Anesthesia of the Surgical

Patient

Presenter; DR MENGIST A(MD,R-1)

Moderator; DR ASHENAFI A(MD,ASSISTANT

PROFFESOR OF GENERAL SURGERY)
 OUTLINE

 Introduction

 Brief history

 Classes of anesthetic agents

 Preoperative preparations

 Intra-operative management and monitoring

 Post- anesthetic management

 introduction

 control of three great concerns: consciousness, pain, and movement.

 combines the administration of anesthesia with the perioperative

management of the patient's concerns, pain management, and critical
illness.

 The fields of surgery and anesthesiology are truly --collaborative and

continue to evolve together
 A Brief History of Anesthesia

 many substances and methods were tried

 Opium, alcohol, exposure to cold, compression of peripheral nerves

 restrained by several attendants

 Modern Beginnings

 In 1842 Crawford Long (1815–1878)--diethyl ether

 Humphrey Davy (1778–1829) suggested -nitrous oxide

 Horace Wells (1815–1848)-NO on himself

 William Morton (1819–1868) -a dentist –public demonstration

 John Snow (1813–1858) -made science out of the art of anesthesia.

 Cocaine: The First Local Anesthetic

 Anesthetic Agents

 local,

 regional, or

 general
 Local Anesthetics

 two groups;

 the amides and

 the esters.
Cont’d
 Cont’d
 Toxicity

 from absorption into the bloodstream or

 from inadvertent direct intravascular injection.

 Central Nervous System

 restlessness to complaints of tinnitus. Slurred speech, seizures, and

unconsciousness follow.

 Sezure-a benzodiazepine or thiopental

 Persistent seizure- intubation

 Cont’d

 Cardiovascular System

 hypotension, increased P-R intervals, bradycardia, and cardiac arrest

may occur.

 Bupivacaine is more cardiotoxic than other local anesthetics.

 Regional Anesthesia

 Peripheral

 Central

 Spinal Anesthesia

 Epidural Anesthesia
 General Anesthesia

 a triad of three major and separate effects:

 unconsciousness (and amnesia),

 analgesia, and

 muscle relaxation

 achieved with a combination of intravenous and inhaled drugs, each

used to its maximum benefit.
 Intravenous Agents
Unconsciousness and Amnesia

 produce unconsciousness and amnesia

 frequently used for the induction of general anesthesia.

 barbiturates, benzodiazepines, propofol, etomidate, and ketamine.

 Except for ketamine, no analgesic properties, nor do they cause

paralysis or muscle relaxation.
 Cont’d

 Barbiturates

 Propofol

 Benzodiazepines

 Etomidate

 Ketamine
 Analgesia

 little effect on consciousness, amnesia, or muscle relaxation.

 Opioid Analgesics

 Nonopioid Analgesics
 Neuromuscular Blockers

 no amnestic, hypnotic, or analgesic properties;

 patients must be properly anesthetized prior.

 no effect on either nerves or muscles, but act primarily on the

neuromuscular junction.
 Cont’d

 Depolarizing

 Non-depolarizing
 Inhalational Agents

 provide all three characteristics of general anesthesia.

 impractical to use an inhalation-only technique in larger surgical

procedure.

 display a dose-dependent reduction in mean arterial blood pressure

except for nitrous oxide, which maintains or slightly raises the blood
pressure.

 the Meyer-Overton rule;

Cont’d
 Anesthesia Management
Preoperative Evaluation and Preparation

 The detailed medical history

 previous exposure and experience with anesthesia

 family history of problems with anesthesia.

 History of atopy (medication, foods, or environmental)

 A careful review of major organ systems and their function

 Cont’d

 The physical exam is targeted

 central nervous system,

 cardiovascular system,

 lungs, and upper airway.

 Preoperative laboratory data and specific testing for elective surgery

should be patient- and situation-specific.
 Risk Assessment

 Originally designed as a simple classification of a patient's physical

status immediately prior to surgery, the ASA physical status scale is one
of the few prospective scales that correlate with the risk of anesthesia
and surgery
Cont’d
 Consideration of Patients with Comorbidities

1. Ischemic Heart Disease

 risk of perioperative death increases

 balance between myocardial oxygen delivery and myocardial oxygen

demand

 muscle relaxants with minimal to no effects on heart rate and blood

pressure, such as vecuronium and rocuronium.
 Cont’d

2. Pulmonary Disease

 General anesthesia can be performed safely.

 Inhaled anesthetics are often used due to their bronchodilating

properties

 Regional and local anesthesia avoids tracheal irritation and stimulating

bronchospasm.
 Cont’d

 Intraoperatively, mechanical ventilation~8 breaths per minute

 should also be well hydrated

 Cont’d

3. Renal Disease

 Virtually all anesthetic drugs decreases in renal blood flow, the

glomerular filtration rate, and urine output, reflecting multiple
mechanisms such as decreased cardiac output, altered autonomic
nervous system activity, neuroendocrine changes, and positive pressure
ventilation.

 Prehydration and the depth of anesthesia may influence the renal

response to anesthesia.
 Cont’d

4. Hepatobiliary Disease

 Severe hepatic necrosis most--decreased hepatic oxygen delivery rather

than the anesthetic.

