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(A2 B2 C2 D2 E2 F2 G2)

Assessing patients preoperatively is an important starting

point to formulate effective anesthetic plan. Pre-anesthesia
assessment includes a good history, a physical examination,
and any indicated laboratory tests.
The guide lines of the American Society of
Anesthesiologists (ASA) indicate that a preanesthesia
visit should definitely include the following:
An interview with the patient or guardian to review
medical, anesthesia, and medication history
An appropriate physical examination
Review of diagnostic data (laboratory, electrocardiogram,
radiographs, consultations)
Assessment of ASA physical status score (ASA-PS)

One of the solutions to effective pre-anesthetic checkup is the

use of good mnemonic that covers all aspects of
pre-anesthetic assessment completely. The mnemonic is A2,
B2, C2, D2, E2 F2, and G2.
(A2 B2 C2 D2 E2 F2 G2)

A - Affirmative history:
The history of present surgical condition with the details of
progression to present state. Details of past illness and
treatment should be elicited.

A - Airway:
Perform detailed airway examination and have a plan for
airway management.
B - Blood hemoglobin, blood loss estimation, and blood
Check for hemoglobin level and take measures to improve.
Assess the requirement of blood based on expected blood
loss and preoperative hemoglobin. Ensure availability of

B - Breathing:
Look for respiratory rate, pattern, and dyspnea.

C - Clinical examination:
Assess pulse volume, rhythm, and blood pressure. Do
detailed systemic examination.

C - Co-morbidities:
Look for co-morbid diseases like diabetes, hypertension,
asthma, and epilepsy and optimize the end organ problems.

D - Drugs being used by the patient:

Elicit the details of current drug therapy and allergies to
plan anesthesia.

D - Details of previous anesthesia and surgeries:

Elicit the details of previous anesthesia and surgeries to
anticipate anesthetic difficulty.

E - Evaluate investigations:
Look for appropriate investigations that would guide
anesthetic management.
E - End point to take up the case for surgery:
to avoid unnecessary postponement if further optimization is
not possible.

F - Fluid status:
Follow fasting guidelines appropriate to the age and surgery.

F - Fasting:
Advice adequate duration of fasting for that particular age
to prevent aspiration.

G - Give physical status:

Assess ASA physical status classification.

G - Get consent:
Discuss the surgical problems and the anesthetic risk with
the patient or guardian to obtain appropriate consent.

In short

A - Affirmative history; Airway

B - Blood hemoglobin, blood loss estimation, and blood
availability; Breathing
C - Clinical examination; Co-morbidities
D - Drugs being used by the patient; Details of previous
anesthesia and surgeries
E - Evaluate investigations; End point to take up the case for
F - Fluid status; Fasting
G - Give physical status; Get consent
(A)Drugs to be stopped before surgery:

1. Oral hypoglycemic

If Minor surgery Omit morning dose

If Major surgery Switch to insulin 48hrs before, and then
omit morning dose of
insulin on day of surgery

2. OCP

Estrogen containing pills to be stopped 4 weeks before

surgery. Stopped for prevention of DVT (Progesterone only
pills can be continued)

3. MAO inhibitors
discontinue 2-3 weeks before Surgery

(Hypertensive crisis can occur when monoamine oxidase

inhibitors are used with sympathomimetics)
(Risk of interaction with perioperative Meperidine,
Ephedrine & Opioids)
4. Oral Anticoagulant

Stop 1 week before and switch to low molecular weight

heparin (which is stopped 1 day before surgery)
Heparin/low molecular weight heparin: The last treatment
dose should be given no less than 24 hours before the
operation. The last prophylactic dose should be given no less
than 12 hours before the operation

5. Aspirin
stop 5 7 days before

6. Lithium (psychiatric drug)

stop 48 72 hrs before.

(May cause electrolyte disturbances and reduced renal
function can precipitate lithium toxicity)
(Antipsychotics can potentiate arrhythmias and enhance
hypotension due to Alpha-1 receptor blockade)

7. ACE Inhibitors &

(Omitted on the morning of the operation, where taken in

the morning, or from the evening before the operation if
taken in the evening. If taken twice daily, both evening and
morning doses should be omitted)

8. Diuretics.

(7 & 8: hold one dose before surgery, to reduces risk of

immediate post-induction hypotension particularly with

Note: Smoking should be stopped 6 weeks before surgery.

