Beruflich Dokumente
Kultur Dokumente
Anesthesia
Surgeons and
Anesthesia
S Ahanatha Pillai MD DA
Emeritus Professor
The Tamil Nadu Dr MGR Medical University
Chennai, Tamil Nadu, India
Former Professor
Department of Anesthesiology
Madurai Medical College and Government Rajaji Hospital
Madurai, Tamil Nadu, India
Foreword
Sam C Bose
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Surgeons and Anesthesia
First Edition: 2014
ISBN: 978-93-5090-837-2
Printed at
Sri Ramajeyam
Om Anandamayi Chaithanyamayi Sathyamayi Parame!
Dedicated to
Who is better suited to write the foreword for a well-thought out book for
surgeons by an Anesthetist? Certainly, an Anesthetist!
But when a surgeon is asked to study the 236-page book and write
the foreword, it is a pleasure and honor. Pleasure, because one is
educated even in his eighth decade of life and over six decades of nodding
acquaintance with surgery since 1952.
A lesson which I learned is, in the first 10 years learn ‘how’ to do surgery,
second 10 years ‘when’ to do surgery, third 10 years ‘when not’ to do surgery
(these three were taught by the Jambavans of yesteryears), and finally
when ‘stop’ doing surgery!
In conclusion, I congratulate Professor Dr S Ahanatha Pillai for writing
this wonderful piece of educative manual throwing open the nuances of
high quality anesthesia wizardry for the benefit of future generation of men
and women of all specialties including ‘surgeons’!
This small book is aimed at the young surgeons who would like to know
something about anesthesia while developing expertise in their own field.
I am fortunate to be in the field of anesthesiology from the ‘open drop
ether era’ to the modern-day anesthesia for about four decades and had
the fortune of working with three generations of surgeons specially, some
of the great stalwarts in surgery of yesteryears. Hence, I humbly feel fit to
write about the subject on the title Surgeons and Anesthesia.
There is a natural question, ‘Why should a surgeon know about
anesthesia?’ The answer is very straightforward and simple; surgery and
anesthesiology are very intimately related and interdependent fields, and
as anesthesiologists and surgeons work in the same team, each one must
have some orientation about the other’s work so as to give the best possible
service to the patient in the teamwork.
I brought out the book Anesthesia for Undergraduate sometime in 1995.
Since then, there had been a persistent request from many of my good
friends and colleagues belonging to various surgical specialties for a simple
and comprehensive book that deals with the basics of anesthesiology and
other important aspects related to anesthesia and operating department. I
am very grateful to all my esteemed colleagues, for their love to me.
My close association with my dear surgical colleagues was so pleasant
and enduring for the past four decades that the idea of this book was deep
in the back of my mind all these years. Now it is taking shape.
After a lot of thought and planning, keeping all their requirements in
mind, this book has been designed a little differently.
The topics and chapters have been chosen in such a way that it may
be useful to the postgraduates in surgery as well as practicing surgeons.
Preanesthetic assessment and preparation of the patient which would tell
upon the ultimate outcome of surgery has been adequately dealt with.
Without going deep into the subject, all the practical aspects are discussed
with their clinical relevance. This will certainly help the surgeons to easily
spot and identify the anesthesia-related problems in the perioperative period
so that remedial steps could be taken without delay; and if necessary, call
the anesthetic colleague for help.
Apart from discussing fundamentals of clinical anesthesia, less commonly
discussed topics such as surgical team, surgeon-anesthesiologist relations,
operation theater discipline, planning an operating department, asepsis,
sterilization of equipment, coordination of theater work, postanesthetic
care, etc. have been included. The chapter “Vital Organs Function and
Anesthesia” has been specially included that precisely deals with the
possible alterations in function of vital organs due to anesthesia.
x Surgeons and Anesthesia
S Ahanatha Pillai
Acknowledgments
1. Introduction 1
Anesthesia 2
2. Anesthesiologist 7
Learning anesthesiology 7
Functions of the Anesthesiologist 7
Surgeon-Anesthesiologist Relations 11
Operating theater suite and theater discipline 13
Operating department Manager 16
3. Surgical Team 19
Members of Surgical Team 19
Job descriptions of Anesthetic Technician 23
Unskilled personnel working inside the operating room 25
Coordinator of the Team 27
4. Safe practice of Anesthesia 32
Ten Golden Rules of Anesthesia 33
Indian Society of Anesthesiologists 34
Safety in anesthesia 36
Accidents during Anesthesia 37
Anesthetic Records 40
Monitoring during Anesthesia 43
Monitoring the anesthetic machine 45
The cardiovascular System 45
5. Preanesthetic Assessment 48
The purpose of preoperative visit 49
Guidelines for Preanesthetic visit 49
Definition 51
History taking 51
Physical examination 52
Basic Laboratory Investigations 52
Grading of Risk (American Society of Anesthesiologists) 54
Fit for anesthetic 55
Informed Consent for anesthesia and surgery 57
Preoperative starvation 60
Canceling cases 61
Choice of anesthesia 62
6. Preanesthetic Medications (Premedication) 65
Definition 65
Preanesthetic Medication Drugs (Premedication Drugs) 66
Effects of Premedication 71
7. Clinical Anesthesia: Balanced Anesthesia 73
The Purpose of Anesthesia 73
Guedel’s classification of Anesthesia 73
The Triad of Anesthesia 75
Definition of Anesthesia 76
xiv Surgeons and Anesthesia
Balanced Anesthesia 77
Modern Anesthesia 78
Recovery from Anesthesia 83
Classification of Anesthesia 86
8. The Operating Department 87
Operating Department, Operating Suite, Operating Theater 89
Access Zones 89
Patient transport 91
Design 93
Construction 94
Lighting 94
Pendant services 99
Ventilation 99
Storage 102
9. Theater Asepsis and Equipments Sterilization 104
Operating theater environment and asepsis 104
History 105
Definitions 107
Theater Disinfection Schedule 107
Ultraviolet Rays 110
Ultraviolet Rays air cleaning system 110
Sterilization of Equipments 113
Cleaning and Sterilization 114
Gamma rays 128
10. Operating Table and Positions for Surgery 132
Positions for Surgery 134
Supine or Dorsal Recumbent Position 135
Trendelenburg Position 136
Gallbladder and Liver position 136
Lateral Position of Extension (Kidney Position) 137
Lithotomy Position 139
Position for Abdominoperineal Resection of Rectum 140
Supporting pads for positioning 143
11. Assessment of Blood Loss and Volume Replacement 144
Facts about Blood Transfusion 145
Assessment of blood loss during surgery 145
Recommendations from various authorities regarding transfusion 147
role of colloid solutions in blood volume replacement 147
Commonly used IV Fluids, their Composition and Indications 149
12. Vital Organ Function and Anesthesia 155
Anesthesia and liver 155
Anesthesia and Kidney 160
Anesthesia and Brain 166
Anesthesia and Heart 170
13. Recovery room: Postanesthesia Care Unit (PACU) 178
Postanesthesia Care 178
Recovery Room 179
The Transport to Recovery Room 180
The purpose of Recovery Room 181
Recovery Criteria 188
Contents xv
Index 237
Quotes
‘It is a great mistake to suppose that nature always stands in need of the
assistance of art... Nor do I think it below me to acknowledge that, when
no manifest indication is pointed out to me what was to be done, I have
consulted the safety of my patients, and my own reputation effectually by
doing nothing at all.’
— Thomas Sydenham
‘No hospital is too small for learning and no doctor is too wise not to be
benefited from the experience of others.’
‘It is a common mistake to believe that general anesthesia is dangerous
and conduction anesthesia (regional) is safe’.
Hospitalization
1 Introduction
Introduction
Anesthesia and surgery are intimately interlinked and interdependent specialties.
If we carefully look back into the past, surgery done without anesthesia was an
agony and surgical techniques could not develop because speed of surgery was
considered as an essential quality of a good surgeon.
Till middle of 18th century, nothing effective was available for improving the
situation. The dawn came only on 16th October 1846, when general anesthesia with
Ether was introduced by WTG Morton. The surgeons were eased of their technical
difficulties due to a struggling patient held down forcefully by the strong men who
were always the part of the surgical team in those days (Fig. 1.1).
Because the patient was quiet under good anesthesia, the surgeon could do the
surgical procedure without hurry to his satisfaction for the benefit of the patient.
This situation permitted the surgeons of that era to improve and reach perfection in
their techniques. Since then, both the specialties started developing simultaneously
and continued to improve the standards for the past two centuries into the modern
sophisticated status as we see today.
Anesthesiology is a science that provides relief of pain for the mankind. This
is the simplest way of defining this wonderful branch of medicine.
General anesthesia is a reversible, drug induced state of unconsciousness. This
is another definition though old and incomplete, explains what General Anesthesia
means.
Fig. 1.1: Surgery without anesthesia where the ‘Strong men’ hold down the patient
2 Surgeons and Anesthesia
Anesthesia
The meaning of the word ‘Anesthesia’ is given differently in different dictionaries.
• “A defect of sensation” (Bailey’s English Dictionary—1721)
• “Privation of the senses” (Encyclopedia Britannica—1771)
• “A sleep like state that makes painless surgery possible” (English Dictionary—
1751)
• “Absence of sensibility to external impressions, particularly touch” (Modern
English Dictionary).
Anesthesia is the basic requirement for any surgery to be conducted as, any
surgical procedure, however small, is certain to inflict pain on the patient.
All human beings irrespective of their socioeconomic status or any other
discrimination have their basic fear about two things; one is fear of pain and the
other is fear of death. In day-to-day life, the fear of pain persists even with a very
trivial injury, and in the event of illness, that too in an illness associated with need
for surgery, they develop these two fears together, that is fear of pain and fear of
Chapter 1 Introduction 3
possible death as a consequence of surgery. The patients when they are questioned
many times they refer to this and express this as “fear of the unknown”.
Though physiologically pain is a protective reflex to prevent movements
and further damage to injured tissues thereby promoting the healing process,
uncontrolled pain of severe degree of any cause is detrimental to the physiology
itself. Hence, relief of pain in any form is a heavenly blessing. So relief of pain
of surgery is essential both during and after surgery, otherwise irreversible damage
may be caused to the individual that may even be fatal.
“The relief of pain is purchased always at a price. The price both in morbidity
or mortality does not greatly differ, whatever the agent or agents used”
— Ralph Milton Waters
This statement of Ralph Milton Waters, who was one among the pioneers who
had contributed enormously for the development of anesthesia, is absolutely true
as anesthesia is a highly interventional specialty meaning thereby, the normal
physiology is modified for the sake of relief of pain and for the protection of the
patient from the ill effects of surgery. Though this modification of physiology is
done with an intention of protecting the patient from the likely damage by the
pain and reflexes induced by the surgical procedure, there is a limit for this
modification. This limit of modification of physiological status grossly varies from
patient-to-patient depending upon their physical and physiological status, when it
is crossed, certainly leads onto risks that may result in a fatal outcome.
Let us think about this;
Have we ever seen a man walking on the pavement suddenly becoming
unconscious for a few minutes and lying flat on the ground, then getting up and
walking again? Or have we ever seen someone traveling in our next seat in a bus
or a train suddenly stops breathing for a while and after sometime shakes his head
and starts breathing again?
Both these things can never happen during normal life, but during anesthesia
a patient is made unconscious and is paralysed. To prevent him from dying
the anesthesiologist takes over the respiration and ventilates him manually by
compressing a bag intermittently till he is back to normal to breathe on his own.
When the patient’s physiology is artificially modified and deviated from
normal, even if it is within the so called limits of safety, it means he is no longer
in a position to take care of him. Then it becomes the prime responsibility of the
anesthesiologist to take care of the patient, till he is able to do it himself.
In fact, over the past two centuries, the deep concern of all those involved in
surgical teamwork is only ‘Patient safety’.
Three aspects have to be taken into very careful consideration before
anesthetizing a patient.
1. The physiological status of the patient at the time of taking him up for anesthesia
and surgery.
2. The nature of surgery and the degree of modification of his physiology required
for that surgical procedure.
3. The choice of technique of anesthesia and the choice of drugs needed for that
purpose and their doses in accordance with the patient’s condition.
4 Surgeons and Anesthesia
1. In a healthy person in normal life, the safety margin is very wide as all the
compensatory physiological mechanisms are functioning well and all protective
reflexes are fully active. Usually mild to moderate physiological insults
occurring in such individuals are well compensated and no risk to life is caused.
2. The same healthy individual, once anesthetized, cannot protect himself from any
untoward thing that is likely to happen. He becomes almost totally dependent on
the care of the anesthesiologist for the safety, because he loses the physiological
protection to a varying degree depending upon the type and depth of anesthesia.
This induces a potentially hazardous situation as long as he is under anesthesia
and also in the immediate postoperative period till his physiological protective
mechanisms are fully regained. Hence the safety margin of even a otherwise
healthy person is reduced considerably. That is the reason for grading a perfectly
healthy person undergoing anesthesia as Risk I.
3. If the patient is suffering from a mild systemic disease, the ‘Safety margin’ is
further reduced, making the anesthetic management difficult. Good degree of
skill is required to manage and wherever possible, less duration of surgery will
help to reduce the insult to the patient by anesthetic procedure.
4. When the patient has a severe systemic disease (Cardiac, respiratory renal
etc), the damage is so severe, that the patient’s system may not stand the stress
of anesthesia and the ‘Safety margin’ becomes still narrower. Very intricate
modulation of anesthesia is needed for this patient to prevent risk to life.
5. Mild derangement of multiple systems will have almost the same situation, but
as more than one system is deranged, the risk becomes higher and this further
narrows the ‘Safety margin’. So, the risk is higher than severe derangement of
one system.
6. When a patient is presented with multiple organ failure, he is said to be in a
‘moribund’ state (close to death). In such patients, literally there is no ‘Margin
of safety’ available for modulating the anesthesia. Even an attempt to induce
sleep with very small dose of ultra short acting barbiturate (thiopentone sodium)
may abolish all those feeble reflexes which sustain life till that moment and
cause cardiac arrest with no chance of revival. It is not worth attempting for
all known reasons.
Chapter
2 Anesthesiologist
Chapter Outline
Learning anesthesiology
v
Functions of Anesthesiologist
v
Surgeon-Anesthesiologist Relations
v
Operating suite and theater discipline
v
Operating department manager
v
Learning anesthesiology
“Anesthesia is a science but learned and practiced as an art.”
Anesthesiology bridges the gap between the basic sciences and clinical sciences.
Of all the disciplines, it is the one which is most suited for reinforcement of
information learned in biochemistry, physiology and pharmacology in the context
of a patient’s disease. Anesthesia practice is the ideal setting for teaching ventilatory
control and adequacy of respiratory exchange, circulatory monitoring, assessment of
level of consciousness and care of comatose, fluid replacement and all such clinical
aspects. Tracheal intubation, insertion of venous cannulae and spinal tap are also
logically taught on an anesthesia service. Postgraduate training in anesthesiology
differs from that in other fields because it must be individualized. Considering the
breadth of the surgical and obstetrics fields, this specialty has wide exposure to
many disciplines and has the advantage of receiving information from all.
Practically all hospitals still seek qualified anesthesiologists interested in
teaching and research as well as in clinical practice.
Good
He must be very kind and compassionate to the patients, working with human touch
and takes care of every patient with personal interest and involvement. He must
treat all the patients equal and show no discrimination for any reason.
In fact everyone is a VIP. We conveniently forget one clear fact that if there are
no patients there is no work for the doctor and if there is no patient for surgery in
the operating list there is no work in the operating room for that day. So the VIP in
any hospital premises can only be the patients and so also in the operating room
and treat every patient with respect.
Many anesthesiologists believe that they need not have any interaction with
the patients. This is absolutely untrue as communication is a basic skill one must
develop to be successful in any endeavor. The anesthesiologist must have the
capability of positive communication to the patient that matches their level of
intelligence to make them understand that he is there to take care of the patient.
Without effective communication with the patient the anesthesiologist’s job is only
half done and incomplete.
Actually positive communication is defined as the capability of forming the
correct sentences by using appropriate words and passing on to the right person
in the right time and in the right manner so as to transfer the information which
you wanted to pass on to him.
He must be very careful in choosing the word because an inappropriate word
may spoil the purpose of communication and may lead on to confusion in the
minds of the patients. It is essential to understand proper meaning of the word or
the definition of every technical word which he uses.
Chapter 2 Anesthesiologist 9
Efficient (Skillful)
He must be willing to learn the basic techniques very clearly and sincerely so as to
gradually acquire the necessary skills and refining them everyday so that as days
pass on his skill improves remarkably. So also, he must be updating his skill with
newer innovations in the field, if needed by attending training programs.
Safe
He must be deeply concerned with the safety of the patient. He must not compromise
the safety of the patient for any reason. Here it may be necessary to have extensive
lengthy discussions with the team mates about the risk and seek their cooperation
to establish safety.
The patient does not show any interest to know about the qualification of the
anesthesiologist and not even about his experience, but would like to know whether
he is a safe anesthesiologist and whether he will safeguard him from any possible
catastrophe during anesthesia and surgery.
To be safe he may imbibe the following three characters:
Discipline
He must maintain punctuality. Punctuality does not imply coming in time. Coming
sufficiently before time to check the equipments, keep the right drugs loaded in
syringes and start the work in the scheduled time is described as punctuality. The
work must be done in an orderly fashion so that no step is missed and no error is
happened.
Devotion
He must consider the work place as a place of sanctity. He must enforce maintenance
of silence as far as possible and not making unnecessary conversations not relevant
to the work.
Dedication
He must be willing to do any type of work for the sake of patients with fullest
involvement with a willingness to sacrifice his own comfort.
“The principal tasks of the anesthesiologist are to provide relief of pain for
patients during operation and optimal operating conditions for the surgeons, both
in the safest possible manner.”
To do this the anesthesiologist must be a competent physician and a clinical
pharmacologist, with a broad knowledge of surgery and the ability to utilize and
interpret correctly a variety of monitoring devices.
10 Surgeons and Anesthesia
Surgeon-Anesthesiologist Relations
(From the writings of the famous author and a loved teacher Robert D. Dripps.,
in his own words)
Surgeons and anesthesiologists constitute a team of physicians dedicated to the
welfare of the surgical patient whose interest is best served if each member of the
team recognizes his or her responsibilities, yet remains aware of the problems faced
by colleagues. The anesthesiologist’s position on the team is clearly defined: he or
she must have a thorough knowledge of the patient’s medical history, the operation
proposed, and the risks involved. The stresses placed upon the bodily systems by
the contemplated anesthesia and surgical procedure must be understood. There
must be discussion with the surgeon and other consultants concerning unfamiliar
aspects of the patient’s disease. The surgeon should be informed of the patient’s
progress, not by routine recitation of vital signs but by instant transmission of
important information. A multitude of details must be constantly monitored that
would distract the surgeon’s attention from the technical problems of operation.
Care of the patient in the crucial immediate postoperative period must be closely
supervised while the surgeon is engaged elsewhere.
12 Surgeons and Anesthesia
A surgeon should consult with the anesthesiologist before operation and discuss
the details of surgical management. It is unwise to insist upon unnecessary speed
in induction of anesthesia, since this can be detrimental to the patient. A particular
anesthetic or technique rarely should be demanded, as the surgeon may not know
the limits of an anesthesiologist’s capabilities or the potential for harm of certain
anesthetics and techniques. Cadaveric relaxation never is needed and cannot
be produced with genuine safety under any circumstance. Problems peculiar to
anesthesia must be realized and time allowed for their solution. On occasion the
surgeon must agree to rapid conclusion of the operation if the anesthesiologist
believes that the patient’s condition is deteriorating; development of malignant
hyperthermia is a good example.
A team is at its best when its members have worked together repeatedly. It
takes time for individuals to learn where they fit into the scheme of things and
how associates perform their particular tasks. Good team work arises from mutual
respect. A new member of the team must be proved worthy before acceptance on
the same basis as the others.
Surgical team works under variety of circumstances. In most operations there
should be little tension, but in difficult operations or those in which complications
arise; tempers may flare and harsh words may be exchanged. The care of the
patient may suffer as a result. Surgeon and anesthesiologist must visualize each
other’s predicament. Technically simple operations may be performed under trying
anesthetic conditions, while an intricate, difficult operation may be performed
without anesthetic incident. If irritability is displayed by any member of the team,
the others must assess the situation and minimize friction if possible. The operating
room is no place for verbal battle. Words spoken in anger can be withdrawn later
on, but if the patient has suffered, irreparable damage may ensue.
The inexperienced observer sometimes believes that the anesthesiologist
occupies a position subordinate to that of the surgeon. This feeling often arises from
lack of experience with the team performance of complex operations, although the
anesthesiologist may contribute to his subordinate status by failing to participate
fully in medical care. Evidence that an anesthesiologist is first a physician and
then a competent specialist will assure acceptance as an equal in the overall care
of patients.
Confusion often exists in the minds of both surgeons and anesthesiologists
as to medicolegal responsibility in anesthesia. A study of court rulings confirms
that surgeons are responsible for the anesthetic, only if administered by a nurse or
technician under their medical direction. Anesthetics given by anesthesiologists
constitute their legal responsibility.
One must summarize the essentials of surgeon-anesthesiologist relations as
comprising mutual professional confidence, understanding, frankness, honesty,
courtesy, and fair-mindedness.
Appraisal
Because of the intimate association with so many other specialty areas, a discerning
anesthesiologist is more likely than not to stay abreast of the advances in medicine.
The relationship with the basic sciences is close, perhaps more so than in other
specialties.
Chapter 2 Anesthesiologist 13
Some have charged that the practice of anesthesiology is too routine and
lacks intellectual challenge. This is a matter of individual opinion, for certainly
the authors of this text (Robert D. Dripps and Leroy D. Vandam) have not lacked
for challenges. Every branch of medicine has its share of routine. How much of
a pediatricians day is spent in examining normal infants and children, in giving
prophylactic injections, or treating respiratory infections? Obstetricians deal mostly
with normal women who will deliver without incident, and a day in an internist’s
office has more than its share of routine work. So with anesthesia! Most patients
will be healthy, undergo elective, uncomplicated operations, and recover from
anesthesia without incident. Few specialists, however, encounter such a high ratio
of stressful moments in which a wrong or a tardy decision may spell disaster.
of the operating room in their own clothing without wearing cap and mask. This
has to be curtailed and stopped in the interest of the well being of the patients.
Personnel preparing the sterile instruments table for operations must cover their
hair and generally wear masks in addition to wearing suitable clothing and foot
wear. Visitors and other staff are similarly attired. The hair should be completely
covered with a closely fitting cap manufactured from a non-woven fabric.
Cotton poplin or polyester cotton are the most commonly used material for
theatre clothing; blue or grey color scrub suits (normal theatre wear), and
green color for operating gowns. But special fabrics like non-woven fabrics are
found to have superior resistance for bacterial permeation. White and Bailey
(1984) considered that “it was better to prevent the dispersion of bacteria
from people in theatre rather than allow the bacteria to be dispersed, and then
removed by air ventilation. Low airborne dispersion of bacteria from people
can be achieved by well designed clothing using fabrics effective in preventing
bacterial dispersion.”
Masks are probably the greatest potential source of infection. The traditional
four to six layers of muslin offer little protection as the mask soon becomes
saturated with moisture from the wearer’s breath. The most efficient mask is,
the one made from synthetic fibers. (Ford et al., 1967; Furunhasi, 1978; Meffin,
1980). These masks, which should be moulded to fit the facial contour snugly
when worn, actually filter the respirations rather than deflect as with ordinary
paper masks. It is claimed that such masks achieve 98 % efficient filtration
compared to 40% with muslin masks; however not all filtration masks are
equally efficient (Rogers, 1980).
When removing the mask, care should be taken to avoid touching that part
which has acted as a filter, for the hands can easily become contaminated with
microorganisms.
Masks should be changed at least every operating session and should never be
worn “around the neck”.
Loud talking among the members of surgical team must be avoided as that
causes more dispersion of bacterial contamination. It is always essential that
verbal communications among the operating team as well as the other members
of the team must be reduced to the minimum and preferably in the lowest
volume of voice or more acceptably, wherever possible, communication is
done by signs only.
Fig. 2.1: Nail brush with wooden handle and soft nylon bristles
16 Surgeons and Anesthesia
The nail beds are good breeding grounds for bacteria. Cleaning under the nails
must be done with a suitable nail brush. When scrubbing up to carry out surgical
hand disinfection, care must be taken to ensure that all parts of the hands and
forearm are cleansed thoroughly, special attention being given to the nails and
between the fingers (Fig. 2.2).
Considering all the facts described above, the steps of hand wash may be
summarized in the following steps;
–– When using ordinary soap, the scrub up should last 5 minutes under running
water.
–– Less time is required when a detergent solution containing chlorhexidine
(Hibitane) or an iodophor (Betadine) is used. With these, the forearms and
hands are washed for 1 minute with a small quantity of the solution and
then rinsed with sterile water.
–– Particular attention is paid to the nails, utilizing either a sterilized nail brush
with a light friction which is then discarded.
–– The main wash should occupy a further full two minutes and consists of
reasonably vigorous massage of the hands and forearm up to elbow level with
a mixture of the solution and water. Care must be taken to ensure adequate
cleansing between the digits and skin folds.
–– Finally the hands and forearm are rinsed thoroughly under running water.
The taps are turned off with the elbow and the hands kept in an elevated
position to prevent water running down from the elbows. The hands and
forearm should then be rinsed or wiped with alcohol and dried with sterile
towel before assuming the sterile gown and gloves.
Fig. 2.2: Steps of surgical hand scrub (Courtery: Royal Berkshire Hospital, Reading)
Further Reading
1. Ballinger WF, Treybal JC, Vose AB. Alexander’s Care of the Patient in Surgery, St.
Louis: Mosby, 1972.
2. Blowers R, Williams RFO, Mc Clucky, Garrard LP. Hospital Infection: Causes and
Prevention, 1966.
3. Chrch J, Sanderson PJ. Surgical glove punctures. Journal of Hospital Infection, 1980;
1:84.
4. Clarke, PE, Dixon E, Freeman D, Whitaker M. Nurse staffing and training in the
operating suite. The Design and Uses of Operating Theatres, edited by IDA. Johnston
and AR hunter. London: Arnold. 1984.
5. Douglas DM. Lancet, (1962);ii:245.
6. Ford CR, Peterson DE, Mitchell CR. American Journal of Surgery 1967;6:787.
18 Surgeons and Anesthesia
3 Surgical Team
Chapter Outline
Members of Surgical team and their job descriptions
v
Unskilled personnel working inside the operating room
v
Coordinator of the team
v
“A surgical procedure should be planned so that the patient, with the least possible
risk and loss of time, will receive the greatest possible benefit.”
— Charles H Mayo
the surgical work may suffer to varying degrees. So, we shall consider the essential
members and their responsibilities in the team work in a little detail.
The team consists of many people with varying capabilities to put their efforts
together in the best possible way to achieve the best outcome of the work, which
means efficient and safe surgery. Though the number of persons involved in the
team may be more than ten in the sophisticated centers, we have to note that the
basic minimum of persons is five.
Every member must be able to contribute his best for the purpose of ultimate
successful outcome of surgery.
Schematic representation of all members of the surgical team and the unskilled
personnel working inside the operating room is shown in (Fig. 3.1).
The members of the team are:
1. The surgeon and his assistant
2. The anesthesiologist
3. An efficient, well trained nurse to assist the surgeon
4. An anesthetic technician
5. A nursing assistant.
Without the efficient contribution from all these people the surgical work may
be incomplete and inefficient.
Hence it is essential to know the “job description” of each one of the members
that makes one realize how the contribution from each member is highly significant
towards the outcome.
Job Descriptions—(Responsibilities)
Surgeon and his assistant
The Surgeon shall examine the patient in the outpatient department, make a
clinical diagnosis of the surgical disease, and order for relevant investigations
needed for the confirmation of the diagnosis.
After confirming the diagnosis, he discusses with the patient and his relatives
regarding the surgery to be performed and advises accordingly after explaining
the degree of risk involved. He shall explain the probable outcome of surgery
and the chances of recurrence of the surgical problem if any, etc. if the surgery
is elective.
If the surgery is to be done as an emergency procedure, he may explain to them
the need for the emergency surgery and the possible consequences if it is not
done immediately and advise them suitably.
Before the surgery, if the patient has any correctable problems like respiratory
infection, dehydration or any such medical conditions, he may institute
necessary treatment so that the patient may be presented for the proposed
surgery in a more fit condition to stand the stress of anesthesia and surgery.
At this time he refers the patient to the anesthesiologist with a clear note about
the surgical problem and the proposed surgery for assessment for the fitness
for anesthesia.
After getting this clearance, he may fix up the date for surgery and post him
on the list on that day.
On the day of surgery he brings the patient to the operating theater with
adequate preparations and under proper anesthesia he operates on the patient
and takes care of him in the postoperative period till the time of discharge
from the hospital.
The assistant surgeon would assist the surgeon in all these jobs from the
beginning till the time of discharge, so that he knows full details about the
patient.
Anesthesiologist
The Anesthesiologist shall examine the patient referred by the surgeon very carefully
for any undetected medical diseases like hypertension, respiratory problems, etc.
and if detected gives suitable advises for the correction of those problems.
Once these problems are corrected, he shall reassess the patient at a later date
for the appropriate anesthetic procedure for undergoing the proposed surgery. any
special instruction if needed and a clear note about the premedicant drugs, their
doses and the time of administration are written in the assessment note.
If considerable and significant blood loss is expected during surgery, he may
order for reservation of adequate number of units of compatible blood.
On the day of surgery he shall examine the patient again, administer the
preanesthetic medication in the right time, take up the patient, and administer
anesthesia, takes care of him throughout by continuous monitoring of his vital signs.
After the conclusion of surgery he shall reverse the patient from the anesthesia
carefully, assess his status by keeping in the recovery room (PACU) for sufficient
length of time.
22 Surgeons and Anesthesia
He would give this care as long as needed, till his recovery criteria are normal
and then transfer him to the postoperative ward.
He shall visit the patient in the postoperative ward to ensure that the patient
continues to maintain normal vital parameters and everything is well.
In case of necessities he shall support the surgeon in giving postoperative care
of the patient such as cardio vascular support, ventilatory support, etc.
Nursing Assistant
This assistant’s job is taking care of the surgical instruments and assisting the
Nursing staff who is assisting the surgery.
In the course of any surgery, if the assisting nurse wants an additional
instrument, he shall take it from the sterile store of instruments (Bin) and hand it
over to the nurse and shall keep an account of that for final counting at the time of
completion of surgery.
When the day’s work is over he shall clean and decontaminate all the instruments
and pack them in bins and send them to the Central Sterilization Department for
autoclaving, get them back for the next days work.
These five people are the skilled members of the team, meaning thereby each
one has a special job to do, utilizing their skill fully for the best outcome of the
work.
Two more nursing staff will be usually present in bigger centers where the
workload is higher and multiple operating rooms work in one complex. They are:
1. The circulating nurse
2. The nursing supervisor
Circulating Nurse
Apart from the assisting nurse scrub nurse there will be one or two nurses in the
operating theater.