 Regional anesthesia may be useful

 general anesthesia is selected--modest doses of volatile anesthetics with

or without nitrous oxide or fentanyl often is recommended.

 nondepolarizing muscle relaxants --consider clearance mechanisms for

these drugs.
 Cont,d

5-Metabolic and Endocrine Disease

 primary reason for surgery or can exist in patients requiring surgery for
other unrelated disorders.

 Preoperative evaluation - relevant medical history, glucose or protein in

the urine, vital signs, history of fluctuations in body weight, survey of
sexual function, and concomitant medications.

 diabetes mellitus, hypothyroidism, and obesity.

 Cont,d

 Improved glycemic control

 avoidance of hypoglycemia and hyperglycemic events is the standard of

care in these patients.

 blood sugar in the range of 120 to 180 mg/dL

 regional anesthesia may carry greater risks to the diabetic patient with
autonomic neuropathy

 Anesthetic management of the obese patient is problematic

 Cont’d

6-Central Nervous System Disease

 Diseases of the central nervous system (CNS) present unique situations

for the anesthesiologist.

 relationship between

 intracranial pressure (ICP),

 cerebral blood flow (CBF), and

 cerebral metabolic rate of oxygen consumption (CMRO2).

 Cont’d

7- Hypertension

 the most common preexisting medical disease

 ACE-I/ARB hypotension

 diastolic pressure 110 mm Hg or higher-The incidence of hypotension

and myocardial ischemia intraoperatively is higher
 Intraoperative Management

 Induction of General Anesthesia

 the most critical component of practicing anesthesia

 majority of catastrophic anesthetic complications occur during this

phase.
Cont’d
 Cont’d

 Management of the Airway

 including by face mask,

 a laryngeal mask airway (LMA), or

 most definitively by endotracheal intubation with a cuffed endotracheal

tube.
 Cont’d

 challenges to endotracheal intubation, then;

 The Bullard rigid fiberoptic laryngoscope

 intubating laryngeal mask airway (ILMA)

 flexible fiberoptic intubation scope is the gold standard for difficult

intubation
Cont’d
 Cont’d

 Fluid Therapy

 dilution of platelets and coagulation factors and may lead to

coagulopathy (i.e., dilutional coagulopathy)

 impact on renal function

 lower incidence of nausea, vomiting, and antiemetic use

 decreases the incidence of dizziness, drowsiness, thirst, and headache

 relative impact of crystalloids and/or colloids on pulmonary function

 Monitoring the Surgical Patient

1- Monitors of Oxygenation

 Pulse oximetry

2- Ventilation Monitors

 arterial carbon dioxide tension (PaCO2) is 40 mm Hg

 Capnography - visual display of the CO2 concentration at the airway

 combination of the capnometer and the pulse oximeter creates a

dynamic duo for beat-to-beat and breath-to-breath surveillance of
metabolism, circulation, ventilation, and oxygenation.
 Cont’d

3- Circulation Monitors

 systemic arterial blood pressure

4- “Awareness” and Level of Consciousness Monitors

 electroencephalographic (EEG) analysis

 Recovery from Anesthesia

A. Reversal of Neuromuscular Blockade

 anticholinesterase agents

 neostigmine, pyridostigmine, and edrophonium.

 The common side effects

 bradycardia, bronchial and intestinal smooth muscle contractions,

and excessive secretions from salivary and bronchial glands.
 Cont’d

B. The Postanesthesia Care Unit

 recovery period-10% of all anesthetic accidents

 Postoperative nausea and vomiting (PONV), airway support, and

hypotension requiring pharmacologic support

 However, abnormal bleeding, hypertension, dysrhythmia, myocardial

infarction, and altered mental status are not uncommon.
 Cont’d

C. Postoperative Nausea and Vomiting

 20 to 30% of surgical cases

 serotonin receptor anatagonists ---most efficacious choice.

 Metoclopramide
 Cont’d

D. Pain: The Fifth Vital Sign

 One frequently used graduated scale

 four-point measure of pain intensity (0 = no pain, 1 = mild pain, 2 =

moderate pain, and 3 = severe pain) and

 five-point measure of relief (0 = no relief, 1 = a little relief, 2 = some

relief, 3 = a lot of relief, and 4 = complete relief).

 assessment of pain as the fifth vital sign

 Malignant Hyperthermia

 volatile anesthetics (e.g., halothane, enflurane, isoflurane, sevoflurane,

and desflurane), and the depolarizing muscle relaxant succinylcholine

 hypermetabolic state, tachycardia, and the elevation of end-tidal CO2 in

the face of constant minute ventilation.

 Respiratory and metabolic acidosis and muscle rigidity follow, as well

as rhabdomyolysis, arrhythmias, hyperkalemia, and sudden cardiac
arrest.

 A rise in temperature is often a late sign of MH.

 Cont’d

 Treatment must be aggressive and begin as soon as a case of MH is

suspected:

1. Call for help.

2. Stop all volatile anesthetics and give 100% oxygen.

3. Hyperventilate the patient up to three times the calculated minute

volume.
 Cont’d

4. Begin infusion of dantrolene sodium, 2.5 mg/kg IV. Repeat as

necessary, titrating to clinical signs of MH. Continue dantrolene for at
least 24 hours after the episode begins.

5. Give bicarbonate to treat acidosis if dantrolene is ineffective.

6. Treat hyperkalemia with insulin, glucose, and calcium.

7. Avoid calcium channel blockers

8. Continue to monitor core temperature.

references
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