIIII a-ism. RIBIM rillk (RRiwru pilclbD Vlrild O.llll lAd 11.11. Sidllfllc:ts incUded a significant inc,_ in d_...!Qr droperidol (RR 1.32jllld hlldadle (Qr ondal..-(1.161. The Clllllii1Ne runber neededto1Jad- 3.57. CancUin: Anlienwtic lllldicllian illlllctiVI (Qr TIMU:ing t t . - af posl-llplllltiwl'llllllll IIIII vomiting. H-. fuJIIIer iMstigllion lllllldl to be cb1e 111 de1emine 1'11111her lllliemetics t:an t:IUie rmre- (IIIII ililly11rel side-etlei:ts, Yotich clldllbr haw lillllly'dlly 111 Ulld.

Al8 Anesthesia

Pain Management
Sensory cortax
1issua

Toronto Notes 2011

..,., , .-----------------,
WHO Analail Ladder
Mild Pain Acetaminophen NSAIDS Moder.tePain Codeine Oxycodone

dsmsgeby: . Thermal -Chemical - Mechanical forces

order afferent neuron

Modulatory neurons release:

- Endorphins - Enkaphlins

Senre l'lin
Oxycodone

Morphine Hydromorphone
FIIIIBnyl

- Norepilephrine -Serotonin
-GABA

Inhibit release of

'l" order
afferent neuron

Figura I. Acute Pain Mechanism

Pharmacological Management of Acute Pain ask the patient to rate the pain out of 10, or using visual analog scale, to determine severity

,,t-----------------, ,
Uu NSAIDs wilb C.lllion in witb: 1.A5thma

Tabla 9. Commonly Used Analgesics

NSAIDs
Exlmpla
Tylenol-

Opiails

Aspirin, ibuprofen. naproxen Oral: codeine, axycodone, morphine, ketorolac {IV) hythlmorphone Parenllnl: morphin11, hychnorphone, fenllrly1 for mild acut& pain Mihknodarata pain Oral: mild and maderat& acut& pain Parenll!llll: severe acute pail

2. CoiiQUiopathy 3. Gl uk:e.-.
4. Rsnal insufficiii!Cy 5. Pragmmcy, 3rd 1rima&ler

7Cyclooxy!janasa-2

..._,,

,,., .-----------------,
PCA Paramntn 1. loading d0111 2. Bolus dose 3. lockout inteMII 4. Continuous infusion (optional) 5. Max. 4 tr limit (optional)

1. Nausea and vomiting 2. Cof151iplllion 3. Sedation 4. Pruritis 5. Abdominal pllin 6. Urilarv retention 7. !Mpinrtory diplnsion

Common Sld1 Eff.cb vf Opiaids

.-----------------,

Non-salacliw COX-1 and -2 Dampans nocicepliw 1ransmission {COX-2) ll!ducing between 111 and order neurons in ? Modulation of endogenous proinftammatory prostaglandin the dorsal hom cannabinoid system synthesis Actival8s ascending modulatory in ralea1e of inhibitory neuro1ransmitters lnhilits peripheral inftllllllllltory response and hyperalgesia Affacbl mood and anxisty- allaviabls the alfective component of perceived pain Umiled by analgesic ceiling Umited by analgesic ceiling beyond which there is no beyond which there is no analgasia additional analgesia Opioid-&plling MBX dose of 4 Qf24hrs Significant intEr-individual varilrtion in efficacy No analgesic ceiling {except lor codeine) Can be adminislenld intrathecal {spinal block) or by continuous infusion See Clinical Plurmacolggy: CP14 for opioid analgesic equivalencies Respiratory depression Constipation and abdominal pain Sedation Nausea and

Side EllectiiTaxicity

,,..-----------------, ,
Adnnt&gil1 of PCA Blltter pain control

Considered relatively safe Gastric ulceratiorvbleeding Uwr toxicity in IIIIMIII!d Dacraasad 1111al parfusion doses PhotDsensilivity l'rema1ure closure of the ductus arteriosus in pregnancy

Pruritus
Confusion {particularly in the elderly)

Fewer side effects Accomodatas pll1illnt Accomodatls chlngn in opioid

rsquinlmlntl

patient controlled analgesia (PCA) involves the use of computerized pumps that can deliver a constant infusion as well as bolus breakthrough doses of parenterally-administered opioid analgesics limited by lockout intervals most commonly used agents: morphine and hydromorphone refer to Table 12 for suggested infusion rate, PCA dose, and lockout intervals

'IbroDlo Nota 2011

Anesthesia Al9

Opioid Antagonists (naloxone, naltrexone) opioid overdose manifests primarily at CNS (e.g. respiratory depression)- manageABCs opiald antagonists competitively lnhlbit opiold receptors, predominantly Mu (jJ.) receptors naloxone is short acting (t1.12 = 1 hr); effects of narcotic may return when naloxone wears off, therefore the patient llUI8t be ob6erved closely following its administration nalttemne .iB longer acting (tul = 10 brs); less likely to see return of narcotic effects relative overdose of naloxone may cause nausea, agitation, sweating, tachycardla. hypertension, re-emergence of pain, pulmonary edema, seizures (etSentl.ally oploid withdrawal)