They are also known as theater runners. One stays in the operating theater,
watching the scrub nurse and ready to bring anything she requires during surgery.
The first circulating nurse also ties up gowns of washed up surgeons and nurses,
being careful to avoid touching any part of the gown other than the tapes.
He or she replenishes sterile warm or cold water in the lotion bowls and checks
the swabs, displaying them on counting rack in the required order. (Godfrey, 1983;
Shaw, 1984).
She will be dispensing articles from sterile bags or packs, she replenishes sterile
gowns and gloves on a sterile trolley or worktop reserved for the purpose.
The main duties of the second circulating nurse are:
To see that the instruments and trolleys are ready for the next case
Should help in placing the patient on the table, if a stretcher bearer or technician
is not available
Chapter 3 Surgical Team 25
She should also help the scrub nurse if the first circulating nurse has to leave
the theater
On no account, the theater must be left without at least one circulating nurse
The duties will of course, depend on the layout and system of particular
operating department
She must keep all the notes and X-rays relating to the patient available and it
is her duty to ensure that these are easily at hand for reference.
In some institutions, one or two anesthesia technicians or operating department
assistants (ODA) are posted to act as circulators to help the scrub nurse.
Nursing Supervisor
These are senior nurses belonging to the category of nursing tutors or supervisors.
One such person will be in charge of the supervising work done by the theater
nurses of two to three operating rooms preferably situated in the same complex
or at least on the same floor.
She makes regular visits to all theaters under her control in the morning
before starting the day’s work, organize the work pattern depending upon the
availability of the personnel.
She gets into the operating room where there is some deficiency, or a better help
is needed for a major difficult surgery and stays on until the problems are solved.
The most important aspect to be remembered at this juncture is, if one member
in one category is to be replaced (for any reason he or she has to be replaced) by
a person belonging to the same category and not by a person belonging to another
category. For example, a nurse should not be replaced by a doctor or a theater
assistant should not be replaced by a nurse and so on in the best interest of the
outcome.
The best outcome in any teamwork for that matter depends upon the total
involvement of each member of the team. Apart from that mutual understanding,
mutual confidence and mutual trust contribute very much for that.
Stretcher bearer
At least two persons must be posted for one operating room depending upon the
number of operating tables and the time taken for finishing the operation based on
type of surgery. It is essential that they must be physically fit to do this type of job.
26 Surgeons and Anesthesia
General worker
At least one person must be available. They are meant for doing petty jobs
and assisting others in manual works such as shifting the patients, washing the
instruments, etc. Physical fitness is essential for them also as they have to do make
shift duties.
Sanitary worker
Ideally two persons must be posted for one operating room. Their job is to clear the
soiled linen from the operating room as soon the surgery is over. After each surgery,
they have to clean the surface of the operating table with clean cloths soaked in a
disinfectant solution, and wipe it dry and then to clean the floor in the same way.
After this the nursing assistant will cover the operating table with a clean sterile
cloth and keep it ready for the next operation.
However, these three categories of personnel can have their work exchanged
in case of necessity. It is essential to ensure the following basic aspect with regard
to the posting of these people.
They must be taught the basic discipline of the theater work and the steps needed
for maintaining the asepsis.
They must have the willingness to work in the operating room environment.
They must be posted regularly for quite a good length of time so that they
will get acclimatized to the routine of the operating room schedule. This helps to
improve their work efficiency.
Nurse
She is either a qualified or a trained nurse with adequate experience in the
operating theater work and the principles of theater asepsis
She will be incharge of the operation theater and coordinates the entire work.
Nursing Assistant
He/she will be assisting the nurse-in-charge to run the operation theater
He/she must have basic knowledge of theater asepsis.
Anesthesia Technician
He will be incharge of the anesthetic machine and accessories and maintains
them.
He will keep things ready well before starting the operation and assist the
anesthesiologist and stay by his side to assist although the work
In smaller setups like this, usually the anesthesiologist will be a visiting
consultant
Chapter 3 Surgical Team 27
Every individual anesthesiologist will have his own pattern of working. So
also, the assistance required for each anesthetist may vary
The anesthesia technician may have to know the individual anesthetist’s pattern
of work and their requirement for managing anesthesia
He will set things ready accordingly
He will assist the in-charge nurse in the overall management of the operation
theater.
Stretcher Bearer
He is a physically fit person who can do the shifting and transferring of the
patient
He may be a general worker doing all assistance in the operation theater work.
Sanitary Worker
He will be doing the washing and cleaning of the operation theater after every
day’s work is completed
After completion of each surgery, he will collect the soiled linen and send for
washing
He will clean the operation table, wipe it with a cloth soaked in germicide or
antiseptic
Afterwards he cleans the floor and wipes the floor with germicide or anti-
infective solution.
The above mentioned five categories of personnel are essential for effective
functioning without compromising the safety of the patient. In such settings,
excellent cooperation, coordination, tolerance, mutual understanding and
involvement among the team members is possible.
In fact, in many of such small setups, good amount of major surgical works
are going on well.
spend for coordinating the work. For this reason, it is universally accepted as a
norm that the anesthesiologist takes over the big responsibility of managing the
theater activities, which is really a tough job. Usually surgeon could not do the
job of this coordination work, as he has other jobs to look after such as outpatient
clinic, review clinic, postoperative rounds on different days in a week and can not
be available in the operation theater.
On certain occasions, a senior experienced Theater Nurse or Head Nurse may
be taking up this responsibility.
These factors play very important role in managing the list efficiently and
finishing it in time. Proper planning involves deciding and fixing the order in which
the patients are taken up, the number of patients to be taken up in the first round
and among those how many under general anesthesia and those under regional
technique, etc.
Secondly decision on the major surgery to be taken up first in the list has to be
made. This is made after considering the type of procedure, the anticipated duration,
the degree of blood loss expected, the degree of intense care needed for the patient
based on his general condition and the expertise required for anesthetizing that
particular patient.
With the proper understanding of the real situation and good mutual
understanding and the willingness to do more service to the needy, the planning
of the operating list is never a difficulty.
Further Reading
1. Bunker JP. The anaesthesiologist and the Surgeon Partners in the operating room, Little.
Brown Co, 1972.
2. Eckenhoff JE. Anaesthesia from Colonial times. Philadelphia, JB Lippincott Co, 1966.
Greene NM: Anaesthesiology and the University. Philadelphia, JB Lippincott Co, 1975.
3. Lidwell OM. Bacterial considerations in the Design and Utilization of Operating
Theaters. Edited by IDA Johnson and AR Hunter. London: Edward Arnold, 1984.
4. Medical Defence Union, Medical Protection Society, Medical and Defence Union of
Scotland., National association of Theater Nurses and Royal College of Nursing of the
United Kingdom. Theater Safeguards, MDU, MPS, MDU of S, NATN, RCN, 1986.
5. Meffen K. The good and the bad. Nursing Mirror. NYAN Supplement, 1980.
6. Nagai I, Kadota M, Tackchi M, Kumomoto R, Nakano S, Jitsukawa S. Studies on the
bacterial permeability of non-woven fabrics and cotton fabrics. Journal of Hospital
Infections, 1986;7:261-8.
7. National Association of Theater Nurses Guideline to the total patient care and safe
practice in the operating theaters, NATN, Harrogate, 1983.
8. Nimmo WS. British J Anaesthesia, 1990;64:7.
9. Reybrouck G. Hand washing and hand disinfection: a review article. Journal of Hospital
Infection, 1986;8:5-23.
10. Robert D Dripps, Leroy D Vandam: Introduction to Anesthesia. Philadelphia, Saunders
Company, 1978;1:1-8.
11. Vandam LD. Early american anesthetists: The origin of professionalism in anesthesia.
Anaesthesiology, 1963;38:264.
12. Vincent R. Br J Anesthesia, 1997;79:188.
13. Whyte W, Bailey PV. Reduction in microbial dispersion by clothing. Journal of
Parenteral Science and Technology, 1984;39:1.
32 Surgeons and Anesthesia
Chapter
Safe practice of
4 Anesthesia
Chapter Outline
Ten Golden Rules of Anesthesia
v
Indian Society of Anesthesiologists
v
Safety in anesthesia
v
Accidents during Anesthesia
v
Anesthetic Records
v
Monitoring during Anesthesia
v
The cardiovascular System
v
Staffing
1. A suitably trained or qualified theater assistant must help anesthesiologist in
all critical areas like operation theater, recovery ward and ICU.
2. The assistant must be exclusively available to the anesthesiologist until the
anesthesiologist indicates that he is no longer required. During induction,
maintenance or at the conclusion of anesthesia the assistant should always be
available to help the anesthesiologist.
Basic equipments
1. Each operation theater must have the following:
–– Stethoscopes
–– Sphygmomanometer with adult and child cuffs
–– At least two laryngoscopes with three blades appropriate to the age of the
patients treated in the hospital
–– Suction apparatus and suction catheters exclusive for the anesthesiologist.
–– Appropriate face masks
–– A range of oropharyngeal and nasopharyngeal airways
–– A range of endotracheal tubes, connectors, introducers and catheter mounts.
Intraoperative monitoring
1. The best possible monitor is the anesthesiologist. Every patient undergoing
any type of anesthesia must be supervised by an anesthesiologist. He must be
present right from the time of the induction of anesthesia, to the conduct of
the whole anesthetic, termination of the procedure and transfer of the patient
to the recovery area.
2. Continuous monitoring of ventilation and circulation by clinical observations
must include the following:
–– Chest wall movement and movement of reservoir bag
–– Color and response to surgical stimulus
–– Auscultation of heart and breath sounds by a pre-cordial or esophageal
stethoscope
–– Pulse rate and blood pressure should be measured at least every 5 minutes
in every patient receiving any form of anesthetic or sedation.
3. Every patient subjected to anesthesia must be monitored by cardioscope. It
should be displayed before induction and continued until further surveillance
is deemed unnecessary.
4. Every operation theater suite must have in readiness one defibrillator.
5. In all pediatric patients the core temperature either by rectal or esophageal route
must be monitored both postoperatively as well as in the recovery ward.
6. Wherever necessary pulse oximetry and end tidal CO2 may be measured. The
same applies to neuromuscular function monitoring.
7. Monitoring of intra-arterial, central venous and pulmonary artery pressures
should be done only when indicated as they are all invasive methods.
36 Surgeons and Anesthesia
Safety in anesthesia
Facts to be accepted
1. The topmost priority in anesthesia is only “safety” and all others come next.
2. “There is no shortcut for safe anesthesia.” Only proper understanding of the
underlying pathology and its effect on the various systems of the patient and
appropriately modifying the anesthetic technique and giving intense care in the
perioperative period are the ways for a safe anesthesia.
3. Giving a higher grading in ASA to cover up inefficiency of the anesthesiologist
or surgeon and to accept a bad outcome is considered as untenable.
4. In modern days of safe anesthesia, many surgeons have unrealistic expectations
about the comfort during surgical procedure as well as the duration of surgery.
They believe that the duration of anesthesia has no implication in the overall
outcome of surgery. At least in very ill patient, the prolonged anesthesia and
prolonged surgical handling has serious deleterious effect on the outcome.
5. Some anesthesiologists believe that continuous epidural with opioids to provide
postoperative analgesia will keep the patient pain-free and cheerful, but we must
understand that this blocks the pain pathway and thereby the pain perception,
but the morbidity related to the biochemical process of damage due to injury
and handling continues and will take a long time to heal.
6. Hence, long duration of surgery without due justification causes inevitable
increased handling of tissues, eventually resulting in manifold increase in
morbidity that cannot be justified by any means.
7. It is the prime duty of the anesthesiologist to give the best possible comfortable
working condition for the surgeon without compromising the safety of the
patient even to the slightest extent.
8. The surgeon must always remember that if a bad outcome ensues it will have
the primary impact on the surgeon’s image particularly in Indian context, though
everyone in the team is responsible.
Chapter 4 Safe practice of Anesthesia 37
9. The meticulous technique of surgery and the speed of surgery tell upon the
overall outcome.
10. Meticulous technique with unduly prolonged duration sometimes ends up in
bad outcome because of multiple factors particularly in a relatively very ill.
11. When an ordinary technique with a relatively good speed is employed without
unnecessary handling of tissues, that results in a good outcome even in a poor
risk patient.
12. Ideally a good technique of surgery and good speed counts.
Somethings that are not openly discussed in the work place considering courtesy,
have to be discussed tactfully with a open mind to take up the facts, in this situation
in the larger interest of the patients, without causing any ill effects or hurt to any
one concerned.
Here it is appropriate to recollect the statement made by the British surgeon
Sir William Heneage Ogilvie (1887–1971), about the four decades in a surgeon’s
life. Though as a surgeon himself he made the statement pointing to the surgeons,
this holds good to any specialty. The statement goes as follows;
The first ten years a surgeon leans—‘How to operate’
The second ten years he learns—‘When to operate’
The third ten years he learns—‘When not to operate’
The fourth ten years he learns—‘When to Stop’.
This clearly indicates that for anyone to acquire the wisdom of understanding
the point at which he has to stop the particular work, it takes at least three decades.
To prevent we have to follow the safety rules meticulously and also that others
have to do the same.
In Anesthesia everyone in the operating team has to follow the discipline and
the rules, so that safety is ensured and accidents prevented. Our entire anesthesia
practice should be ruled by the application of carefully considered decisions made
on the basis of previous systematically analyzed experiences. That is, after all
medical audit.
“All anesthesiologists however experienced and however accident free should
be humble enough to recognize that they may make mistakes at any time. These
errors may be in technique, judgment or failure of vigilance.”
—John Alfred Lee.
Can there be anyone who can be called as accident-free anesthesiologists?
This again is extremely difficult in these modern days for the following reasons.
Average life expectancy has gone up, so more geriatric patients with various
system disorders are presented for anesthesia.
Increased health care is available, so patients with multi-organ failure may be
presented to anesthesia.
38 Surgeons and Anesthesia
In other words, severely ill patients with a very high risk for anesthesia who
were considered “Unfit” for anesthesia in olden days are frequently coming up for
surgery. These patients in olden days either did not live up to that age or they were
deemed “Unfit”.
So we have to sort out and analyze the ways of conducting a safe anesthesia.
No one should feel or declare that he is accident free anesthesiologist because
accidents occur accidentally—as they are unexpected in spite of adequate care
and caution.
Accidents can be due to factors related to;
1. The anesthesiologists
2. Equipments and drugs
3. Monitoring
4. The patient.
We shall see all that one by one.
The anesthesiologists
Even after careful selection and training, there is the need for continuing
education.
Surveys of mortality and morbidity often reveal the poor assessments and
inadequate treatment or resuscitation of the patient before surgery.
Delegation to a junior colleague or assistant may be inappropriate.
Regular audit, morbidity and mortality meetings contribute to safe anesthesia.
Stylized training is useful for infrequent but particularly hazardous situations,
for example, difficult or failed intubation, cardiac arrest, unexpected cyanosis,
anaphylaxis and malignant hyperpyrexia.
As with pilots, computer based simulators have been developed.
The use of artificial intelligence in patient’s management such as a sophisticated
simulator complete with mannequin, anesthetic machine and monitors are
available.
However, there is little formal assessment of practical skills in anesthesia,
neither of trainees nor their trainers.
With attention to details, it should be possible to prevent the minor error turning
to a disaster. No anesthesiologist (particularly a trainee) should be persuaded
to treat a patient beyond his capabilities.
The anesthesiologist works in a complex environment and so his behavior will
be influenced by some factors that are out of his control, such as climate, economy
and even architecture. The provision of a safe environment depends in part on
hospital administrator, although advised by the professionals.
The anesthesiologist needs to prepare for the unexpected and be alert.
Commonsense says a reasonable amount of sleep and rest is necessary before
taking a patient’s life into his hands. This is a legal requirement in New York State.
Sleep deprivation causes mood changes, but functional impairment is not always
apparent. But relatively easy tasks that are so important to the safety of anesthesia
require a high level of personal arousal to perform well.
Chapter 4 Safe practice of Anesthesia 39
All anesthesiologists must have skilled assistants. CEPOD (Confidential Enquiry
into Perioperative Deaths) has revealed that at least 14 deaths have been caused
simply because the anesthesiologists worked without such help from skilled assistant.
Equipments and Drugs
The anesthesiologist must understand the working of all equipment, and be
satisfied that it has been properly maintained. both equipment and drugs must
be checked before use.
Accidental disconnection of parts of the breathing circuit is an ever present
hazard. Ill fitting connectors must be discarded. Even minor leaks can have
serious consequences.
Some safety features are incorporated in modern anesthetic machines; inability
to deliver hypoxic gas mixtures, limits on CO2 flow, built in monitors.
In the future, features such as digital control of gas flow and vaporizers, self
check and servo control of vapour concentration within a circle may provide
additional safety. But correct usage of such equipment will be always crucial.
The anesthesiologist must be satisfied that the drug to be injected into a patient
is the one intended and prepared at the correct dilution.
New drugs require special vigilance and are marked by an inverted black
triangle in British National Formulary and in MIMS.
Monitoring
Monitoring has made a big contribution to the safety in anesthesia. Many countries
have introduced minimum standards of monitoring. These usually include the
continuous presence of an anesthesiologist in theater or briefly in the anesthetic
room if the intervening door is open.
Monitors of the anesthetic machine (oxygen failure alarm, inspired oxygen
concentration, ventilator disconnect alarm.) and of the patient (circulation—ECG, pulse,
blood pressure; respiration—bag movement, capnography, pulse oximetry; temperature;
neuromuscular transmission) such standards are legally enforced in certain states.
Time and motion studies of anesthesiologist in the operating theater reveal
much time is not spent observing the patient, and an implicit reliance on monitors
and their alarms.
The judgment of the anesthesiologist is the most important. Anesthesiologists
must know the limitations of the monitors, set appropriate alarm limit know how
to check that they are working correctly and be able to interpret the data.
An excessive number of monitors may lead to distractions, complacency and
a blind adherence to ‘standards’. Alarms frequently sound when there is in fact no
danger to the patient.
The patient is exposed to as much danger in the postoperative recovery room
as in theater. The CEPOD report shows that many hospitals don’t have adequate
recovery facilities. There must be a safe hand over of patient to recovery staff.
The patient
The anesthesiologist plays an important role in ensuring that the correct operation
is performed on the correct patient. A Medic Alert bracelet warns an attending
doctor of hazards such as allergies, sensitivity to suxamethonium or susceptibility
to malignant hyperpyrexia.
40 Surgeons and Anesthesia
Anesthetic Records
It is absolutely essential that a record should be kept of all administrations of
anesthesia
It is a telltale evidence for the type and quality of care given to the patient
intraoperatively and to identify whether there were any problems or
complications during the course.
Its value is in three aspects; to contribute to patient care, teaching and medico-
legal reasons.
Patient care
Though it consumes about 11% of an anesthesiologist’s time, it stimulates
vigilant anesthesia.
It is an aid for audit of an anesthesiologist’s work.
To analyze and correct any defect in management of the case.
teaching
Similar to audit it is used to teach the learners how a case has to be managed.
Medico-legal reasons
In case litigation arises, this is considered as a very valuable document to
support the anesthesiologist
There are many anesthetic records available designed and supplied by various
companies, which are suitable for general use in any operating room
Nosworthy’s cards are in use for many decades and are periodically updated
with the addition of newer agent and techniques
An institution may design their own anesthetic charts according to their
convenience. A model Anesthesia Chart is shown in (Figs 4.1A and B).
Much harm may be done to an anesthesiologist’s defence of a civil claim if his
record is not full, accurate, contemporaneous and legible. Although patient care
should always take precedence over record keeping, events should be recorded as
soon as possible after they happen. Any correction should be made in such a way
that will not arouse suspicion that the record has been falsified. Handwritten records
are still effective and common.
The simplest record should contain the patient details, date and time of
operation, the surgeon and the assistant, the anesthesiologist, operation
performed, technique of anesthesia used and the drugs, record of vital signs
such as pulse and blood pressure, oxygen saturation (Figs 4.1A and B).
Intravenous fluids administered, the type of fluid, the duration of administration
in the order must be recorded.
Vital signs are recorded every 5 minutes as a routine, but this can be extended
as 15 minutes interval in straight forward cases and it should not be extended
further which means inadequate care and record.
If the BP and pulse have been checked every 10 minutes and has not been
recorded, the court of law takes that it has not been done.
Blood loss is estimated carefully and periodically recorded and the total loss
estimated at the end.
Chapter 4 Safe practice of Anesthesia 41
Quantity of blood replaced in terms of units, the time of starting and the time
of completing the transfusion along with a note of any reaction.
Finally the details of the total volume of blood loss, the total volume replaced,
any deficit, any further transfusion needed in the postoperative period all must
be noted clearly.
In some hospital the anesthetic charts incorporate carbon copies, which may
be retained in the department for official records and the original is sent with
the case sheets with the patient to postoperative ward.
Many of the monitors have printer facilities, are connected to the computers that
give printouts after every case, these printouts, though not equivalent, to the
“Black Box” flight recorder, yet considered similar to that. Anesthesiologist’s
have been noted to fail to record manually the extremes of blood pressure that
are captured by the automatic recorders.
Instructions to the postoperative recovery room nurse must be very clearly
written without any chance for ambiguity of meaning. Wherever possible these
instructions are verbally communicated to the concerned nurse.
Chapter 4 Safe practice of Anesthesia 43
In every case, after completion, the anesthesiologist should write with his
own handwriting, the details in the anesthesiologist’s register provided in the
operating room, by filling in the columns. This register also is a very valid
document of proof, in case of litigation.
been “crying continually and wishing she were dead, rather than submit” to the
removal of ingrowing toe nail. Shortly after induction she had a cardiac arrest. This
illustrates two points.
Firstly, disasters can and do happen to young fit patients during the most
minor procedures.
Secondly, since the earliest years of anesthesia, mishaps have been common.
Our mistakes being rare, we must learn from the errors of others.
We may also hope to learn from their wisdom. One of the first dedicated
anaesthesiologist, Joseph Thomas Clover, claimed in 1871 to have administered
over 11000 anesthetics without a death. He explained his success simply. “It was
my habit …to watch the pulse as well as the breathing….” This “habit” would
have prevented most anesthetic mishaps to date. As anesthetic techniques develop,
new problems emerge and the need for changes in monitoring.
Demerits of Monitors
Monitors may distract and confuse particularly when there are too many.
Each additional monitor distracts attention from the patient and from the other
monitors. A normal looking ECG trace for example, may delay recognition that
the patient has become pulseless.
All patients undergoing anesthesia are at risk. Most disasters stem from failure
to recognize some simple problem, for example a ventilator disconnection. Most
such problems can be detected by relatively simple, safe, monitoring, which is
therefore recommended for all patients.
Chapter 4 Safe practice of Anesthesia 45
The first set of standard to be published was that of Harvard Medical School
System in 1986. The American Society of Anesthesiologists endorsed a similar set
of recommendations the following year. The Association of Anesthetists of Great
Britain and Ireland published its own recommendations in 1988 and these were
revised in 1994.
Most important is that monitoring begins before induction and continues until
after recovery, with the anesthesiologist present throughout. Monitoring is clinical
observation supplemented by a variety of techniques including Oximetry, Capnography
and Electrocardiography, as well as intermittent determinations of blood pressure.
This represents the minimal acceptable provision of care for anesthesia in
developed countries. Medico-legally and ethically, it would be difficult to defend
a practice which fell short of these standards.
Respiration:
During IPPV, airway pressure, ventilatory volume, capnography, disconnection
alarm, and pulse oximetry.
Metabolic status:
Capnography, blood glucose, acid-base balance.
Neuromuscular transmission:
Peripheral nerve stimulator—when muscle relaxants are used.
ECG
Valuable information concerning cardiac rhythm may be obtained by monitoring
the electrocardiogram. Most ECG machines calculate the ventricular rate. This
should not distract the anesthesiologist from monitoring the peripheral pulse rate.
46 Surgeons and Anesthesia
Modern ECG monitors are very reliable and less subject to interference. As the
technique is noninvasive, simple and accurate, it is now a mandatory monitoring
in UK that it is used in all patients undergoing anesthesia, no matter how minor
the surgical procedure.
Standard lead II monitoring is used widely. However, the CM5 lead
configuration (Fig. 4.2) has been advocated for routine intraoperative monitoring
because it reveals more readily ST segment changes produced by left ventricular
ischemia. This configuration is achieved by placing; the Right arm lead over the
manubrium sterni, the Left arm lead on the V5 position over the left ventricle, and
the indifferent lead over the shoulder.
It is important to appreciate that the ECG is an index of electrical activity
only. It is possible for a normal electrical wave form to exist in the presence of a
negligible cardiac output. Consequently, information from the ECG should be used
in conjunction with data acquired from monitoring of perfusion.
Peripheral pulse
Regular palpation of peripheral pulse is one of the simplest and most useful
methods of monitoring during anesthesia and is mandatory for even the most
minor surgery. Information may be obtained by observation of the rate, volume
and rhythm.
Pulse plethysmography: Automated devices are available for monitoring peripheral
pulsation. Usually it is available with sophisticated models of pulse oximeters. Pulse
monitors provide a guide to the pulse pressure. Thus an increased signal may be
seen in peripheral vasodilatation or increased cardiac output, and low pulse pressure
is seen during vasoconstriction or low cardiac output states. The exact mechanism
of plethysmography is described elsewhere later.
Further Reading
1. Adams AP. Recent Advances in Anesthesia. In: Atkinson RS and Adams AP (Eds).
Edinburgh: Churchill Livingston, 1992:17.
2. Atkinson RS, Rushman GB, Davies NJH (Eds). Lee’s Synopsis of Anesthesia. 11th
edition; Butterworth Heinemann. England, 1993;19:356-60.
3. Gravenstein JS, Hozler JF (Eds). Safety and Cost containment in Anesthesia. Boston:
Butterworths,1988:2.
4. Risk Management in Anesthesia. Int Anaesthesiol Clin,1989;27:3.
48 Surgeons and Anesthesia
Chapter
5 Preanesthetic Assessment
Chapter Outline
The purpose of preoperative visit
v
Guidelines for Preanesthetic Visit
v
Definition
v
History Taking
v
Physical Examination
v
Basic Laboratory Investigations
v
Grading of Risk
v
Fit for Anesthesia
v
Informed Consent for Anesthesia and Surgery
v
Preoperative Starvation
v
Canceling Cases
v
Choice of Anesthesia
v
educational process for both patient and anesthesiologist; the patient learns what
anesthesia has to offer, and if misconceptions exist they can be dispelled. The
interview must be unhurried and tactful; if the patient is eating or receiving
special therapy it is better to return at another time. If visitors are present they
must be asked to leave before examination.
If a patient has not yet informed of the decision to operate, anesthesia can
be described as though it were to take place in the future. It is best to avoid
discussion of matters in the surgeon’s domain. Questioning should proceed
along lines of past anesthetic experiences, familial problems with anesthetics,
routine use of drugs, and unusual reaction to drugs and the concurrent illness.
While assessing the patient’s emotional state, one should look for physical
characteristics that may cause technical difficulties during anesthesia. The
individual with a short and stout neck readily develops respiratory obstruction
once unconscious; the athlete requires more medication than the asthenic. If
there are lose or caries teeth or delicate dental work, the patient should be
warned that dislodgement or damage may occur upon airway insertion and
a note to that effect should be written on the chart. Patient should be told to
remove dentures and leave them in the room so that they may not be broken
or misplaced.
Questioning pertaining to the patient’s cardiopulmonary reserve must be
carefully asked.
Simple pulmonary function tests may be performed. His exercise tolerance
may be assessed by questioning abut his profession and daily work pattern or
asking him to walk fast in the corridor or walk up a flight of stairs to detect
shortness of breath or claudication.
If regional anesthesia is planned it is essential to inspect and palpate the site
selected for injection of spinal or caudal anesthesia.
Once the preliminaries are over, the patient is told of the plans of anesthesia,
if the patient wishes to know about it and is intelligent enough to understand
things. Some patients will accede readily, while others may show concern
about many things such as, fear for face masks, postoperative vomiting or
pain. Some will object to spinal anesthesia for fear of headache or backache,
etc. explanations and reassurance usually settle most of these problems. Most
patients accept physician’s advice when confidence is inspired.
Patient must have good sleep during the previous night. Anxious patient may
be adequately supported with suitable medications to induce sleep with an
advice to go to bed early.
When the anesthesiologist leaves the patient, a summary of the preliminary data
is recorded on the case sheet or anesthesia chart, a physical status category is
assigned, preanesthetic orders written. From medico-legal point of view, this
summary is more meaningful than simply signed anesthesia fitness.
Finally anesthesiologist must develop enough judgment of their own to make a
surgical diagnosis and to predict the effect of the surgical position and operation
on physiologic processes.
As experience is gained the anesthesiologist will find that the preanesthetic visit,
above all else, sets the stage for a safe course both during and after surgery.
Chapter 5 Preanesthetic Assessment 51
Because anesthesia by itself is interfering with the basic physiology and
modifying it for the purpose of performing the surgery, to know how much of
modification can be done safely, we have to assess the physical and physiological
status of the patient and look for any diseases affecting any system from which the
patient suffers already.
Definition
Preanesthetic assessment is the process of evaluating the physical and physiological
status of the patient who is likely to be submitted for anesthesia and surgery, by
doing a careful clinical examination aided by relevant laboratory investigations and
thereby assessing the capability of the patient’s systems whether it can withstand
the stress of anesthesia and surgery.
Accordingly the risk for anesthesia is graded so that appropriate planning and
modifications are made regarding the anesthetic and surgical techniques.
Incidentally assessing the psychological status of the patient is absolutely
essential as that has implication on the preoperative medication and the choice of
anesthetic techniques and drugs.
Routinely the following practice is done:
Looking at the patient’s general condition to assess whether he looks normal,
healthy, and fit
A careful short history taking to get relevant information related to anesthesia
Examination of cardiovascular system
Examination of respiratory system.
History taking
Listen to the patient carefully what he has to tell us, before putting any question
to him.
Ask about habits particularly such as smoking, chewing tobacco, alcohol, etc.
History of past illness especially the following:
Chronic diseases like tuberculosis, bronchial asthma, hypertension, epilepsy,
etc.
Jaundice within the past 3 months
Recent infective diseases
Any medications taken currently for any ailment and the details.
Physical examination
Observe the patient when he walks towards you. This provides much
information that a routine examination cannot give
Look whether tall or short, well built or thin built, big frame or small frame,
obese or normal
Look whether he has any obvious deformity like limping, kyphoscoliosis,
gross asymmetry, any structural anomalies, etc. and all these must be given
adequate importance
Look for facial expression whether normal, has painful expression, or
melancholic (may be drug induced or disease induced).
Cardiovascular System
Blood Pressure: Both in supine and upright posture
Pulse: Feel in all palpable peripheral vessels and note the points given here.
Count for one full minute. Counting the pulse for shorter time there is a chance
of missing an occasional ectopic beat. Concentrate on the following three
characters:
–– Volume
–– Rate
–– Rhythm (arrhythmias can be due to cardiac causes or electrolyte imbalance).
Auscultation of heart sounds: All the four areas of pre-cardium to rule out any
abnormality or murmur.
