Islam’s notes Anaesthesia Al Qassimi hospital

Al- Qassimi notes

Anaesthesia
Perioperative assessment:
Full body assessment than need to be done before any operation.
This assessment should cover 5 items:

1-AGE
Male: if above 40 >> you should do ECG.
Female above 45 >you should do ECG.

Any abnormal ECG finding refer to cardiology and you can postpone the elective surgery tell
the patient health become optimal.

2- Previous medical illness

•History of MI
Recent MI (previous 3 months) if the operation done there is high risk for re-infarction.
Optimum period is 6 months (needed for healing after MI) to consider the patient as low risk

•History of diabetes
Know: duration, complications (systemic or organ complications) controlled or not controlled
(do HbA1c)
treatment (oral hypoglycaemia> stop and switch to insulin)
Why insulin?
IV insulin better bioavailability and you can control effusion rate
All sings of hypoglycaemia will be masked by Anaesthesia

Anaesthesia is considered as stress and will lead to release stress hormone from adrenal gland
by activating sympathetic system

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Islam’s notes Anaesthesia Al Qassimi hospital

•History of hypertension
Complications of hypertension (systemic and organic complications)
Treatment (controlled or not controlled)
Risk of cerebral haemorrhage and heart failure is increased during any surgery for
hypertensive patient

All drugs in preoperative should be continued (thyroid medication and Hypertension) ( oral
hypoglycaemic switch to insulin)

3- history of previous surgery and events during it (to exclude any complications or to
avoid it during the second surgery)
Ask about ICU admission.

4- Allergy history

5- social history
Smoking (nicotine cause tachycardia)
(CO levels higher in smoker, which has higher affinity to hemoglobin and this will increase
the risk of desaturation)
Hyperactive airway and high mucus secretions in smoker patient which will require high dose
of inhalation anaesthesia in order to maintain it.
To avoid all these complications, you should ask the patient to stop smoking up to 8 weeks
before the operation.

Alcohol consumption
Check liver function and live enzyme
Cytochrome p450 is used in the metabolism of inhaled anaesthesia which is the same enzyme
used to breakdown alcohol, so they are active and induced. Which means faster breakdown
for inhaled anaesthesia and higher dose will be needed in order to maintain appropriate
level.

Camel milk consumption also will lead to similar problem which requires high dose of
anaesthesia in order to be effective.

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Islam’s notes Anaesthesia Al Qassimi hospital

Physical examination
1- Check mallampati score (1-2-3-4) to assess for any possible difficulty in intubation

2- ask the patient to fully extend the neck and measure length from mental process of
mandible till the tip of thyroid cartilage if 4 cm or more > easy intubation less than 4 cm
difficult intubation.

3-General examination (head to toe).

Investigations (labs):

CBC: Hb =10 and HMC= 30 are they optimum value for oxygenation

WBC count to exclude infections

Platelet count / PT and PTT to check for coagulation defects.

Liver and kidney function (most drugs which used in anaesthesia will be metabolised by liver
and excreted by kidney)

Electrolyte and blood sugar (HbA1C)

ECG related to age and gender

Chest X-ray

Informed consent

(Minimum age is 18) (married or stable job can do below 18)

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Islam’s notes Anaesthesia Al Qassimi hospital

Medication of anaesthesia

Initiate with propofol (diprivan) (white like yogurt) duration of action: 10 mins only and you
should maintain with other drug.

Maintain by Inhalation anaesthesia Sevoflurane and Desflurane (sweet smell)

note that the airway will not be protected without intubation (acidic aspiration destruction of
trachea).
With inhaled anaesthesia there is increased dead space in the lung so in order to prevent all
these complications above we do the intubation immediately in the beginning

You can’t intubate (insert tube) while patent is sleep due to risk for any vocal cord injury
which may cause laryngeal Edema > to avoid this we can give muscle relaxant.

Two types of Muscle relaxant can be used during operations:

depolarizing muscle relaxant: Succinylcholine

(break down by Pseudocholinesterase enzyme after 3 - 5 mins).
This enzyme production in the control of 1 gene (if 1 gene is missing we called it
heterogeneous defect) (if 2 gene missing we called it homogenous defect)

Normally we don’t test routinely for this enzyme before any operation
But if we find any deficiencies, we can treat by give blood transfusion from other normal
person.
This can be prevented by asking if there is any family history for any surgery problems

non-depolarizing agents (other group of drugs can be used also)

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Islam’s notes Anaesthesia Al Qassimi hospital

Local anaesthesia
Regional anaesthesia: Bock the nerve that supply the affected area only

Pros:
1- Awake patient
2- Period of recovery is faster and less hospital stay.
3-Post operative pain free period is more that GA and you can insert a catheter in same
location or in epidural space and inject local anaesthesia to extend the period.

Cons:
1- Chest is negative pressure space that may collapse with any injury to prevent this form
happening we should apply positive pressure inside the lung.
2- It is a Blind technique which may lead to any injury to the surrounding structures like
blood vessel injury (hematoma) and compress the nerve rotes.
3- need expert physician or Good trainer.