Regional Anesthesia
Definition of Regional Anesthesia
local anesthetic agent (LA) applied around a peripheral nerve at any point along the length of the nerve (from spinal cord up to, but not including, the nerve endings) for the purposes of reducing or preventing impulse transmission no CNS depression (unle85 overdo&e oflocal anesthetic); patient mnscious regional anesthetic tecbnlques categorized as follows: epidural and splnal anesthesia (neuruial anesthesia) peripheral nerve blockades IV regional anesthesia (e.g. Bier block)

Preparation for Regional Anesthesia

Patient Preparation thorough pre-operative evaluation and assessment of patient technique explained to patient IV sedation may be indicated before block monitoring should be as extensive as for general anesthesia Relative Indications for Regional Anesthesia avoids some of the dangers of general anesthesia, e.g. known difficult intubation, severe respiratory failure, etc. patient speclfi.cally requests regional anesthesia high quality post-operative pain relief general anesthesia not available/contraindicated titration of LA dosage for differential blockade. e.g. can block pain but preserve motor function Complications of Regional Anesthesia failure of technl.quelinadequate anesthesia systemic drug toxicity due to overdose or intravascular injection injury to muscle, ligament or bone (back pain), to nerve root/spinal cord (nerve deficit), to epidural vein (hematoma) infection (e.g. osteitis, epidural abscess. meningitis) spinal and epidural: sympathetic blockade causing hypotension and bradycardia (occurs early. followed by sensory then motor blockade)

....

. . . . at lllllallll Anlllhltll
lledu.:.d pulm.,..ry complicetions lledu.:.d requinlmllllhl DaC1111118d PONY Aedu.:.d l*lod loss .Ablly to mOiilor CNS lllllu1 diDla procedLn Improved pa'fusi1111 incidiiiCI DfVTI:

Epidural and Spinal Anesthesia

Anatomy of SplnaVEpldural Area (Figure 9) splnal cord extends to 1.2, dural sac to S21n adults nerve roots (cauda equina) from L2 to S2 needle inserted below 1.2 should not encounter cord, thus L3-L4, 1.4-15 interspace commonly used structures penetrated
skin subcutaneous fat suprasplnousligam.ent

intersplnousllgament ligamentum flavum (last layer before epidural space) dura + arachnoid for splnal anesthesia

fiur 9. Llnd. .rks far Placement of Epldurai/Splraal

A20 Anesthesia

Regional Anesthesia

Toronto Notes 2011

.....

,9.-----------------, ,

Table 1D. Epidural versus Spinal Anesthesia

Epidural Spinal LA deposited in epi!U'al space (space between LA i;ected into sLmlraclrloid space in the dural sac ligamentum flavum and dura) surrounding the spinal cord and nerve roots Initial blockade is at the spinal roots followed by some degl88 of spinal cord anBIIhesia 81 LA diffuses into the subaractr10id space 1troo!tJ the dura Onset Significant blockade ruquil85 1G-15 minutes Slower oosat of side effectli Eflectiveness of blockade can be variable Technicaly mora greater failure rata Rapid blockade {onsat in 2-5 minutes)

landrnarldng EpidaraVSpinal Anllldlesia Spinous procassas should be maximally

flexed
L4 spinous procesSIIS found bBtwalln

iliac cmts Common silas of insertion are L3-L4

and L4-L5

.....

,..}----------------- ,
puncture

Effectiveness Difficulty

effective blockade Easier to perform due to visual confirmation of CSF ftow Hyperbaric LA solution- position of patient importlrlt

Clasic l'rlle.ation of Dural

PunctueHMdacbl 1. 0111816 h,.- 3 daY$ lifter dural
2. l'olilund componerrt (WUIIII sillingl 3. Occipillll or frontal localization 4. tinnilu$, diplopia.

Plliant I'Diiti111ing

Positioo of patient not 81 important; specific gravity not an issue

Specific Gravity/Spread Solutions injected llere spread throughout the LA solution may be made hyperbaric (of greater polllntial space; specific !P'liVitv of solution does specific lfiVily th1r1 the cerebrospinal ftuid by mixing not alfact spread with 10% daxtrose, 1hus increasing spread of LA to 1he dependent {low) areas of the subarachnoid space)

._.fnlmlllnlwfii...._.Trilll BMJ 2000; 321:1-12 ,.,_: To estilllllll oflhe lllllctJ flllllllllill bb:bdl will ipilulll or
nii'IUty.

. . . . . af l'lllliplnlhllllldy. . Mdillrwilll (!ilbllar!pilll-.....1:

D1111111
Cantin111u1 lllfulian ComplicatiGIII

i..a'gar volume/dose of LA (usually > toxic IV dose)

Use of catheter allows for cootinuous infusion or repeat injections Failure oftecmique

Smaller dose of LA re"-'ired (usually < toxic IV dose) Nooe Failura of tecmique

&pmlai1IJII!a;ia an pGIIDpenlliva I!Dibidty and

lllldamirJiian1D inln-oplll1ivll nuuial hlrx:kldl

WIUIIII.