Respiratory System
Observe whether the patient is breathing effortlessly
Look for tracheal deviation
Look for any chest deformities, abnormal or restricted movements, etc.
Auscultate all the areas of lung and if no abnormal sounds are heard, then it is
taken as the respiratory system is normal
Breath holding time must be > 20 seconds (Sabroz’s test).
Hemoglobin
It indicates the general health of the patient. At least 10.4 g % (70%) is considered as
a baseline value for a normal person. It is an arbitrary value. If all other parameters
are normal, a small deviation in this value can be accepted without any untoward
effects, provided the proposed surgery itself does not cause a severe blood loss.
Urine Albumin
No normal patient should have albumin in urine. If present, three different
specimens must be taken and tested to confirm it. If positive, that indicates renal
damage. This patient needs a careful evaluation by doing elaborate renal function
tests, so as to assess the degree of damage and the available renal function.
This is important because, many times until about 35 % of functioning nephrons
are present a patient with mild to moderate renal damage may not have any clinical
manifestations at all.
Urine Sugar
If urine sugar is positive, test three specimens and confirm it. Then suspect diabetes.
Blood Sugar: Normal value is 80 to 120 mg%.
If the value is above 140 mg % repeatedly it is significant. If urine sugar is
positive and blood sugar level also is elevated, GTT may be done for proper
evaluation of diabetic status that needs adequate control before surgery.
Uncontrolled diabetes involves very grave risk.
Blood Urea
Normal value is 20–45 mg%.
It is a poor indicator of renal function. If more than 45 mg %, it does not
indicate poor renal function. There are various other non-renal reasons for elevated
blood urea. It may be elevated in dehydration, hyper metabolic state, etc. The test
inevitably has large margin of errors and technical error is always possible.
Serum Creatinine
Normal value is 0.9–1.2 mgs.
More sensitive test, if it is persistently raised it indicates that there is reduction
in renal function and necessitates elaborate renal function tests.
X-ray chest: Irrespective of the age, if the patient is suffering from any chronic
respiratory illness such as bronchial asthma, or gives history frequent respiratory
infections or similar illness X-ray chest is indicated.
This is needed to assess the condition of bony cage of the chest and the lungs.
It also gives idea of any increase in the size of heart by heart shadow.
Many of the elderly patients may present with emphysematous changes in
relation to their age, with a “Fixed Barrel” shaped chest. There may be minimal or
no chest wall movement. This status is clinically very significant as these patients
easily develop post operative pulmonary complications.
The purpose of all these elaborate examination and investigations is to identify
whether any particular organ as kidney or liver is affected and to do relevant
investigation to assess the functioning capability of the organ (available function)
and to assess its ability to stand the stress of anesthesia and surgery so as to make
suitable modification in the technique of anesthesia, the drugs and their dosage.
Based on these information an assessment of the risk involved in the patient
is classified as follows as per the norms prescribed by American Society of
Anesthetists (ASA).
In the light of more detailed ASA status analysis the global concept of “fitness”
is outmoded. Physical status is close to, but not the same as “Risk”.
Described norms for the classification of ASA Gr. I, II, III, IV and V are a little
complicated and is not accepted by all the anesthesiologists in the world but it still
continues.
This scoring system is an arbitrary one. All authorities do not agree with this
Grading System because it has the following lacunae and fallacies.
The age of the patient has not been given any significant consideration. We
know that with the process of advancing age there will be progressive decrease
in organ function. So geriatric patients have different risk for anesthesia when
compared to a younger patient for the same surgery
The type of surgery and its magnitude has not been considered. Different
surgeries involve different risk factors
The degree of blood loss related to a particular surgery has not been considered
Competence of the surgical team in managing the case has not been considered
The competence of the anesthesiologist is not considered
Finally if the patient suffers from an advanced malignancy with cachexia that
has not been taken into consideration.
All the above said factors can grossly modify the grading of risk and the outcome
of the anesthetic and surgical work.
Questions are often raised concerning the chance of survival or the risk involved
in undergoing anesthesia. In 1954, Beecher and Todd found that anesthesia played
a primary or contributory role in the death of one patient in every 1500 operations.
On the other hand, in a later study Dripps and his coworkers (1961) reported an
incidence of anesthetic related death as one in 780 for spinal and one in 259 for
general anesthesia. The disparity in figures arises in part from the difficulty in
defining death caused by anesthesia and in making a distinction between the effects
of the patient’s disease, the operation, and the anesthesia.
In the stand point of the individual, “Risk” encompasses many variables. In
addition to the factors already mentioned, risk might involve the technical skills
of the anesthesiologist or surgeon, socioeconomic factors in home or hospital
environment, extremes of atmospheric conditions, or duration of operation.
Too often a patient is called a “poor risk” only after a catastrophe has taken
place; this may represent a conscious or subconscious effort on the part of a
physician to conceal errors in diagnosis or management. From a statistical or
prognostic stand point, therefore, the term “Risk” is untenable and improvement
in patient care does not lie in attempting to establish the degree of risk.
56 Surgeons and Anesthesia
“Consent for surgery need not be taken as the consent for anesthesia.”
58 Surgeons and Anesthesia
In these patients, the parents, next of kin, guardian or court of law can give the
consent.
Jehovah’s witnesses
Though this sect of believers in Christianity were not living in our country earlier,
now quiet a considerable number of them are living to the extent of having frequent
conventions. the 2nd convention was held in Madurai on 12th November 2005
and, subsequently in the following years attended by lakhs of followers. The facts
about them must be known to the surgical team, so that when a patient belonging
to this sect comes for any surgery, suitable modifications in the approach may be
made without hurting their belief.
Their interpretation of the Scriptures has caused them to believe that ‘blood is
sacred’ and therefore a Christian must “abstain from blood”. In addition, the
Bible says that the blood removed from a body is to be disposed of, not stored
for later use. This, rules out all blood transfusions for a patient belonging to
the sect of Jehovah’s witnesses.
They may refuse to accept transfusion of blood or blood components. In elective
operations, an adult patient in good mental fitness has lawful right to demand
that he need not be given blood. In return the anesthesiologist or the surgeon
may elect to refuse the patient for care and therapy.
In an emergency, an appeal may be made to the court for an emergency writ.
In case of a minor child, the court can give a verdict to order for transfusion
against the will of the parents.
Preoperative starvation
Preoperative starvation for many hours before induction of anesthesia has been
practiced from the days of ether anesthesia. That was because of the following
reasons:
Ether was probably the only anesthetic used commonly
Ether is an emetogenic agent and almost all the patients vomited after operation
With ether anesthesia the patient is likely to be semiconscious or drowsy
during recovery
Vomiting that occurs during recovery; particularly of solid food material from
stomach had proved very dangerous
Many patients died because of aspiration of stomach contents into the airway.
It is essential to remember that the stomach is never empty even if the patient
starves for more than six hours as there is continuous of gastric acid secretion
which amounts to at least 25–50 ml/h. Excessive starvation and dehydration are
to be avoided especially in children that may cause severe hypoglycemia and
hypotension during anesthesia and cause postoperative nausea and vomiting.
Chapter 5 Preanesthetic Assessment 61
It has been established that the delay can be as long as 12 hours if food is
ingested after a severe injury particularly solid food. Hence if the preoperative
starvation is taken lightly and is not strictly followed, it can cause preventable
deaths related to anesthesia. Moreover there are some factors that cause enormous
delay in gastric emptying time.
Anxiety and fear
Multiple injuries
Severe pain
Opioids (narcotic like morphine) premedication
Atropine and glycopyrrolate premedication
Pregnancy. Any pregnant woman particularly in late pregnancy is considered
as full stomach patient
Increased intracranial pressure due to any reason
Any pathology that causes intestinal obstruction. There may be retrograde flow
of intestinal contents into the stomach.
Attempts are made to hasten the gastric emptying by using “prokinetic” drugs
like metoclopramide 10 mg either by IV or IM route about 45 minutes before
induction of anesthesia.
It certainly helps in faster emptying by increasing the tone of lower esophageal
sphincter relaxing the duodenal sphincter and increasing the normal peristaltic
movements of the stomach. However this does not give any assurance of emptying
the stomach in patients with a full meal just before anesthesia. Hence preoperative
starvation is essential and cannot be dispensed with.
Similarly attempts are made to decrease the volume of gastric secretion and
neutralizing the acidity to bring the pH to a higher value by adding an alkalinizing
agent. 0.3 % sodium molar citrate orally given in a dose of 30 to 60 ml is likely
to neutralize the acid and raise the pH above 5, so that even if it is aspirated will
not cause acute acid pulmonary aspiration syndrome (Mendelson’s Syndrome).
Bigger children may become uncomfortable if they wait without taking food
and fluids. Hence it is accepted and advised that up to 10 ml/kg of clear fluid can
be given safely one hour prior to anesthesia. Most of it is absorbed rapidly from
the stomach leaving the stomach almost empty at the time of induction.
Canceling cases
calculated risks may have to be taken with agreement of the patient’s relatives and
the patient. Many times the patient may not be in a position to decide.
For an inexperienced anesthesiologist there will always be a temptation to take
up every patient for anesthesia. It needs lot of experience and wisdom to curtail
the temptation and the less experienced person may seek the opinion and advice of
a more experienced colleague available nearby without feeling inferior about it. Our
entire anesthesia practice should be ruled by the application of carefully considered
decisions made on the basis of previous systematically analyzed experience.
Operations may be cancelled:
Because of the inadequate preparation of the patient, that may prove hazardous.
The anesthesiologist must be sympathetic but inflexibly firm when there is a
grave risk.
Because of the risk arising from the poor condition of the patient, the
anesthesiologist must ask, ‘Is there any way in which this patient’s condition
can be improved? ‘Is it possible to postpone the surgery?’ If the answer is yes,
the operation may be postponed.
If not, the question becomes ‘Do the probable benefits of the surgery justify
the risk of anesthesia?
If the answer is “No”, then would a different type of anesthesia be suitable?
If the answer to this negative, due to shortcomings in patient’s health, shortage
of facilities in the hospital, shortage of intensive care or nursing staff, etc.
the anesthesiologist has the right to refuse anesthesia either temporarily or
permanently. He also has the right to postpone an anesthetic (even in an
emergency case) if he thinks that the patient’s condition can be improved by
a delay. CEPOD (Confidential Enquiry Into Perioperative Deaths) found that
only one in 20 of their ‘out of hours’(night and weekend) cases were true
emergencies and concluded that many patients are put at unnecessary risk by
being operated on as emergencies.
In this situation, the anesthesiologist may well be faced by an angry patient, an
enraged surgeon or both. He may be accused of work-dodging, cowardice or
even incompetence. He will be asked for the results of many tests to justify his
clinical judgment. When insulted, he should resist the temptation to insult in
return. He should offer sympathy and constructive advice, e.g. referral to another
unit with more facilities. It must be remembered that one is not refusing the
patient an operation, but only an anesthetic in particular set of circumstances.
Subsequently the patient may be offered to another anesthesiologist (often of
less experience) without any hint of previous cancellation. It may be humbling
to discover that another anesthesiologist has ‘got away with’ the risk that one
originally thought was unjustifiable. It is not a matter for regrets.
Choice of anesthesia
It is common mistake to believe that general anesthesia is “dangerous” and regional
anesthesia is “safe”.
Chapter 5 Preanesthetic Assessment 63
In a general hospital, about 70–75% of surgery is performed under general
anesthesia, and the remainder is performed under regional or local anesthesia.
Operations about the head, neck, chest, and abdomen are best performed under
general endotracheal anesthesia, since with this method the airway is free and under
control at all times. However, the final decision concerning the type of anesthesia to
be employed rests with the anesthesiologist in consultation with the surgeon.
“The surgeon should not demand or insist on a particular technique of
anesthesia, as he may not know the limitations of the technique or the capability
of the anesthesiologist to manage the particular technique”
—John Alfred Lee
In many circumstances such a demand may prove fatal.
In one incidence, the surgeon suggested that he can operate on a patient
with perforative peritonitis if the anesthesiologist could give epidural. The
anesthesiologist was not well versed with the technique and was not confident and
competent. But without telling that, he attempted to give an epidural. Unfortunately
he ended up in a ‘total spinal’. He was neither competent to give epidural nor did
he know how to manage a ‘Total spinal’. The result was the patient developed
cardiac arrest from which he couldn’t be resuscitated.
This is not an uncommon scenario, which should be avoided by clear and honest
communications.
The anesthesiologist must consider various factors before choosing the type of
anesthesia.
Age
In infants and children, obviously, general anesthesia is the method of choice.
In adults general, regional or local techniques may be chosen depending upon
the situation.
Physical status
Preoperative disease: some diseases like poliomyelitis, myasthenia gravis,
etc. The use of muscle relaxants may be problematic. In patients who receive
anticoagulant therapy, it s wiser to avoid regional techniques.
Severe impairment of vital functions: particularly reduction of pulmonary or
cardiovascular reserve, dictates careful choice of techniques.
Emotional, mentally ill, uncooperative, senile, or disoriented patients may
better be managed by general anesthesia.
An obese patient with short neck: Usually thick neck easily develops airway
obstruction after induction of anesthesia and also in postoperative period.
Adequate planning and precaution must be taken if general anesthesia is
contemplated. If possible regional technique may be safely employed.
Type of surgery
Lengthy operations require general anesthesia.
In addition procedures done in prone, lateral, or other awkward positions require
general endotracheal anesthesia to secure satisfactory control of airway and
ventilation.
64 Surgeons and Anesthesia
Teaching purpose
In teaching institutions the operations last longer and general anesthesia is the
choice, particularly for lengthy procedures. In these operative situations, the
instructor and resident physicians are more relaxed and can speak freely, without
the need to choose their words carefully to avoid alarming the patient. If regional
or local anesthesia is selected, however, the patient is well sedated.
Further Reading
1. Bodlander FMS. Deaths associated with anesthesia. Br J Anesthesia, 1975;47:36.
2. Brown DL (ed). Risk and Outcome in Anesthesia. Philadelphia: Lippincott, 1988.
3. Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality.
1961;178:261.
4. Lee’s Synopsis of Anesthesia, 11th edition. Butterworth-Heinemann Ltd, London.
1993;5:85.
5. Maxwell H. Preparation for anesthesia (Stevens AJ ed) Clinical Anaesthesiology,
1986;4:473.
6. Medico-Legal Reports. Appearing in Court. London: Medical Protection Society, 1989.
7. Palmer RN Anesthesia. Consent, Confidentiality. Disclosure of Medical records.
London: Medical Protection Society, 1987;43:675.
8. Textbook of Anesthesia, Aitkenhead AR, Smith G (Eds), Third Edition, 1996;18:305-15.
Chapter
Preanesthetic Medications
6 (Premedication)
Chapter Outline
Definition
v
Pharmacological Aspects
v
Premedicant Drugs
v
Effects of Premedication
v
During preanesthetic rounds, the following factors are considered and a decision
is made on the conduct of anesthesia.
Mental and physical status of patient
The patient’s problems
The surgeon’s requirements
The anesthesiologist’s own skills.
Based on the above factors a rational premedication is decided. Anesthesia is
said to have begun when these medications are given. Wise choice of medication
can pave the way for an uncomplicated anesthetic and postoperative course;
improper choice can lead onto an unsatisfactory experience for all concerned.
Definition
This is a medication comprising of a drug or more drugs chosen as per the need
of the patient in precisely calculated dose and administered preoperatively in
appropriate time and by suitable route, before induction of anesthesia. The purpose
is to have their beneficial effects on the systems of the patient in preoperative,
intraoperative and postoperative periods.
this is essential for the safe conduct of anesthesia.
This is known as pre-anesthetic medication, which may be administered by
oral, IM (Intramuscular) or IV (Intravenous) route as per the requirement of the
particular patient.
The purposes are:
To alley the fear and anxiety
To relieve the pain—if the patient is suffering
To support pain relief during anesthesia (background analgesia)
To induce sleep before anesthesia (basal narcosis)
To dry up the secretions (reduce the secretions) of salivary glands and
tracheobronchial tree—which may interfere with gaseous exchange
66 Surgeons and Anesthesia
Timing
Oral premedication 2 hours prior to induction
Intramuscular premedication 45 minutes prior to induction
Intravenous premedication A few minutes prior to induction
(Intravenous premedication is usually given only in dire emergency for patients in
shock, where IM drugs will not be absorbed)
Tranquilizer
It is a drug that depresses the central nervous system very minimally so that
the patient’s cognitive functions are not affected but his excitement or anxiety
is relieved.
Chapter 6 Preanesthetic Medications (Premedication) 67
He appears more calm and quiet. For example Diazepam in a dose of 2 mg
orally causes calmness of mind without affecting other higher functions.
So the tranquilizer is prescribed for those who have minimal anxiety and no
pain preoperatively.
Sedative
It is a drug that depresses the central nervous system a little more than the
tranquilizer, in the sense that it makes the patient drowsy so that he does not
show much interest in the environment.
Any visual or auditory inputs may not disturb him. For example Diazepam in
a dose of 5 mg orally causes depression of central nervous system to the extent
of making the patient drowsy.
Here inevitably cognitive functions are also depressed. So a sedative is
prescribed for a patient who is more agitated than simple anxiety but has no
pain preoperatively.
Hypnotic
It is a drug that depresses the central nervous system more than a sedative, that
it induces sleep in the patient so that he is totally cut off from the environment
is not aware of things happening around him.
For example Diazepam in a dose of 10 mg orally makes the patient to go into
sleep very smoothly.
So a hypnotic drug is prescribed for a patient who is severely apprehensive
with manifestations of sympathetic stimulation, tachycardia and hypertension.
This clearly indicates that the degree of central nervous system depression
required during the preoperative period differs with individual patients depending
upon their psychological build and so the choice of the drug and its dosage must
be tailored according to the individual.
Analgesic
It is a drug that relieves the pain.
This may be a drug acting on the central nervous system by blocking the pain
perception at various levels or on the peripheral mechanisms related to the
pain perception.
Its effect on the level of consciousness is either relatively very minimal or
absent, depending on the type of drug used. For example, codeine phosphate one
of the opium alkaloids (Papaver somniferum) acting on the central mechanism
of pain perception, has good analgesic property with negligible effect on the
wakefulness when compared to the other opium alkaloids.
Similarly, the Non Steroidal Anti Inflammatory Drug (NSAID) like Diclofenac
Sodium relieves pain by acting mainly on the peripheral mechanisms by
inhibiting the synthesis of Prostaglandin E and also has their direct analgesic
effect on the higher centers.
So the analgesic drug is prescribed for a patient preoperatively when he suffers
pain. Other non-analgesic central depressant drugs like diazepam do not help.
68 Surgeons and Anesthesia
Narcotic
It is a drug that acts on the central nervous system and induces sleep as well
as provides analgesia.
Morphine was the first narcotic known to the world and it was derived from the
plant Papaver somniferrum. It is the main alkaloid from that plant. Narcotics
are now known as opioids for this reason.
They are known also as Narcotic Analgesics, now better known as ‘Opioids’.
Morphine Sulphate
The name derived from the Greek word—‘Morpheus’ the God of dreams (the
son of Somnos the God of sleep)
It is the drug that was known as the “Queen of Analgesics” and was the “yard
stick” for measuring the potency of other opioids. Its dose for an average
healthy adult is 10 mg.
Pethidine Hydrochloride
It is the first synthetic opioid
It is 10 times less potent than Morphine and the dose for an average adult is
100 mg.
Now it is clearly established that there are specific opioid receptors in central
nervous system both in brain and spinal cord as well as peripheral nerves. These
receptors have been sub typed and each having specific pharmacological effects
related to analgesic effect as well as side effects such as nausea, vomiting, etc.
Semisynthetic alkaloids
Diamorphine hydrochloride – 5 mg.
Dihydrocodeine – 50 mg.
Dihydromorphinone – 2 mg.
Synthetic agents
Piperidine derivatives:
Pethidine HCl (Mepiridine) – 100 mg.
Phenoperidine – 2 mg.
Fentanyl – 0.1–0.2 mg. (100–200 mics)
Alfentanil – 0.25–0.5 mg. (250–500 mics)
Sufentanil – 0.005–0.01 mg. (5–10 mics)
Lofentanil – 0.005 mg. (5 mics)
Remifentanil – 0.05 mg. (50 mics)
Diphenylheptane derivatives:
Methadone hydrochloride – 10 mg.
Dextromoramide acid tartrate – 5 mg.
Mixed Agonist/antagonists:
Pentazocine tartrate – 30 mg.
Buprenorphine hydrochloride – 0.3 mg.
Butorphanol – 2 mg.
Among these different drugs, the most commonly used drugs are Morphine,
Pethidine, Pentazocine, Fentanyl, Sufentanil and Remifentanil.
Clinical significance
What is the effect of intravenous atropine?
Intravenous antisialagogues (Atropine) does not produce the drying of
secretions instantaneously, but it takes about 10 to 15 minutes for establishing
the drying effect.
Induction, laryngoscopy and intubation will hardly take 1 to 2 minutes, so
before the drying effect starts, the instrumentation of oral cavity will be over.
But it will certainly cause unnecessary tachycardia.
70 Surgeons and Anesthesia
Clinical significance
Where do we use intravenous premedicant drugs?
For patients in shock:
Intravenous route is used only in emergency as in shocked patients where
peripheral perfusion is closed down; Perfusion to the muscles will be almost
totally absent.
Intramuscular (im) route is not advised particularly for CNS depressants and
Opioids because no absorption of the drug from the muscle occurs at the time
of induction. It forms a ‘depot’ of the drug in the muscle.
But when the perfusion improves after volume resuscitation during anesthesia
and surgery, improved absorption may occur later and cause high blood levels
when it is added to the intraoperative supplementations resulting in serious
Central nervous system depression which may be fatal.
Therefore, even opioids must be given in small increments titrating just the
right dose which provides the desired level of analgesia.
In these patients, intravenous atropine is seldom required as in severe
hypovolemia as the perfusion to gland is almost stopped, it stops secreting
saliva and the oral cavity is dry.
Intravenous atropine will induce tachycardia in a patient who is already in
compromise with severe compensatory tachycardia resulting in reduced
ventricular filling time and reduction in cardiac output.
Effects of Premedication
After giving a premedication, it is necessary to give at least 45 minutes for the drug
absorbed to achieve the peak blood level before anesthesia is induced. The graph
I shows how the peak is reached and the plateau is maintained.
Note:
Premedication pethidine 50 mg IM was given and waited for 45 minutes
Blood level the drug reaches the peak in about 45 minutes and maintains a
plateau
This plateau of drug gives basal analgesia lasting for varying periods based
on the metabolic status (hypermetabolic or hypometabolic)
On this basal analgesia, intraoperative IV analgesic supplementations can be
done as and when required.
Figure 6.1: Shows that;
Induction is done 45 minutes after giving pre-medication of pethidine 50 mg
with Atropine 0.6 mg by intramuscular route.
By waiting for 45 minutes after premedication, the peak blood levels of
premedicant drugs are reached.
This is important and advantageous particularly with narcotic analgesics which
maintain the “Basal Analgesia”.
Once the peak level is reached, there is a very gradual decrease in the blood
level depending upon the rate of metabolism that maintains a plateau which
may last for a few hours. It is known as ‘Basal Analgesia’.
This basal analgesia can be easily boosted by IV supplementation of analgesics
at the time of incision and also whenever the analgesic requirement increases
according to the steps of surgical procedure.
In a normal individual, a premedication given by intramuscular route gets
absorbed slowly and steadily so that the blood level of the drug reaches a peak
by about 45 minutes with minimal variations due to the pharmaco-dynamics
and pharmaco-kinetics of the drug. Since then the peak level slowly declines
in the form of a plateau that goes on for a few hours, again depending upon the
metabolism and elimination of the drug.
72 Surgeons and Anesthesia
In hypometabolic state, the plateau will be more horizontal and longer, e.g.
myxedema.
In hypermetabolic states, the plateau will decline very fast, e.g. hyperthyroidism
This plateau maintains a basal analgesia in case of analgesic (a basal sedation
or hypnosis in case of sedatives) that gives an advantage in the management
of intraoperative analgesia.
Intravenous supplementation with small increments of analgesics will maintain
adequate analgesia which is easy to modulate.
In severely ill patients, the peak is reached late and the plateau is high and
almost horizontal (Fig. 6.2).
The premedication of Pethidine 50 mg IM was given and waited for 45 minutes
Because of poor peripheral perfusion due to dehydration and metabolic
impairment the drug was absorbed very slowly.
So, there is a delay in reaching the peak blood level—more than an hour and
the peak is higher than normal.
This higher peak reached very late develops a plateau which is almost horizontal
and maintained for a longer period because of poor metabolism and delay in
elimination.
This may lead to relative overdose and cause delay in recovery.
Chapter Outline
The Purpose of Anesthesia
v
Guedel’s Classification of Anesthesia
v
The Triad of Anesthesia
v
Definition of Anesthesia
v
Balanced Anesthesia
v
Modern Anesthesia
v
Recovery from Anesthesia
v
Classification of Anesthesia
v
Ether inhalation for surgical anesthesia depending upon the plane required may
vary from 3% to 13%. From the above discussions, we can understand that a good
surgical anesthesia has some characteristics.
Patient is unconscious
Respiration regular and adequate
Pupils moderately dilated and reacting
Reflexes are suppressed adequately (pain is abolished and surgical stimuli are
suppressed)
Muscles are reasonably relaxed.
These three aspects were originally known as ‘The Triad of Anesthesia’ where
unconsciousness is inevitable.
But in modern anesthesia we don’t rely entirely on one inhalational anesthetic
agent like ether. Multiple drugs are being used, and so the unconsciousness
induced inevitably by ether can be modified as ‘hypnosis’ (sleep). This means, the
unconsciousness can be eliminated and the patient may be kept in a state of good
sleep.
Now condensing all that we have discussed so far about anesthesia, we
can understand that general anesthesia comprises of only three aspects that are
commonly known as “The Triad of anesthesia”.
1. Hypnosis – Keeping the patient in good degree of sleep by using a
drug which induces sleep and continuing it throughout,
e.g. Thiopentone sodium, Diazepam, Midazolam, etc.
2. Analgesia – Relief of pain by using analgesics or narcotics (opioids),
e.g. Morphine, Pethidine, Pentazocine, Fentanyl, etc.
3. Reflex suppression – Mainly by muscle relaxants supported by analgesics.
(Once pain induced by surgery is relieved by analgesics, the further reflexes
are caused usually by tissue handling and retraction of muscles).
There is a need for further explaining ‘Reflex suppression’.
The causes of reflexes during surgery and managing them scientifically are
discussed below. Reflexes may be caused by;
The pain inflicted by the surgery: This will be suppressed well with the adequate
doses of analgesics given for pain relief.
The handling of tissues: This may also mediate reflexes by stimulating pain and
thereby the sympathetic system. Good analgesia suppresses that also.
The handling of viscera: This mainly causes autonomic reflexes only as the
viscera do not possess somatic pain fibers. Depending upon the innervations,
it may stimulate either sympathetic or parasympathetic. The predominance of
sympathetic or parasympathetic varies with different situations and patients.
Theses reflexes are suitably suppressed using either anticholinergic or anti-
adrenergic drugs.
The retraction of muscles during surgery: This may stimulate reflexes mediated
through muscle spindles. During retraction of abdominal muscles, along with
the muscle spindles being stimulated, the parietal peritoneum which is densely
innervated with pain fibers is also stimulated by the broad surfaces of the
retractors to cause pain.
This situation is suppressed first by additional dose of muscle relaxant that
relaxes the muscle well so that the retractors do not badly stimulate the pain fibres
of parietal peritoneum. Then, if needed it can be further suppressed by adding a
little analgesic.
Having an orientation of the stages and planes of anesthesia and ‘The Triad of
Anesthesia’, modern anesthesia could be defined as follows.
Definition of Anesthesia
Carefully controlled reversible modification, modulation or depression of various
modalities of C.N.S. (pain perception, wakefulness, motor activity, respiration,
Chapter 7 Clinical Anesthesia: Balanced Anesthesia 77
reflexes, etc.), ANS, (vasomotor tone, heart rate, etc.) and peripheral Nervous
System, (Mainly in Regional anesthesia), by using small, incremental, titrated
doses of various pharmacological agents to achieve a specific physiological goal.
The goal being, the protection of the patient from the detrimental effects of various
reflexes caused by pain of surgery, handling of tissues and viscera, and retraction
of muscles.
The key words are: Reversible, small, incremental, titrated doses.
The reversibility is obviously essential; otherwise anesthesia will end up in a
disaster. For that purpose, the right dose of the required drugs for the individual
patient for the specific procedure must be used, neihter bigger nor smaller dose.
Balanced Anesthesia
Balanced anesthesia based on the ‘Triad of Anesthesia’ can be well realised from
the (Fig.7.1).
The term ‘Balanced Anesthesia’ is used very frequently by anesthesiologists
and it has a very high significance in the overall outcome in a surgical patient.
The components of the ‘Triad’ are numbered as: (1) Hypnosis (sleep); (2)
Analgesia; (3) Reflex suppression.
Among the triad of anesthesia ‘Hypnosis’ or ‘Sleep’ is ‘the base’ on which the
other two components are being balanced (Fig.7.1).
The other two of the ‘Triad’ namely ‘Analgesia’ (pain relief) and ‘Reflex
suppression’ (suppression of reflexes caused by handling of tissues, viscera,
retraction of muscles, etc.) has to be balanced depending upon the requirements
of the particular surgery.
The ‘hypnosis’ or sleep is induced at the time of ‘induction’ of anesthesia and
has to last throughout the ‘duration of surgery’ up to the time of ‘recovery’. At
no time during surgery the patient is allowed to be awake.
The hypnosis is depicted as ‘the base of the triangle’ and incidentally the base
of the triangle indicates the duration of surgery. The apex of the triangle is the
point on which there is a balancing rod, on either side of which ‘Analgesia’
and ‘Reflex suppression’ are to be balanced.
In any surgery ‘Pain’ is the main component and so the number 2 in the Triad
is always ‘Analgesia.
In many minor surgical procedures the main aspect to be managed is only
pain and further reflex stimulation may be negligible or absent. This means
the adequate pain relief manages the balance well. Hence the number 3 of the
triad is always ‘Reflex suppression’.
Various surgeries induce varying degree of pain and reflexes. No two surgeries
of similar magnitude induce the same type of reflexes as well as pain due to
various reasons related to the technique, degree of handling, individual patient
variance, etc.
Hence based on the assessment of the degree of pain and degree of reflexes
induced during surgery, a fine balance is maintained by supplementing analgesia
or using methods of suppressing the reflexes as the case needs.
If the balancing is done perfectly, there will be no damage to the systems of
the patient.
This assessment is done by using the clinical parameters and monitors and it
requires good knowledge and experience.
Clinical significance
After assessing the status of the patient, planning the technique of choice is done.
When ‘General anesthesia’ is contemplated, the drugs and the doses of drugs
appropriate for that individual patient are the chosen so that the right doses of drugs
that does not adversely affect the systems are administered and that ‘The Triad of
Anesthesia’ is achieved without causing overdosage. In other words, the right doses
in appropriate time are used and not a higher or lower dose.