Even if not stopped then, it will still benefit if stopped 12 hrs
before surgery.

(B)Drugs that can be continued.

1- Anti-parkinson medications (Levodopa)

2- Psychiatric medications

3- Cardiovascular Drugs: AntiHypertensive (except ACE

inhibitors, ARBs & diuretics)AntiAnginals (except Aspirin)
& Antiarrhythmic drugs.
4- AntiThyroid drugs.

5- Progesterone (only pills can be continued)


7- Bronchodilator

These recommendations are only valid for an anesthesia

system that conforms to current and relevant standards
and includes an ascending bellows ventilator and at
least the following monitors: capnograph, pulse
oximeter, oxygen analyzer, respiratory volume monitor
(spirometer), and breathing system pressure monitor
with high and low pressure alarms.
Verify backup ventilation equipment is available

and functioning.*
High Pressure System

Check oxygen cylinder supply.*

Check central pipeline supplies.*

Low Pressure System

Check initial status of low pressure system.*
Perform leak check of machine low pressure

Turn on machine master switch and all other

necessary electrical equipment.*

Test flowmeters.*

Adjust and check scavenging system.*

Breathing System
Calibrate O2 monitor.*

Check initial status of breathing system.

Perform leak check of the breathing system.

Test manual and automatic ventilation systems and

unidirectional valves.
Check, calibrate, and/or set alarm limits of all
Check final status of the machine.
Vaporizers off.*

APL valve open.

Selector switch to Bag mode .

All flowmeters to zero.

Patient suction level adequate.

Breathing system ready to use.

related links : learning video ( how to check anesthesia
machine )

Anesthesia Machine Video Part 1 of 3

Anesthesia Machine Video Part 2 of 3

Anesthesia Machine Video Part 3 of 3
Anesthesia Machine Checkout Procedure

Patients at risk Respiratory complications of anaesthesia: :


Congestive heart failure


3-surgery type

Aortic aneurysm repair

Thoracic surgery
Abdominal surgery
Upper abdominal surgery
Head and neck surgery
Emergency surgery
Vascular surgery

Major intracranial surgery & Thoracic surgery > Upper

abdominal surgery

Upper abdominal surgery > Lower abdominal surgery

Lower abdominal surgery > Limb surgery

4-Prolonged bed rest

5-Long surgery > 180 minutes

6-Elderly > 65 yearw


8-ASA class 2

Recommendations of the American College of Physicians to
reduce perioperative pulmonary complications in patients
undergoing non-cardiothoracic surgery.

Recommendation 1:

All patients undergoing non-cardiothoracic surgery should

be evaluated for the presence of the following significant risk
factors for postoperative pulmonary complications in order to
receive pre- and postoperative interventions to reduce
pulmonary risk:
chronic obstructive pulmonary disease, age older than 60
years, American Society of Anesthesiologists class of II or
greater, functionally dependent, and congestive heart failure.

The following are not significant risk factors for

postoperative pulmonary complications: obesity and mild or
moderate asthma.

Recommendation 2:

Patients undergoing the following procedures are at higher

risk for postoperative pulmonary complications and should be
evaluated for other concomitant risk factors and receive pre-
and postoperative interventions to reduce pulmonary
prolonged surgery (>3 hours), abdominal surgery, thoracic
surgery, neurosurgery, head and neck surgery, vascular
surgery, aortic aneurysm repair, emergency surgery, and
general anesthesia.

Recommendation 3:

A low serum albumin level (<35 g/L) is a powerful marker of

increased risk for postoperative pulmonary complications and
should be measured in all patients who are clinically
suspected of having hypoalbuminemia; measurement should
be considered in patients with one or more risk factors for
perioperative pulmonary complications.