Pllilnll: 1411riels inclnling !1559 pltiiiiiiS. Mlil 0*-: All causemor111ily, Ml, IM, I!IWion p1181111D11i1, ott.
ilfecliJnl, IIIJiiltary relllllmn. . . . .: Ovallll murllity -181b:&d br 11lild in pltiantslllocatJd 1D IIIUIIIIill blocbda. N&uruill bb:bditliJduoad lhe lilt of PI: by 55\ 1M br 44\, l!lnRJsili lltillll111111 br 50\ pniiii'ICIIIia br 39\ illlll respirltaly br 59\. n.. were llaoliJductiona in Mllnd renal !abe.The llftii)OI1ionll reducbs in II'DIIaily did nit t:i8lllv cllar br IIUllil:ll group, type of blocbde (epidural or spiniG, or in 1hose 1rills in which niiU!IIilll bldade- cambial will gennl enastllesia willl1rills ill whic:h IIIUIIIIill blockade -laid lllone. c.:luianl: NanDI blockade lllllct1 posl1iferltive 11111111ily and D1her llllilus

Hypotension Bradycardia if cardiac sympalhetics blocked {only if (only if - T2-4 block) - T2-4 block). i.e. ,igh spinal" Epidural or subaraclrloid hematoma Epidural or subarachnoid hematoma Accidental subarachnoid injection can produce Post-spinal headache {CSF leak) spinal_ana_sthasia (and of the above Persistent pnsthesias {usually transient)
Systemic toxicity of LA (accidental inlnlvenous) Spinal cord trauma, infection Catheter (shearing. kinking. vasculll' or subaraclrloid placement) Infection Duralllii!CilR Combined SpinaJ.Epi-.1 Combines the benefits of rapid. reliable, intense blockade of spinal anesthesia together with the flexibility of 111 epidural catheter
lA=

Hypotension Bradycardia if cardiac sympathetics blocked

camplic8tions.

Contraindication& to Spinal/Epidural Anesthesia

absolute contraindications lack of proper equipment or properly trained personnel lack ofiV access allergy to LA infection at puncture site or underlying tissues coagulopathies raisediCP

sepsis/bacteremia
hemodynamic instability/uncorrected hypovolemia relative contraindications bacteremia pre-existing neurological disease aortic/mitral valve stenosis (ie. fixed cardiac output states) previous spinal surgery, severe kyphoscoliosis severe/unstable psychiatric disease or emotional instability

Toronto Notes 2011

Regional Anesthesia/Local Anesthesia

Anesthesia A21

Peripheral Nerve Blocks

generally used for post-operative analgesia; sometimes uses for intra-operative anesthesia relatively safe 2 cardinal rules: 1. Avoid intraneural injection 2. Avoid neurotoxic agents e.g. brachial plexus block, femoral nerve block, digital ring block, etc. can be ultrasound-guided to prevent neural injury

Contraindic:ations to Peripheral Nerve Blockade allergy to local anesthetic (LA)

patient refusal, lack of cooperation lack of resuscitation equipment lack of IV access certain types of pre-existing neurological dysfunction (e.g. ALS, MS) local infection at block site

Local Anesthesia
Local Anesthetic Agents (LA)
see Table 17 for list oflocal anesthetic agents

Definition and Mode of Action LA are drugs that block the generation and propagation of impulses in excitable tissues: nerves,
skeletal muscle, cardiac muscle, brain LA bind to receptor (on the cytosolic side of the Nachannel, i.e. lipid soluble), inhibiting Naflux and thus blocking impulse conduction different types of nerve fibres undergo blockade at different rates

Absorption, Distribution, Metabolism

LA readily crosses the blood-brain barrier (BBB) once absorbed into the bloodstream eater-type LA (procaine, tetracaine) are broken down by plasma and hepatic esterases; metabolites excreted via kidneys amide-type LA (lidocaine, bupivicaine) are broken down by hepatic mixed-function oxidases (P450 system); metabolites excreted via kidneys

Selection of LA
choice of LA depends on onset of action: influenced by pKa (the lower the pKa, the higher the concentration of the base form of the LA and the faster the onset of action) duration of desired effects: influenced by protein binding (longer duration of action when protein binding of LA is strong) potency: influenced by lipid solubility (agents with high lipid solubility penetrate the nerve membrane more easily) unique needs (e.g. sensory blockade with relative preservation of motor function by bupivicaine at low doses) potential for toxicity

Systemic Toxicity
see Table 17 for max doses, potency and duration of action for common LA agents occurs by accidental intravascular injection, LA overdose, or unexpectedly rapid absorption CNS effects first appear to be excitatory due to initial block of inhibitory fibres; then subsequent block of excitatory fibres CNS effects (in order of appearance) (Figure 1 0) numbness of tongue, perioral tingling, metallic taste disorientation, drowsiness tinnitus visual disturbances muscle twitching, tremors unconsciousness convulsions, seizures generalized CNS depression, coma, respiratory arrest cvs effects vasodilation, hypotension decreased myocardial contractility