In modern anesthesia, the concept is to achieve the ‘Triad of Anesthesia’ not
with one single drug, but with many drugs in smaller increments as required
(polypharmacy). Each drug usually takes care of one aspect of the ‘triad’. The major
advantage of the use of multiple drugs in such combination is that, the individual
drug in smaller doses gives the maximum benefits without causing side effects.
Modern Anesthesia
How to orient the orthodox stages and planes of the anesthesia described by
Guedel in modern ‘Balanced Anesthesia’?
Normally a patient is premedicated with an opioid and a vagolytic such as
atropine sulphate. For example, the patient is given injection Pethidine 50 mg with
injection Atropine 0.6 mg combined and given intramuscularly.
The patient is made to wait in the waiting room for about 45 minutes for the
premedicant drug to get absorbed from the muscles to reach the peak blood level.
(see the Fig.6.1 in the Chapter 6 Preanesthetic medications).
Chapter 7 Clinical Anesthesia: Balanced Anesthesia 79
In modern anesthesia the Stage I and the Stage II can be very easily and
conveniently skipped and by-passed by the practice of intravenous induction of
anesthesia. This is usually achieved by injecting thiopentone sodium, an ultra short
acting barbiturate, intravenously in a dose of 5 mg/kg as 2.5% solution, very slowly
which induces sleep smoothly in one arm-brain circulation time, i.e. in less than
30 seconds.
In this process, Stage I (stage of induction) and Stage II (stage of excitement
or stage of hyperreflexia) that are seen with inhalational induction particularly with
ether are quietly skipped.
This is immediately followed by intravenous injection of a short acting muscle
relaxant suxamethonium in a dose of 1–2 mg/kg. This is a depolarizing relaxant
(the only one available) which produces excellent relaxation of all the skeletal
muscles of the body in 30 to 60 seconds lasting for about 5 minutes. The patient
will become apneic, when he will be ventilated with 100% oxygen through a mask.
By these steps, the patient is now taken to the Stage III, Plane 1 and passes
on to Plane-2, because the ‘Triad of Anesthesia’ is well established.
Hypnosis – is achieved by Thiopentone.
Analgesia – is achieved by the ‘Basal Analgesia’ already caused by
the opioids in the premedication.
Reflex suppression – is achieved by the excellent muscle relaxation by
suxamethonium.
Now the patient is subjected to laryngoscopy commonly using Macintosh curved
blade laryngoscope and after visualizing the larynx, intubation of the trachea is
done with appropriate size tube needed for the patient.
Here it has to be remembered that with the endotracheal tube in trachea, the
plane of anesthesia required for tolerating the tube without inducing reflexes from
glottis is Stage III, Plane-2.
At that time, the patient is fully paralyzed and is not breathing (apneic). He has
to be ventilated artificially. So the endotracheal tube is secured with adhesive tapes
and then the tube is connected to a breathing system of an anesthetic machine and
artificially ventilated by intermittent positive pressure applied on a reservoir bag
(IPPV) using a mixture of 40 % oxygen and 60% nitrous oxide.
Soon the effect of the short acting muscle relaxant suxamethonium starts
wearing off and the patient will show attempts of respiration. It is the time to
switch over to longer acting muscle relaxant of non-depolarizing type such as
Pancuronium, Vecuronium, Atracurium, Rocuronium etc to continue the muscle
relaxation.
At this time analgesics have to be supplemented in small increments
intravenously to boost the ‘Basal Analgesia’ that already exists (Fig.7.2). By this,
the patient is brought in a perfect stage of ‘Balanced Anesthesia’ with all the ‘Triad
of Anesthesia’ properly balanced in Stage III, Plane-3.
Though nitrous oxide is a very weak analgesic, it has synergism with the
analgesia provided by the ‘basal analgesia’ and ‘boosted analgesia’ and enhances
the degree of analgesia (Fig.7.2).
At this stage, the surgeon may be permitted to make the skin incision and
proceed.
80 Surgeons and Anesthesia
Fig. 7.2: Boosting of basal analgesia with small incremental dose of analgesic
Clinical significance
The only implication is that even though the patient is induced into anesthesia, he
might not have reached the right plane of anesthesia necessary to make an incision.
If the incision is made when the patient is in inadequate plane of anesthesia,
(the preferable plane is just above plane 2) the incision itself induces severe
reflex sympathetic stimulation leading on to tachycardia and hypertension
that may be grossly detrimental to the patient particularly if he suffers from a
cardiac problem like ischemia.
Sometimes, for making the skin incision it may be adequate, but to proceed
further it may need a little additional supplementation of drugs or a little time
(a few minutes) for the drug given already to act on the receptors to produce
the desired effect.
Very rarely, immediately after induction, the anaesthesiologist might have
encountered an unforeseen problem or complication that he might be busy in
managing.
It is quite natural that the team has to wait, till things are back to normal.
The following discussion with an example may help in understanding the need
of different planes for different steps of surgery.
Taking the case as P.G.J with vagotomy, as an example the points of various
steps of surgery with their requirements of plane of anesthesia are marked in the
form of a graph in (Fig.7.3).
Medical management of acid peptic disease with excellent drugs available and
now it is rare to see a patient with the disease progressing to a stage of cicatrizing
ulcer causing duodenal obstruction. But the procedure of “Posterior Gastro-
jejunostomy with Vagotomy” is considered as a major abdominal surgery that does
not involve significant blood loss. So that is taken as an example.
In this example, a normal otherwise healthy individual is posted for posterior
gastrojejunostomy and vagotomy (Fig.7.3).
Skipping stages I and II, Stage III is reached by intravenous induction,
suxamethonium for relaxation and intubation of moves the patient to Stage
III Plane 2.
With the endotracheal tube in position—the plane required for tolerating the
tube without inducing reflexes—is stage III plane 2.
Subsequent management of anesthesia will be by modulating the plane between
plane 2 and plane 3 depending upon the need of surgical procedure.
This could be achieved by intravenous supplementation of incremental
analgesics or muscle relaxants depending upon the need.
If pain is the cause for inducing reflexes intravenous incremental supplementation
of analgesic is done to boost the basal analgesia.
82 Surgeons and Anesthesia
Facts to be remembered
Muscle relaxants per se do not kill a patient, but lack of ventilation after a
relaxant will.
It is quite impossible to be dogmatic about the dose of relaxant.
Cadaveric relaxation is never required for any surgery and it cannot be achieved
with genuine safety.
Blocking all the neuromuscular junctions in the body is never needed and is
not compatible with life.
It is estimated that blocking about 50–60% of neuromuscular junctions produce
excellent relaxation needed for any known major surgeries.
All abdominal surgeries don’t need the same degree of relaxation; there is a
gross variation with different incisions made for exposure. In the increasing
order it may be,
–– Roof top incision
–– Right or left sub costal muscle cutting incision
–– Transverse incision in pediatric patients (muscle cutting)
–– Mid line incisions (upper or lower)
–– Para median incisions (upper or lower)
–– Grid iron incision (McBurney’s).
The anesthesiologist may discuss with the surgeon about the details of the
procedure, the likely duration of surgery, the incision he proposes to make and the
type of assistance he is going to have and based on all these decide the degree of
relaxation needed and the drug to be used.
It may be emphasized here that it is unsafe to demand for more relaxation when
the anesthesiologist has already crossed the limits. There may be other reasons
other than inadequate relaxation for the difficulty the surgeon encounters.
Definition
“It is the period from the cessation of administration of anesthesia to the time when
the patient is awake with active protective reflexes”.
Therefore, for recovery from anesthesia the key words are awake and active
protective reflexes.
It is the prime duty of the anesthesiologist to ensure that the patient has
recovered from anesthesia adequately, as he (anesthesiologist) only induced him to
84 Surgeons and Anesthesia
sleep or unconsciousness. If only the patient is awake with all protective reflexes
he may be sent to the postoperative ward.
There are certain recovery criteria proposed by various authorities to ensure
adequate recovery. Some have proposed even twenty criteria. When we look into
them many of them are difficult to ascertain as the patient may not be cooperative
or may not be intelligent enough to understand them. There is no documentation to
prove that one set of criteria is superior to the other. Taking all the criteria proposed
by various authorities and the essential aspects of them, putting them in a nut shell,
we get the following five recovery criteria. If we are sure that all the five recovery
criteria are satisfactory, we may send the patient to the postoperative ward.
The five recovery criteria
1. Fully Awake
Patient must be fully awake. He must respond to a conversational volume of
voice by opening the eyes. He must not be too drowsy. An unconscious patient
should not be sent to the postoperative ward.
2. Fully Oriented
Patient must be fully oriented with time, space, etc. He must be able to tell his
name, his profession, his native place, the name of the relative who accompanied
him to the hospital, etc. without confusion. A disoriented patient should not be
sent to the postoperative ward. The cause of disorientation must be identified
and corrected by observing him in the recovery bed.
3. Must not suffer severe pain
Patient must not be suffering from severe pain. Mild bearable pain may be
accepted. If left undisturbed the patient goes into sleep. This status is ideal.
Though completely pain free postoperative period is possible in modern days by
using techniques like epidural opioids, patient controlled analgesia, etc. These
can be ventured only in setups where facilities for continuous monitoring is
possible.
4. Must have active protective reflexes
Patient must have his protective reflexes particularly cough reflex and deglutition
reflex well recovered. This patient may be able to protect his respiratory tract
from soiling by aspirating secretions, vomitus, etc.
5. Complete reversal of muscle relaxants
The residual effect of the neuro muscular blocking drugs (muscle relaxants) is
fully reversed with antagonists like neostigmine along with atropine. All the
skeletal muscles must have near normal power.
This can be ideally tested with a peripheral nerve stimulator. There are excellent
scoring systems available to ensure that. The suitable scoring system may be used.
The recovery criteria and other test for recovery is elaborately discussed in
Chapter 13 (Recovery room: Postanesthetic care unit).
“A postoperative patient is very quiet and sleeps with loud snoring”.
Is it a good sign? Be careful!
When there is a snoring sleep, we should never be happy about it, feeling that it is a
good sleep (sound sleep?). Particularly when a postoperative patient has a snoring,
Chapter 7 Clinical Anesthesia: Balanced Anesthesia 85
be very careful. It may be a warning about an imminent danger of severe airway
obstruction, hypoxia and cerebral damage. How?
Snoring is caused simply by the vibration of structures of the upper airway
indicating that there is obstruction and that causes the noise. We have nothing to
be happy about any noise anywhere in the respiratory tract whether it is upper
airway or lower airway. All lead to inadequate ventilation.
When a postoperative patient sleeps with a loud snore, we have to remember
the two points;
First, any noisy breathing is an obstructed breathing.
Second, the patient may be in a very deep unconsciousness. This may be due
to residual effects of anesthetics, CNS depressant drugs particularly opioids.
Both these situations are potentially dangerous. A sub-acute hypoxia, either
during anesthesia or in the immediate postoperative period leads on to hypoxic
damage to the neurons. First the cellular metabolism is affected as these are the only
group of cells that cannot have anaerobic metabolism. Initially in response to the
hypoxia neurons swell, thereby increasing the brain mass. This is actually known
as “cerebral swelling” which is different from “cerebral oedema” that occurs a
little later as a consequence of the effects of cerebral swelling. In fact, cerebral
swelling is a reversible phenomenon. A modest increase on the inspired oxygen
concentration, and relieving the airway obstruction and aiding venous drainage of
head and neck by posture totally reverses this problem.
As per the Munro Kelley’s doctrine, when one of the three compartments
(cells, vasculature and CSF) tries to expand, in the cranial cavity bound by rigid
bony skull, it can do so at the expense of the other two compartments. Hence the
expanding brain mass will first encroach on the CSF compartment and then on
the vascular compartment resulting in compression of cerebral vasculature. This
further reduces the blood flow to the brain causing more cerebral ischemia creating
a vicious cycle. This is the early effect of cerebral hypoxia particularly when it is of
sub-acute or insidious in nature meaning thereby, mild degree of hypoxia occurring
over relatively long period compared to an abrupt anoxia.
If the cerebral swelling is allowed to progress further, then it leads onto
further reduction in blood flow, and this gross reduction in oxygen supply further
perpetuates the neuronal damage. Incidentally, during hypoxia the capillary
endothelial cementing substance get damaged, its integrity is lost, fluid starts leaking
into the interstitial compartment thus worsening the situation and that is cerebral
edema. This stage is relatively more difficult to treat.
A patient who apparently recovered well who is fully awake, may slowly sink
into unconsciousness, secondary to this delayed cerebral edema and develop airway
obstruction, start snoring which may progress to irreversible cerebral edema. This
is likely to occur commonly in first few hours of recovery period.
“This patient recovered well immediately sir. Even when we visited him after
one hour in the postoperative ward, he was very quiet comfortably sleeping with
loud snoring. Soon afterwards we got a call that patient developed cardiac arrest”.
Such statements are commonly heard in the postoperative wards when unwary
house man takes a serious situation as a simple one i.e, a hypoxic encephalopathy
is mistaken for deep sleep. The scientific background of the story is that described
above earlier.
86 Surgeons and Anesthesia
Classification of Anesthesia
The following can be taken as a broad classification of “Types of Anesthesia”.
Chapter Outline
Operating Department, Operating Suite, Operating Theater
v
Access Zones
v
Patient Transport and other Activities
v
Design
v
Construction
v
Lighting
v
Pendent Services
v
Ventilation
v
Storage
v
Until the middle of 19th century, surgery was carried out in any convenient room,
frequently one which was used for other purposes. Although the introduction
of antisepsis resulted in the washing of the instruments and operating table, the
operating room itself was ignored as a source of infection. Operating rooms were
designed with tiers of wooden benches around the operating table for spectators;
thus the term operating theater was introduced! (Figs 8.1A and B). During the
early part of 20th century, large windows were incorporated, as artificial light was
relatively ineffective, and high ceilings were introduced to improve ventilation.
Additional facilities became necessary for preparing and anesthetizing the patient,
for sterilisation of instruments and for the surgeon and other theater staff to change
clothes and scrub up. In addition, the design of operating theaters changed, and
smaller theaters were introduced to facilitate frequent cleaning and efficient
decontamination of atmosphere and fumigation.
Modern operating theater incorporates the following design features:
Environmental control of varying degree of complexity, to reduce the risk of
air-borne infection. This includes microfiltered air-conditioning with pressure
gradient airflow systems, laminar flow system, etc.
Services for surgical and anesthetic equipments
Operating table or tables as the case may be for placing the patient and
positioning for surgery with modern facilities such as remote control for
changing of positions etc.
Artificial lighting appropriate for the surgeon and the anesthesiologist.
Measures to ensure safety of patient and staff.
Additional facilities required based on the type of surgical work and the quantity
of work may be provided.
88 Surgeons and Anesthesia
Figs 8.1A and B: Old operation theater and the wooden operating table
Definitions
Operating Department comprises of a unit of two or more operating suites and
supporting accommodation.
Operating Suite comprises the operating theater or operating room, together with
its immediate ancillary accommodation.
Operating Theater is the room in which surgical operation and some diagnostic
procedures are carried out.
The department must be easily accessible from the inpatient wards, intensive
therapy unit—ideally on the same floor level—and with the shortest possible route
to the accident and emergency departments. The facilities incorporated depend
upon the requirements based on the work load, the specialties served, etc.
Access Zones
Aseptic discipline is an important aspect of operating theater technique, and it is
common sense not to permit unrestricted access to all parts of the department. But
the use of the traditional terms ‘clean’, ‘sterile’, and ‘dirty’ zones, which have long
established architectural connotations are no longer appropriate. However, four
access zones are described.
Red line
A distinctive red line is drawn between the entrance of the department and inner
zones where patients will be transferred from the ward trolley to the theater trolley
and vice versa. This ensures that the trolley wheeled on the corridors of hospital does
not enter the theater. Staff entering this route is obliged to change into appropriate
clothing before crossing this line.
Patient transport
The safety and comfort of patients, the need to reduce the number of transfers,
maneuverability of the trolley through the hospital corridor, etc. should be taken
into account. In general, a trolley traveling in the unsterile hospital corridors should
not be allowed in to the limited access zone. In other words, the outside trolleys
are restricted beyond the “red line” (Fig. 8.5A). At this point, transfer of patient
from outside trolley to the theater trolley has to be done.
92 Surgeons and Anesthesia
Fig. 8.5A: Sliding the stretcher from ‘outside trolley’ (unsterile) onto the ‘theater trolley’
Supplies
Policies for supply must be clearly defined. The supply may be derived from the
Central Sterilizing and Disinfecting Unit and some special equipment such as
endoscopic instruments may be sterilized in the theater itself. Decision will have
to be made whether all supplies should enter through a single main entrance, or
alternatively via a separate entrance to the main department store.
Disposal
The method adopted for the identification and disposal of used items for destruction
or recycling, and to provide a disposal hold at a convenient point is needed.
Catering
Most commonly accepted practice is a basic service for preparation of beverages
and limited snack, which may include vending machines. This may be augmented
by provision of hot meals from the hospital main kitchen.
Cleaning
Internal construction materials must be such that it minimizes the maintenance
and cleaning costs. Cleaning policies must be decided at the planning level and
suitable store for keeping cleaning material and equipment should be provided.
Design
Operating facilities must be centralized in the operating department rather than
dispersed in the hospital, since this has been shown to be a most economic approach
in terms of engineering services, the use of equipment and deployment of personnel.
The operating department must be so constructed that it is separate from general
traffic and air movement in the rest of the hospital. Care must be taken to prevent
transmission of noise from the ventilation plant situated nearby.
Movement of patients is made easier, if there are good planning relationship
between the operating department, surgical wards and intensive therapy unit (ITU),
with easy access to the accident emergency (AED), and radiodiagnostic (X-ray)
departments. Convenient access is required to the sterilizing and disinfecting unit
(SDU) and laboratory facilities.
Ventilation should be on the principle that the direction of airflow is from the
operating suites towards the department entrance. This has been discussed in detail
earlier. There should be no interchange of air movement between one operating
suite and another.
Construction must be such that a high standard of cleanliness may be obtained
and maintained. All surfaces should be washable and all joints between walls,
ceilings and floors curved to facilitate cleaning.
No constructed storing spaces like cupboards should be there, they are dust
traps.
Construction
Operating room is designed around its centrally situated operating table with
overhead lighting and ventilation systems. The ideal shape is circular, but it is
inconvenient, so most operating rooms are square or nearly square. In 1980, The
Royal College of Surgeons of England suggested that the floor area must be 625 sq
ft (approximately 58 sq meters) and no smaller than 484 sq ft (approximately 45 sq
meters). Theaters for specialized surgery may require larger area to accommodate
bulky equipments.
All piped gases and electrical sockets must be positioned close to the head end
operating table either through booms or by pendants. Electrical cables should not
lie across the floor.
Floors
These must be able to withstand the rolling loads of heavy operating tables
and mobile X-ray machines. The surface should be slip resistant under wet
conditions and impervious to frequent cleaning with scrubbing machines. Flexible
thermoplastic sheet or tiles with welded joints are acceptable, but the joint should
not run across the theater. The adhesives used must be strong enough to prevent
waves in the floor finish when heavy objects are moved on the floor. Antistatic
floors (conducting floors) are not needed in the modern theaters as now flammable
anesthetics are not in use.
Lighting
Some amount of natural day light is always preferable. Wherever possible, high
level windows which give a visual appreciation the “outside world” should be
Chapter 8 The Operating Department 95
provided in the operating theater. Alternatively this can be achieved by means of
borrowed light from the windows across the corridor.
If external windows are fitted, solar heat gain or loss which may affect the
control of environmental conditions must taken into account. It may be necessary
to give triple glazing of windows.
Artificial light fittings for the corridors are always flushed with the surface of
the roof and should not cause areas of shadows (Fig. 8.6).
Color corrected general artificial lighting which permits true color rendition of
the patient’s skin tones is required, together with ceiling mounted operating theater
table luminaire. If the main supply fails, there must be ‘No break’ emergency
supply which provides adequate lighting and power to complete the operation
and in emergency to commence another. In an emergency unnecessary lights are
avoided and the lights switched off as soon as possible. This will help to reduce
the generator load or battery drain. This system must be fully automatic and must
be tested frequently.
Sometimes mobile emergency luminaires are used. This incorporates a trickle
charger which is connected to the socket, this keeps the batteries continually charged
and the luminaire ready for immediate use. Battery should be completely sealed and
the charger must be away from the operating zone as far as practicable for fear of fires.
General lighting
This should be provided by color corrected (which emits all the colors of spectrum
or at least red and related colors) fluorescent lamps, recessed or surface ceiling
mounted and arranged to produce even illumination of at least 500 Lux at working
height with minimal glare. There should be means for dimming or switching off at
the time of procedures like endoscopy as that requires dark environment.
Color
Color corrected general light is advised. For operating light, the surgeon must be
able to differentiate between normal and diseased tissues and perform tasks with
materials having little color contrast, for example using blood soaked sutures. The
color quality of light most generally acceptable for this purpose is in the region
of 4000 kelvin (4000 K). Operating luminaires are available at color temperature
between 3600 K and 5000 K which should meet most personal preferences.
Intensity/pattern
The density of light achieved in the operating area at operating table is directly
dependent on the intensity of light directed upon it. With a luminaire approximately
100 cm (40 inches) from the task area, the light pattern should be at least 20 cm
(8 inches) in diameter, with brightness at the pattern center of between 50,000 and
100,000 Lux, and at least 15,000 Lux at periphery. This is very high compared
with the normal general intensity of 500 Lux in the working area. The main reason
for such large levels of brightness is because of the high light absorption and low
level of reflectivity of the tissues; a large proportion of light is simply absorbed
and thus contributes for poor visibility (Fig. 8.10).
Shadow reduction
Operating luminaires are designed to produce beams of light from a variety of
angles, so that when the light source is partially obscured by the surgical team’s
heads or hands, the task area is still illuminated. Total shadow reduction is
undesirable, because if all shadows are eliminated, there will be no ‘modeling’ of
contours and three dimensional perception for the surgeon is lost.
Elimination of heat
It is important that the heat from the beams of light is kept as low as possible
to prevent ‘drying out’ or burning of delicate tissues. Most modern operating
luminaires reduce this heat by means of dichroic reflectors (cold mirrors) combined
with heat absorbing reflectors or filters.
Dichroic filters reflect visible radiation as a light beam but transmit the heat
producing infrared energy backwards for dissipation by the luminaire housing.
The radiant heat emitted by a luminaire light beam providing 100,000 Lux will
produce a temperature rise in the field of surgery approximately 12o C above the
ambient temperature. British standard norms stipulate that this temperature should
not exceed 22°C.
Maneuverability
The ceiling mounted operating luminaires should be suspended and counterbalanced
in such a way that it is easy to move, allows multiplicity of positions, horizontal
and vertical and does not vibrate or drift once it has been positioned. Some form of
the removable, sterilizable handle should be provided which enables the surgical
team to make minor adjustments if required.
Chapter 8 The Operating Department 97
The terminology
Lamp: Refers to the filament lamp (Fig. 8.7).
Luminaire: Refers to the operation theater light whether suspended from the
ceiling or on a mobile stand (Fig. 8.9).
Task area: This is the area, usually circular, illuminated by a luminaire. The
principle of task area illumination is shown in (Fig. 8.10) and the actual
illumination on the operation table is shown in (Fig. 8.11).
Pendant services
The pipeline supply in the operating theater is best provided in two ceiling pendants
to minimize the hazard of trailing leads; one for the surgical team and the other for
the anesthesiologist. These pendants may be rigid although telescopic, retractable
versions provide adjustment in height and simplify the connection of the hoses and
electric cables (Fig. 8.12).
These pendants have outlets for oxygen, nitrous oxide, compressed air, central
suction and multiple electrical outlets for running monitoring devices, infusion
pumps, etc. The retractable pendants have at least two shelves for keeping
monitoring equipments.
Ventilation
The ventilation system provided in the operation department has three main
functions:
1. To control the temperature and humidity of the operating suite.
2. To dilute contamination by airborne microorganisms and expired air anesthetic
gases.
3. To provide acceptable air movement within the operating suite such that
the transfers of airborne microorganisms from less clean to cleaner areas is
minimized. This is achieved by the supply of heated or cooled, humidified,
clean air to the operating suite.
–– Aerobic culture using a non-selective media should indicate that not more
than 35 microorganisms—carrying particles are present in 1 cubic meter
(m3) of the supply air.
Fig. 8.12: Retractable pendant service for pipeline gases and electrical outlets
100 Surgeons and Anesthesia
Storage
Special mention about the storage of essential items in the operating theater has to
be made, as this is, most often, one of the neglected aspects in the stage of planning.
Main supply store; this should provide storage for both sterile packs in protective
outer wraps and bulk clean supplies. For convenience of deliveries it is situated
near limited access zone.
Clean supply will include some pharmacy items.
Equipment store; A centrally positioned store is required for bulky mobile
equipments not in daily use such as operating microscope, laser, and bypass pumps,
etc. the store should be zoned to protect equipments, some of which are delicate
and costly. Mobile X-ray equipment and image intensifier should be parked in a
separate space, with easy access to a mains power socket for charging batteries.
Gas cylinder store; Storage of limited quantities of ready to use cylinders (a type
cylinders that could be fixed to an anesthetic machine) of oxygen and nitrous oxide
for anesthesia machine is required.
Chapter 8 The Operating Department 103
Further Reading
1. Aitkenhead AR, Smith G. The operating theater environment. Textbook of Anesthesia.
Churchill Livingstone, Edinburgh, 1996.
2. Arrowsmith lWM. Design aspects of ultraclean ventilation system for operating rooms.
Journal of Sterile Service Management, 1986;17–8.
3. Arrowsmith lWM. Ultraclean ventilation system for operating rooms. Health Service
Estate, 1985;55:65–8.
4. Ayliffe SA, Babb JR, Collins BJ, Lowbury EJL. Journal of Hygiene (Camb), 1969;
67:4174–25.
5. Bartlett D. Operating Theater Lighting. NAT News, 1978:24.
6. Berry EC, Khon l. Introduction to Operation Room Techniques, 4th edition, New York:
A. Bleninston Publication, McGraw-Hill Book Co, 1972.
7. British Standard Institution. 1986;BS 4533: Section103.2 London BSI.
8. Clarke P, Dixon E, Freeman D, Whitaker M. Nurse staffing and training in operating
suite. The design and use of operating theaters, edited by IDA Johnston and AR Hunter.
London: Arnold 1984.
9. Department of Health And Social Security. Operating Department. Health Building
Note, 1989,26.
10. Department of Health and Social Security. Ventilation of Operating Departments: A
Design Guide, 1983.
11. Houghton M, Hudd J. Aids to Theater Technique, 4th edition. Chap1, London, Bailliere.
12. Johnston IDA, Hunter AR, Lidwell OM. Bacteriological considerations. The design
and Use of Operating Theaters, London: Arnold, 1984.
13. Lidwell OM, Lowbury EJL, Whyte W, Blowers R ,Stanely Sj, Lowe D. Effects of ultra-
clean air in operating on deep sepsis in the joint after total hip or knee replacement: A
randomized study. British Medical Journal, 1982;I:285.
14. Lovett PA, Halstead MB, Hill AR, Palmer DA, Ryan TJ, Sonnex TS. Color rendering
of fluorescent lamps for use in hospitals Pro. CIEW, 20th Session, 1983;1:E 28/1-2.
15. Male CG. Theater Ventilation. British Journal of Anaesthesia, 1978;50:1257.
16. Medical Research council, DHSS and Regional Engineers Association, Joint Working
Party. Operating Theater Requirements, London, MRC? DHSS, 1972.
17. Rait A. Planning Operating Departments, the principles of Commissioning. NAT News,
1982;11–14.
18. Weeks J. Planning Operating Departments, the planning of operating suites, NAT News,
1982;9–12.
19. Williams M. Planning Operating Departments, commissioning theaters, NAT News,
1983;15–18.
20. Wyon DP, Lidwell OM, Williams REO. Thermal comfort during surgical operations,
Journal of Hygiene, London1 5–18.
Chapter
Theater Asepsis and
9 Equipments Sterilization
Chapter Outline
Operating Theater Environment and Asepsis
v
Definitions
v
Theater Sterilization Schedule
v
Types of Equipments
v
Cleaning and Sterilization
v
Cold Chemical Methods
v
Methods Available
v
Physical Methods
v
Chemical Methods
v
Gamma Rays
v
Ultraviolet Rays
v
Sterilization of each Group of Equipments
v
Tuberculosis Infection
v
Tests for Adequacy of Sterilization
v
Central Sterile Supply Department (Cssd)
v
“There is no substitute for perfect asepsis for safe and successful surgery and it
is maintained by the sincere efforts of dedicated scrupulously strict nurses in the
operating room.”
— William Newman
History
Until middle 19th century, surgery was carried out in any room, frequently the one
which was used for other purposes.
Although the introduction of antiseptics resulted in washing of the instruments
and operating table, the operating room itself was ignored and never recognized as
a source of infection.
“Asepsis” which means “no infection” is the term used in modern days which
evolved gradually from “Antiseptics”, “Disinfectants”, and “Germicides”.
Operating rooms were designed with tiers of wooden benches around the
operating table for spectators; thus the term ‘operating theater’ was introduced.
Early 20th century large windows were incorporated, as artificial lights were
ineffective and high ceiling was introduced to improve ventilation in the operating
room.
Later more complex facilities were incorporated to improve the quality of work
and environment, more for sterilization of equipments (instruments). The design
changed and smaller theaters were introduced for frequent cleaning.
More than anything else, the successful outcome of any surgical procedure
primarily depends upon the perfection in asepsis reached both in intraoperative
and postoperative periods.
The following discussion is about the maintenance of aseptic atmosphere in
the operating room as well as achieving perfection in the operative procedure.
This chapter essentially explains the principles and the methods of maintaining
theater asepsis. This includes the methods of preventing pollution of atmosphere as
well as perfect sterilization of instruments and equipments used for all procedures
in the theater.
Hospital infections
Cross infection from antibiotic resistant pathogens poses a serious threat to
every patient in the hospital. About 50% of the hospital patients acquire an
106 Surgeons and Anesthesia
Source of infection
1. Patients, personnel, anesthesia equipments, air-conditioning equipments,
cleaning techniques and Intravenous fluid therapy equipments.
2. Inhalation therapy equipments, nebulizers and ventilators.
The anesthesiologist and his assistant have contacts with many ill people in
the hospital, especially within the operating room, delivery room, and intensive
care units. They must share in the responsibility for decreasing and controlling
cross-infection. They cannot control the virulence of the pathogenic bacteria or
the resistance of the patient, but they can control the total amount of pathogens in
the atmosphere.
It has been clearly demonstrated both in the operating room and in the laboratory
that all parts of anesthesia breathing equipment can become contaminated and cause
cross-infection. It is well known that mechanical ventilators and humidifiers used in
inhalation therapy can be responsible for cross-infection. It has to be accepted that
in general, adequate care is not taken care in this aspect even in many sophisticated
centers (WHO report 2009).
Apart from bacterial infections most serious infections are some, such as HIV,
Hepatitis B transmitted by contact with blood and body fluids. Hepatitis B, C and
D are transmitted by blood.
