● Visual observation or quantitative electromyography may be

done, although the former is usually relied upon

Figure 16. Peripheral Nerve Stimulator

IV. INTRAOPERATIVE MANAGEMENT

A. PREPARATION OF ANESTHESIA TABLE

● Three steps in preparing the anesthesia table (Royal College of
Anaesthetists, 2018): Figure 17. Proper preparation and labelling of anesthetic drugs
→ Checking the anesthesia machine
→ Preparing and checking the basic anesthetic equipment
→ Preparing the drugs for induction

1. CHECKING THE ANESTHESIA MACHINE

● Basic function of an anesthesia machine 🡪 to prepare a

mixture of anesthetic gases which can be delivered to the
patient through a breathing system (Gurudatt, 2013)
● Anesthesiologist’s most important equipment in the OR
→ He/She must be able to do a mandatory full machine check
prior to use at the start of every case
● Association of Anaesthetists of Great Britain & Ireland (AAGBI)
produced safety guidelines regarding proper checking of
anesthetic machine and anesthetic equipment (See Appendix)
2. PREPARING AND CHECKING THE BASIC
ANESTHETIC EQUIPMENT
● Monitors
→ Displays configured in such a way that on-screen data will be
shown using the optimum size and arrangement
→ Shows regular updating of displayed values
● Alarms
→ Anesthesiologist must review and reset the upper and lower
limits as necessary, as default alarm settings may be
inappropriate
● Airway equipment
→ Include bacterial filters, catheter mounts, connectors and
tracheal tubes, laryngeal mask airways, etc.
→ Check for patency and availability of appropriate sizes
→ Single-use items (i.e. bacterial filters and catheter mounts)
must be replaced for each new patient to ensure infection
control
→ Difficult airway equipment must be available nearby for
management of anticipated or unexpected difficult airway
cases
→ Alternative means of ventilation (i.e. self-inflating bag) should
be immediately available for emergency purposes
● Resuscitation equipment
→ Resuscitation trolley and defibrillator must be available
→ Patient’s trolley, bed or operating table must also be checked
if it can be tilted head-down rapidly
3. PREPARING THE DRUGS FOR INDUCTION
Figure 18. ASTM International color code standards for anesthetic drugs
● Prepared and labeled beforehand
● Labels are colored according to American Society for Testing
and Materials (ASTM) International standards (see Figure 18).
● Drugs for induction:
→ Induction agent (propofol, thiopental, midazolam)
→ Opioids (fentanyl, alfentanil) for decreasing the
cardiovascular response to airway manipulation
→ Muscle relaxants
▪ Depolarizing muscle relaxants (suxamethonium/
succinylcholine) for Rapid Sequence Induction
▪ Non-depolarizing muscle relaxants (atracurium,
vecuronium, rocuronium) for routine intubation
→ Saline flush
→ Antiemetics and antibiotics if indicated in the surgery
→ Volatile or intravenous agent to keep the patient asleep
● Emergency drugs should also be prepared accordingly, drawn
up in a syringe and ready to use
→ Vasopressor agents (ephedrine, metaraminol) for
hypotension associated with induction
→ Anticholinergic agents (atropine) for severe bradycardia
due to hypotension
B. ANESTHESIA OF CHOICE
INTRAVENOUS ANESTHESIA
● The anesthesia to be administered is a general anesthesia in
the form of an IV anesthetic.