CUI_,..
Ccn

Figure 1D. Local Anesthetic Systemic Toxicity

T--

CooMaln nllnlilmn uodotwithill

l.ig-

lrrilull

A22 Anesthesia

Local Anestheaia/Obstetrlcal Anesthesia

Toronto Notes 2011

dose-dependent delay in cardiac impulse transmission prolonged PR. QRS intervals sinus bradycardia CVS collapse treatment of systemic toxicity early recognition of signs 100% 02> manage ABCs diazepam or sodium thiopental may be used to increase seizure threshold ifthe seizures are not controlled by diazepam or thiopental, consider using succinylcholine (stops muscular manifestations of seizures, facilitates intubation) manage arrhythmias consider Intralipid 20% to bind local anesthesia in circulation

Local lnfiltrationr Hematoma Blocks

..... ,

Local Infiltration injection of tissue with local anesthetic agent (LA), producing a lack of sensation in the
infiltrated area due to LA acting on nerve endings suitable for small incisions, suturing, excising small lesions can use fairly large volumes of dilute LA to infiltrate a large area low concentrations of epinephrine ( 1:100,000-1 :200,000) cause vasoconstriction, thus reducing bleeding and prolonging the effects of LA by reducing systemic absorption

...----------------.

Where Not to Uu Local Anesdledc Apnt ILAI with Epinephrine "Fing1111, Toes, .,.nis, Nou"

Fracture Hematoma Block

special type oflocal infiltration for pain control during manipulation of certain fractures hematoma created by fracture is infiltrated with LA to anesthetize surrounding tissues sensory blockade may be only partial no muscle relaxation

Topical Anesthetics
. . Eht of Efidlnl Anqlllil Lllloll',
AmJIIlstetGjtnecd2002; 1B6:S6t-n SlUr- MeiHnllysis rt 14 Aldies willl4324
....-. Crilalia: Allldomiled coaioled lrills and pnllpllctiva cohort lllllill belwaan 1!11B-2001 apioid

......

various preparations of local anesthetics available for topical use, may be a mixture of agents, e.g. EMLA cream is a combination of 2.5% lidocaine and prilocaine must be able to penetrate the skin or mucous membrane

Obstetrical Anesthesia
Physiologic Changes In Pregnancy

""'II

uniiVIIIIIU ............: eik epidulllllgesil pndlrll opiaid

ldminislndion dlling llbu Pri:ipllls:lltaldt,t woman wilh

I. airway
2. cardiovascular system increased blood volume > increased RBC mass -+ mild anemia decreased SVR proportionately greater than increased CO -+ decreased BP prone to decreased BP due to aortocaval compression 3. central nervoua system decreased MAC due to hormonal effects increased block height due to engorged epidural veins 4. gutrointeatinal system delayed gastric emptying increased volume and acidity of gastric fluid decreased LES tone increased abdominal pressure combined, these lead to an increased risk of aspiration

upper airway becomes edematous and friable decreased FRC and increased 0 2 consumption -+ desaturation

ldminislndion dlling llbu 0......-.I .......:MIIemll-llllltwere

110dilfiiiiiC111

3 ffl(lllb ar 1Y8IW from PC . NeorHI-lllere were no dillwences betweln 1lla 2ljllluplfor incidllllCI rt falllhulrt lite lhnonnalilies, intrlplrtum maconiun, poor 5-min Apg. KOf8, ar law umbii:ll1118ry pH...,_, 1lla incidiiiCI al paar1min Apgar ICIIII 1nd fllld for -nlllllaxone Wlllli.lber in the pn11ml Cl!liaid gniUp. Cllclllin: I'Pduflllllllgesia is asale Rl8lhod for lllw Plin 11irlf and shidd not IMiid epidllllllllllgesillar r.r rt1180111111 b111111, dllivlry, difticullill.ioro-ln bt::k pin arlorQ-ln uriniiY ilcantilance.

infilll-tllgl lilblu lui, incidlllce of e-ra. d8twly, incidence of inD'IInarad WQinll diiWiy for dyslllcia, T'IUIII, .. mid-111-bv beck Plin post-pr111n. IIICGIIdIIIQIIIIbaur llnglh -IIIIIQII' lm=15 mini IfNI 1lln WUl1l (jiBitlr raporll '-IIIII 1lle epidurll group. Also, bwer Plin- and griiQr Sl1ilflctioa Mh llflllg85il- Teporlld 111111111Q the llpilbll PJP. 111m- na diflllranCI in lu:lltilliUcc:elllllt 6waekl111d llinlry incantilanCI was mara fracpnt in tt. .Pcllfll irmedillltt post1)11Un.btlt not It

Options for Analgesia during Labour

I. psychoprophylaxis - Lamaze method patterns of breathing and focused attention on fixed object 2. systemic medication easy to administer, but risk of maternal or neonatal depression common drugs: opioids (morphine, meperidine) 3. inhalational analgesia easy to administer, makes uterine contractions more tolerable, but does not relieve pain completely 50% nitrous oxide

eu-

'IbroDlo Nota 2011

Obstetrical

Anesthesia

Anesthesia A23

4. rqional aneathCiia

provide8 excellent analgesia with minimal depressant e1fects hypotension is the most common complication maternal BP monitored q2-5 min for 15-20 min after initiation and regularly thereafter epidural usually givm as it preferentially blocks sensation, leaving mO'txlr function intact

....