The means available for eliminating this hazard may be grouped into three,
namely;
Decontamination
Disinfection
Sterilization
For maintaining asepsis in the operating room now the following systems are
almost universally followed.
Disposable sterile equipments must be used whenever possible.
Non-disposable equipments should be decontaminated with 2% glutaraldehyde,
washed with soap and water and left in glutaraldehyde for further 3 hours.
Chapter 9 Theater Asepsis and Equipments Sterilization 107
Contaminated floors and surfaces should be washed with 1% hypochlorite
solution (kills HIV virus and Hepatitis B virus). Gloves must be worn during
washing.
It has been recommended that a bacterial filter must be placed between the
endotracheal tube and the breathing system to prevent cross-infection from a
patient with undiagnosed infection.
Effective bacterial filters without causing undue resistance to breathing are
available.
Definitions
Antiseptics
These are chemical agent which kills or restricts the growth of the microorganisms.
These agents can be used on humans (living tissues), e.g. alcohol, chlorhexidine.
Disinfectants
These are chemical agent which kills or restricts the growth of the microorganisms
in general, used mainly on instruments and equipments but cannot be used on living
tissues, e.g. phenol, formalin, glutaraldehyde.
But some antiseptics which are commonly used on humans for disinfection
of skin may be used as disinfectants for instruments, e.g. ethyl alcohol, isopropyl
alcohol.
Germicide
Usually talked about phenyl compounds. These are chemical agents which
kill microorganisms whether vegetative or spores. These may be antiseptics
like chlorhexidine with alcohol or any disinfectants (an antiseptic may be used
as a germicide but not vice versa), e.g. phenol, lysol, dettol, formaldehyde,
glutaraldehyde, etc.
Detergent antiseptics
These are chemical agents that reduce the surface tension, thereby loosen and
soften the material so that an antiseptic can penetrate and act more efficiently on
the microorganisms, e.g. cetavlon cetrimide (antiseptics may be detergents but
not vice versa).
“An antiseptic can be a disinfectant, but a disinfectant need not be an
antiseptic.”
Daily
Washing with a disinfectant or germicide.
Wiping with chlorcresol, lysol, dettol or any chemical of this nature.
This is for floor and wall up to a height of 5½ feet.
108 Surgeons and Anesthesia
Carbolising
Wiping the walls and all the articles with a cloth dipped in anyone of the
disinfectants.
Article means all the items like trolleys, Mayo’s table, operation tabletop, etc.
Swabbing the floor with a disinfectant solution after each surgery is completed.
Weekly washing
Washing the theater thoroughly and wiping with cloth soaked in disinfectant.
This is done, after making suitable arrangements for protection of switchboards,
lights, etc.
First washed with plain water and then with 1% lysol in water and wiping out
thoroughly with a swab.
In modern operating rooms with false ceiling, and the air-conditioning ducts
passing above that, washing of roof need not be done, but effective fumigation
is enough.
Composition
Glutaraldehyde 100 mg/g.
Benzalkonium chloride (benzyl-C12-18-alkyl dimethyl ammonium chloride)
60 mg/g.
Alkyl urea derivatives (didecyl dimethyl ammonium chloride) 60 mg/g.
Advantages
Very cost effective
Good material compatibility
Excellent cleaning properties
Virtually no residues
Provides complete asepsis within 30 to 60 minutes.
Areas of application
Bacillocid is suitable for the disinfectant cleaning of washable surfaces using
the wet-wipe-procedure
Especially suitable for economic short-term disinfection in risk areas that are
likely sources of infection.
Boiling
For one cubic foot 0.5 to 1 ml of 40% formalin is used
Keep the calculated formalin in a basin on a stove near the center of the
operation room and allow it to boil by using a stove
The stove may be a kerosene or electric stove
Electric stove is ideal because after sometime when the formalin fumes fills the
air, the kerosene stove may be put off before completely boiling the formalin
Electric stove can be effectively used with a switch control from outside the
operating room
The efficacy of this process is uncertain at temperatures below 20oC and relative
humidity below 70%
Separate sterilization must be used for each room in the operation theater
complex.
Therefore, after adding the potassium permanganate, one has to rush out and
close the door.
110 Surgeons and Anesthesia
Ultraviolet Rays
Special lights emitting ultraviolet rays are fixed on the roof of operating theater
in appropriate angles, so that the whole operating room area and equipments
are exposed to UV Irradiation for 12–16 hours daily (Fig. 9.2)
It is commonly used for overnight sterilization of the operating room
The switch control for the light is usually kept out side the operating room for
operating the light without being exposed to the rays
Exposure to ultraviolet rays may cause damage to the skin (sunburn) and retinal
damage may also be caused
In the morning, after switching off the light, the air is exhausted to remove the
radiation and the personnel are permitted to enter only after one hour
Clean sterile water can be generated from a unit where water is passed through
ultraviolet rays to destroy the bacteria
This UV sterilized water is used for washing hands during “scrub up”.
Patients and personnel must be protected especially the skin and eyes as it may
cause sunburn and damage to retina.
A blower drives the ambient air of the operating room through this chamber
continuously at a regulated speed, where it is exposed to the UV rays and the
microorganisms are killed
The air passes through a filter before entering the chamber and so the air coming
out of the chamber will be particle-free and sterile
As this process is continuous, the air in the operating theater is repeatedly passed
through this unit, the microorganisms are destroyed, and thereby the bacterial
load in the air will be reduced significantly
The antibacterial effect is little more than 90%
Hence, it is a very simple and effective way of reducing the bacterial load in
the theater atmosphere, while the surgery is in progress. When the presence
of many personnel is essential for the work inside the room, the bacterial
contamination of air contributed by their exhalations is more. This equipment
is especially useful in such situations
These units are available in various capacities as per the requirement of the room
(cubic feet) and in two types; wall mounting and table top type (Figs 9.3A and B).
Sterilization of Equipments
Types of equipments
All the equipments used in the operation theater are potential transmitters of
infection from one patient to the other. If not properly handled, they can be
responsible for surgical sepsis and can cause serious morbidity to the patient.
Based on the chances of transferring infection they are classified into three groups.
They are;
Low risk equipments
Intermediate risk equipments
High risk equipments.
Intermediate equipments
These are pieces of equipments that come in contact with the skin and mucous
membranes. For example, anesthetic face mask, oropharyngeal airway, laryngeal
mask airway, etc.
Endotracheal tube though can be classified in this group, for an obvious reason
of safety is classified into high risk equipments.
Steps
Cleaning and decontamination
Disinfection
Sterilization.
Decontamination (Cleaning)
Physical removal of infected organic matter like tissue debris, pus, blood, etc.
on which the organism live. Microorganisms cannot thrive if no organic matter
is present. The organisms may be in dormant form or in active form depending
upon multiple factors. Decontamination can be done by using the following steps.
Thorough soaking
Scrubbing
Washing with detergents.
Chapter 9 Theater Asepsis and Equipments Sterilization 115
Decontamination is essential for subsequent disinfection or sterilization
whichever is following, as the presence of foreign material (organic material) will
make the process of sterilization inefficient and incomplete.
The decontamination can be done in as follows:
i. Manual
• Thorough cleaning by scrubbing with brush
• Using soap and water for cleaning infected material
• A detergent antiseptic may be a better choice for loosening organic matter
• Thorough rinsing with clean water for flushing the contaminants.
ii. Automatic Washing Machine
• This usually combines the processes of cleaning and disinfection one by
one.
• Like a dish washer, this is provided with racks for holding equipments. It
uses treated clean water with detergents and cleans articles by pumping
water as multiple jets.
• Then disinfection is done by circulating water at 80° C and holding it for
10 minutes (pasteurization).
iii. Ultrasonic Washer
• The instruments to be decontaminated are kept immersed in a water bath
and are subjected to ultrasonic vibrations which clean the debris and
contaminants that cannot be reached by a brush (Fig. 9.6).
• Decontaminates smaller pieces of instruments with intricate shapes such
as instruments meant for microsurgeries that are difficult to clean by other
means.
The process of “decontamination” is sufficient for “low risk” items that come
in contact with the skin and are not introduced into the patient. For example, face
mask.
Disinfection
This is removal or killing of most or all infective organisms with the exception
of the most resistant ones such as spores
Those that are not destroyed are reduced to the level that is harmless to health
(not infective). This is considered adequate for “intermediate risk” items
These are equipments that come into intact skin or mucous membrane. For
example, face masks, airway, etc.
Methods of disinfection
Cold chemical methods
Pasteurisation
Boiling.
Sterilization
This is the ultimate step for asepsis
Destroying all microorganisms including bacteria, viruses, fungi and their spores
This prevents passing on infection to patients
Essential for all “High Risk” items which means, those items that come into
contact with a break in skin or mucous membranes or introduced into the body.
1. Moist heat
Moisture increases cellular permeability
Heating coagulates the protein of bacterial cell
This is the mechanism of killing the bacteria.
i. Boiling
• Boiling the instrument in water at 100° C for 15 minutes in a sterilizer (Fig. 9.7)
• Kills all the vegetative forms of bacteria, but spores may escape.
If the pressure inside the container of water is increased, the temperature
also will rise. Besides, this will destroy the spores by better penetration
because of increased pressure and temperature. (It will be possible in
specialized equipments known as “Autoclave” which will be discussed later)
ii. Pasteurization
• Heating the article to 70°C for 20 minutes or 80°C for 10 minutes
• This can be best done in a water bath
Chapter 9 Theater Asepsis and Equipments Sterilization 117
Fig. 9.9: Huge autoclave with motorized door for sterilizing in CSSD
Ideal Packing
The articles are packed in the bin with sufficient space in between for the
passage of steam
It should not be tightly packed. A tight packing of linen will hamper penetration
of steam uniformly to reach all articles to sterilize them
Instruments need not be packed, but can be kept in a bag of linen
Sterilization of instruments needs 15 minutes and for linen it is 30 minutes
For rubber and plastic 15 minutes at 121°C may be enough
At the end of the procedure the articles must be dry
As an alternative, the instruments can be packed in thick linen, and then covered
with crepe paper that allows penetration of steam (Figs 9.12A and B)
The properly packed instrument packs or bins are loaded in special racks meant
for that and are then loaded into the autoclave (Figs 9.13A and B)
The soft spongy items like gamgee pads, bandages are packed in perforated
basket and are loaded into the sterilizing chamber of autoclave.
a b
Figs 9.12A and B: Packing the instruments for autoclaving: (A) Note that the instruments
are packed in thick linen folded in such a way to open it without touching the contents;
(B) Then this pack is packed in crepe paper folded in the similar way and “Signaloc”
indicator tapes are stuck on it
a b
Figs 9.13A and B: Loading the packed instruments into the autoclave: (A)Note that the
packed instruments are loaded in a rack mounted on a trolley for loading; (B) Cotton
bandages, gamgee pads, etc. are loaded in perforated basket containers on a rack
mounted on a trolley
Chapter 9 Theater Asepsis and Equipments Sterilization 121
Advantages of autoclaving
Most efficient, simple and the most cost effective method
Suitable for even smallest hospital as different sizes are available
Rapid method of heat sterilization in common use
Spores are destroyed
Linen and rubber are not destroyed even after repeated autoclaving.
Dry Heat
Hot Air Sterilizer (Oven)
The temperature inside the sterilizer is maintained at 160°C by a thermostat
At 160°C it needs one hour for sterilizing dry objects
The temperature and time can be programmed and the door could not be opened
before program is completed (Fig. 9.14)
Most suited for powders, greases, glass syringes, etc.
Flames
Ophthalmic instruments are directly heated on flames (approximately 1000°C)
This technique is not commonly employed.
Advantages
Most of the methods are technically easier
Suitable for equipments that are damaged by heat sterilization
Sophisticated chemical methods like ethylene oxide achieve perfection in
sterilization.
Disadvantages
Some of the chemicals act only on exposed surfaces and so may not reach all
areas
Some react with metals so may not be suitable for some metal objects
Some impregnate with the materials such as rubber and plastics and could not
be removed and may cause tissue irritation
The residual chemicals form a source of irritation
May destroy rubber and plastics.
The chemical agent may be
1. Vapor – Formaldehyde.
2. Gas – Ethylene oxide or propylene oxide
3. Liquid – Ethyl alcohol, isopropyl alcohol, glutaraldehyde, etc.
1. Vapor (Formaldehyde)
Specially designed formalin chambers with multiple trays for storing
instruments are used (Figs 9.15A and B)
Para formaldehyde tablets contain 95% formaldehyde in polymerized form and
contain 5% residues. These tablets are kept in adequate number in each tray
These tablets release vapor by slow and sustained sublimation (solid turning
into vapor)
Hence, the action of formalin tablets depends upon the rate of sublimation
Formaldehyde vapor requires moisture for action
May take 2 hours for adequate sterilization
May be useful for endoscopic equipments
Alternatively, 40% formalin can be nebulized in the chamber.
a b
Figs 9.15A and B: Formalin chamber: (A) The chamber has many sliding trays to load the
instruments; (B) Note that the second picture shows the endoscopy instruments loaded
with adequate number of formalin tablets
124 Surgeons and Anesthesia
a b
Figs 9.16A and B: Ethylene oxide sterilizer: (A) The cylinder contains10% of ethylene
oxide with 90% CO2; (B) A conventional ethylene oxide sterilizer
Chapter 9 Theater Asepsis and Equipments Sterilization 125
At room temperature this gas can be a liquid with a boiling point of 10.6°C
In modern sophisticated programmable ethylene oxide sterilizers 100% ethylene
oxide cartridges are used (Fig. 9.17).
a b
Figs 9.18A and B: Automatic programmable EO sterilizer: (A) The sterilizer in closed
position showing the program panel and display; (B) The sterilizer in open position and
the cartridge placed
126 Surgeons and Anesthesia
First, the air in the chamber is evacuated and steam is pumped and sprayed into
the chamber to raise the humidity to the required level
At this point, a pin from below punctures the EO cartridge and the gas is
released into the chamber with vacuum and penetrates into all the containers
of instruments
Once the sterilization is completed, the gas is evacuated through a special exit
that opens at a high level above the building (to prevent the gas being breathed
by people working there)
When the whole program is over, the door can be opened and the sterilized
equipments can be removed aseptically and transferred to the aerator where
HEPA filtered air circulates to remove the residual gas to the required duration
(usually 6 days).
3. Liquids
1. Phenol
2. Iodine
3. Ethyl alcohol, isopropyl alcohol
4. Hexachlorophene
5. Chlorhexidine gluconate
6. Glutaraldehyde 2% (cidex)
7. Iodophores
8. Chlorine compounds
9. Detergent antiseptics
10. Hypochlorite 1%.
Phenol
1–5% used to clean the surface of equipment
It is highly corrosive. So should not be used on surfaces, which are coming in
contact with the patient
Does not kill the spores (not in common use now).
Iodine
0.5–2% in alcohol solution was used as tincture iodine—one minute for
sterilization
Tincture iodine may irritate the skin
Povidone iodine (Betadine) is non-irritant and is in aqueous solution, needs 3
minutes for sterilization.
Chapter 9 Theater Asepsis and Equipments Sterilization 127
Ethyl Alcohol
70–80% is more efficient than absolute alcohol (100%)
Isopropyl alcohol 50–70% used in catgut sterilization in the pack itself.
Hexachlorophene
50–70% solution was commonly used; now it is not in use
One of the antiseptics which work in the presence of soap.
Chlorhexidine Gluconate
0.1% aqueous solution disinfects endotracheal tube if immersed for 20 minutes
0.5% in 50% ethyl alcohol sterilizes the skin of operating area in 30 seconds
Remarkable effect in 0.5% in alcohol in sterilizing the skin without irritation
is the reason for this agent being universally used as an ideal hand scrub for
surgeons.
Glutaraldehyde (Cidex)
The only actual sterilizing fluid available, as it destroys spores also
2% solution is made alkaline by adding 0.3% sodium carbonate and activated
Activated solution maintains its potency for 15 days
Kills bacteria in 15 minutes and spores in 3 hours
Used for sterilizing endoscopes, endotracheal tubes, breathing equipments, etc.
Equipments after sterilization must be rinsed thoroughly in clean sterile water
before use, because it is a skin irritant.
Nu–Cidex
A newer agent that has come into use which is similar to Cidex
It is a solution of stabilized, buffered, peracetic acid
It acts as an oxidizing agent both on the cell wall and the nuclei of micro
organisms.
Iodophor
It is an organic iodine compound where sodium is loosely combined with surface
acting material.
Chlorine Compounds
Commonly used for floor sterilization.
Detergents
These are quaternary ammonium compounds
They lower surface tension of solution
Good against gram positive and gram negative organisms. For example,
cetavlon cetrimide.
128 Surgeons and Anesthesia
Gamma rays
It is derived from a cobalt 60 source
Lethal dose for bacteria is 2.5 mega rads
Tubes, catheters, endotracheal tubes, plastic equipments, all can be sterilized
in a transparent plastic envelope with an indicator
Needs protected special environment. Hence cannot be installed easily as it is
highly expensive
In our country, it comes under the control of Atomic Energy Regulatory Board,
Government of India and it is highly expensive to install a unit
A National Institute can do this for consumer with an indicator on the bag
Most common method used for sterilizing disposable equipments such as
endotracheal tubes after manufacturing
In our country, this was available only in Bhabha Atomic Research Center
(BARC) in a unit named “ISO MED”
Now recently in 2004, it is made available in Dankuni, West Bengal. This has
been established under technical collaboration with Board of Radiation and
Isotope Technology
It has been monitored by Atomic Energy Regulatory Board, Government of
India. The unit is known as “VIKIRAN”. This plant employs highly effective
radiation technology to eliminate microorganisms in healthcare and food
products.
If it cannot be done,
Kept in 0.1% chlorhexidine solution for 1 hour
Then they can be cleaned and scrubbed with soap and water
After this they can be sterilized by boiling or autoclaving
Boiling for 3 minutes will kill the tubercle bacilli
Immersed in 2% glutaraldehyde (cidex) for 1 hour
Chapter 9 Theater Asepsis and Equipments Sterilization 129
a b
Hepatitis B
This virus is not killed by boiling but killed by autoclaving and gamma radiation
Chemical sterilization—1% hypochlorite is helpful.
Utilization
Sterile instrument sets are kept ready for use in the operating department store
for delivery when required to each operating suite
After use, sets are returned immediately to the Central Sterile Supply
Department for processing and sterilization
New sterile sets are received from the sterile supply counter and taken to the
operation theater
The sets of instruments are primarily packed in linen in a way that can be easily
opened and this pack is covered in a second packing with a special craft paper,
sealed with stickers, and sent for autoclaving after keeping on a tray
Chapter 9 Theater Asepsis and Equipments Sterilization 131
Soiled instruments returned from operation theaters are received in a separate
counter for cleaning, disinfecting and packing for sterilization
Sterile packs are issued only in exchange for soiled sets after checking and
verification
The department houses many large autoclaves, large bins for bulk sterilization,
all types of sterilization devices like hot air oven, low-pressure autoclave, etc.
Sets of instruments in large numbers, modern mechanical automatic cleaning
devices, washing machines with steam generators and other equipments in
adequate quantities depending upon the load of work.
Further Reading
1. Ayliffe GAJ, Coates D, Hoffmann PN. Chemical Disinfectants in Hospitals. London:
Public Health Laboratory Service, 1984.
2. British Standard Institution. Specification for paper bags for steam sterilisation for
medical use. 1982;BS6254, BSI.
3. Maurer IM. Hospital Hygeine. London: Edward Arnold, 1985;79.
4. Sills GA. Sterilisation, Nursing, 1986;1(3):109–110.
5. Whyte W, Bailey PV. Reduction of microbial dispersion by clothing. Journal of
Parenteral Science and Technology, 1984;39:1.
Chapter
Operating Table and
10 Positions for Surgery
Chapter Outline
Operating Table and its components
v
Positions for Surgery and the Caution Required
v
Supine or Dorsal Recumbent Position
v
Trendelenburg Position
v
Gall Bladder and Liver Position
v
Lateral Position of Extension (Kidney Position)
v
Lithotomy Position
v
Position for Abdominoperineal Resection of Rectum
v
Pads used for Positioning
v
Who is responsible for the maintenance of the operation table? The surgeon? The
Anesthesiologist? The theater-incharge sister? or The theater technician? There is
no single word answer for this question as this responsibility is entrusted to various
people in different institutions and setups. However, it is reasonable that all the
members in the surgical team are collectively responsible for the best maintenance
of the operating table. In fact, that is true.
For reasons of safety and practicability, the anesthesiologist and his assistant
(Anesthesia technician) are directly responsible for maintaining the operation
table.
The anesthesiologist must be well versed with the operating controls of the
table, as he is the person who will be modifying the positions that is comfortable
for the surgeon. At the same time he knows the limit which may compromise
the safety of the patient.
Because of this reason, the olden day’s operation tables had the provision
of all the controls at the head end of the table that is convenient for the
anesthesiologist to operate and modify the positions.
All the modern Hydraulic operation tables have hydraulic device for adjusting
the height of the table (Fig.10.1).
General purpose four section operation tables are in common use. The sections
are for supporting Head, Back, Lumbar region, and Legs.
The leg section may be a single piece or double piece for individual leg.
Now electrically operated tables with remote control are available for easy
operability. It is powered by self-contained rechargeable battery giving backup
for several days’ operation (Fig. 10.2).
Chapter 10 Operating Table and Positions for Surgery 133
The standard size of the pillow is 18 inches long, 12 inches broad, and 2–3
inches thick made of soft foam or quilt which is comfortable for the patient.
It is essential that all the members of the theater staff familiarize themselves
with the operation table and its accessories which must be easily accessible
and ready for immediate use.
This will be of immense help during the time of any crisis, to urgently change
the position of the table to head down to protect the airway of the patient in
case of vomiting or regurgitation of stomach contents.
The whole apparatus must be maintained in good working order and checked
before each operation list.
Points to note
All positions, except supine (lying on the back) affect the patient in various
ways, by limiting the respiratory excursions and vital capacity or by affecting
the circulation.
In the prone position, it must be made possible, the abdominal wall, and thus
the diaphragm, must be left free to move by supporting the patient at hip and
the chest (supported prone position).
Trendelenburg Position
This position, a modification of supine, (deep head down Figs 10.5A and B)
is used for intrapelvic operations, the object being to allow the intestines to
displace away from the pelvic cavity by gravity towards the upper abdomen.
They may then be packed off readily with an abdominal pack to have easier
access to pelvic organs.
The arm must be secured either on the side of the body and tucked securely or
kept on a side arm board and secured with straps.
The flexion of the knee must be directly over the junction of the foot and the
central sections of the table.
The pressure points to watch and protect are: The heels, leg strap (folded towel
between the strap and legs must be used), behind the knees and the shoulders.
The well padded shoulder rests must be positioned to the point of the shoulders.
On any account, the shoulder rest should not be placed at the root of the neck,
because this would cause pressure upon the brachial plexus and result in
paralysis.
These rests must prevent the patient from slipping and becoming suspended
by flexed knees, which would cause pressure on the lateral popliteal nerve.
Alternatively, well-padded pelvic supports may be used to retain the patient
in position.
a b
Figs 10.5A and B: (A) Trendelenburg position; (B) Reverse trendelenburg position
Pressure points to watch and protect are: The heels, behind the knees and at the
point where the arm is extended from the table.
Lithotomy Position
This position is used for operations on the external genital organs, perineum,
and anal region (fig. 10.11)
For Vaginal hysterectomy this position is commonly used
The buttocks projects well over the edge of the table at the junction of the center
and foot section, which is either lowered or removed
The legs are flexed at the hips and knees, and raised with the feet supported in
webbing slings. These slings are suspended from the lithotomy poles (Fig. 10.12)
The arms are secured in the usual manner
The patient is first placed supine on the table and is then lifted down until his
buttocks are at the edge of the center section (foot section lowered or removed).
Both legs are then flexed at the same time, abducted and secured by the webbing
slings outside the poles
The legs may be supported with the leg support (Fig. 10.11) or by slings
(stirrups) at the feet (Fig. 10.12)
The proper position of leg support pads (Fig. 10.13) or leg and foot support
pads (Fig. 10.14) are used to prevent pressure effects.
Pressure points to watch and protect are: The forearms, buttocks, and the inner
aspect of the thighs, which must be protected from the pressure by the poles with
pads of gamgee or sponge rubber. Note that the lithotomy poles are padded with
sponge rubber to minimise still further any pressure on the patient’s legs.
140 Surgeons and Anesthesia
Fig. 10.14: The way of using the leg and foot support pads
Fig. 10.15: Supported prone position with relton frame and pads
Prone Position
Prone position is commonly used for spine surgeries by posterior approach.
Some times used for lung surgeries
Always a supported prone position is used to prevent pressure on abdomen
that will hamper respiration by preventing movement of diaphragm
Support may be given at the upper thoracic region and on the pelvic girdle to
leave lower thorax and abdomen to move freely
The support may be achieved by using firm pads of appropriate sizes or relton
frame with pads (Fig. 10.15) may be used.
The pressure points to watch and protect are:
The head is supported at proper level with pillows and head ring
The head is turned to one side and the eyes are protected with eye cotton pads
and plaster
The side of the face is protected with a soft cotton pad
Pressure on major vessels of upper limb and lower limb must be prevented by
adequate padding
Upper limb is properly supported to prevent stretch injury to brachial plexus.
142 Surgeons and Anesthesia
a b
Figs 10.16A and B: Positioning on ortho table with C—arm (image intensifier)
Fig. 10.17: A wedge pad made of sponge and covered with washable rexin
Further Reading
1. Aitkenhead AR, Smith G. Textbook of Anaesthesia, 3rd edn. Edinburgh, Churchill
Livingston, 1996.
2. Martin JT, Warner MA. Positioning in Anaesthesia and Surgery, 3rd edn. Philadelphia,
WB Saunders, 1997.
Chapter
Assessment of Blood Loss
11 and Volume Replacement
Chapter Outline
Facts about Blood Transfusion
v
Assessment of Blood Loss During Surgery
v
Recommendations from Various Authorities Regarding Transfusion
v
Role of Colloids Solutions In Blood Volume Replacement
v
Commonly Uses Iv Fluids—Their Composition and Indications
v
Considering all these facts blood has to be treated as a dangerous yet necessary
commodity which has to be used only with proper indications and cautions.
Gravimetric Method
The simplest and most commonly employed method
The swabs and gauzes used are weighed before and after use the gain in weight
is calculated by weighing them
One gram is approximately equal to 1 ml of blood
To this, the amount of blood collected in the suction bottle also is added
This method is said to underestimate the loss by 25%.
146 Surgeons and Anesthesia
Colorimetric Method
Swabs and mop pads are washed thoroughly with a large known volume of
water which is then estimated colorimetrically
Errors may occur due to incomplete extraction of all the blood from the swabs
or contamination with bile
Patient’s hemoglobin must be known
Blood loss (ml) = (colorimetric reading × volume of solution ml)/200 ×
patient’s Hb%.
Dextran 70
Dextran 70 is the same polysaccharide with a molecular weight of 70,000
6% solution is available in saline or dextrose
It is hyper-oncotic. Infusion of 500 ml will usually increase the circulating
plasma volume by 750 ml
Has an acid pH 4.5–6 and may degrade acid labile drugs
Proved useful as a plasma volume expander and in the prevention of venous
thromboembolism
Used to reduce the incidence of thrombosis
If more than 1.5 liters are infused within 24 hours, may interfere with blood
grouping and cross-matching owing to rouleaux formation
May interfere with plasma protein estimation
Large volumes can cause bleeding by interfering with platelet stickiness,
enhancing fibrinolysis and blood flow
Chapter 11 Assessment of Blood Loss and Volume Replacement 149
Remains in the circulation in decreasing amount, for up to a week. Some of its
larger molecules are stored in reticuloendothelial system
Only 25% is excreted within 3 hours and only 50% can be recovered from urine.
Gelatin
These are produced by hydrolysis of collagens. They have long shelf life, reasonable
cost, and there is no risk of transmission of viral diseases.
Haemaccel
It is 3.5% solution of polymer of degraded gelatin with all the electrolytes in
the same concentration as plasma
Urea linked gelatin, the molecular weight is 35,000
pH is 7.2–7.3
Because it contains calcium it should not be given along with citrated blood
Infusion of 500 ml will substitute a lost volume of 600 ml
It helps in promoting postoperative diuresis.
Gelofusine
It is 4% succinylated gelatin in normal saline
Molecular weight is 30,000
pH is 7.4
Duration of useful effect on plasma volume is about 2 hours
No effect on blood cross matching, but only dilutional effect on clotting factors
may be caused
Short biological half life, less than 12 hours
85% excreted by the kidney.
For inducing the anesthesia with intravenous agents in a very pleasant manner
For modulating the anesthesia by intravenous agents supplemented by careful
incremental doses
For maintaining fluid balance by infusing IV fluids, if necessary for transfusion
of blood
For administration of emergency medications during any period of crisis
For supplying calories and fluids as long as the patient is not allowed oral fluids
in the postoperative period.
In general, it is commonly used only for administering intravenous fluid for
maintaining fluid and electrolyte balance and supplying calories as well. Hence, it
is essential to have a clear idea of the commonly used intravenous fluid and their
composition.
Dextrose Injection
This is available in three concentrations.
Dextrose injection 5% w/v
Dextrose injection 10% w/v
Dextrose injection 20% w/v
Benefits
Provides ready energy for the body metabolism when oral food intake is not
possible
Higher concentration may be used in conditions where there is restriction for
water intake while need for supplying more energy.
Indications
Dehydration or excessive water loss through urine and sweating
Prevention of excessive tissue protein catabolism and liver glycogen depletion
Promotion of sodium diuresis following excessive use of electrolyte solutions
Preventing ketosis due to starvation, diarrhea, vomiting and hyperpyrexia.
Drip rate
The maximum infusion rate should not exceed 0.35 g/kg/h.
Contraindications
Concurrent administration with blood
Water intoxication
Neurosurgical procedures particularly in the presence of intracranial hemor-
rhage.
Electrolytes mEq/Lit
Sodium 154
Chloride 154
Energy 190 calories
Benefits
Used in conditions where calories are needed and the chloride loss is greater
than sodium loss.
Indications
Dehydration, excessive protein catabolism, liver glycogen depletion, chloride
loss, deficient calorie intake and alkalosis.
Drip rate
In normal circumstances 400 ml/h and more rapidly in shock.
Contraindications
Renal insufficiency, edema in patients with cardiac, hepatic or renal disease.
Electrolytes mEq/Lit
Sodium 131
Potassium 5
Calcium 4
Bicarbonate 29 (as lactate)
Chloride 111
Benefits
Supplies electrolytes similar to that of plasma along with lactate a precursor of
bicarbonate for correction of mild acidosis
Lactate is rapidly metabolised to bicarbonate except in patients with liver
diseases, hypoxia, shock, or congestive failure where already the blood lactate
is elevated.
Indications
Dehydration
Restoration of normal fluid balance
Moderate metabolic acidosis
Replacement of extracellular fluid not characterized by marked acid base
disturbances.