Recommendation 4:

All patients who after preoperative evaluation are found to

be at higher risk for postoperative pulmonary complications
should receive the following postoperative procedures in
order to reduce postoperative pulmonary complications:
deep breathing exercises or incentive spirometry and the
selective use of a nasogastric tube (as needed for
postoperative nausea or vomiting, inability to tolerate oral
intake, or symptomatic abdominal distention).

Recommendation 5:

Preoperative spirometry and chest radiography should not

be used routinely for predicting risk for postoperative
pulmonary complications.
Preoperative pulmonary function testing or chest
radiography may be appropriate in patients with a previous
diagnosis of chronic obstructive pulmonary disease or asthma.

Recommendation 6:

The following procedures should not be used solely for

reducing postoperative pulmonary complication risk:
right heart catheterization and total parenteral nutrition or
total enteral nutrition (for patients who are malnourished or
have low serum albumin level

Common side effects and minor risks associated with


Most side effects of general anesthesia are minor in people

who are otherwise healthy and they can be easily managed
by your anesthesia care team.

Some of the most common ones are discussed below.

1. Nausea and vomiting after surgery

(Also called postoperative nausea and vomiting)

occurs in the first 24 hours after your surgery.

It affects 20-30% of patients.

Nearly half of all patients who do not have PONV in the

hospital, experience nausea and/or vomiting in the first few
days after discharge.

Who is at risk?

1-being female
2- having a history of motion sickness
3-history of PONV after a previous surgery.
4- Some anesthetic drugs and painkillers, the morphine-like
painkillers (called opioids in medical terms) and laughing
gas (called nitrous oxide in medical terms).
5- Surgery on the ear or intestines and laparoscopic

Can it be prevented and/or treated?

1-It is important to inform your anesthetist that you had this

problem in the past. Your anesthetist can choose a different
way of giving your anesthetic

2. When the choice is available, patients should be advised

that the risk of PONV decreases when regional rather than
general anaesthesia is administered
3. The perioperative use of opioids should be minimized.
Surgeons should evaluate the risks/benefits of opioid
administration to decrease the risk of PONV

4. Prophylactic antiemetics should be administered to

patients with moderate or high risk of developing PONV. (
metoclopramide 10 mg
5. In patients with a high risk of developing PONV,
combination antiemetic therapy should be considered.
(metoclopramide &ondansetron)

6. When prophylaxis with one drug has failed, a repeat dose

of this drug should not be initiated as a rescue therapy;
instead, a drug from a different class of antiemetic drugs
should be

7. As patients who undergo surgery in surgical daycare units

may have PONV after they are discharged, they should be
given instructions for its management.

8. Patients at high risk of developing PDNV should be

provided with rescue treatment.

2. Sore throat

Sore throat and hoarseness in the first hours to days after

anesthesia occurs in up to 40% of patients.

Who is at risk?

1- Being female
2- younger than 50 years old
3- having a general anesthetic lasting more than 3 hours.
Can it be prevented and/or treated?

1-Having a regional anesthetic will completely prevent this

2-However, if you need a general anesthetic, your anesthetist
may chose a smaller size for the device used to help you
breath during surgery.
3- Some drugs have also been proven to be beneficial, such
as a freezing medication or an anti-inflammatory
4-In addition, the use of some over the counter substances
such as Tantum or Strepsils can help alleviate acute sore
throat pain.

3. Teeth damage

The most frequently injured teeth are the upper front ones
(the upper incisors)

Who is at risk?Those with poor dental health and where the

anesthetist have had difficulty to get the breathing tube
down (called a difficult intubation).

Can it be prevented?

1-Although the anesthetists are always very careful,

prevention of dental damage is not always possible.
2-Several devices have been used such as mouth-guards and
bite-blocks but provide no guarantee.

4. Shivering/Chills

25-50% of patients.

Who is at risk?

1-Cooling down is the most common cause.

( cold IV fluids , cold OR temperature)
2-Other causes including include pain, fever and stress after
3- It seems to be more common in males and after longer
surgeries, but it is quite rare in elderly patients.

Can it be prevented and/or treated?