',
....._IIIII

NDCicepllwll'dNrllyl
Dellvlry

Options for Caesarean Section 1. rqioual: spinal or epidural 2. general: used ifcontraindlcations or time precludes regional blockade

labour CIIMCII dilltian end a"-mant VIICII'III niMI fib111111Di1111 the 'Pinal at n O-ll
Dellvlry

Distardian of 1 -wgina and

Potential compUcations of aaesthet1a in Caesarean tedion: aspiration under general anesthesia: due to increased gastroesophageal reflux hypotension and/or fetal distress: caused by aortocaval compression; corrected by turning patient into the left lateral decubitus (LLD) position or using left uterine displacement (LUD)
uninlentional total spinal anesthesia LA-induced seizures: due to iDtravucular injection of LA post-dural puncture headache nerve Injury (rare)

plrinaum

Somatic nacicsptivl imllda'lil1he pudandal ..rve llllllring'lha 11*11 coni at SZ-S4

Pediatric Anesthesia
Respiratory System

in comparison to adults, anatomical differences in infants include (Figure 11) large head. short trachea/neck, la.rge tongue, adenoids and tonsils narrow nasal passages (obligate nasal breathers until5 months) narrowest part ofairway at the levd of the aicoid va. glottis in adults epiglottis is longer, U shaped and angled at 4S degrees; carina is wider and is at the level of T2 (T41n adults) physiologic differences include faster RR, immature respiratory centres which are depressed by hypanalhypercapnea (airway closure occurs in the neonate e.t the end ofexpiration) less oxygen resent: during apnea - decreased total lung volume, vital and functional resent: capacity together with higher metabolic needs greater V/Q mismatch -lower lung compliance due to immature alveoli (mature at 8 yean) greater work of breathing- greater chest wall compliance, weaker intercostal.s/diapluagm and higher resistance to airflow a pediatric breathing unit is required for all ch1l.dren <20 kg
Cardiovascular System blood volume at birth is approximately 80 mLikg; transfusion should be started if> 1096 of

1. L.argartongua 1'1 proportion In mouth 2. Smaler llharvnx

3. t.gar IRI mara flaccid apiglutlia

blood volume lost children have a high pulse mte and low BP CO is increased by increasing HR. not stroke volume because oflow heart wall compliance; therefore, bradycardia -+ severe compromise in CO

4. U.VOX il men superior and anterior 5. NIIIDWIIal pam! at cricoid Cllrtlllgll B. TI'IIChaa il mare namw ..d 11111 rigil

va. Adult Airway

Figura 11. Campan.an af Palllllic

Temperature Regulation vulnerable to hypothermia minimize heat loss by use of warming blankets, covering the infant's head, humidification of inspired gases and warming ofinfused solutions Central Nervous System the MAC of halothane is increased compared to the adult (Le. 0.7596 adult, 0.87% neonates, 1.296 infant) the neuronuJK11la.r Junction is lmmature for the first 4 week!l of life and thus there is an

....

',
min

Ta n:...... alwlallr mial1a vanllation ilnaonabls, inCI'IIII nsphtory 1"118, nat tidal whme.

N_.. 311-40 bpm

1-11vn !24- !IA!IZJI

increased sensitivity to non-depolarizing relaxants parasympathetics mature at birth, sympathetics mature at 4-6 months -+ autonomic imbalance infimt bram is 1296ofbodywdght and receives 3496 ofCO (adult: 296 body weight and 1496 CO)
Glucose Maintenance infants less than 1 year can become seriously hypoglycemic during pre-operative fasting and post-ope.ratlvely iffeeding is not recommenced as soon as possible after 1 year children are able to maintain normal glucose homeostasis in exce38 of 8 hours

... ..
m
=

,
IIIIIW'll + 12

Sizing in '-liltrial Dilmlll Ill trachaal tubl in children (mm) .rt. I , _ = +4

Langth of lnl:ha,..luba (em)

A24 Anesthesia

Pediatric Anestheaia/Uncomm.on Complications

Toronto Notes 2011

Pharmacology
higher dose requirements because of higher TBW (75% vs. 60% in adults) and greater volume of distribution barbiturates/opioids more potent due to greater permeability of BBB muscle relaxants non-depolarizing immature NMJ, variable response depolarizing must pretreat with atropine or may experience profound bradycardia, sinus node arrest due to PNS > SNS (also dries oral secretions) more susceptible to arrhythmias, hyperkalemia, rhabdomyolysis, myoglobinemia, masseter spasm, and malignant hyperthermia

Uncommon Complications
Malignant Hyperthermia (MH)
hypermetabolic disorder of skeletal muscle due to an uncontrolled increase in intracellular Ca (because of an anomaly of the ryanodine receptor which regulates theCa channel in the sarcoplasmic reticulum of skeletal muscle) autosomal dominant (AD) inheritance incidence of 1-5:100,000, may be associated with skeletal muscle abnormalities such as dystrophy or myopathy anesthetic drugs triggering MH crises volatile anesthetics: any drug ending in "-aneD depolarizing relaxants: succinylcholine (SCh), decamethonium

....