152 Surgeons and Anesthesia
Drip rate
5–10 ml/kg body weight per hour
Can be infused rapidly at the rate of 30 ml/kg/h in the absence of cardiac and
other contraindications.
Contraindications
Severe metabolic alkalosis
Impaired lactate metabolism as in severe liver insufficiency
Addison’s disease (potassium free fluids are preferable).
Electrolytes mEq/Lit
Sodium 130
Potassium 4
Calcium 3
Chloride 109
Acetate 28
Calories 9
Indications
Restoration of intravascular volume following hemorrhage
Restoration of normal fluid and electrolyte balance, following external loss of
extracellular fluid or translocation into third space due to surgery, shock and
other cardiovascular emergencies
Burns, fractures, infection, peritonitis, and such clinical conditions
Correction of moderate metabolic acidosis as in mild renal insufficiency, infant
diarrhea, diabetic ketosis
Dehydration of any type with less fluid intake or increased water and electrolyte
excretion.
Contraindications
Severe metabolic acidosis that has to be corrected with 1/6 molar sodium
lactate solution
Chapter 11 Assessment of Blood Loss and Volume Replacement 153
Severe metabolic alkalosis which has to be treated with ammonium chloride
solution.
Electrolytes mEq/Lit
Sodium 154
Chloride 154
Benefits
Replaces sodium and chloride ions which are important constituents of extra-
cellular fluid.
Indications
Alkalosis in the presence of fluid loss
Sodium chloride solutions are still useful, nevertheless in cases where the
chloride loss has been greater than or equal to the loss of sodium.
Drip rate
400 ml per hour in adults normally
Higher rates of infusion according to necessity in shock due to sodium loss.
Contraindications
Renal insufficiency, edema in patients with cardiac, hepatic or renal disease.
Benefits
Useful for replacing electrolyte and fluid loss in pediatric patients.
Indications
Excessive sweating, vomiting due to pyloric obstruction, gastric suction with
loss of hydrochloric acid
Dehydration.
154 Surgeons and Anesthesia
Benefits
Invert sugar is metabolized faster than glucose, as it bypasses the steps catalyzed
by glucokinase and phosphofructokinase and, therefore, provides energy more
rapidly than glucose
Fructose is also less dependent on insulin which is required for glucose
metabolism.
Indications
Severe dehydration (along with electrolytes)
Pre and postoperative conditions
Intensive care patients
Trauma and burns patients
Hospitalized infective hepatitis patients
Hyperemesis gravidarum.
Drip rate
2.5–5 ml/kg/h.
Contraindications
Lactic acidosis.
Chapter
Vital Organ Function and
12 Anesthesia
Chapter Outline
Anesthesia and Liver
v
Anesthesia and Kidney
v
Anesthesia and Brain
v
Anesthesia and Heart
v
Anatomy
It is the largest organ in the body situated below the right costal margin just under
the diaphragm. It usually weighs between 1.5 to 4 kg, and is imperfectly divided
into two lobes, a large right and a small left one. On the inferior and posterior
surface between the right and left lobes are two smaller lobes, the caudate and
quadrate. The falciform ligament consists of two layers of peritoneum which are
closely united until they reach the upper surface of the liver, where they part from
each other to cover the peritoneal surface of the right and left lobe. This ligament
joins the liver to the diaphragm and the anterior abdominal wall. In its free edge
stretching from the umbilicus to the lower border of the liver is the ligamentum
teres containing small para-umbilical veins. At its upper end the two layers of the
falciform ligament separate widely to expose a small triangular area—“the bare
area of the liver”.
The porta hepatis is found on the inferior surface of the liver lying between
the quadrate lobe in front and a process of the caudate lobe behind. This structure
is important because it consists of a deep fissure containing most of the essential
structures of the liver. Viewed from below these structures, from right to left, are
156 Surgeons and Anesthesia
the common hepatic duct, which gives off a branch—the cystic duct—leading on to
the neck of gallbladder, the bile duct, the portal vein and finally the hepatic artery
with a plexus of hepatic nerves.
The microscopic structure of liver comprises of a whole mass of neatly arranged
lobules. Each lobule consists of numerous cells arranged in columns which radiate
from around a central vein. Irregular blood vessels or sinusoids can be seen between
the columns of cells. The blood supply to these lobules comes from the hepatic
artery and the portal vein. Both these vessels, soon after entering the porta hepatis,
divide into right and left branches. Each branch then undergoes dichotomy many
thousands of times to supply all the lobule.
The hepatic artery brings fresh oxygenated blood for the liver cells almost
directly from aorta, whereas the portal vein carries all ingested material in the
venous blood from the gastrointestinal tract and spleen. It is necessary to remember
that hepatic vein forms 80% and hepatic artery forms 20% of the blood supply to the
liver. These two vascular supplies are carried throughout the liver on the periphery
of the lobules. Small branches are given off from both the vessels which encircle
the lobule as the interlobular plexus and from these plexuses small capillary like
vessels (sometimes described as sinusoids) run between the columns of cells of the
lobules and finally drain into the vein in the center of the lobule – the central vein.
All the central veins join up to form the hepatic veins which finally drain into the
inferior vena cava (Fig. 12.1).
Hepatic Artery supply is small 20%
Portal vein supply is larger 80%
Mixing of blood in sinusoids makes it less oxygenated (hypoxic)
Cells in the periphery of lobule get better oxygen and the cells near the central
vein receive minimal oxygen.
Clinical significance
During anesthesia if for any reason the patient suffers hypoxia for a pronged time
or there is an episode of severe hypotension for a prolonged period, the liver suffers
serious hypoxic damage than any other organ.
The nerve supply of the liver consists mainly of non-medullated sympathetic
fibres which ramify around the vessels and bile ducts and finally terminate in the
liver cells. It arises from celiac plexus.
Physiology
The blood flow to the liver is about 1500 ml/minute. Of this total, about 80%
(1200 ml) reaches the liver though the portal vein and the remaining 20% (300
ml) comes through the hepatic artery. However, the blood in the hepatic artery
is about 95% saturated with oxygen whereas that in the portal vein is about 85%.
It has been estimated that the liver normally requires about 60 ml of oxygen
per minute, of which 17 ml is supplied by the hepatic artery and the remainder
by the portal vein. The total amount of oxygen available to the liver cells can be
reduced by a number of reasons;
Anesthesia may cause:
–– Reduced hepatic blood flow
–– Reduced oxygen saturation in blood
Lowered cardiac output as in shock, hemorrhage or hypotension
Inhalation of low inspired concentration of oxygen
Hypermetabolic states, e.g. hyperpyrexia
Hepatotoxic substances
Obstruction to the portal vein or hepatic artery.
It is clear, therefore, that the cells surrounding the central lobular vein are
the last to receive nourishments and oxygen. The cells at the proximal end draw
the oxygen and nutrients and by the time the blood reaches near the central vein,
there is very little in the blood to deliver, then they are the first to suffer from
any deprivation. This can be compared to the house situated at the tail end of the
supply area from an electricity transformer, receiving relatively a lower voltage.
With toxic substances such as chloroform one might expect the cells surrounding
hepatic artery to suffer the worst damage, but it is the toxins that cause the hepatic
cells to swell, and it is this swelling which further interferes with the blood supply
to the central cells and cause them to suffer worst damage.
Storage
Fats, proteins and glycogen and likewise certain vitamins such as vitamin B
are stored.
Synthesis
Liver synthesizes plasma proteins, prothrombin, fibrinogen and heparin.
Detoxification of drugs
Liver is able to remove many foreign substances by oxidation.
Anatomy
The two kidneys are retroperitoneal organs situated on either side if the vertebral
column. The upper pole is at the level of 12th thoracic vertebra. The lower poles
reach to the level of 3rd lumbar vertebra. The right kidney is always a little lower
than the left. The approximate weight of the kidney is 150g in male and 135g in
female.
Anteriorly it is related to various intra-abdominal structures. The upper pole
is closely attached to the suprarenal gland. The renal vessels and the ureter enter
through the hilum in the medial border. Kidney is ensheathed in a fibrous capsule
which can be easily removed exposing a layer of smooth muscle fibers beneath. A
cross section of kidney shows an outer cortical and an inner medullary substance.
Vascular system
The renal artery divides into four or five branches as it enters the hilum and each one
of these give off a small branch which runs to suprarenal gland. The main branches
then proceed to divide into lobar arteries which run to the renal papillae, and each
of these forms two or three interlobar arteries which pass towards the cortex of the
kidney. On reaching the point of junction between medulla and cortex at the base
of the pyramids each interlobar artery divides into two and in a “T” shaped fashion
each branch runs at right angles to the parent stem between the cortex and medulla.
These vessels do not anstomose with their opposite number in the neighbouring
lobe, but they give off important branches which pass into the cortex to supply the
glomeruli (glomerular artery). The venous drainage is similarly arranged (Fig.12.2).
Chapter 12 Vital Organ Function and Anesthesia 161
Fig. 12.2: Anatomy of kidney showing the pattern of vessels and calyces
Urinary System
The glomerulus consists of a mass of capillary vessels surrounded by the blind
end of an expanded renal tubule called the glomerular capsule
This apparatus is concerned with filtering substances other than protein from
the blood stream
The glomerular tubule leads to the first convoluted tubule, down the spiral part
to the descending loop of Henle and then up again through the ascending loop
to the irregular or zigzag tubule
From here it leads on to the second or distal convoluted tubule, from where it
finally drains into the collecting tubule
The function of this tubular system is selective re-absorption so that the material
that finally reaches the ureter is urine.
Nerve supply
This is derived from “the renal plexus” which is composed of branches from the
Celiac and aortic plexuses, the lower part of celiac ganglion, and from the lesser
and lowest splanchnic nerves. All the nerves which run to the kidney arise from
the 10th to 12th thoracic segments.
Physiology
Under normal resting conditions, about 20–25% of the total cardiac output
passes through the renal circulation each minute
162 Surgeons and Anesthesia
The two kidneys between them receive a blood flow of 1100–1200 ml/minute
Approximately half of this total consists of plasma and the remaining is cells
Despite various shunts described, it is believed that all this blood passes sooner
or later to the glomerular capsule
Here the hydrostatic pressure of systemic circulation, opposed only by the
osmotic pull of the protein content of the blood, drives the fluid across the
glomerular membrane to reach the renal tubule
Thus, of the original total of about 1000 ml of blood that enters the kidneys
every minute, about 1/10th or 100 ml passes down the tubules
At this point the selective re-absorption mechanism plays a major role and
almost all the fluid content passes back into the circulation again
Of each 100 ml of fluid entering the tubules, 99 ml is re-absorbed
This means that 1 ml of urine is formed from every 1000 ml blood that goes
to the kidneys
In other words, normally functioning kidneys are likely to secrete urine
approximately at a rate of 1ml/kg/h.
Tubular Reabsorption
The contents of the glomerular filtrate are identical with that of plasma lying
across the glomerular membrane inside the tuft of capillaries. Proteins are
absent
Though the liquid starts out on its journey through the tubular system resembling
plasma, by the time it reaches the end it bears no relation to it at all
On its way down, enormous quantities of water and certain electrolytes are
reabsorbed
This process of reabsorption is selective, so that the kidney tubules play an
important part in controlling the electrolyte balance of the body
For every 100 liters of water that enters the tubules, less than 1 liter (0.9 liters,
to be precise) reaches the urine
Any glucose which passes through the glomerular membrane is completely
reabsorbed so that none enters the urine
Nearly all the sodium, chloride and calcium ions are reabsorbed
8% of potassium ions and 25% of phosphate are absorbed
Water content of the body is controlled by the antidiuretic hormone (ADH)
of posterior pituitary. Nearly all anesthetic drugs stimulate the release of this
hormone.
vasoconstriction does not wear off for several hours. This vasoconstriction is
believed to be nervous in origin
After four hours of renal ischemia produced by hypotension, the vasoconstriction
may take many days to pass off even after suitable transfusion therapy, it may
become irreversible. This persistent vasoconstriction is thought to be of humoral
origin (Renin etc.)
In hypoxia and hypercarbia, the renal vessels tend to constrict
The ganglion blocking drugs cause dilatation of renal vessels and the renal flow
closely follows any change in the systemic pressure.
On the other hand, if the renal function is failing then the kidney loses its power
to concentrate urine by the absorption of water in the tubules, so that the specific
gravity cannot rise above 1,010.
It is estimated that as much as 450 ml of water per day is added to the total
body fluids simply due to the tissue metabolism, and a further 150 ml are
obtained from carbohydrate. This means that the body itself can produce as
much as 600 ml of water per day. This volume has to be kept in mind while
calculating the total requirement of fluid/day.
Cerebral metabolism
Brain is unique in that it entirely relies upon carbohydrate for energy
requirements. Glucose is oxidized to CO2 and H2O
Hypoglycemia by reducing the amount of substrate produces all degrees of
functional disturbances leading to coma
Brain needs uninterrupted supply of oxygen through circulation
Total circulatory arrest causes loss of consciousness in less than 10 seconds
There is no anaerobic metabolism in brain
“During anesthesia it is essential to see that Hypoxia, Hypoglycemia are
avoided”.
Chapter 12 Vital Organ Function and Anesthesia 167
Anatomy of circulation
Derived from internal carotids and vertebral arteries.
2/3 supply from the internal carotids. 1/3 supply from vertebral arteries.
The vertebral arteries arise from subclavian artery on each side and join at the
level of lower border of pons to form the basilar artery.
The circle of Willis is formed by the anastomosis between the transverse
branches of the basilar artery and the two internal carotid arteries.
The purpose of circle of Willis is to guarantee that whatever be the position of
the head in relation to the trunk and to gravity, the possible variations in blood
flow are always compensated within the cranial cavity by the freest anastomosis
of arteries. Normally, regional variations in cerbral blood flow does not occur
because the arteries distal to the anastomosis only reach the brain.
The blood stream in the circle of Willis does not usually cross the midline and
mix in the midline. There is a “Zero point” or “Dead point” in the midline,
referred as similar to the “Blue Niles” and “White Niles” river.
There will be mixing of blood only when there is a block in one side (Fig. 12.3).
In young person the occlusion of one carotid does not affect the cerebral blood
flow, but in elderly person it often produces evidence of cerebral ischemia.
Venous drainage
Venous drainage has no such pattern as the arterial supply. The Jugular bulb receives
2/3 of flow from brain. About 3% flows to extracranial veins.
Arterial PCO2
There is a linear relationship between the partial pressure of CO2 and blood flow.
If the PaCO2 is reduced to 20 mm Hg, blood flow is reduced half whereas if it is
raised to 80 mm Hg, the blood flow is doubled.
The blood flow returns to normal over about 24 hours if the change in PCO2 is
maintained, as the CSF bicarbonate is adjusted.
This limits the period of hyperventilation that is beneficial in reducing the
cerebral edema.
Arterial PO2
Inhalation of 100% oxygen reduces cerebral blood flow only to 10%.
Autonomic system
There is extensive sympathetic supply from superior cervical sympathetic
ganglion
Sympathetic have very little control in the CBF
Alpha 2 receptor stimulation causes vasoconstriction
Beta 1 receptor stimulation causes dilatation
Parasympathetic is vasodilator and is derived from the facial nerve.
Temperature
Hypothermia reduces cerebral blood flow (CBF). Incidentally, it reduces the
cerebral metabolism also.
Chapter 12 Vital Organ Function and Anesthesia 169
Hyperthermia increases cerebral blood flow (CBF). It increases the metabolism.
“Hypothermia protects the brain, while hyperthermia damages brain cells by
inducing demand hypoxia”.
Blood viscosity
If blood viscosity falls, the blood flow (CBF) increases and vice versa. So in anemic
status there is increased blood flow to brain.
Age
After the 60 years of age or more, there is a fall of blood flow, about 0.5% per year
and this fall is confined to the gray matter.
Drugs
All the inhalational anesthetic agents are cerebral vasodilators
The resultant increase in intracranial pressure will be greater in patients with
space occupying lesions
Ketamine is a cerebral vasodilator and increases the ICT and should not be
used in patients with increased ICT
All the intravenous anesthetics—barbiturates, propofol, benzodiazepine reduce
the CBF with a fall in cerebral metabolism.
Failure of autoregulation
When the range of 50 mm Hg to150 mm Hg is crossed
Increased PaCO2
Arterial hypoxemia
Very deep anesthesia
Extensive surgery
Circulatory arrest.
Intracranial pressure
It is not the same or synonymous with cerebrospinal fluid pressure. Both are not
one and the same. In patients with increased intracranial tension (ICT), there will
be increase in CSF tension also.
“If the ICT equals the arterial pressure, then no perfusion can occur”.
Definition
It is the pressure exerted by a unit area of cortex of the brain juxtaposing the unit
area of cranial vault.
As the cranial cavity is bounded by rigid bony wall it cannot expand in case of
increase in the size of the contents. There are three compartments namely, brain
tissue, vascular compartment and CSF compartments.
Hence, whenever there is a space occupying lesion, it compresses first, the CSF
compartment, then the vascular compartment and once there is no further space
the brain tries to herniate through the foramen magnum.
Cerebrospinal Fluid
This is an ultrafiltrate of blood formed by the choroid plexus in the lateral ventricles
pass through the foramen of Monro on each side to join that formed from the choroid
plexus of the third ventricle. Then it passes through the aqueduct of sylvius to the
fourth ventricle. CSF leaves from this to the subarachnoid space through the central
formen of Magendie and the lateral formina of Luschka and reaches the cisterna
magna. It bathes the whole of the central nervous system and is absorbed into the
venous sinuses through the arachnoid villi.
Total amount is 120–150 ml
Secreted at the rate of 4 ml/min
Pressure: 120 cm of CSF in the lateral position, and 300 cm of CSF in sitting
position
It is different from blood in that it almost free from cells and proteins
Proteins 30 mg %
Cells 5/c.mm
Specific Gravity 1003–1005
pH 7.3–7.4
Increased production, decreased absorption or any obstruction—all these cause
hydrocephalus.
The blood supply of the neuromuscular tissue of the heart is of some importance.
The Sinoatrial (SA) node receives a branch directly from either the right or
left coronary artery
The atrioventricular node (AV) is supplied by twigs from the left coronary artery
The atrioventricular (AV bundle) bundle has abundant blood supply, receiving
branches from the left coronary artery which accompanies the bundle in the
moderator band and supply the right division of the bundle
The left limb of the bundle has no specific branch and is supplied by small
arterioles in the neighborhood.
Cardiac output
Changes in cardiac output have marked effect, since coronary flow varies inversely
with it. When the cardiac output falls the coronary flow increases and vice
versa.
pH of blood
A fall in pH of blood leads to an increase in flow.
Blood pressure
The mean aortic pressure influences the coronary flow. An increase in pressure leads
to an increased flow. But this does not take into consideration the other factors like
cardiac output, coronary artery diameter and peripheral resistance.
Cardiac output
It is the volume of blood that each ventricle pumps out per minute
When it is related to the body surface area, it is called as “cardiac index”.
Normal–3.5 liters/sq. m
Cardiac output is not solely dependent on heart rate, as 5 fold rise in heart rate
could raise the cardiac output to 2½ time only
The major contribution to increase the cardiac output is the force of contraction
and venous return otherwise known as preload of heart.
Venous return
The venous return must equal the cardiac output
However, instantaneous changes in cardiac output may take place without
corresponding increase in venous return
To achieve such short-term inequalities, the heart must draw the reserve
volumes contained in the heart itself (diastolic volume) or from the pulmonary
circulation
Chapter 12 Vital Organ Function and Anesthesia 175
Further volumes of blood may be acquired from the reduction in the capacity
of larger central veins
There is a compensatory mechanism playing in that by the baroreceptors and
autonomic activity. This invariably causes a temporary “over swing”
The sympathetic stimulation causes three effects;
–– The force of contraction of ventricles is increased
–– three is an increased stroke volume which increases the ventricular
compliance
–– there is augmented atrial contraction to fill the ventricles
Here as per the ‘Starling law’, the better filling of ventricles and the increased
end diastolic pressure and the increased fiber length cause increased force of
contraction and cardiac output.
Vascular system
Circulatory efficiency depends as much on the integrity of the peripheral vasculature
as it does upon the performance of the heart.
It is better to remember some of the essential factors.
Arterial system
This is the resistive element of the circulation and must be optimal
Most of the peripheral resistance results from the one in the muscular arteries
and arterioles
Blood viscosity also plays a major role in the resistance
Selective constriction and dilatation of appropriate arteries is responsible for
distributing the cardiac output according to the tissue requirements
Arteriolar constriction is one of the mechanisms available for support of arterial
blood pressure on the face of a falling cardiac output
Under resting conditions, nearly 50% of the cardiac output flows to the kidney
and viscera.
176 Surgeons and Anesthesia
Vasopressors and other vasoactive drugs tend to constrict these vessels. On the
face of hypovolemia if adequate volume correction is not done, these drugs
may cause severe tissue ischemia
The arterial side of the circulation contains only about 15% of the total blood
volume.
The capillaries
It is at the level of these smallest vessels that the metabolic exchange occurs
between the blood and tissues
Overall capacity of capillary bed is so large that if all the capillaries open
simultaneously the blood will accumulate in the tissues and circulation will fail
Flow into the capillaries is controlled by the pre- and post-capillary sphincters.
When they are constricted the blood flow by-passes the capillary bed and flows
through short arterio-venous channels
Circulatory failure becomes “Irreversible” when the tone of pre-capillary
sphincter is lost while the post-capillary sphincter remains constricted, so that
stagnant blood accumulate in the anoxic leaking capillary bed
Unlike arteries and veins, where there is primary autonomic control, local
physical and chemical agents are predominantly responsible for the regulation
of the tone in the microvasculatur, e.g. heat and cold, adrenaline, etc.
Tachycardia
Tachycardia, more than anything else does more damage to heart and it has
to be prevented
An increase in heart rate above normal slowly encroaches upon the diastolic
time. As we know that the coronaries get filled in the first half of (phase of
isometric relaxation) diastole, the shortening of diastole means less time for
coronary filling and aggravation of ischemia
In ischemic heart disease patients it may induce infarction
When using a vasopressor if needed the choice of drug and the dose must be
such that it does not induce undue tachycardia.
Bradycardia
“Bradycardia is a forerunner of arrhythmias”:
A heart rate less than 60/min is bradycardia
Any rate less than 60/min is not ideal for maintaining normal cardiac output
and coronary perfusion
The increase in diastolic time helps in adequate ventricular filling thereby
stretching the muscles, in turn the force of contraction and the stroke volume
This increased stroke volume is not adequate to maintain the normal cardiac
output as the rate is low
Diastolic coronary filling will be better, but the end diastolic pressure is high
and that reduces the endocardial perfusion
Considering all these factors, the inference is that for maintaining optimum
cardiac function the heart rate has to be maintained from 60 to 70/min.
With all that understood by knowing the anatomy, physiology and pharmacology
related to heart, we come to know that to protect the heart in specific and the
cardiovascular system in general during anesthesia and postoperative period, the
following factors must be avoided meticulously:
Hypoxia
Hypercarbia
Hypotension
Tachycardia
Hypoglycemia.
Autonomic imbalance
Though this appears as simple five factors, it is not very easy and simple to achieve
the perfect anesthesia which avoids all these. However, if one strives hard with
continuous monitoring, it will be possible to achieve this and even the crippled
heart will be protected from further damage.
Chapter Recovery room:
13 Postanesthesia Care Unit
(PACU)
Chapter Outline
Postanesthesia Care
v
Recovery Room
v
Transport to Recovery Room
v
The Purpose of Recovery Room
v
Systems Mainly Affected during Recovery
v
Facts about a patient recovering from anesthesia
v
Recovery Criteria
v
Clinical Assessment of Adequacy of Reversal of NMB
v
Guidelines for Postanesthetic Recovery Care
v
Postanesthesia Care
Recovery from anesthesia is defined as the period from the cessation of the
administration of anesthesia until the patient is awake with protective reflexes.
Recovery from anesthesia is not a simple and uniform process. Every individual
patient presents with gross variations in that. The physical and physiological status
of the patient has the basic implication on this. Apart from that, the pathology
associated with various systems and the drug treatment instituted for correcting it,
the technique of anesthesia and the drugs used for that purpose, the duration of the
surgery and the amount of blood loss and so many other factors may modify the
recovery process. Incidentally, it is this variation that makes the recovery period
potentially more hazardous and vulnerable for dangers.
Anesthesia is usually compared to a flight of an aircraft, the induction is
considered as “take off”, the maintenance of anesthesia is “the actual flight in air”
and the recovery or emergence is “the landing”. More than 90% of the accidents
related to an aircraft occur during landing. Similarly 90% of the accidents related
to anesthesia occur during recovery indicating that it is the most vulnerable period
for mishaps.
In a study done in United Kingdom, analyzing the cause of postoperative deaths
that occurred during the period of 7 years from 1970 to 1977 (Medical Defense
Union. MDU), it has been proved that more than 50% of the deaths occurred in the
immediate postoperative period. Two other analyses done one in 1987 and another
in1990 (Confidential Enquiry into Perioperative Deaths CEPOD) indicate that more
than 80% of the postoperative deaths occurred in the first hour of postoperative
period and among them more than 75% were due to hypoventilation resulting from
Chapter 13 Recovery room: Postanesthesia Care Unit (PACU) 179
the residual effects of anesthetics and opioids or residual neuromuscular blocking
agents, rarely due to recurarisation. The CEPOD report described inadequate
recovery facilities in many hospitals in United Kingdom.
In a wider analysis of the facts about these deaths, it has been concluded that;
These deaths were preventable
Most of them occurred due to lack of care
In many cases there were no recovery rooms available at all
Many patients died during their transport from the theater to the postoperative
ward.
All these clearly indicate the importance and necessity for adequate and proper
postanesthetic care to prevent the problems and complications of the recovery
period, the worst catastrophe being death of the patient.
“One of the most illogical situations in present day anesthesia is the immense
amount of expert skill and care that is lavished upon the patient in the operating
theater, often only to be abruptly abandoned the moment the anesthetic is stopped”.
—WD Wylie
Though Wylie made this statement sometime in early 70s, the scenario has not
changed markedly over the years, particularly in Indian context.
History
1921—Facilities for postoperative care was advocated by AL Flemming,
President of Anesthetic Section, Medical Institute of Birmingham.
1942—In Mayo Clinic, John Silas. Lundy. Introduced a postoperative
observation room under his direction.
1955—In Southend Hospital. UK, the first postoperative observation room
(recovery ward) was instituted.
Now the terminology is variably used. “Recovery Room”, “Recovery Area”,
“Postoperative Care Unit” and “Postanesthetic Care Unit” (PACU) all carry the
same meaning.
Recovery Room
It is an integral part of an operating suit.
This is a setup located in the near vicinity of operating theater, preferably
in the clean area of the theater complex where adequate facilities with regard to
infrastructure, equipments and efficient well trained nursing staff are available to
give specialized nursing care and support for the patient in the immediate post-
operative period, who mostly require this type of care for varying periods from a
few minutes to a few hours and rarely for 24 hours.
This must be in the operating suit for the anesthesiologist to have a close
observation of the patient as frequently as needed.
The responsibility of the patient’s welfare here remains with the anesthesiologist.
“Probably the safest place for the patient to recover from anesthia is the operating
theater itself, since all necessary equipments and drugs are closeby for access in
the event of any mishap.” — Michael B Dobson
180 Surgeons and Anesthesia
Cardiovascular System
Hypotension may be present
Residual effect of anesthetic drugs may cause reduction in peripheral resistance
and cardiac output particularly in the absence of surgical stimuli
Hypovolemia may be present because of inadequate fluid and blood replacement
during surgery or due to continuous bleeding
Hypertension may be manifested due to various factors. Increased sympathoad-
renal response after recovery or due to inadequate analgesia and severe pain.
Respiratory System
Hypoventilation may occur very commonly
Residual effect of volatile anesthetic agents as well as opioids may cause severe
respiratory depression
182 Surgeons and Anesthesia
Identifying obstruction
A patient with a clear airway breathes very effortlessly and there will be no
noise during breathing
If the airway is partially obstructed, there is usually noise during breathing
If the airway is completely obstructed, then there is absolutely no sound
Very loud snore with apparently regular breathing also indicates respiratory
obstruction
Observation of movement of the patient’s chest and abdomen invariably give
an idea of cause of obstruction
The characteristic “paradoxical respiration” could be observed, where during
inspiration as no air enters the lungs, the chest wall is drawn inwards and the
abdomen protrudes out because the diaphragm contracts. The reverse occurs
during expiration without any air movement.
Quickly the patient becomes cyanosed. The airway has to be restored
immediately to prevent hypoxic brain damage.
Recovery position
The patient may be turned onto ‘recovery position’ which takes care of airway and
drainage of secretions. It is turning the patient onto his side with the head and neck
extended and one of the knees pulled up to prevent him falling onto his face. The
patient may be retained in that position till he is able to maintain his airway well.
a b
Figs 13.1A and B: The common mechanism of airway block and relieving it
• Note the relaxed mandible and tongue sitting on the posterior pharyngeal wall blocking the airway
• After removing the pillow, extension of the head and tilting the chin upwards makes the airway
patent
a b
Figs 13.2A and B: Jaw thrust and chin up postion for keeping airway patent
184 Surgeons and Anesthesia
This recovery position is best suited for both transport as well as for nursing during
recovery unless there is objection for keeping the patient in this position for surgical
reasons (Fig. 13.3).
Artificial Airways
If muscle power and reflexes have not recovered during this time, manually
maintaining the airway like this may be difficult. Now the right size Guedel’s
airway (Fig.13.4) may be inserted properly in the oral cavity and simple lifting
of chin will maintain the airway (Fig.13.5).
Alternatively ‘Berman’s Airway’ which is very similar in shape may also be
used (Fig.13.6).
It must extend from the lips to the angle of mandible.
Sometimes the patient may not tolerate the oropharyngeal airway (Guedel’s
airway). Then forcing that in position may induce vomiting. Now a
nasopharyngeal airway well lubricated with local anesthetic jelly can be
passed through the widest nasal cavity and left near the glottis by carefully
listening to the breath sounds at the proximal end of the airway and fixed in
that position (Fig.13.7).
Carefully clearing the oropharyngeal secretions by using suction with adequate
power will keep things under control. Electrically operated suction is usually
available in all postoperative wards. Foot operated suction may be an effective
tool to be carried anywhere (Fig.13.8).
If all these efforts fail to maintain the airway patent, the next option without
causing further delay must be intubating the patient with a proper size cuffed
endotracheal tube and observe him in the recovery room till he is able to
maintain his airway (Fig.13.9).
a b
c d
Figs 13.4A to D: Different Guedel’s airways and assessing the right size for the patient
a b
Figs 13.5A and B: Method of inserting a Guedel’s airway and maintaining the patency
a b c
a b
Recovery Criteria
These are criteria to certify that the patient has recovered adequately from the effects
of anesthesia and surgery and is fit to be transferred to the postoperative ward.