Mechanisms of action: Block Na channel and prevent depolarization.

Types of local anaesthesia:

1- infiltrative > ingrown nail.

2- spinal > till subarachnoid space ... low volume (2cm) and heavy marcade > because there
is carrier, and we want it to stay down in the lower space / causes both sensory and motor
block.

Complications:
Immediate:
1-vasovagal attack (stop and make the patient flat/ give o2 and fluid / if there is Bradycardia
give atropine )
2- hypotension: nerves supply arteries are blocked so less arterial peripheral pressure / they
are also supplying veins so less venous tone > less venous return and venous pooling.

3- dehydration and hypovolaemia (give 500 ml crystalloid before operation)

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Islam’s notes Anaesthesia Al Qassimi hospital

4- if spread cranially they may affect sympathetic system of heart which will led to less
contraction and rate)

Don’t allow any agent to spread to cranially by prober patient position and prober agent use
(heavy marcade).

But if all techniques fail you should start medications.

Ephedrine: alpha blocker and increase catecholamines secretions.

5- apnea > due to cephalic spread which block respiratory muscles (mainly diaphragm >>
correct by elevate the patient give oxygen by mask >>> fails shift to GA and do intubation.

Late complications:
1- headache > less CSF volume and less pressure due to CSF leak ( to avoid it use small
needle > large number) patient lay flat > push fluid and analgesia > if all failed > most
definitive treatment for post spinal head is epidural patch (using own patient blood and inject
it in epidural space ) small amount will go to subarachnoid space and the other will cause
pressure

Epidural anaesthesia (negative pressure space) (walking anaesthesia)

Difference between spinal and epidural
1- Anatomy
2- no injury to organs or structure
3- more sensory block than motor
(sensory nerve superficial unmyelinated and thin while motor nerve deep and Myelinated and
larger)
3- high dose mercade (10-15) and isobaric
4- no headache and more hemodynamic stability
5- we can insert catheter and increase the dose to prolong post-operative pain free period.

Bier’s block: Intravenous local block (only extremity) (use tourniquet and inject IV agent 35
cm in veins) very dangerous and need to be done in well-equipped OT

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Islam’s notes Anaesthesia Al Qassimi hospital

Pharmacology
GA > 4 stages know them
All will Target RAS in brain > should be lipid soluble (higher solubility will cause faster
action )
Induction always IV with propofol
Then go with inhalation agent for maintenance.

Induction drugs:
Thiopental sodium: lot of side effects used only in ECT
absolute contraindication: porphyria

etomidate: used in cardiac anaesthesia / pain with injunction / inhibit cortisone secretion

Propofol (can use as sedative) mixed with zylorate to reduce injunction pain it causes
(profound hypotension and airway obstruction ) arm to brain effect

Ketamine works in NMDA receptor. Has analgesia effect >>> dissociative amnesia

Side effects: hallucinating and excessive salivation, tachycardia, airway spasm

contradictions in hypertension and heart disease
Route of administration: IM, IV, rectal and intranasal
Flumazenil is antidote for benzodiazepines

Maintenance
Desflurane > causes tachycardia and airway initiation
Malignant hyperthermia (contraindication for inhalation anaesthesia)
Dantolorine is the antidote which can be used in malignant hyperthermia
Also, you should give cooling bath and monitor vitals
You should Avoid all exposure to inhalation anaesthesia if there is previous history
(susceptibility)
Non depolarising (antidote acetylcholinesterase inhibitor with atropine to block muscarinic
action and leave nicotinic action which are the receptors in end motor neurone plate)

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Islam’s notes Anaesthesia Al Qassimi hospital

General anaesthesia
Preoperative medication (dormicum (midazolam)) 1 night before operation the patient should
be fasting)
Can be given to reduce stress and allow the patient to sleep
(second dose can be given intraoperative)

Intubation associated with severe stress and catecholamine secretion

Sedative before induction by fentanyl (opioid) then IV short acting propofol (for 10 to 15
mins surgery alone) if long surgery you should give maintenance (inhalation anaesthesia)
(Desflurane causes irritation > not recommended for children)
Then muscle relaxant (causes apnea and paralysis to Vocal cord)

Succinylcholine choline side effects: fasciculations, hyperkalaemia and postop muscle pain.

Incremental dose (if you want to compensate for metabolised muscle relaxant) (second dose
after first dose)

Train of 4 (two electrodes on radial nerve give 4 stimulations (2 or less actions > no actin
needed) (3 or more you should give second dose of muscle relaxant)

At the end of surgery give neostigmine (acetylcholinesterase inhibitor) give only of the
patient attempted for respiration (see capnogram) (curved respiration end tidal co2)

Reversal (neostigmine and atropine (to block muscarinic action)

Suction for secretion after anaesthesia and when cough reflex start you should remove the
tube and give oxygen.
send to recovery area when retain consciousness or responded to pain stimuli
Acidic Aspiration with full stomach (damage for alveolar capillary membrane which can’t be
regenerated).

Complications of GA
Blood loss, hypotension, and malignant hyperthermia.

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