,...----------------. ,

Clinical Picture
onset: immediate or hours after contact with trigger agent increased oxygen consumption increased end-tidal C02 on capnograph tachycardia/dysrhythmia tachypnea/cyanosis increased temperature (late sign) hypertension diaphoresis muscular symptoms trismus (masseter spasm) common but not specific for MH (occurs in 1% of children given SCh with halothane anesthesia) tender, swollen muscles due to rhabdomyolysis trunk or total body rigidity

Signa !If Mallgnllllt HvPitfthmia

Unexplained rise in end-tidal C02 Increase in minulll venlillltion

Tachycardia Hyperthermia (1m lign) Rigidity

Complications
death coma disseminated intravascular coagulation (DIC} muscle necrosis/weakness myoglobinuric renal failure/hepatic dysfunction electrolyte abnormalities (e.g. hyperkalemia) and secondary arrhythmias ARDS pulmonary edema suspect MH in patients with a family history of problems/death with anesthetic dantrolene prophylaxis no longer routine avoid all trigger medications (use regional ifpossible} and use "clean equipment central body temp and end-tidal C02 monitoring

Prevention

..... ,

...----------------.

Malignant Hyperthermia Management [Based on Malignant Hyperthennia Association of the U.S.

(MHAUS) Guidelines, 2008] 1. notify surgeon, discontinue volatile agents and succinylcholine, hyperventilate with 100% oxygen at flows of 10 Umin or more; halt the procedure as soon as possible 2. dantrolene 2.5 mglkg rapidly IV, through large-bore IV if possible repeat until there is control of signs of MH; sometimes up to 30 mg/kg is necessary 3. bicarbonate 1-2 mEqlkg ifblood gas values are not available for metabolic acidosis

a.lic Principl !If IIH lllllflllllmenl CALL FOR HELP Tum off potential1riggerinv agents Notify operating personnel Administer dantrolene 2.5 m!ll'ka q5minute.
Cool patient to 38"C Monitor and corract blood IJII&es, electrolytes, and glucose

Toronto Notes 2011

Uncommon Complications/Common Medications

Anesthesia A25

4. cool the patients with core temp >390C lavage open body cavities, stomacli, bladder, rectum, apply ice to surface, infuse cold saline IV stop cooling if temp is <38C and falling to prevent drift to <36C 5. dysrhythmias usually respond to treatment of acidosis and hyperkalemia use standard drug therapy except Ca channel blockers as they may cause hyperkalemia and cardiac arrest in presence of dantrolene 6. hyperkalemia treat with hyperventilation, bicarbonate, glucose/insulin, calciwn bicarb 1-2 mEqlkg rv; calcium chloride 10 mglkg or calcium gluconate 10-50 mglkg for lifethreatening hyperkalemia and check glucose levels hourly 7. follow ETCO:z, electrolytes, blood gases, CK, core temperature, urine output and colour with Foley catheter, coagulation studies if CK and/or potassium rises more than transiently or urine output falls to less than 0.5 ml/kglhr, induce diuresis to > 1 ml/kglhr urine to avoid myoglobinuric renal failure 8. maintain anesthesia with benzodiazepines, opioid, and propofol 9. transfer to ICU bed

Common Medications
Table 11. Intravenous Induction Agents
Tbia..nlll {Pintalllljll. lOIIi tlliapantal, sadium thio..IIIIN]
CIBS
Alk-AIIlenol- hypnatic

Klllmila {KIItll.,e,

BenzodazepiDIS [11idlzal1111

(Versadllj, diuep1111 (\lllium]. lcnzeplm (AtivlnJ]

BlllllDdiazapiles

Ultra-5hort acting 1hiobarbillrata - hypnotic Pllencyclidile(PCP) derivative dissociative

Ac:tion

Decrea&ed tina Cl chllmels open 1acililllting May act on NMDA, opiate and Caus111 ilcraased glycine imibitory lmibitory at GABA Decreased cerebral metabolic GABA and supressing gkrtanic acid o1her receptln n1!U1'11111111Smitter, facilitates GABA rate + blood ftow, decreased Decreased cerebral metabolism + Increased HR, increased BP, Produces antianxiety and skeletal ICP, decreased SVR, decreased decreesed blood flow, decreased CPP, increased SVR, increased coronary musde relaxant effects BP. and decrea&ed SV decruil&ed CO. decreased BP, decr8il&8d flow, incrail&ed myocardial Minimal cardiac reflex tachycardia, decreased respiration uptake, CNS + respiratory depression, bronchial smoo1h muscle relaxation lncllction Maintananca Total in1nMinous aneslhesia (TIVA] Induction Control of convulsive stal8s Major 1nluma, hypovolemia, severe Used for sedation, amnesia and as1hma bacause 5y111)1thomimatic anxiolysis

lndic:ations

Allergy (egg. soy] Allergy to barbiturates Pts who camot tolerate sudden Uncontrolled hypotension, shock, cardiac decreased BP (i.e. fixed cardiec failure output or ihock] Porphyria,liwr disease, $lirtus a&thmiltiCU$, myxedema