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● IV anesthetic was chosen so that the effects of the anesthesia ● Weak gas with low solubility
could be induced for an indefinite amount of time to address → Low blood-gas coefficient > less amount needed to raise
the variability of the time it takes to finish the frozen partial pressure > quicker to establish equilibrium > blood
sections. concentration rises rapidly
● Additionally, general anesthesia was chosen in order to secure ● Minimal cardiac and respiratory depression
the patient’s airway. → Dose-dependent
● Propofol is the anesthesia of choice for this patient. ● MAC = 105
● Propofol acts on the GABAA receptor that allows more GABA → If MAC > 100% - no immobility in 50% of patients even when
to bind with GABAA in order to induce its effects all molecules of the gas are inspired
● Propofol preparations is often mixed with soybean oil, glycerol ● Not anymore used
and egg lecithin. Egg lecithin is utilized in order to address → Causes pollution
the allergy problem induced by older preparations. → Most serious complication: diffusion hypoxia
● Propofol has a rapid onset, short duration and less “hangover” ▪ During emergence from nitrous oxide anesthetic, rapid
making it suitable for outpatient anesthesia elimination of nitrous oxide from the lungs dilutes other
● Physiologic effects: alveolar gases (e.g. oxygen)
→ Dec. Arterial BP ▪ Management: stop giving NO2 and give the patient 100%
→ Respiratory depression oxygen
→ Dec. Cerebral blood flow and intracranial pressure
→ Anti-emetic Why combine sevoflurane and nitrous oxide?
→ Anti-convulsant ● Nitrous oxide decreases the minimum alveolar
→ Anti-pruritic concentration (MAC) of sevoflurane in a linear additive
● Adverse reactions manner. This means that less amount of sevoflurane is
→ Hypotension required to be administered for it to have an effect.
→ Apnea ● Second Gas Effect
● A good alternative IV anesthetic for this patient is Ketamine → Studies have shown that uptake of high concentrations
→ Ketamine is a good IV anesthetic for pediatric patients of nitrous oxide at induction of inhalational anesthesia
because it allows them to have good dreams. produces an increase in alveolar concentrations of
→ Adverse reactions: oxygen and the accompanying volatile anesthetic
▪ Nightmares in adults agent (i.e. sevoflurane)
▪ Post-operative agitation
NEUROMUSCULAR BLOCKING AGENT (NMBA)
INHALATIONAL ANESTHESIA ● NMBAs are usually administered during anesthesia to facilitate
● Used to maintain general anesthesia during medical endotracheal intubation and/or to improve surgical
procedures conditions.
● Unique route of administration allows a more rapid appearance ● Used only as an adjunct to anesthetics since they have no
of the drug in the arterial blood (as compared to IV anesthetics) amnestic, hypnotic, or analgesic properties.
● Capable of exhibiting the 3 characteristics of general ● There are two classes of NMBA namely: depolarizing
anesthesia: (Succinylcholine) and non-depolarizing
→ Unconsciousness o All nondepolarizing NMBAs have a slower onset and
→ Analgesia longer duration than succinylcholine.
→ Muscle relaxation o A nondepolarizing NMBA is usually selected for the
● Choice of agent for the case: Sevoflurane + Nitrous Oxide maintenance phase of general anesthesia unless the
surgical procedure is expected to last only a few minutes.
Sevoflurane ● Since the duration of biopsy procedure varies depending on the
● Volatile halogenated anesthesia for induction and maintenance result of frozen section (kung benign pwedeng isara na, kung
of general anesthesia malignant kailangan pa mag-excise ng more tissue), the use of
● MAC = 1.71 NMDAs with intermediate to long duration of action may be
→ The lower the MAC, the more potent the agent is considered.
● Non-pungent ● Recommended in this case: Atracurium (according to Doc So)
→ Does not trigger airway irritation o It has good control over the duration of action of the drug.
● Rapid induction o There is little to no cumulative effect with repeated
● Rapid emergence
doses or continuous infusion because recovery from
→ Rapid fall in alveolar concentration upon discontinuation
atracurium-induced neuromuscular block occurs by
→ May cause emergence agitation / delirium
spontaneous, nonenzymatic, nonsaturable chemical
▪ Severe restlessness, combativeness, disorientation,
degradation (Hofmann elimination) rather than
incoherence, and unresponsiveness
metabolism or redistribution.
▪ Can go from 10 to 45 minutes
▪ With continuous infusion, no dosing revisions
▪ Usually self-limiting
are required to maintain a stable depth of
neuromuscular block, even with prolonged
Nitrous Oxide (NO2) infusions.
● “Laughing gas”
o Adverse effect includes dose-dependent histamine
● Colorless, odorless
release that becomes significant at doses above 0.5
● More rapid onset than the more “potent” gases

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 mg/kg (However, according to Doc So, this is rarely seen Neck Circumference ● A neck circumference of greater than
in clinical practice). 27 in is suggestive of difficulties in
▪ Other ADE: Hypotension, Tachycardia, and the visualization of the glottic
Bronchospasm for asthmatic patients opening
Jaw/Mandibular ● The ability to slide the lower incisors
C. AIRWAY MANAGEMENT Protrusion Test in front of the upper ones
(Figure 20) ● Limited jaw protrusion can help
● Successful ventilation (with or without intubation) must be predict both difficult mask ventilation
ensured to avoid patient mortality and morbidity and laryngoscopy which may require
jaw thrust maneuver
Reporter’s notes:
● The case requires the patient to be placed in a prone
position, thus, some modifications and additional
maneuvers on airway management techniques will be
performed to facilitate successful ventilation