Different authorities have proposed different recovery criteria to be fulfilled
before sending a patient to postoperative ward. Some of them quote even twenty
criteria particularly for day care set up. But unfortunately not all of the proposed
criteria are foolproof and reliable. Moreover, many of the criteria are practically
difficult to test. However every institution must have their own recovery criteria
scientifically formulated depending upon their work load as well as the availability
of personnel and equipments. If the recovery criteria are not fulfilled before sending
the patient to the postoperative ward, then there is every chance that the patient is
exposed to an unjustified risk of the two most common life threatening recovery
problems namely, respiratory inadequacy and cardiovascular depression. So the
main concentration in the postanesthetic recovery is pointed towards these two.
Taking all of these into consideration and putting all that proposed criteria in
a nutshell, the following five recovery criteria may be considered practical, ideal
and reliable. They are:
1. The patient must be fully awake.
2. He must be well oriented.
3. He must not be suffering severe pain.
4. His protective reflexes must have recovered fully and are active. Particularly
cough reflex and deglutition reflex must be active enough to protect his airway.
5. Residual neuromuscular blockade must have been fully reversed.
1. The patient must be fully awake: Patient must be awake or in quiet sleep,
could be aroused with verbal command of conversational volume of voice. Too
drowsy or unconscious patient should never be sent to postoperative ward.
2. He must be well oriented: This is tested by various methods advocated by
various authorities but ideally if the patient is able to tell his name, his profession
and the name of his relative who accompanied him to the hospital, etc., it is
acceptable. This information could be easily gathered from the patient just
before induction or when he is in the preoperative waiting room.
3. He must not be suffering severe pain: Suffering from severe pain may increase
the restlessness and muscular activity along with moderate hypertension
and tachycardia. All these increase O2 demand in general and particularly to
myocardium that may be detrimental to patients with ischemic heart disease.
Such patients must be given adequate analgesic in recovery room by intravenous
route with small increments and titrated for desired response and relief.
–– Mild pain where the patient is comfortable and when left alone going into
sleep is acceptable.
4. His protective reflexes must have recovered and active: Particularly cough reflex
and deglutition reflex must be active enough to protect his airway.
–– Even if vomiting occurs, the patient may be able to protect the airway to a
greater extent than a patient with depressed reflexes.
5. Residual neuromuscular blockade must have been fully reversed: This could
be essentially checked with the help of a peripheral nerve stimulator to be sure
Chapter 13 Recovery room: Postanesthesia Care Unit (PACU) 189
that it is more than 80%. Ideally a TOF ratio of 0.8 is considered adequate.
Even this is questioned by some authorities on the grounds that the response
of respiratory muscles for nerve stimulation is different from that of the other
skeletal muscles.
There are many places where a peripheral nerve stimulator may not be readily
available at hand. Even in these circumstances, it is essential to assess the adequacy
of reversal of residual NMB. There are clinical tests that can be used to assess the
adequacy of reversal.
For example, if the patient is not able to open his eyes either due to depression
by opioids or due to residual neuromuscular blockade, it is meaningless to proceed
further with the other tests. It is essential to carefully observe the patient and give the
necessary support till the patient recovers to the level suitable for doing these tests.
The six tests are:
Ability to open the eyes and look up continuously for more than 7 seconds
Ability of sharp protrusion of tongue out of mouth
Ability to close the mouth and swallow
Ability to cough effectively on command
Ability to take the hand from the side of the body to reach the nose, touch with
the index finger and then go back to the original position. Some authors have
put this test as—the ability to raise the hand and touch the opposite shoulder.
Ability to raise the head off the pillow and sustain it for more than 5 seconds.
1. Ability to open the eyes and look up continuously for more than 7 seconds:
This indicates the recovery of levator palpabre superioris muscle which is the
elevator of upper eyelid. This muscle is affected very early with the lowest dose
of non-depolarizing relaxants before any other muscle gets affected. This is
correlated well as the earliest clinical sign noted in Myasthenia Gravis. If this
muscle has recovered, it is reasonably accepted that the other muscle would
have recovered adequately.
The limitation of this test is, if the patient is too drowsy and couldn’t be
commanded, he may not open the eyes even when the muscles have recovered
well.
2. Ability of protrusion of tongue out of mouth: Protrusion of the tongue out
of mouth essentially needs both the intrinsic muscles and extrinsic muscles
of tongue in full power. If the tip of the tongue looks sharp and the surface
shows longitudinal grooves on it, that indicates the full recovery of intrinsic
muscles. If almost half of the tongue comes out of mouth that indicates that the
extrinsic muscles have also recovered fully. Recovery of these muscles has the
significance that they take part in the first step of deglutition.
3. Ability to close the mouth and swallow: Closing the mouth basically needs
effective contraction of two muscles.
One is masseter—one of the very strong muscle. This has the power of crushing
a hard nut kept between the teeth. Closing the mouth by bringing the mandible
up towards the maxilla needs less than 1/10 of its power. So if the patient is
having a relaxed mandible, possibly his level of neuromuscular recovery is
very poor. But here again if the patient is too drowsy mandible may be seen
relaxed.
The second muscle is “orbicularis oris”. This is one of the muscles of facial
expressions, a subcutaneous muscle without any bony attachments and is known
as the sphincter of mouth. This slender muscle only when fully recovered can
contract to close the mouth. If a patient is able to close the mouth and swallow,
it means the muscles of deglutition have recovered well and if the delicate
muscle orbicularis oris has recovered well it is reasonably correct to say that
the other muscles of body would have recovered fully well.
Chapter 13 Recovery room: Postanesthesia Care Unit (PACU) 191
4. Ability to cough effectively on command: Ability to cough indicates that the
intrinsic muscles of larynx have recovered well particularly the tensors of vocal
cord. Secondly effective cough needs the power of abdominal muscles (the
secondary muscles of respiration). This is a very good index of NM recovery.
5. Ability to take the hand from the side of the body to reach the nose, touch with
the index finger and then go back to the original position.
Some authors have put this test as—the ability to raise the hand and touch the
opposite shoulder.
Whatever way it is done, this is a very sophisticated test. This involves very
well coordinated, complicated movements of various groups of muscles starting
from trapezius, deltoid, flexors and extensors of elbow, flexors of digits and
intrinsic muscles of hand. Excellent coordination and balance of action among
all these muscles are required to do this and also a good degree of wakefulness
and orientation.
If a patient is able to do this successfully, it indicates that all groups of muscles
of upper limb have recovered fully and so also the muscles of other parts of the
body. This is a very sensitive test.
Sometimes the patient may be able to flex the elbow and try to touch the nose
but may not be able to go back to the original position by extending the elbow.
The explanation for this is; in upper limb the flexors are antigravity muscles
and are more powerful than the extensors. Even if there is 20% recovery in
flexors the patient may be able to flex the elbow and touch the nose, but as
the extensor (triceps) is a weak muscle, 20% recovery is not sufficient to do
the extension of elbow. So the recovery is inadequate, we have to observe the
patient for further recovery or give additional titrating dose of neostigmine as
the case may be.
6. Ability to raise the head off the pillow and sustain it for more than 5 seconds:
The interesting fact about this test is that almost all the scoring systems have
included it as one, because it is a very reliable indicator of adequate recovery.
It indicates TOF 0.85 or more. But this also has limitations as this maneuver
causes powerful contraction of the anterior abdominal muscles, particularly the
rectus abdominis. This should not be done in patients with abdominal incisions
more so with upper abdominal incisions as it may detrimentally affect the sutures
which may give way resulting in incisional hernia later. Incidentally, it increases
the pain and morbidity. So also it could not be done in head and neck surgeries.
It is generally accepted that if four out of six tests are positive strongly, the
recovery is excellent. These tests very well correlate with more than 80%
recovery proved by peripheral nerve stimulator.
If the cardiovascular system is stable as ascertained by a normal and stable BP
without fluctuations and normal volume, rate and rhythm of pulse, the major
problems related to anesthesia could be excluded.
Except bleeding all the other problems are basically related to anesthesia and
it is the responsibility of the anesthesiologist to manage them.
The real life threatening problems are related to respiratory and cardiovascular
systems.
Expectations
No patient is left uncared in the postoperative period
To keep them in a common place for giving them the required care
To look out for the common problems and complications, identify them
To manage the problems if encountered
To tackle the complication if any successfully
To be prepared for managing any eventualities.
Formulating Guidelines
The guidelines may be broadly classified into three heads. They are:
1. Infrastructure
–– Location and set up
–– Space allocation
–– Equipments
2. Staffing—personnel
3. Procedure—protocol.
1. Infrastructure
Location
Recovery room must be located in the clean area of the theater complex or
operating suit, as close to the operating room as possible which would permit the
following. Anesthesiologist must be able to accompany the patient to recovery
room and inspect him as and when required.
Chapter 13 Recovery room: Postanesthesia Care Unit (PACU) 193
Equipments:
The equipments required for a recovery unit may include monitors, resuscitation
equipments, supportive equipments such as warming devices, infusion pumps,
ventilators, etc.
Monitors for every bed
Pulse oximeter
Noninvasive BP
194 Surgeons and Anesthesia
ECG Monitor
Capnography—particularly when the patient is received in PACU in intubated
state.
For surgeries done for many hours in air conditioned theater particularly with
the abdominal viscera exposed and also in pediatric patients, hypothermia is a major
problem during recovery. These patients need to be actively warmed artificially by
using warming devices to prevent secondary complications due to hypothermia.
Similarly, there are occasions where a bigger pediatric patient with an infective
focus in a hot climate may develop hyperpyrexia that needs active cooling.
For hypothermic patients:
Temperature probe/thermometer
Forced air warming devices
Heating lamps
Thermo blankets warming/cooling.
2. Staffing (Personnel)
The effective functioning of a good recovery room service mainly depends on the
availability of adequate number of well trained, efficient, devoted nursing staff
to observe the patients closely, identify the problems immediately and institute
appropriate measures in time to prevent a catastrophic outcome.
Round-the-clock staffing is essential unless it is a day care unit
Nurses specially trained in special monitoring techniques and techniques like
intubation and ventilation are essential
A proper handing over and taking over protocol must be strictly followed by
the nurses in recovery room
The patient-nurse ratio varies according to the status of the patients
One for one patient: In “high dependency patient”
One for three patients: In “medium dependency patients”
One for four patients: In “low dependency patients”.
Chapter 13 Recovery room: Postanesthesia Care Unit (PACU) 195
3. Procedure Protocol
All patients must be handed over to the recovery nurse properly by the
anesthesiologist or the nurse who accompanies the patient with verbal transfer
of information about the patient’s status.
The level of consciousness, BP, pulse rate, respiration and the oxygen saturation
must be informed.
Any other special instruction regarding any support needed must be informed.
Wherever possible patient is nursed in “Recovery Position” unless contra-
indicated for surgical reasons. If needed a slight head down tilt with extension
of head and neck and one of the knees drawn up to prevent the patient rolling
onto the face are added.
Continuous monitoring is done to assess that the recovery is complete.
Assessment of recovery related to the central nervous system, respiratory system
and cardiovascular system must be done in order by the protocol to certify that
the patient may be transferred to the postoperative ward.
It must be ensured that the patient does not suffer severe pain. If he does, it
must be adequately relieved and patient observed for sufficient time before
sending to the ward.
If spinal opioids are used for postoperative analgesia, special care must be
given to them as it may produce ventilatory depression. Care in using parenteral
opioids is advised.
Special protocol for observing the surgical wound must be used. Without
observing the surgical wound patient should not be sent to the ward.
Ensure
The patient is fully awake—not too drowsy
Well oriented. He must be able to tell his name, profession, the relative who
accompanied him to the hospital, etc.
Comfortable and quiet—not restless (if restless , find out the cause and treat it)
Does not suffer from severe pain.
If the patient suffers severe pain, suitable analgesic is given by IV route in
small increments till the desired pain relief is achieved. Usually, when the pain is
relieved almost completely, the patient may manifest respiratory depression caused
by opioids. (Pain is the physiological antagonist for the respiratory depression
caused by opioids.) There is a potential danger of the patient developing severe
respiratory depression or even apnea. So such patients are observed in the recovery
room for sufficient time to ensure that the respiration is not depressed.
Conclusion
All patients must pass through the “Recovery Room” irrespective of the type
of anesthesia or surgery
No unconscious patient should be sent to the postoperative ward
Proper protocol and care in PACU will prevent mortality and minimize
morbidity.
Further Reading
1. Andrade J, et al. Consciousness and Cognition,1994;3:148.
2. Association of Anaesthetists of Great Britain and Ireland. Immediate Postanaesthetic
Recovery. AAGBI. London, 1993.
3. Buck N, et al. Report of the Confidential Enquiry into Perioperative Deaths. London:
Nuffield Provicial HospitalsTrust and the Kings Fund for Hospitals, 1987.
4. Cedric Prys-Roberts, Burnell R. Brown Jr. International Practice of Anaesthesia.
Volume-I Butterworth. Meinman, 1996;53:1–11.
Chapter 13 Recovery room: Postanesthesia Care Unit (PACU) 197
5. Cooper GM. Monitoring the recovery from Anesthesia: Monitoring in Anaesthesia and
Intensive Care. In: Hutton P and Prys Roberts C (Eds). Saunders, London, 1994;350 –64.
6. Crosby DL, Rees GAD Ann, Crosby DL, et al. Royal College of Surgeons. England.
1983;65:391; Ann. Royal College of Surgeons. England. 1990;72:309.
7. Department of Health and Social Security, Operating department. Health Building Note
26. HMSO, London, 1975.
8. Frost EAM, Thomson DA. Post-Anaesthetic Care. Bailliere’s Clinical Anaesthesiology,
London, 1994,
9. Hatfield A, Tronson M. The Complete Recovery Room Book. Oxford University Press.
Oxford, 1996.
10. Moller JT, et al. Anaesthesiology, 1990;73:890.
11. Pharmacology of Muscle Relaxants and Their Antagonists. Miller 5th Ed. and 7th Ed.
12. Smith G, Power I. Anaesthesia, 1998;53:521–2.
13. Standards for Post Anaesthesia Care. American Society of Anaesthesiologists, 1988.
14. The High Dependency Unit. London: Association of Anaesthetists, 1991.
Chapter
Local Anesthetic Drugs and
14 Regional anesthesia
Chapter Outline
Definition of Regional Anesthesia
v
Pharmacology of Local Anesthetics
v
Structure Pharmacological Relationship
v
Mechanism of Action
v
Xylocaine
v
Bupivacaine
v
Toxicity Reactions of Local Anesthetics
v
Techniques or Regional Anesthesia
v
This group contributes for the local analgesic This group is usually available as water
action. As it has high affinity for lipoproteins. soluble salt such as hydrochloride. This
The cell membrane of the neurons or axons makes the local analgesics available as a
of the nerves which is made mainly of water soluble crystal.
lipoproteins, take up the drugs by absorption
on the membrane. The membrane becomes
stabilised—depolarisation is prevented and
conduction of impulse beyond this point is
not possible.
200 Surgeons and Anesthesia
Mechanism of action
These drugs cause “membrane stabilization” —by preventing ionic exchange
between inside and outside of the membrane of the axons. This means depolarization
and repolarization of that area of the membrane is not possible. So no conduction
occurs beyond that point.
Based on the structure, mainly the link or the chain, the drugs are classified as
‘ester linked’ or ‘amide linked’.
1. Ester linked local Analgesics: (No longer in use now)
For example: Cocaine, procaine .
Disadvantages
Toxic drugs—Narrow safety margin
More prone to cause anaphylaxis
very unstable as solution
Degraded by hydrolysis.
Advantages
Less toxic—wide margin of safety
less chances for anaphylaxis—very rare
Detoxified by oxidative de-alkylation in the liver
Can be autoclaved many times without loss of potency
Addition of adrenaline causes local vasoconstriction and prolong the duration
of action.
because of the delay in absorption blood level rises slowly. So, the dose also
can be increased.
Xylocaine
(1947 lidocaine or lignocaine—an amide linked drug)
Colorless crystalline salt available as hydrochloride dissolved in water.
Dose : 3 mg/kg body wt
7 mg/kg body wt—if adrenaline is used for local vasoconstric
tion and prolongation of action
Duration of action : 1 hour—1 hour 30 minutes
With adrenaline : Up to 2 hours
Availability
5% Xylocaine with dextrose 2 ml ampoule. (Xylocaine heavy) Sp. Gr. is around
1024–1035. The Sp. Gr. is higher than that of CSF—for spinal analgesia.
2% Xylocaine plain—for nerve blocks, local infiltration, etc.
can be diluted to 1.5%, 1%, 0.5% or 0.25%.
Chapter 14 Local Anesthetic Drugs and Regional anesthesia 201
2% Xylocaine with adrenaline 1 in 200,000 concentration
can be diluted as 1%, 0.5% or 0.25%, for local infiltration.
2% Xylocaine without preservative for iv use.
To prevent or to treat cardiac arrhythmia.
4% Xylocaine solution (pink color added to differentiate).
For spraying or packing the mucous membranes.
10% Xylocaine solution in sealed container with calibrated dose delivery device
and sprout. Each time spray delivers 10 mg.
4% Xylocaine viscous with hydroxymethyl cellulose.
For use on mucous membrane of mouth, esophagus and stomach.
For esophagogastroduodenoscopy.
5% Xylocaine ointment with paraffin base.
For use in mucocutaneous junction, as in anal orifice.
2% Xylocaine jelly in carboxymethyl cellulose as the base. It is water miscible,
for use in mucous membranes of nose, trachea.
Can be used on endotracheal tube or on urethra—for dilatation.
Bupivacaine
Amide linked drug introduced in 1963
Longer duration of action due to very high lipophillic nature.
Duration of action 3 to 6 hours
Dose 2 mg/kg body weight
Availability 0.25% and 0.5% for nerve blocks and infiltration block
0.5% solution with dextrose (heavy) for spinal
More toxic than Xylocaine
Addition of adrenaline does not increase the duration of action.
Manifestations of toxicity
Mainly affects two systems, central nervous system and cardiovascular system.
Manifestations
Slight disorientation
Drowsiness
Incoherent talk
Circum oral numbness
Twitching of facial muscles.
muscles of facial expression, mainly orbicularis oris and orbicularis oculi are
involved.
At this moment the following steps may be helpful:
Increasing the flow rate of iv fluids that dilutes the concentration of the drug
and reduce the blood level
Administration of 100% O2 with a mask may reduce the irritability of neurons
and protect the brain and thereby abort the toxic manifestation
Without warning, the patient may throw convulsions suddenly
Now the management is to paralyse the patient with 50 mg of suxamethonium
and continue 100% O2 by IPPV usually the patient recovers well and by the
time the blood level also falls
Chapter 14 Local Anesthetic Drugs and Regional anesthesia 203
If the convulsions recur even after this, the dose of suxamethonium may be
repeated to continue the paralysis at the same time IPPV is continued with
100% O2.
Cardiovascular System
It will be only over all depression of CVS. conduction system is depressed.
Bradycardia and hypotension are the manifestation. Usually it is not very significant,
but with bupivacaine CVS toxicity may be significant, with cardiovascular collapse.
With suitable technique these nerves can be blocked either in the subarachnoid
space or in the epidural space. These two blocks—‘Subarachnoid’ and ‘Epidural’
are known as Central Neural block.
The nerves may be blocked as soon as they leave the spinal cord as anterior
and posterior spinal roots and lie within the subarachnoid space, bathed by CSF.
This is called as Spinal anesthesia or Subarachnoid block.
These nerve roots join together to form the mixed spinal nerves, before entering
the intervertebral foramen. In that process these nerves cross the two layers of dura
for a very short distance. These nerves could be blocked at this point by depositing
local anesthetics there in between the two layers of dura. This is called as Epidural
block.
Spinal anesthesia and Epidural anesthesia are together known as Central Neural
Block.
with 8 to 10% dextrose to make it heavy (hyperbaric). Experience shows that the
technique is safe in expert hands. In addition, there is better understanding about
the effects of the injected solutions in terms of both physiological and potential
toxic effects. For example, review of the Woolley and Roe case in the light of
modern understanding shows that it is unlikely that the phenol was the cause for
the paralysis. Therapeutic injection of phenol for chronic pain, does not give rise
to the same clinical picture. A much more likely explanation is that the apparatus
used was sterilized by boiling in a sterilizer that had been contaminated with acid
substances used to prevent scale formation.
(Anesthesia et al; February 2001, series 8.1, from Eureka Alert: www.eureka alert.org.)
Anatomy
The vertebral column consists of 7 cervical, 12 thoracic, 5 lumbar, 5 sacral and 4
or 5 coccygeal vertebrae. The sacral and coccygeal vertebrae are fused in adult life.
The spinal column has four curves of which the thoracic curve and sacral curves are
primary and are concave anteriorly. The cervical and lumbar curves have convexity
forward, and so when the spine is fully flexed, the cervical and lumbar curves are
obliterated. In supine position the 3rd lumbar vertebra marks the highest point of
lumbar curve whereas the 5th thoracic vertebra is the lowest point of the curve.
These curves have practical significance, particularly when the highest level
of spinal block is concerned. Immediately after spinal block the lumbar curve will
become almost flat and straight whereas the thoracic curve will be straightened only
Fig. 14.1: Sagittal section of spinal column showing the various structures
passed by the needle
Chapter 14 Local Anesthetic Drugs and Regional anesthesia 207
minimally because of the limitation caused by the bony thoracic cage. Altogether
considering these changes that occur after changing the position of the patient to
supine, the probable level of blockade could be assessed.
Any anatomical deformity such as Kyphosis, Scoliosis, etc. will make the
lumbar puncture difficult. The direction of the spinous process determines the
direction in which the spinal needle must be inserted. The spinous process of the
cervical, the first two thoracic and the last four lumbar vertebrae are all practically
horizontal and therefore opposite the bodies of their respective vertebra. Other
spines are inclined downwards and their tip opposite to the bodies of the vertebrae
next below. The first lumbar spine is opposite to intervertebral disc. The fifth
lumbar spine over hangs the lumbosacral interspace. The interesting fact is, that
the interlaminar space in this level in the widest (lumbosacral interspace). So in a
difficult spinal tap a trial in this level may be successful.
The various anatomical structures of spinal column as seen in a sagittal section
are shown in Figure 14.1. The structures encountered by the needle to reach the
epidural space or sub-arachnoid space could also be seen in the figure.
Palpable bony land marks used for spinal and epidural block:
The spinous process of 7th cervical vertebra is prominent and easily palpable
The tip of the spine of T3 is opposite to the roots of the spines of scapulae with
arms at the sides of the body
The T7 Spine is opposite to the inferior angle of scapula
A line joining the highest point of both iliac crests is at the level of L4 or
L4–L5 interspace.
Clinically significant Anatomical points:
The spinal cord ends at the level of lower border of L1
The dural sac ends at the level of lower border of S 2
The dural sac below the level of L1 is filled with CSF that contains cauda equina
and filum terminale interna.
Lumbar Puncture
It is the procedure of passing a long fine needle through an interspinous space in
lumbar region below the level of L2 to reach the subarachnoid space of the dural
sac so that CSF can be drained or drugs may be deposited inside the sac.
Lumbar puncture can be performed in any interspinous space between L2 and
L4, when the patient is kept in right lateral position with well flexed spinal column
on a horizontal surface.
Local analgesic deposited by passing a long fine needle through an interspinous
space below L2 (so that the spinal cord is not damaged by the needle) into the dural
sac.
The local analgesic solution, which is heavy, (meaning thereby has specific
gravity higher than that of CSF) settles where it is injected. The CSF containing the
local anesthetic bathes the spinal nerves passing through the point. High lipophilic
nature of the drug causes immediate and rapid absorption of the drug into the
nerve fibers and cause conduction block, effectively causing anesthesia of the area
supplied by these nerves and below that level.
208 Surgeons and Anesthesia
The Drugs
Xylocaine 5% with 7.5% dextrose for making it heavy 2 ml ampoules
Bupivacaine 0.5% with 8.5% dextrose 4 ml ampoules
Addition of dextrose makes the solution ‘Heavy’ or ‘Hyperbaric’. (Sp Gr 1035
to 45).
When the patient is turned supine, the solution being “Heavy” settles in the
site of injection backwards (posterior) and acts more on the posterior nerve roots
and prevents the higher spread by rapid diffusion.
with a sterile three tail towel and tied over the abdominal wall to prevent further
contamination. Lesser area than this is not acceptable on technical reasons.
The anesthesiologist must scrub up and wash the hands scrupulously without
any flaw. No compromise shall be accepted in this step. Wearing a sterile gown
and gloves must be followed as for any surgery.
Absolute aseptic care is taken in laying a table for spinal anesthesia. Usually
for every case a separate table with all the required equipments is advisable.
However, in bigger institutions, where many spinal anesthesia are to be given in
one operating session, a suitably planned table with multiple sets of equipments
arranged properly to prevent cross contamination of the table from the patients
may be accepted provided proper protocol is followed very meticulously.
These smaller details are commonly ignored and leads onto complications and
sometimes fatal outcome.
Order of blockade
Local anesthetics are taken up by absorption onto the spinal roots only and very
little is absorbed on the spinal cord
Membrane stabilization inhibits action potential at the nodes of Ranvier
At least 3 nodes must be blocked for complete interruption of impulses
50% less concentration of the drug is needed to block A δ fibers (pain and
temperature) than A γ (motor and proprioception)
Sympathetic block is 2–3 segments higher than the sensory block
Muscle tone is abolished even if the A γ fibers are not affected, because the
reflex arc is broken by blockade of afferents.
It is interesting to note that the order of blockade is related to the diameter and
myelination of the nerve fiber. The finer nerve gets blocked first. Hence, the order
is as follows;
Autonomic
Temperature (cold before warmth)
Pin prick pain (sharp pain)
Pain greater than pin prick
Touch
Deep pressure
Motor fibers
Vibration
Proprioception.
Recovery
The recovery is in the reverse order. However, the sympathetic returns before
sensation. This is clinically significant. Though autonomic fibers are blocked by
the lowest concentration of drug, the blockade is short lived. Otherwise there is a
possibility of a longer duration of hypotension.
When can a patient walk after spinal?
This is a question based on the understanding of the physiology of spinal anesthesia.
It is not advisable to allow a patient to walk for at least for 24 hours for various
reasons of safety. However, the answer for this question is; when the patient has
Chapter 14 Local Anesthetic Drugs and Regional anesthesia 211
all his spinal reflexes recovered fully, he may be permitted to walk. This can be
assessed by the following parameters;
Presence of sensation around anus
Patient has no hypotension (no postural variation also)
Strong plantar extensor
Presence of proprioception of great toe.
Spinal Hypotension
The management of hypotension occurring during central neural block is a subject
of debate for over many decades. Unfortunately, in olden days this hypotension
was named as “Spinal shock” which is a misnomer and is no longer in use today.
Proponents for the use of either volume loading or vasopressors are expressing
212 Surgeons and Anesthesia
dogmatic views. Neither of the two is the real answer for the problem. Hypotension
is a manifestation where in the background there are numerous factors. Hence, it
is essential to understand them to have a scientific approach to it.
It is important not to be too specific in the approach to this problem and to
treat each patient on individual merit, recognizing that many factors may influence
arterial pressure during anesthesia and surgery.
Organ perfusion
It is usual to find every one worrying too much about a fall of BP. A normal BP does
not guarantee that everything is fine. Similarly a fall in BP is many times benign and
Chapter 14 Local Anesthetic Drugs and Regional anesthesia 213
is not always an indication of a disaster. We have to remember that hypotension by
itself does not kill any one. In fact, during a very deep sleep, a healthy individual
continues to have a systolic BP of 80 mm of Hg for many hours.
We are measuring the arterial pressure and trying to adjust it to the desired level
(the level which we desire that the patient should have and not what is desirable for
the patient’s systems to function), but it is important to remember that the perfusion
of vital organs with adequate flow of blood is the vital factor. If the vital organs
are well perfused and oxygenated, the arterial pressure even if it is lower may not
harm the organs. Compensatory mechanisms ensure that the flow to the vital organs
is maintained over a wide range of pressures. This range of pressure in which the
perfusion of the vital organ is not affected and adequately maintained is known
as “autoregulation range” meaning thereby, beyond this range, this protection is
lost and the perfusion is either reduced or increased depending upon the pressure.
This is the “Autoregulation” which may be under the influence of “Myogenic or
Chemical” control.
Cerebral circulation
Cerebral blood vessels are devoid of sympathetic nerve supply. Autoregulation
flow occurs between 50 mm and 180 mm Hg by reflex arteriolar constriction in
hypertension or vasodilatation in hypotension. Thus normal cerebral perfusion
is maintained until mean arterial pressure is less than 50 mm Hg. As we know
that the mean arterial pressure is the product of diastolic pressure + 1/3 of pulse
pressure, the systolic pressure when MAP is 50 mm Hg is very much lower
indicating that perfusion will not be significantly affected unless there are other
factors like severe hypovolemia coexisting. At such a pressure, ischemia occurs,
leading to local hypercapnia and hypoxia, both of which stimulate the vasomotor
center chemically to increase sympathetic tone and systemic vascular resistance
in an attempt to restore arterial pressure.
It is emphasized here only to make it clear that arterial pressure alone is not
the factor that maintains the cerebral well being and worrying unduly about BP
and ignoring the other vital aspects like blood volume and oxygen saturation will
not do good to the patient.
Coronary circulation
Coronary blood flow is autoregulated between 60 mm and 150 mm Hg. If coronary
perfusion pressure decreases, the myocardium becomes relatively hypoxic and ADP
accumulates. This is converted onto adenosine, a potent coronary vasodilator,
which restores local blood flow. A decrease in arterial pressure results in decreased
left ventricular work and oxygen demand. Therefore hypotension may have a
benign effect unless there is concomitant tachycardia or a significant pressure
gradient across the aortic valve, both of which impair coronary filling during
diastole.
Hence, if a normal healthy individual has hypotension after spinal anesthesia
without respiratory depression and hypoxia and has a normal heart rate,
indicates that the cardiovascular system is absolutely stable without the need for
compensation.
214 Surgeons and Anesthesia
Renal perfusion
Renal autoregulation occurs between 80 mm and 180 mm Hg. The afferent
glomerular arteriole has a myogenic response to stretch and constricts with
hypertension and dilates with hypotension to maintain a constant renal perfusion
pressure. This can be overridden by the sympathetic innervation of kidney. A
small decrease in arterial pressure produces sympathetic stimulation and causes
vasoconstriction of the efferent arteriole to maintain filtration pressure in the
glomerulus in the presence of decreased renal blood flow.
A marked decrease in arterial pressure and more intense sympathetic stimulation
results in constriction of the afferent arteriole and a decrease in both renal blood
flow and glomerular filtration. In clinical practice, glomerular filtration rate is
reduced only to a smaller extent (10%) during central neural block and this is not
enough to cause significant impairment of normal renal function.
All these indicate that the orientation of hypotension should be based on its
effects on central neural or circulatory system.
Vasopressors
Prophylactic use of vasopressors has no scientific basis. In addition, IM injections
produce unpredictable absorption and peak levels. Large bolus doses may cause unac-
ceptable hypertension. When to use the vasopressors? This question is to be answered
based on the clinical situations. There are many vasopressors in use, but in our country
only a few drugs are in common use. They are ephedrine and mephentermine.