Kellrnine allergy Marbd respiratory depression TCA medication (interaction causes HTN and dysllhytlmias] Hi&tory of p&yeho&i& Pt cannot tolerate HTN (e.g. CHF. increased ICP, aneurysm] IV induction 1-Z Dissociation in 15s, analgesia, armasia and unconsciousness in
Unconscious for 10-15 min, analgesia for 40 min, amnesia for 1Zin t11z -3 hr& High incidence of emergenca reactions {vivid dreaming, out-dbody sensation, illusions] Pretreat glycopvnolate to decrease salivation Antagonist: flumazenii(AnexataJ COIJ1latitiw mibitor, O.Z mg IV uwr 15s, ll!pe8! with 0.1 mQimin !max of 2 mg], l1tz of 60 minutes Midazolam also has amnestic (antagrade) Bffect + decreased risk of 1hrontophlebitis Onset less !han 5 minutes W given IV Duration of action long but wriabla' somewhat unpredictable

Doling

IV induction: Z.&-3.0 mQI\g !less with opioids or premeds] TIVA Unconscious <1min Lasts min t112=0.9 hrs Decreased sedation, recovery time, NN

IV induction: TIVA Unconscious about 30s Lasts 5 min Accumulation with repeat dosing - not for maintenance t,tz=S-12 In Post.q> sedation lasts hours Combining rocuronium causes to form

Spacill G-30% decreased BP due to Considal'ltioll vasodilation Reduce burning at IV site by mixing with lidocaine

A26 Anesthesia
Tabla 12. Opiaids

Common Medications

Toronto Notes 2011

Alent
Morphill

Infusion IIIII
0.3.0.9 mWb 25-50 IIQI1l 0.1.{).2mWlJ

PCADose 0.2.0.3 mg 2(}.30 1111 0.15!111

PCA Loclalut lnlllml

30 minutes 15 minutes

Flllltil.,t
H)'llramorph-

30 minutes

Afllllt
Morphill Mlpariline (De11eral"'

Modnta Dase(IV]
0.2.0.3ll'lgll<g mQ11cg

Oasat Moderate (5-1 0min) Moderate (10 min)

Duration Moderate (4-5 h) Moderate (2-4 h)

Special Cansidaralians Histanine release leading to decrease in BP Anticholinergic, hallucinations, less pupillary constriction than lllllabolita build up may cause seizures Primllily post-operative use, nat for IV use

Cadlina
Hydramorph(DilludiiPI
Fllllllllayl

0.5-1 mWkg (no lVI

Late (3G-6D mini

Madel'lllll (15 min) Rapid (<5 min) Rapid min)

Moderate (Hi hi Modalllle (4-5 h) Short (0.5-1 h)

Transient muscle rigidity in vwy high doses Only use during in!llclion and mainll!llanca of anesthesia

lllmifaltlnil

Ultra short ( <10 min)

pareni!III!Ut i12-3 tines more P*t than cnl.

Tabla 13. Valltila lnhalational Agents

Sevafhnne
MAC
2.0 Increased ICP

Dlllllur.e 6.0 Increased ICP

1116rane
1.2 Decreased

E'.dlrii!B
1.7

Hllathane
0.8 lncraBSid ICP and CBF

(NzD)

Mtraua oxid11

104 (%gas in 021

CNS

cerebllll
metabolic rate lncraasad ICP

ECG saizunt-likll activity, ina-eased ICP

Respiratory depression {severely decreased lV, increased RR), decreased response to respiratory C02 refi8X85, bnmclhodilation

cvs

Lass decrease of contractility, stable HR

Tachycardia with rapid inaease in concentration

Decraasad BP Stable HR, and CO. decraBSid increased HR, contractility theoretical chance of coronary staal**

Decreased BP. CO. HR and corDiction Sensitizes myacniurn to apinaphrineinlllcad arrhythmias

Can cause decraBSid HR in pediatric cases in !hose with uisting heart disease

MSK

Muscle relaxation, patentialion of ather muscle reiBXBnts, uterine reiiiXIIIion

Advlna Effac11fl IU 10 MAC, nitrous oxida is cminad with otharanlllthatic Q1111 toatllil Ulliclllllllllhesia. AMAC II 104\\ is possible in pnlwized chlll'k 011ly. Sec:ond Gas Eect ll8tanniluls of II Orcat cf"'llatile AS. Expm\liOII 1:1 ciDsad lpiCIIS: cllll8d llpaCIIIJCh pnaumotharu.lhl midlll Bit baWii IJman am ETT c:uffwil mullldly nrva w is dilirllfld. Illusion hypaicia: Ill ring anesthesia, die washllll 1:1 Nz(llilln body stores inlllalwol t:111 db the alveolar [DzL crealiig a hypmcil: mixhn I the ariginaii02J il bN. "Coronll)' Staal: Nz(l C8U881 mlwssal dilalion wliich m11y C01111rotnillll blood flow ID poorly pllfulllld 11811S II heart.