Airway management procedures associated with general

anesthesia:
● Preanesthetic airway assessment
● Preparation and equipment check
● Patient positioning Figure 19. Upper Lip Bite Test
● Preoxygenation (denitrogenation)
● Bag and mask ventilation (BMV)
● Intubation or placement of a laryngeal mask airway, if indicated
● Confirmation of proper tube or airway placement
● Intraoperative management and troubleshooting
● Extubation

1. AIRWAY ASSESSMENT
● Performed to estimate the difficulty of endotracheal intubation
and apply appropriate anatomical or functional maneuvers Figure 20. Mandibular Protrusion Test

Table 7. Factors to Consider in Airway Assessment ● 3-3-2 Rule (Figure 21)

Airway Description → 3 fingers fit the mouth
Assessment Test → 3 fingers fit from the mentum to the hyoid cartilage
Mouth Opening ● An incisor distance of 3 cm or → 2 fingers from the floor of the mouth to the top of the thyroid
greater is desirable in an adult cartilage
Upper Lip Bite Test ● The lower teeth are brought in front
(Figure 19) of the upper teeth
● The degree to which this can be
done estimates the range of motion
of the temporomandibular joints
Mallampati ● Examines the tongue in relation to
Classification the oral cavity.
● The greater the tongue obstructs the
view of pharyngeal structures, the
more difficult intubation may be
● Performed during anesthesia
consultation and inside the operating
room before the procedure is Figure 21. 3-3-2 Rule
initiated:
→ In sitting position, head in neutral
position, chin slightly tilted up,
2. PATIENT POSITIONING
mouth widely opened and tongue ● Important aspect in anesthesia practice to reduce anesthesia-
fully out related mortality and morbidity
→ Inside the operating room, the
patient may lie in supine position
Sniffing Positioning (Figure 22)
Thyromental ● Distance between the mentum and
● Described as “sniffing morning air” or “draining a pint of beer”
Distance superior thyroid notch. A distance
● Goal: bring the path from the incisor teeth to the larynx into a
greater than 3 fingerbreadths is
straight line or to expose the glottis and facilitate endotracheal
desirable.
intubation

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 → Main advantage of this position is the optimal exposure of
glottis to facilitate intubation (with direct laryngoscopy)
● Involves alignment of three axes: oral, pharyngeal and
laryngeal through:
→ Flexion of the lower cervical spine
→ Extension of upper cervical spine
→ Extension of atlanto-occipital joint
Figure 22. Sniffing Position
Figure 23. Patient Positioning
A. Three axes in neutral position; B. Three axes in sniffing position
3. PREOXYGENATION (DENITROGENATION)
● Preoxygenation with face mask oxygen should precede all
airway management interventions
● Increases the duration of apnea without desaturation improves
patient safety in cases which ventilation is delayed after
induction of anesthesia
→ In the presence of a patent airway, insufflation of 100%
oxygen increases the apneic duration, permitting multiple
airway interventions should a difficult airway be encountered
● Oxygen is delivered for several minutes prior to anesthetic
induction.
→ The functional residual volume (FRC) is purged of nitrogen.
→ Up to 90% of the normal FRC [of 2 L] is filled with oxygen and
with an average oxygen consumption of 200-250 mL/min, a
preoxygenated patient may have 5 to 8 minute oxygen
reserve.
Reporter’s notes:
● Prior to placing the patient in prone position for the
elective surgery, the patient can be preoxygenated with
100% oxygen for 3 minutes with the head lying to one
side and placed on a cushioned head ring.
4. BAG AND MASK VENTILATION (BMV)
● First step in airway management in most situations
● Enables delivery of oxygen or anesthetic gas from a breathing
system by creating an airtight seal with the patient’s face
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through face mask with a contoured rim that conforms to a
variety of facial features.
● Two requirements of effective BMV:
→ Gas-tight mask fit to prevent leakage
→ Patent airway
▪ Squeezing the bag must result in the rise of the chest
● May be performed either with one-handed face mask
technique or two-handed technique.
→ One-handed technique will be used of this case (further
discussed below)
→ Two-handed technique is used in patients with difficult airway
One-Handed Face Mask Technique (Figure 24)
● Mask is usually held against the face by downward pressure
applied by the left thumb and index finger.
● The left middle and ring finger grasp the mandible to facilitate
extension of the atlanto-occipital joint.
● The little finger is placed under the angle of the jaw to thrust the
jaw anteriorly.
● If left is used to hold the mask as described above, the right
hand is used to generate positive-pressure ventilation by
squeezing the breathing bag
Figure 24. One-handed Face Mask Technique
Reporter’s notes:
● A case from the Journal of Anesthesia revealed that there
are 3 options for airway management in prone position:
→ Endotracheal intubation guided by direct
laryngoscopy
▪ Indicated for prone position and is the procedure
chosen for this case
→ Awake fiberoptic intubation
→ Insertion of laryngeal mask airway (LMA)
5. ENDOTRACHEAL INTUBATION
● Utilized for the conduct of general anesthesia and to facilitate
the ventilator management of the critically ill.
● A procedure in which a tracheal tube (TT) is inserted through
the mouth (orotracheal intubation) or nose (nasotracheal
intubation) down into the trachea to protect the airway and
maintain airway access.
● Indications
→ Patients who are at risk of aspiration
→ Surgical procedures involving body cavities or the head and
neck.
Techniques used in Orotracheal Intubation
● Before any attempt on endotracheal intubation is performed,
preparatory measures must be performed:
→ Correct patient positioning
→ Ventilation with 100% oxygen
→ Preparation of necessary equipment
 → Administration of drugs to aid intubation such as sedatives,
muscle relaxants or vagolytics
● Tracheal Tube selection
→ Based on the patient’s general data (i.e., age and sex)
→ Appropriate internal diameter is important due to the following
reasons
▪ Lower airflow resistance
▪ Facilitates suctioning secretions
▪ Allows passage of bronchoscope
▪ May aid in liberation from mechanical ventilation.