Ephedrine
Ephedrine was used first in 1927 to counteract hypotension caused by spinal
anesthesia
Most commonly used vasopressor. It has direct and indirect mechanisms of
action and stimulates both alpha and beta receptors to increase cardiac output,
heart rate, systolic and diastolic arterial pressure
Coronary, cerebral and muscle blood flow are increased, while renal and
splanchnic blood flows are decreased
It can be used in small increments of 3–6 mg and depending upon the response
titration may be done
In larger doses it may be causing side effects like tachycardia, anxiety, central
stimulation, tremors, etc.
Mephentermine
It has direct and indirect sympathomimetic actions which increase cardiac
contraction and venous tone and hence increase the arterial pressure.
This drug may be used in increments of 3–6 mg and titrated till desired level
is achieved.
Just for completion drugs such as dopamine, dobutamine and adrenaline have
to be mentioned though they are very rarely indicated in the management of spinal
hypotension.
In the management of spinal hypotension, the following important points have
to be remembered.
Spinal hypotension as such very rarely kills anyone, but the associated factors
and complication only cause major damage.
Preoperative dehydration should be corrected before attempting spinal
anesthesia wherever possible.
Preloading with fluids may not have many benefits.
The disparity between the vascular volume and the vascular capacity can be very
easily combated by giving the fluid infusion a little fast during initial period.
It is essential to administer 100% oxygen and rapid infusion of fluids along
with other measures when a patient develops hypotension.
When a patient under the effects of premedication with a CNS depressant drug
develops hypotension, reduction of blood flow to the vital centers like respiratory
center and vasomotor center occurs. This will depress these vital centers further
resulting in aggravation of hypoxia and vasodilatation. This perpetuates a vicious
cycle to cause serious hypotension. Administration of 100% oxygen through a
mask to corrects hypoxia of vasomotor and respiratory centers and breaks the
cycle easily. Rapid infusion of fluids corrects the volume disparity.
Chapter 14 Local Anesthetic Drugs and Regional anesthesia 217
The degree of fall is less important but the rate of fall is more significant.
A healthy patient who has developed a fall from a systolic BP of 120 mm Hg
to 80 mm Hg. over a period of 30 minutes has good compensation and does
not require aggressive management.
Whereas a similar patient develops fall from 120 mm Hg to 80 mm Hg within
the first 10 minutes indicates that his compensations are inadequate and are
likely to fail soon. He requires aggressive management.
When the BP drops below the permissible limit, give small increments of a
vasopressor, repeat if needed to titrate to the desired effect.
The decision on what degree of hypotension requires treatment can be made
only for individual patients, but there are few who cannot tolerate a decrease
of 25–30% quite safely.
An example
Think about the following clinical situation and analyze that.
An educated healthy young man of 28 years, weighing 60 kg, and belonging to
ASA Gr I, is posted for undergoing inguinal hernia repair. Preoperative counseling
by the anesthesiologist was done with clarification of his doubts and answers for his
questions about anesthesia. He was given a premedication of injection pentazocine
30 mg along with injection atropine sulphate 0.6 mg IM 45 minutes before the
proposed anesthesia.
On the operation table, he was found to be cheerful and cooperative. The BP
recorded was 120/70 mm Hg and the pulse rate was 84/min. The spinal anesthesia
was performed on the horizontal table with the patient on right lateral position.
Using a 27 G disposable spinal needle 3 ml of 0.5% bupivacaine heavy solution
was injected slowly into the subarachnoid space through the L3 – L4 interface
and the patient turned to supine position without causing undue turbulence. An
IV line was secured and dextrose with normal saline infused relatively at a faster
speed so that 250 ml of solution is infused in first 10 minutes and then the rate is
slowed down. Pulse oximeter and sphygmomanometer were connected. Sp O2 was
continuously 96–97%. The level of block was T10 as assessed after 5 minutes.
After 5 minutes the surgeon started painting the area of surgery after informing
the patient that he will feel the touch but will not have pain. Now the anesthesiologist
is communicating with the patient and patient says he is comfortable. The BP was
checked and was recorded as 110/70 mm Hg. The pulse rate was 80/min with a
very good volume. The dorsal veins on the hand appeared reasonably well filled
indicating that the volume status was good.
By the end of 10 minutes the BP was checked and was 100/70 mm Hg. Pulse
rate was 82/min with the same good volume. Respiratory rate was 14–16/min all
along. Patient was asked to put out his tongue and it was moist and pink. At this
time injection midazolam 2 mg IV was given slowly which made the patient sleep
in two minutes. With the patient in good sleep, by now it was 15 minutes, the
parameters were checked; BP 90/60 mm Hg, pulse 84/min with the same volume,
respiratory rate 14/min. The head was turned a little to the side and chin-up. No
airway obstruction could be noticed.
Patient continued to sleep quietly and the parameters continued to be the same
with the oxygen saturation of 97 and a systolic BP of 90 mm Hg. The patient was
218 Surgeons and Anesthesia
not disturbed but was closely monitored. After 30 minutes the BP started rising
94 mm Hg and by 45 minutes it was 100 mm Hg. When the surgery was over by
about an hour the patient was aroused and he woke up with a pleasant smile. By
this time the second pint of fluid was on flow half way.
With a BP of 110/70 mm Hg, pulse rate of 98/min and oxygen saturation of
97%, the patient was shifted to recovery room, retained there for one hour for
observation and then transferred to postoperative ward.
Obviously this patient has not been given any support for cardiovascular
system as the hypotension was slow in onset over 30 minutes and the compensation
appeared adequate as proved by no changes in other parameters and no further fall.
Clinically the patient was comfortable with pink moist tongue.
If we carefully analyse this status, the cardiovascular system is in an
unphysiological state with no vascular reflexs in the lower part of the body and so
with partially deprived reflex protection. But, if offers certain advantages to the
heart to enjoy, which does not happen in normal life.
The patient is lying quietly under good sedation with reduced metabolism and
lesser oxygen demand
The lower part of body has the vascular tree totally relaxed, offering almost
no resistance to flow
Upper part of the body the vascular tree is moderately relaxed due to a good
sedation
Altogether there is a gross reduction in the afterload of the heart leading onto
modest hypotension that is not likely to affect vital organ perfusion. Workload
and oxygen demand are considerably reduced and myocardium gets good
oxygen supply
As the patient is lying horizontally, the heart has no need for pumping blood
against gravity, reducing workload to heart
In horizontal position both the onward flow of blood into the arteries as well as
the venous return to the heart are not hampered, so no reduction in cardiac output
The heart rate was within normal range allowing adequate diastolic time for
coronary filling.
Considering these benefits due for the heart no effort was taken to counteract
the hypotension in this case. Incidentally this hypotension kept the field of surgery
relatively bloodless and so the surgeon had an advantage of operating more
comfortably.
Epidural Anesthesia
This is the technique of depositing the local anesthetic solution in appropriate
concentration and volume with or without adrenaline (1 in 200,000) in between
the two layers of dura, i.e. the investing layer and the periosteal layer so that the
mixed spinal nerve that crosses the epidural space before entering the intervertebral
foramen is acted upon by the local anesthetic to cause a conduction block.
The epidural space can be identified by various methods using various types
of indicators. But universally either loss of resistance technique or hanging drop
technique is used. If the patient is unconscious, the rapid injection of the cold
Chapter 14 Local Anesthetic Drugs and Regional anesthesia 219
solution into the extradural space is accompanied by an increase in rate and depth
of respiration (Durrans sign).
Sufficient volume of the solution has to be used to block the required number
of spinal nerves.
The mixed spinal nerve takes along with it a cuff of investing layer of dura
before entering the intervertebral foramen. So the local anesthetic has to penetrate
this dural cuff before acting on the nerve. This is the reason for the delay in the
onset of action of epidural anesthesia.
This causes slow onset of sympathetic blockade, so that the compensatory
mechanisms have adequate time to work, to prevent rapid fall of BP. Hence, in
epidural anesthesia the rate of fall is relatively slow and the degree of fall also is
less because of adequate compensation occurring during the delay.
The differences of this technique from spinal anesthesia are:
Low percentage of local anesthetic is needed. Usually 1.5% of xylocaine with
1 in 200,000 dilution is used
Large volume of solution is necessary to cover the required number of spinal
segments
This may cause accidental overdose unless one is not careful
Adrenaline can be added to the solution to increase the duration of anesthesia
by delaying the absorption. Incidentally with adrenaline the safe dose is
relatively higher.
Depending upon the region where the epidural injection is given, it is classified as:
Lumbar epidural
Caudal epidural (sacral epidural)
Thoracic epidural
Segmental epidural (only required segments are blocked selectively).
Drugs
Xylocaine 1.5% with adrenaline (1 in 200,000)
Bupivacaine 0.5 % (without adrenaline).
Advantages
Onset of hypotension is slow and relatively minimal
No chance of postspinal head ache
Continuous epidural can be used.
By passing fine graduated polyvinyl catheter into the epidural space and
after securing it repeated injections can be made to continue the anesthesia. This
technique is called as “Continuous Epidural”. This technique may be used for
prolonged surgeries and postoperative analgesia.
Total Spinal
A totally reversible dreaded complication of epidural anesthesia
Injection of large volume of local anesthetic accidentally into the subarachnoid
space causing complete blockade of all the spinal and sometimes the cranial
nerves.
Further Reading
1. Bannister J, McClure JH, Wildsmith JAW. Effect of glucose concentration on the
intrathecal spread of 0.5% Bupivacaine. British Journal of Anaesthesia, 1990;64:232–4.
2. Bilsback P, et al. Br J Anaesthesia, 1985;57:943.
3. Bromage PR. Epidural Analgesia. Philadelphia: Saunders, 1978.
4. Coe AJ, Revanas B. Is crystalloid preloading useful in spinal anesthesia in the elderly?
Anaesthesia, 1990;45:241–3.
5. Collins C, Gurug A. Anaesthesia for Caesarean section. Update in Anesthesia, 1998;
9:7–17.
6. Cook PR, Malmqvist LA, Bengtsson M, Tryggvason B, Lofstrom JB. Vagal and
sympathetic activity during spinal anesthesia. Acta Anaesthesiologica Scandinavica,
1990;34:271–5.
7. Covino BG. Cardiovasacular effect of spinal and epidural anesthesia. Regional
Anaesthesia, 1978;1:23–6.
8. Donadoni R, et al. Anesthesia, 1985;40:748.
9. Hemmingsen C, Poulson JA, Risbo A. Prophylactic ephedrine during spinal anesthesia:
Double blind study in patients in ASA groups I–III. British Journal of Anesthesia,
1989;63:340–2.
10. Hutter CDD. The Woolley and Roe Case: A reassessment. Anaesthesia, 1990;45:859 –64.
11. Labat G. Regional Anaesthesia. Philadelphia: WB Saunders, 1923:436–55.
12. Lee JA. A Synopsis of Anaesthesia, 11th Edn. London: Butterworth-Heinemann Ltd.,
1993;25:691–736.
13. Lee JA. A Synopsis of Anesthesia, (2nd Edn). Bristol: John Wright and Sons, 1950;
165.
14. Morgan M. The Woolley and Roe Case. Anaesthesia, 1995;50:162.
15. Morgan P. Spinal Anaesthesia in obstetrics (a review). Canadian Journal of Anaesthesia,
1995;42:1145–63.
16. Ngan Kee WD. Intrathecal pethidine: pharmacology and clinical applications.
Anaesthesia and Intensive Care, 1998;26:137–46.
17. Wildsmith JAW. Spinal anaesthesia—the second fifty years. History Anaesth Soc Pro,
1998;23:40–2.
18. Wright AD. Spinal analgesia with special reference to operations above the diaphragm.
Pro R Soc Med, 1931;24:613–20.
Chapter
Guidelines for Emergency
15 Abdominal Surgeries
A Clinical Approach
First of all the duration of the problem has to be known at least approximately.
It has a very high clinical relevance.
The anesthesiologist must examine a patient before taking up and anesthetizing
him.
For example, the presence of ‘board like rigidity’ of anterior abdominal wall in
an acute perforative peritonitis gives an idea that it is a recent problem whereas
after some hours the rigidity disappears and will be absent in established cases
of days old peritonitis.
Look for signs of septicemia.
Recognize hyperventilation. It is not the same and is different from tachypnea.
In mild acidosis sodium bicarbonate may not be needed. Adequate infusion of
fluids will improve the perfusion and correct it.
After starting the IV fluids periodically feel the pulse for its quality. A pulse oximeter
with a signal bar will be useful in the assessment of the improvement.
Carefully watch for urine output, if fresh urine drains it is a good sign.
Always think of giving an appropriate premedication for an emergency case
also.
Atropine should not be given to these patients intravenously. We must remember
that the perfusion to the salivary glands is almost totally cut off in severe
dehydration and these patient present with absolutely dry mouth.
Intravenous atropine even in normal patients immediately acts on the sinus to
cause tachycardia and it takes more than 20 minutes to have the effect on the
secretions of glands.
IV atropine creates a paradox. That is the drying effect is not immediate,
but the tachycardia is almost instantaneous. In a patient with cardiovascular
compromise and compensatory tachycardia already present, atropine causing
further tachycardia, which is hazardous. It increases the work load of heart as
well as reduces coronary filling by shortening the diastole.
IV premedication is only for relieving the pain. That has to be given by small
incremental titrated doses just to have adequate pain relief and not anything
more than that. Any further dose is likely to cause central depression and
respiratory inadequacy. The increments are given with minimum of 5 minutes
interval for the drug to have full effect on receptors (latent period).
Chapter
Postoperative
16 Nausea and Vomiting
Chapter Outline
Common Recovery Room Problems
v
Nausea, Vomiting, Retching and Regurgitation
v
Factors affecting PONV
v
Vomiting center, CTZ and the receptors
v
Comprehensive orientation of physiology and pathology
v
Pharmacology of antiemetics
v
Prevention and treatment
v
Guiding principles
v
Steroids in PONV
v
Is it a small problem or a big problem? No one has the answer for this question.
So it is often called as a “Little big problem”.
In the modern era of high degree of sophistications, both in the techniques
of anesthesia and drugs, and also in the developments in electronic devices in
monitoring the vital functions of the patients, we are able to provide a very safe
environment to the patients who are submitted for anesthesia and surgery. In spite
of all these developments, there are certain problems related to the postoperative
period such as postoperative pain, nausea and vomiting, shivering, hypoventilation,
airway management, etc. are causing serious concern among the anesthesiologists.
The safety and comforts for the patients are further assured by the presence of
PACU (Postanesthetic Care Units) in every operating suit of all modern hospitals.
These were originally called as “Recovery Room” later renamed as “Recovery
Area”, sometimes known as “High Dependency Area” of the postoperative ward.
The high dependency is because the patients transferred from the operating room
invariably have depressed reflexes due to the residual effect of anesthetics.
In the modern days the term “Recovery” from anesthesia has lost its significance
and is being replaced by the term “Emergence”. Still the word “Recovery Area”
is extensively used carrying the meaning of postanesthesia care unit (PACU).
Even in the best of PACU though the safety of the patients are well assured,
there are certain anticipated problems that are frequently encountered during their
stay in PACU and are known as “Common recovery room problems” namely,
1. Postoperative pain
2. Postoperative nausea and vomiting
3. Postoperative hypoventilation
4. Postoperative hypotension
5. Postoperative bleeding.
Except the postoperative bleeding all the rest need to be managed by the
anesthesiologist in the PACU, particularly in the first 24 hours and more so in the
initial postoperative hours.
Invariably the most common concerns for the postoperative patients are pain,
nausea and vomiting. Among the five problems the foremost in the order of
importance is nausea and vomiting.
In modern times relief of pain in postoperative patient is complete, with various
techniques and drugs, but nausea and vomiting may be present even after excellent
anesthetic management and excellent pain relief, because nausea and vomiting are
of multifactorial origin.
“Many times postoperative pain is suffered in silence, whereas postoperative
nausea and vomiting cannot be suffered that way”.
But when encountered in the PACU, it causes embarrassment to all concerned,
namely, the patient, the by-standers and the doctor. The patient is embarrassed that
he vomits in the presence of the dear ones. The by-stander who is usually a close
kin feels bad to see his or her dear one suffering with vomiting. The doctor when
present when the patient vomits, feels bad to watch it. Besides, he may be blamed
for not anticipating the problem and taking adequate measures to prevent it.
There are some deep concerns about this for the anesthesiologists and the
surgeon and more so for the patients.
1. If the patient vomits in the postoperative period in supine position with a little
depressed reflex, there are more chances for aspiration and lung complications,
if not immediate chocking and death.
2. The usual problem in these circumstances is ‘Acid aspiration syndrome’
otherwise known as ‘Acute exudative pneumonitis’ (Mendelson’s syndrome).
3. Forceful retching and vomiting can cause severe strain on the abdominal
incisions and lead to wound dehiscence. This may later result in incisional
hernia.
4. The strain increases the morbidity by increasing postoperative pain, particularly
with upper abdominal incisions. This may in turn lead to hypoventilation.
Earlier, vomiting and regurgitation were dealt with under the same heading,
because then it was a frequent inevitable event with anesthesia in Ether era.
The patients’ CNS was badly depressed during anesthesia and vomiting or
regurgitation in an unconscious patient contributed for many mortalities and severe
morbidity. The incidence of nausea and vomiting was about 75 to 80%. This rate
has come down to 9 to 45% in the past years. The reasons are quite obvious such
as, the technique of balanced anesthesia, less emetogenic agents and popularization
of regional techniques, etc.
Chapter 16 Postoperative Nausea and Vomiting 227
At present the rate of incidence is 25 to 30%. Here again, though we hardly use
any volatile anesthetics, we depend upon opioids in various applications and also
that there are other numerous factors contributing for vomiting in postoperative
period.
Nausea
It is defined as “an unpleasant subjective feeling prior to the onset of vomiting which
is associated with increased salivation and causes severe distress and discomfort”.
Vomiting
A physiological act related to the rejection of food from the upper gastrointestinal
tract. It may be pathological. There will be increased salivation and nausea prior
to the actual process. Apart from salivation, rapid breathing, pallor, sweating,
tachycardia and discomfort may be associated.
Vomiting center is situated close to respiratory and vasomotor centers. Similarly
salivary and vestibular nuclei are closer to it. This explains that the associated
manifestations are related to the simultaneous stimulation of these neighboring
areas in the brain.
The actual vomiting is a complex and complicated process. The glottis closes to
prevent aspiration of vomitus. The respiration is stopped in the middle of inspiration.
There is reverse peristalsis in the upper intestines to transfer the contents to the
stomach. Then lower esophageal sphincter and esophagus relax. Now there is a
powerful contraction of abdominal muscles. Because the respiration is held and
the thorax is fixed, the muscle contraction increases intra-abdominal pressure and
results in ejection of stomach contents out through the esophagus and mouth. There
are other associated muscular activities for bending forward.
Retching
This is an aborted vomiting which will be in a relatively milder form.
Regurgitation
It is a passive process. It is usually associated with:
Depressed CNS and reflexes, due to residual effects of anesthetic agents
Relaxed lower esophageal sphincter
Presence of ryles tube
Head down position
Stomach full of fluids
Increased abdominal pressure, distension with ascitis
Obstructed bowels.
All these contribute for regurgitation. The stomach contents passively move
into the mouth through esophagus and is aspirated into lungs.
Hydrodynamics of vomiting
In the upright position the pressure of 40 cm of H2O is needed to lift the stomach
contents to the mouth. During the expulsive phase the glottis goes into spasm but
228 Surgeons and Anesthesia
soon it relaxes. So aspiration of stomach contents into the bronchial tree is bound
to happen in an unconscious patient in supine position.
Medical Effects
Disruption of wounds – Caused by strong abdominal contractions.
Vitreous extrusion. Bleeding behind the
flaps.
Electrolyte disturbances – Persistent loss of gastric fluid.
Fluid and nutrition – Inability to maintain adequate intake may
slow recovery.
Interference with drug therapy – Oral medication is not possible, parenteral
route may be needed.
Aspiration of gastric contents – In patients with depressed level of con-
sciousness or patients with jaw wired.
Esophageal injury – Forceful vomiting can cause rupture.
Economic effects
Nursing time – Costs of nursing time, costs of consumables
and laundry.
Delay in discharge – Particularly a problem after day care surgery.
Patient factors
Age – Risk is lower in extremes of ages.
Sex – Females, three times more risk than males.
Weight – Risk increased in obesity.
Starvation – Increased risk with prolonged starvation
(hypoglycemia).
History of “motion sickness” – May be related to early mobilization.
History of PONV previously – Has very strong correlation.
Physiological – Pregnancy.
Gastrointestinal tract disorders – Obstruction, billiary colic, delayed gastric
emptying.
Chapter 16 Postoperative Nausea and Vomiting 229
Surgical factors
Gastrointestinal – Due to mechanical stimulation of autonomic
afferents.
Gynecological – Related to hormonal effect.
Otolaryngological – High incidences with ear surgery and
tonsillectomy.
Ophthalmic – High incidences with strabismus surgery.
Anesthetic factors
Premedication – Opioid premedication increases risk.
IV induction agents – Etomidate and methohexitone increase risk.
Inhalational agents – Ether and other agents are emetogenic. N2O
may increase the risk with bowel distension.
Opioids – All opioids are emetogenic.
Reversal agents – Neostigmine is emetogenic.
Other anesthetic factors – Hypotension, duration of anesthesia,
oropharyngeal stimulation, hypoxia. High
spinal blockade cause nausea, possibly
related to hypotension, hypoxia, unopposed
parasympathetic tone.
Opioid receptors
These are present both in vomiting center as well as CTZ
These are specifically stimulated by opioids only.
230 Surgeons and Anesthesia
Vomiting Center
Though it is called vomiting center it is not basically responsible for the initiation
of vomiting. This is relatively a less sensitive center.
It is situated in the dorsolateral border of lateral reticular formation. This center
has close proximity to nucleus of solitary tract and area of postrema at the level of
dorsal motor nucleus of vagus.
Preponderance of receptors
Vomiting center
Opioid receptors
H1 receptors
Cholinergic muscarinic.
Chapter 16 Postoperative Nausea and Vomiting 231
CTZ
Opioid receptors
Dopamine 2 receptors
5HT3 receptors
With this degree of understanding of basic physiology, it is very clear that the
requirement for the scientific, management of nausea and vomiting must be only
the following two steps:
Suppression of numerous emetogenic peripheral stimuli
Suppression of central neuroemetic receptors.
Cholinergic GABA
5 HT3 5HT3 / D2 D2 H1
Muscarinic Agoinst
Ondansetron Substituted Phenothiazines Diphenhydramine Scopolamine Benzo
Granisetron Benzemide Chlropromazine Meclizine Benzotropin diazepines
Tropisetron Metoclopramide Perphenazine Lorazepam
Dolasetron Cisapride Prochlorperazine Alprozolam
Ramosetron Corticosteriods Promethazine Midazolam
Dexamethasone Triethylperazine
Methyl Prednisolone Triflupromazine
5 HT4 antagonist Benzimidazole derivatives
Mosapride (2.5 mgs) Domperidone
Butyrophenone derivatives
Droperidol
Haloperidol
Surgeons and Anesthesia
Chapter 16 Postoperative Nausea and Vomiting 233
Apfel, et al devised a scoring system using four predictors.
The four predictors are:
Female gender
History of motion sickness/PONV
Non-smoking
Use of postoperative opioids.
When 0, 1, 2, 3, 4 of these factors are present; PONV incidence will be 10; 21; 61;
79 percentages respectively.
Prevention
Now consider all the factors that are likely to cause PONV and eliminate them as
far as possible.
Avoid
Physiological factors like pain, hypotension, hypoxia and hypoglycemia
Psychological factors related to visual, auditory, olfactory stimuli, particularly
from the factors present in the recovery room or from the other patients in the
recovery room.
Psychological factors
Olfactory
If the patient smells something and suspects that someone has vomited, immediately
starts vomiting. Sometimes it may be an unpleasant smell that initiates vomiting.
Visual
Seeing some other patient in the next bed vomiting, the patient starts vomiting.
Auditory
Hearing the sound of someone vomiting in the next room, the patient starts
vomiting.
In fact, it need not be any input related to vomiting at all, any unpleasant inputs
in olfactory, auditory and visual pathways can stimulate vomiting in susceptible
individuals. For example, seeing some unpleasant scene or an unpleasant smell,
etc. may stimulate vomiting in these individuals. This is known as central stimulus
and is a awake response coming from limbic system. So the ideal management is to
adequately sedating the patient so that he is cut off from the effects of environmental
influences. Here only the GABA agonists like diazepam and midazolam help in
controlling psychogenic vomiting.
Choice of drugs for induction of anesthesia and maintenance with prophylaxis:
Propofol 1–2 mg/kg IV bolus for induction followed by 50–100 mg/kg/
min infusion for maintenance
Droperidol 0.625 mg IV 30 minutes prior to conclusion of surgery
Metoclopramide 10 mg IV 30 minutes prior to conclusion of surgery
234 Surgeons and Anesthesia
Treatment
Two steps:
Suppression of peripheral emetogenic stimuli
Suppression of central neuroreceptors.
As a matter of fact, suppression of peripheral stimuli must be aimed at first by
meticulously avoiding the provocative factors in all respects and suppressing them
by good analgesia, maintaining normoglycemia, and adequate hydration, etc., so
that the input reaching the center to stimulate the receptors are maximally reduced.
Now it is advised to use minimum effective dose of a single drug or a combination
of suitable drugs in significantly reduced dose to have better response by action on
many receptors and enhanced action by synergism. Apart from the better response,
the combination therapy has the advantage of reducing the side effects of the drugs.
In the earlier discussion about ‘A good approach—6 points approach’ for the
management, it is clear that the first 5 points are related to prevention and the 6th
points is treatment ‘Using multiple different antiemetic medications acting on
various neuroreceptor site’. In other words, it is about the drugs and their choice
for treatment when vomiting occurs.
If prophylactic antiemetic has not been given, consider their use in the recovery
room. Any one of the following drugs may be used depending on the situation.
Metoclopramide – 10 mg IV
Droperidol – 0.625 mg IV
Promethazine – 12.5 mg IV
Ondansetron – 4 mg IV
Combination of two drugs in appropriate smaller doses is ideal. In very high
risk patient even three drugs may be combined in smaller doses.
In short surgical procedure it may be given IM along with premedication. In
long procedure it may be given IV 30 minutes prior to the conclusion of anesthesia.
So that it has a good postoperative cover.
Smaller doses of combinations of different drugs may be used depending upon
the necessity.
Facts
Prophylactic antiemetics may delay the recovery, particularly phenothiazines.
Hypotension during perioperative period causes a decrease in blood flow to
the midbrain emetic centers, releasing emetogenic chemicals, increasing the
possibility of PONV.
Postoperative pain may be an initiating cause of PONV—it should be treated
with analgesics as needed rather than withholding pain treatment for fear of
opioid induced PONV.
Chapter 16 Postoperative Nausea and Vomiting 235
Availability of D2 receptor antagonist and 5HT3 antagonists have broadened
the options available for the treatment of nausea and vomiting.
Benefits of using combination therapy are reduction in side effects, improved
efficacy and providing various mechanisms of actions.
5HT3 antagonists such as ondansetron may have effect by blocking serotonin
(5HT) receptors both periphery and centrally. centrally on receptors in the
CTZ; in the periphery, receptors in vagal nerve terminals and the receptors
described in the intestinal walls.
Guiding principles
Nausea and vomiting can be prevented by gentle movement of the patient from
supine to walking or delaying that
Identifying the source of stimuli that activate vomiting center before choosing
an agent
Effective treatment depends upon correction of underlying causes
Most patients respond well usually to the use of right agent
Small to moderate doses should be used in combination regimens for better
efficacy and lesser side effects
5HT3 antagonist are significantly more effective than metoclopramide alone
Combination of 5HT3 antagonist and steroids are more effective than 5HT3
antagonists alone.
Steroids
Steroids have a very good antiemetic effect. Addition of steroids to other anti-
emetic therapy enhances the potency.
Steroids reduce the severity and incidences of some adverse effects such as
diarrhea induced by metoclopramide, but may aggravate hyperglycemia in
diabetics.
Because of their side effects, steroids are not used as first line of drugs in the
management of simple nausea and vomiting, but reserved for the cases when
the other agents have failed.
The exact mechanism of action of antiemetic effects of steroids is not clearly
known. They are believed to have effect on D2 or 5HT3 receptors.
Conclusion
Routine use of antiemetics is not needed
Identify the ‘high risk’ patient
Eliminate and minimize the “avoidable risk factors”
Use prophylactic antiemetics in ‘high risk’ patients
Use combination therapy in smaller optimum doses for better efficacy
In intractable cases addition of steroids to 5 HT3 and D2 receptor antagonists
would be very effective.
Index
a Automatic
programmable EO sterilizer 125f
Abdomen 135 washing machine 115
Abdominoperineal resection of rectum 140 Autonomic
Acetated ringer’s solution 152 imbalance 177
Acid aspiration syndrome 226 system 168
Acute exudative pneumonitis 226 AV bundle See Atrioventricular bundle 172
Airway in unconscious patient, maintenance
of 182
Airway obstruction, mechanism of 182 b
Alcohol 107
Alkyl urea derivatives 108 Bacillocid 108
Allergy, history of 51 solution for disinfecting equipments 108f
Alpha bed 193 special 108
Analgesic 67 Back 132
Anaphylaxis 38 Bacterial filters 128
Anesthesia 1, 2, 155 in breathing systems 129f
accidents during 37 Balanced anesthesia 73, 77
chart 41f, 42f definition of 78
classification of 86 Bare area of liver 155
definition of 76 Basal analgesia 71, 71f
purpose of 73 Berman’s airway 184, 185f
record and machine 34 Betadine See Iodophor 15
technician 26, 132 Bhabha Atomic Research Center 128
types of 86 Bins 117
Anesthesiologist’s register 43 for autoclaving 119
Anesthetic technician 22 with perforations for autoclaving 119f
job descriptions of 23 Blood flow
Anticholinergic 66 during hypothermia 159
Antiseptics 107 during hypotension
detergent antiseptics 107 due to autonomic blockade 159
disinfectants 107 with vasoconstriction 159
germicide 107 to liver 157
Antisialagogue 66 with vasoconstrictor drugs 159
Aortic body 174 Blood
Arterial for blood 144
oxygen saturation 47 loss 144
PCO2 168 assessment of 144
PO2 168 during surgery, assessment of 145
pressure, control of 212 pressure 39, 40, 52, 173
system 175 coronary artery dilators 173
Artificial airways 184 stream 161
Asepsis, adequacy of 112 sugar 53
Assisting nurse 22 supply to brain 167, 167f
Atrioventricular bundle 172 tissue 145
Atrioventricular node 172 transfusions 144, 145
Auscultation of heart sounds 52 urea 53
Autoclave 117 viscosity 169
Autoclaving, advantages of 121 volume 144
238 Surgeons and Anesthesia
v w
Vagolytic 66 Walls 94
Vapor 123 Weekly fumigation with formalin 109
Vascular Weekly washing 108
reflexes 174
system 175 x
Vasomotor tone 77
Vasopressor 216 X-ray chest 54
drugs, effects of 164 Xylocaine 199, 200, 208
Venous availability 200
drainage 168