1-While we try to reduce the drop in body temperature

( by using warm fluids, not reducing OR temperature than
2-There are also a few drugs that can be used either to
prevent and/or to treat post-operative shivering as
mepredine (25-30 m
The central venous pressure (CVP) is the pressure measured
in the central veins close to the heart. It indicates mean right
atrial pressure and is frequently used as an estimate of right
ventricular preload.

The CVP catheter is an important tool used to assess right

ventricular function and systemic fluid status.

What is a central venous catheter?

A central venous catheter, also called a central line, is a long,

thin, flexible tube used to give medicines, fluids, nutrients, or
blood products over a long period of time, usually several
weeks or more.

Normal values are 5-10 mmHg

Factors affecting CVP

Factors that increase CVP include:

forced exhalation
Tension pneumothorax
Heart failure
Pleural effusion
Decreased cardiac output
Cardiac tamponade
Mechanical ventilation and the application of positive end-
expiratory pressure (PEEP)
Pulmonary Hypertension
Pulmonary Embolism

Factors that decrease CVP include:

Deep inhalation
Distributive shock

Indications for the use of central lines include

Monitoring of the central venous pressure (CVP) in acutely

ill patients to quantify fluid balance
Long-term Intravenous antibiotics
Long-term Parenteral nutrition especially in chronically ill
Long-term pain medications
Drugs that are prone to cause phlebitis in peripheral veins
(caustic), such as:
Calcium chloride
Hypertonic saline
Potassium chloride
vasopressors (e.g. epinephrine, dopamine)
Peripheral blood stem cell collections
Frequent blood draws
Frequent or persistent requirement for intravenous access
Need for intravenous therapy when peripheral venous access
is impossible

insertion see video

peripheral venous catheter (PVC or

peripheral venous line or peripheral venous
access catheter) is a catheter (small, flexible
tube) placed into a peripheral vein in order to
administer medication or fluids.

A peripheral venous catheter is usually

placed in a vein on the hand or arm. It should
be distinguished from a central venous
catheter which is inserted in a central vein
(usually in the internal jugular vein of the
neck or the subclavian vein of the chest), or
an arterial catheter which can be placed in a
peripheral as well as a central artery. In
children, a local anaesthetic gel (such as
lidocaine) is applied to the insertion site to
facilitate placement


Repeated blood sampling

Intravenous fluid administration
Intravenous medications administration
Intravenous chemotherapy administration
Intravenous nutritional support
Intravenous blood or blood products
Intravenous administration of radiological
contrast agents for computed tomography,
magnetic resonance imaging, or nuclear


No absolute contraindications to intravenous

cannulation exist.
Peripheral venous access in an injured,
infected, or burned extremity should be
avoided if possible.


Infection, phlebitis, extravasation,

infiltration, air embolism, hemorrhage
(bleeding) and formation of a hematoma
(bruise) may occu

pinal Anesthesia
Spinal anesthesia also called spinal analgesia or sub-arachnoid
block (SAB), is a form of regional anaesthesia involving
injection of a local anaesthetic into the subarachnoid space,
generally through a fine needle, usually 9 cm long (3.5 inches).
Spinal anesthesia is a technique in which the patient is given an
injection in the lower back that blocks the nerves that supply
feeling to the lower half of the body.

The medication is injected into a sac of fluid in your lower back

(the subarachnoid space) which contains the spinal nerves.
The medication blocks the nerves in the lower half of the body.
The loss of feeling is temporary and should last from 1 to 4
hours depending on the medication given and other factors


epidural anesthesia, a form of regional anesthesia involving

injection of drugs through a catheter placed into the epidural
space. The injection can cause both a loss of sensation
(anaesthesia) and a loss of pain (analgesia), by blocking the
transmission of signals through nerves in or near the spinal cord.

Difference from spinal anesthesia

The involved space is larger for an epidural, and subsequently
the injected dose is larger, being about 10-20 ml in epidural
anesthesia compared to 1,5-3,5 ml in a spinal.
In an epidural, an indwelling catheter may be placed that avails
for additional injections later, while a spinal is a one-shot only.
The onset of analgesia is approximately 15-30 minutes in an
epidural, while it is approximately 5 minutes in a spinal.
An epidural usually doesn't cause significant neuromuscular
block, while a spinal more often does. An epidural may be given
at a thoracic or lumbar site, while a spinal must be injected
below L2 to avoid piercing the spinal cord.