Figure 26. Position of the Anesthesiologist during Laryngoscopy and

Reporter’s notes:
● This case presents with a 17-year old female patient.
Therefore, according to the tube selection guide), the
internal diameter of tracheal tube to be used must not
exceed 7.5 millimeters.
● Checking of tracheal tube
→ The cuff inflation system should be tested by inflating the cuff
using a 10 mL syringe.
→ Maintenance of cuff pressure after detachment of syringe
● Insertion of stylet (in adult patients)
→ The stylet is used to make the tube straight at the distal
portion and bent upward to form a hockey stick shape.
(Figure 25)
→ This shape avoids blocking the operator’s view of the vocal
cords and facilitates intubation of an anteriorly placed larynx.
Intubation
● With the patient’s mouth opened, the laryngoscope blade is
introduced into the right side of the oropharynx using the left
hand.
● The tongue is swept to the left and up into the floor of the
pharynx by the blade’s flange.
→ The epiglottis is identified to allow correct positioning of
airway landmarks.
→ Using either straight/curved blade, the epiglottis is lifted to
expose the vocal cords
● The tracheal tube is then taken with the right hand and its tip is
passed through the abducted vocal cords with the tube cuff
lying in the upper trachea but beyond the larynx.
● Laryngoscope is withdrawn and cuff is inflated with the least
amount of air necessary to create a seal.

Table 8. Two types of laryngoscope blade

Miller/Straight Blade
Blade is placed posterior to
the epiglottis; the operator
picks up the epiglottis with the epiglottis; the operator
tip of the blade
Figure 25. A tracheal tube with a stylet bent to resemble a hockey stick
Macintosh/Curved Blade
Blade is placed between the
posterior tongue and
indirectly lifts the epiglottis and
moves it out of the line of site
by advancing the blade into
the valeculla and pressing
against the hyoepiglottic
ligament.

Direct Laryngoscopy & Orotracheal Intubation

● Direct laryngoscopy displaces pharyngeal soft tissues to create
a direct line of vision from the mouth to the glottis

Laryngoscope Technique:
● During the procedure, the anesthesiologist must be at the end
of the operating table facing the patient’s head (Figure 26)
● With suction available at hand, hold laryngoscope in left hand
and endotracheal tube in right hand
● Open the patient’s mouth with a right-handed scissor technique
● Insert the laryngoscope blade on the right side of the
oropharynx and sweep the tongue to the left and up into the
floor of the pharynx Reporter’s notes:
→ The epiglottis is identified to allow correct positioning of ● For pediatric patients, straight blade approach with
airway landmarks. Miller blade is used to lift the epiglottis.
→ Provides a better view with almost all of the glottic
opening.
→ This technique is more prone to chipping of teeth and
should be done with utmost care.

● In the case presented in Journal of Anesthesia, the

anesthesiologist was able to visualize the patient’s vocal cords
through direct laryngoscopy on a patient in prone position

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