Toronto Notes 2011

Common Medications

Anesthesia A27

Table 14. Depolarizing Muscle Relaxants !Non-Competitive): SuccinylcholineiSCh) Maclllnilm af Actian

Intubating Dale
Dnllt

Mimics ACh and binds to ACh receptors causing prolonged depolarization; initial fasciculation may be seen, followed by lef1l10111ry paralysis secondary to bloclred ACh receptors by SCh 1-2. mQitg
3G-60 seconds- RAPID (fastest of all muscle reiBXBnts)

Duration

5-10 mirutes- SHORT (no reversing agent for SCh)

SCh is hydrolyzed by plasma cholinesterase (pseudocholinesterase), found not at the NMJ in plasma and

Mnlbalilll
lndcllion1

Assist intubation lncrea&ed risk of aspiration (need rapid pnlysis and aiiWll'f control) Short proceilres (e.g. full stol!llch}, DM, hiatus hemia, obesity, pregnancy, trauma Bectroconwlsive (ECTI Laryngospasm

SidaEff8c:ts

1. SC. also slillllatls muscarinic dlalinalllic autonomic raceptDrs (in adlllian ID nicotinic recep1D11} May cause bmdycardia. dysrhythmias, sinus arrlllt, increasad secr&lions of sllliwry glands (especially in children) 2.. llypallrlllmil Disruption of motor nerve activity cMes iJ'Oiifendion of extrajunctional {outside NMJ) cholinsrgic receptors Depalarization of an increased runiler of receptors by SCh may leed to 1111ssive release of potassium out of muscle cells Patients at risk: 3rd bums 24 hrs-6 mths aftur ir1ury Traumatic paralysis or neuroll'llscular diseases (e.g.ll'llscular dystrophy) Severe intra-tbdominal infections Severe closed head injury Uppar motor neuron lesions 3. Can trigger malignant hyparthamia IMH) 4. Increase ICP/intraocular pressure (IOPVintragestric pressure (no increased risk of aspiation competent lower esophageal sphincter) 5. falciculations. post-41p IIJIIgil- may be minimized asmall dose of non-depolarizing agent giwn befor& SCh adminislndion

ConhildicltiDIIS Absolute

Known hypersensitivity or allergy, positive history of mali!Jlilnt hyperthermia, myotonia (m. congenita, m. dystrophica. paramyotonia congenital), tigh risk for hyparkalemic response Known history of plasma cholinesterase deliciancy, myasthenia gravis, myasthenic syndrome, familial periodic paralysis. open eye injury

Relilive

Tabla 15. Non-Depolarizing Muscla Relaxants (Compatilive) Machanilm af Actian

an.ilicatian
Intubating Da11 lml'llll 0.2
Dnllt{minl

Conitive blockade of postsynaptic ACh receptors preventing depolarillllion

Short
Mivacuronium 2.-3 Rocuronium 1.5

llltlnnadiltl
Vecuronium 2-3 Cisatracurium

Long Pancuronium 3-5 lloxacurium

5-7

Duration (nin)

15-25

3G-45

45-60
Liver
Hofmann Eliminations

90-120
Renlll!major) Uver (minor)

9G-120
Renal

Metlllbalilll
lndcllions
SideEffec:ta

Plasma cholinesterase Liver (major) Renal (minor)

Assist intubation. assist mechanical ventilation in some ICU patients, reduce fasciculations and post-op myalgias secondary to SCh
Yes
Increased duration of action in renal or liver faiura

Hiltamile Release Dlh

Conlidandi11111

No

No

No

No
Tachycardia

Yes

Quick onset of rocuronium allows its use in rapid sequence inilction Cisalracurium is good 1or patients with renal or hepatic insulliciency

Pancuronium if increased HR and BP dasired, doxacurium cardiovascular stability needed

A28 Anesthesia

Common MedicationsJR.eferenc:es

Toronto Notes 2011

Table 16. Reversal Agents for Non-Depolarizing Relaxants Chlilntw-lnhilitur

Onset and Dati111
Machanism Dl Actian
Neostigmine lntennBdiate Pyridostigmine Longest EcnphoniLJD Shortest

lnhibib anzyrnatic dagnnlation of ACh, ilcraases ACh at nicotinic and IIIJ&carinic racaptors, displaces non-depolarizing muscle relaxanb Muscarinic ellects of I'I!VI!I'Sing agents ilcklde unwanted bradycandia, salivation and increased

bowel peristalsis*
0.04.n.OBIIIQI1qj Recommended Anticholinergic DDH of Antichalinar,;c parma Glycopyrrolate 0.2 mg 0.1-0.4mll'kg Glycopyrrolate 0.05 mg 0.5-1 mll'kg Atropine 0.014mg

Table 17. Local Anesthetic Agents

Mu.DuH
dllorapracaine lidocaine bupiviclina 11mll'kg 5mll'kg 2.5mg.tg

Mu. Dun with

Epinephrine 14mll'kg 7mll'kg 3mll'kg

Putwcy Low
Medium High

Duration
15-30 min 12 hours 3-8 hours

References
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