Anesthesia Review

Vic V. Vernenkar, D.O.

St. Barnabas Hospital
Dept. of Surgery
The Anesthesiologist
Initial Assessment
ASA classification is part of the physical
examination of the patient.
Is graded classes 1-6 in order of increasing
risk of mortality.
ASA Classification
Class 1 Healthy
Class 2 Mild systemic disease, no func limitations
Class 3 Moderate to severe systemic disease,
functional limitations
Class 4 Severe systemic disease, constantly life
threatening, functionally incapacitating
Class 5 Not expected to survive with or without
surgery 24h
Class 6 Organ Donor
Class E Emergency
Monitoring
Noninvasive BP monitoring with
appropriate cuff size.
Invasive BP monitoring (A-line) for elective
hypotension, anticipation of wide variations
in BP, need for frequent blood sampling.
Common sites are femoral and radial sites.
Don’t use Brachial artery.
Monitoring
EKG for detection of dysrhythmias, myocardial
ischemia, electrolyte abnormalities.
Leads V2 and V5 together detect 95% of
intraoperative ischemia, allowing for early
intervention.
Pulse oximetry estimates level of oxygen binding
by hemoglobin
SaO2 of 70%, 80%, and 90% correlates to PaO2
of 40, 50, 60.
Monitoring
Temperature- Axilla, esophagus, pharynx, bladder.
Urine output- a measure of end-organ perfusion;
Foley for all cases over 2 hrs,to decompress
bladder (lap procedures).
Swan-Ganz- for LVEDP, CO, SVR.
Capnography- confirms adequacy of ventilation,
ETT placement, estimates PaCO2.
Unexpected rise in CO2: Malignant hyperthermia.
Induction of Anesthesia
IV or mask induction of general anesthesia.
Combination of agents based on patient
characteristics, and procedure.
Includes an amnestic, analgesic, hypnotic,
muscle relaxant, and a volatile agent.
Rapid sequence induction.
Rapid Sequence Induction
Pre-oxygenate with 100% allows de-
nitrogenation of patient’s FRV, extra time.
Indications include recent oral intake,
GERD, delayed emptying, pregnancy,
bowel obstruction.
Lidocaine, Atropine, Etomidate,
Rocuronium (when Succinylcholine is
contraindicated), Versed.
Analgesic Agents
In boluses at induction and before incision, then
maintenance as needed.
Additional doses based upon sympathetic response
to pain, like increased HR, BP.
Fentanyl, a synthetic narcotic, onset 2min, peak
5min. Metabolized by liver.
Gag is blunted, minimal cardiac depression, can
induce respiratory arrest.
40 times potency of morphine, no cross allergy
though.
Analgesics
Morphine- 5min onset, peak at 20min.
Metabolites cleared by kidney
Histamine release with hypotension
possible.
Ketamine- PCP analog, intense analgesia,
amnesia, dissociative anesthesia.
Analgesics
Ketamine increases HR, BP,
bronchodilator, maintains spontaneous
ventilation. Increased CBF.
Illusions, dysphoria.
Not a respiratory depressant, can be sole
anesthetic agent.
One of several induction agents, good for
children, contraindicated in head injury.
Sedative-Hypnotic Agents
Sodium thiopental, a barbiturate, induces
unconsciousness within 30 seconds without
analgesia.
Excellent anticonvulsant.
After single dose drug redistribution into
muscle may result in rapid awakening.
Sedative-Hypnotic Agents
Side effects: hypotension (in hypovolemia),heart
failure, beta blockade, resp. arrest, decreases CBF,
metabolic rate.
Propafol, fast acting, no hangover (great for
outpatients) antipyretic, antiemetic.
Rapid metabolism by liver.
Side effects: hypotension, blunting of airway
reflexes helping in intubation, resp. arrest.
Sedative-Hypnotic Agents
Used for maintaining anesthesia, sedation in
ICU.
1.1kCal/mL!
Etomidate, fast acting, minimal
hypotension, great for induction.
Sedative-Hypnotic Agents
Rapid metabolism by liver, avoid
continuous infusions as can cause
adrenocortical suppression.
Can cause myoclonus.
Benzodiazapines, provide anxiolysis,
hypnosis, amnesia, anticonvulsant, skeletal
muscle relaxant properties.
Sedative-Hypnotic Agents
No analgesic properties here.
Versed most common, short acting, liver
metab, so watch it….crosses placenta.
Ativan long acting.
Flumazenil is a benzodiazapine
antagonist…associated with seizures!
Muscle Relaxants
Used to facilitate intubation.
During abdominal surgery.
When movement can be devastating.
Paralyzed but still feel and remember
everything!
No analgesia, hypnosis, or amnesia.
Diaphragm last to go down, first to recover.