Position of the patient

The patient may be in the sitting position or lateral position
(lying on one side). The sitting patient is asked to slouch and
bend forward slightly from the waist to increase the curvature of
the spine. The lying patient is asked to draw the knees up to the
chin for the same reason.


: 1-

) ( Spinous Processes .


( Spinal -
) Needle


: -


Anaesthetic drugs
A patient receiving an epidural for pain relief typically
receives a combination of local anesthetics and opioids. This
combination works better than either type of drug used
alone. Common local
anesthetics include lidocaine, bupivacaine, ropivacaine,
and chloroprocaine. Common opioids
include morphine, fentanyl, sufentanil, and pethidine. These
are injected in relatively small doses

Patient refusal


Insertion of an epidural needle or catheter into the epidural

space may cause traumatic bleeding into the epidural space.
Clotting abnormalities may lead to the development of a
large haematoma leading to spinal cord compression.

Therapeutic anticoagulation.
( see later)

Skin infection at injection site.

Insertion of the epidural needle through an area of skin

infection may introduce pathogenic bacteria into the
epidural space, leading to serious complications such as
meningitis or epidural abscess.

Raised intracranial pressure.

Accidental dural puncture in a patient with raised ICP may

lead to brainstem herniation (coning).


The sympathetic blockade produced by epidurals, in

combination with uncorrected hypovolaemia, may cause
profound circulatory collapse.
Uncooperative patients

may be impossible to position correctly, and be unable to

remain still enough to safely insert an epidural.

Pre-existing neurological disorders,

such as multiple sclerosis, may be a contraindication,

because any new neurological symptoms may be ascribed to
the epidural.

Fixed cardiac output states.

Probably relative rather than absolute. This includes aortic

stenosis, hypertrophic obstructive cardiomyopathy
(HOCM), mitral stenosis and complete heart block. Patients
with these cardiovascular abnormalities are unable to
increase their cardiac output in response to the peripheral
vasodilatation caused by epidural blockade, and may
develop profound circulatory collapse which is very difficult
to treat.

Anatomical abnormalities of vertebral column may make

the placement of an epidural technically impossible.
Prophylactic low dose heparin

Regional anesthesia and anticoagulants

Full oral anticoagulation with warfarin or standard
heparin (SH) are absolute contraindications to epidural

Partial anticoagulation with low molecular weight heparin

(LMWH) or low dose warfarin (INR <1.5) are relative

Low dose standard heparin (SH), 5,000units bd s/c is not

associated with an increased risk of epidural haematoma.
Wait for 4 hours after a dose before performing epidural.

LMWH : allow 12hr interval between LMWH

administration and epidural; this also applies to removal of
epidural catheters.

NSAID's (including aspirin) do not increase the risk of

epidural haematoma.

Intraoperative anticoagulation using 5000units i/v

heparin following epidural/spinal injection appears safe, but
careful postoperative observations are recommended. .

Fibrinolytic and thrombolytic drugs: avoid epidural block

for 24 hrs, check clotting prior to insertion.

Thrombocytopaenia: epidurals are relatively

contraindicated below platelet count of 100,000/mm3.

An epidural haematoma should be suspected in patients

who complain of severe back pain a few hours/days
following any central neuraxial block or with any
prolonged or abnormal neurological deficit (including.
sensory loss, paraesthesiae, muscle weakness and
disturbance of bladder control and anal sphincter tone).
A high index of suspicion is required, with early
orthopaedic or neurosurgical referral for decompression
of the haematoma. Even with early recognition, the
morbidity of this condition is still very high

Important complications of regional

Pain - 25% of patients still experience pain
despite spinal anaesthesia

Post-dural headache from CSF leak

Hypotension and bradycardia through

blockade of the sympathetic nervous system

Limb damage from sensory and motor


Epidural or intrathecal bleed

Respiratory failure if block is 'too high'