Neck Muscles first to go down, last to recover.
Muscle Relaxants
Depolarizing and non-depolarizing.
Depolarizing agents cause an initial
transient muscle fiber activation before
relaxation occurs.
Muscle Relaxants(Depolarizing)
Succinylcholine, provides rapid
depolarizing blockade. Mimics
acetylcholine, 30 seconds, short duration 5-
10 min.
Rapidly metabolized by plasma
pseudocholinesterase.
The only one!
Muscle Relaxants(Depolarizing)
1in 3000 homozygous for trait where it is
abnormal…prolonged paralysis.
Increase in serum potassium….cardiac arrest in
some.
Contraindicated in stroke, burns, trauma,
myopathy,bedridden, renal failure.
Malignant hyperthermia rare complication of
succinylcholine.An autosomal dominant disorder
of skeletal muscle calcium metabolism.
Malignant Hyperthermia
Combo of volatile anesthetic plus succs.
First Sign is Increased end-tidal CO2.
Acidosis, muscle spasm.
Hypertension, arrhythmias.
Hypoxemia, hyperkalemia
Tachycardia, pyrexia.
Myoglobinuria.
Tx: IV Dantrolene 10mg/kg, cool, D/c volatile
agent.
Non-Depolarizing
Rocuronium
Pancuronium
Vecuronium
Atracurium
Mivacurium
All inhibit acetylcholine at NMJ.
No fasciculation, or increase in potassium.
Non-Depolarizing
Rocuronium, fast, used when succs
contraindicated.
Pancuronium, inexpensive, used for prolonged
paralysis, tachy, prolonged in renal.
Mivacurium dependent on pseudocholinesterase.
All potentiated by hypokalemia, calcemia,
hypermagnesemia.
Monitored by peripheral nerve stimulation.
To reverse, use Neostigmine (blocks acetyl
cholinesterase) plus anticholinergic agent (to
counteract brady) at end of surgery.
Airway
Mask ventilation used at time of induction.
Can be sole means of airway in patients with
minimal risk of aspiration.
Ventilation also facilitated by oral or nasal
airway (tongue, awake patient).
LMA lodges in hypopharynx superior to larynx
preventing soft tissue obstruction of airway.
Contraindicated in aspirators, paralyzed, need for
controlled ventilation.
LMA
Airway
Endotracheal Intubation allows for vent
support, oxygenation, relative protection of
airway.
Confirm position by checking bilateral chest
rising, condensation in ETT, End-tidal CO2,
bilateral breath sounds.
Fiberoptic laryngoscopy in difficult
intubations.
Inhalation Anesthetic
After induction anesthesia is maintained
with a volatile anesthetic.
Provides hypnosis, amnesia, some degree of
analgesia and muscle relaxation.
Differ in blood solubility, potency, side
effect profiles.
Inhalation Anesthetic
Minimum Alveolar Conc. (MAC) is the
smallest concentration at which 50% of
patients will not move in response to
surgical incision.
Solubility of agents correlates with speed of
induction, so insoluble agents provide
quickest onset.
Inhalation Anesthetic Agents
Volatile Agents
Halothane
Isoflurane
Sevoflurane
Desflurane
Side Effects of Volatile Agents
Hypotension via cardiac depression
(halothane) or vasodilitation.
Arrythmogenic (halothane) potentiated by
epinephrine.
Isoflurane least cardiac depressant, most
coronary artery dilation.
Side Effects of Volatile Agents
Rapid, shallow breathing resulting in decreased
minute ventilation, bronchodilation.
Blunts hypoxic drive
Impair cerebral auto regulation, or ability of brain
to maintain cerebral blood flow over a wide range
of BPs.
Isoflurane used in ICP patients
Halothane rarely causes Hepatitis.
Nitrous Oxide
Not potent, requires large inhalation
concentrations.
Insoluble in blood
Minimal cardiac depression, BP changes little. No
muscle relaxant properties like volatile agents.
Not bronchodilator, increases PVR.
May expand air cavities by diffusing in faster than
diffuses out….ba-boom. Avoid in PTX, SBO,
middle ear occlusion.
Regional Anesthesia
Spinal Anesthesia, L3-L4 interspace. Free flow
of CSF confirms subarachnoid placement where
local is injected.
Anesthesia occurs in minutes, lasting up to 2 hrs
depending on agent and dose.
Level of sympathetic block higher than sensory
block, this in turn above level of motor block.
Sympathetic block results in hypotension.
High spinal results in respiratory depression.
Motor recovers before sensory.
Spinal
Regional Anesthesia
In Epidural anesthesia, a catheter is placed
in epidural space allowing for continuous
infusion to relieve postoperative pain.
Final level of sensory blockade depends on
volume injected not dose.
Onset slower than spinal.
Epidural