Direct nerve damage


Damage to the spinal cord - may be

transient or permanent

Spinal infection

Aseptic meningitis

Haematoma of the spinal cord - enhanced

by use of LMWH preoperatively

Urinary retention






1. General anaesthesia: the patient is sedated, using either

intravenous medications or gaseous substances, and muscles
paralysed, requiring control of breathing by mechanical
2. Regional anaesthesia: anaesthetic drugs are administered
directly in or around the spinal cord, blocking the nerves of the
spinal cord (e.g. epidural or spinal anaesthesia). The main
benefit of this method is that ventilation is not needed (provided
the block is not too high).
Regional anaesthesia can also be peripheral - for example:
o Plexus blocks, e.g. brachial plexus
o Nerve blocks, e.g. femoral
o Intravenous blocks whilst preventing venous flow out of the
region, e.g. Bier's block
3. Local anaesthesia: the anaesthetic is applied to one
site,usually topically or subcutaneously.

General Anesthesia

General Anesthesia provides analgesia (no pain), amnesia

(you are unaware and have no memory), and relaxation.

( )
" "

General Anesthesia is usually started and maintained by

giving the patient an intravenous drug , an inhalation drug
or a combination of both.
The anesthesia provider will monitor the progress of the
surgery and the depth of your anesthesia. The depth of
anesthesia can be changed by increasing or decreasing
the amount of drug given.
As the surgeon finishes the procedure, the anesthesia
provider reduces the depth of anesthesia so the patient
will awaken at the end of the procedure or shortly

An intravenous line will be started. After sedation may be

When the operating room and your surgeon are ready,
you will be taken to surgery.
In the operating room, monitors for your breathing, heart,
and blood pressure will be placed on you. You will be
asked to breathe through an oxygen mask for a few
breaths as the anesthetic is given through your
intravenous line (IV).
The next thing you should remember is awakening in the
recovery room. You may be a little when you wake up
in the recovery room, but that should improve as the
anesthetic clears
If you have any pain, you will be given pain medications
through your IV. When you have recovered sufficiently
from your anesthetic, your pain is under control, and your
vital signs are stable, you will be transferred to your
hospital room or prepared to go home


( face mask, oro or naso-pharyngeal airway, laryngeal
mask airway)

- .
- .
- .



Important complications of general anaesthesia
The practice of anaesthesia is fundamental to the practice of
medicine. However, anaesthesia is not without its problems.
General anaesthesia is thought to be a direct cause of mortality
in 1 out of 10,000 operations.

Important complications of general anaesthesia

Nausea and vomiting - up to 30% of patients
Damage to teeth - 1 in 4,500 cases
Sore throat and laryngeal damage
Anaphylaxis to anaesthetic agents - figures such as 0.2% have
been quoted
Cardiovascular collapse
Respiratory depression
Aspiration pneumonitis - up to 4.5% frequency has been
reported; higher in children
Hypoxic brain damage
Nerve injury - 0.4% in general anaesthesia and 0.1% in
regional anaesthesia
Awareness during anaesthesia - up to 0.2% of patients; higher
in obstetrics and cardiac patients
Embolism - air, thrombus, venous or arterial
Idiosyncratic reactions related to specific agents,
e.g. malignant hyperpyrexia with suxamethonium,
succinylcholine-related apnoea
Iatrogenic, e.g. pneumothorax related to central line insertion


) 24( .

) 24( .

The gases are supplied by a high pressure system.

An adjustable low pressure system reduces the
pressure, and mixes the gases along with the
anesthetic vapors.

Since paralysis is a consequence of general

anesthesia, breathing is usually controlled by
a manual breathing system, in which the operator
squeezes a bag to deliver gases to the patient, or

by a mechanical breathing system, in which a

bellows is alternately filled with gases, and emptied
into the airway.

The breathing circuit connects the patient to the

anesthesia machine, of course, and controls the flow
of gases during inhalation and exhalation.

Finally, the exit route for gases is provided by

the scavenging system.

breathing circuit, anesthesia machine, waste gas

scavenger system, and anesthesia ventilator
anesthesia ventilator
breathing circuit

anestheisa ventilator