Anesthesia for NLE Step 2

Chanatthee Kitsiripant, MD. FRCAT. PSU

 Outline
• Preoperative evaluation & preparation

• General anesthesia
- Technique
- Anesthetic agents

• Regional anesthesia
- Local anesthetics
- Complications

• Oxygen therapy

• BLS & ACLS

preoperative
evaluation
 Preoperative evaluation

• V/S
• History in general
• BW, BM I
• Coexisting diseases • Airway assessment
• Current medication - Mallumpati, TMD, ICG,
• Allergy ULBT, neck flex/extend
• Anesthetic history • Heart
• Family History • Lung • Lab
• Social History • Abdomen • Imaging
• Review of system
• Neuro
• RA : Back, Extremities
 Preoperative evaluation

ASA
Classification

Choice of anesthesia
Problem list Anesthetic technique

Postpone surgery/
Expert Consultation
Preoperative preparation
NPO
• Solid food 6 - 8 hr
• Formula milk 6 hr
• Breast milk 4 hr
• Clear liquid 2 hr

Risk of aspiration Aspiration prophylaxis

• Recent meal • Ranitidine
• Abnormail 50 mg IV
peristalsis • Metoclopramide
• Obstruction 10 mg IV
• Delayed gastric • 0.3 M Sodium citrate
emptying time 30 ml po
Preoperative preparation
Sedatives : calm the anxious patient
: help provide a restful night sleep
before surgery
Benzodiazepine : Diazepam, Midazolam

*** Reduce or withhold sedatives and analgesics in

- elderly
- debilitated patients
- acutely intoxication
- upper airway obstruction
- trauma
- central apnea
- neurologic deterioration
- severe pulmonary and valvular heart diseases
Preoperative preparation

Opioids : to relieve pain

especially in known case chronic pain
*** Reduce or withhold opioid in infant, UAO, airway
difficulty or apnea, severe pulmonary and valvular
heart diseases, neurologic deterioration, hepatic or
renal insufficiency

Anticholinergic drugs : dry secretion

• Atropine, Scopolamine, Glycopyrrolate
 Preoperative preparation

Hypertension Diabetes mellitus Asthma

• Diuretics • DTX เช้าวันผ่าตัด • Bronchodilator
• Ca channel blocker • Hypoglycemic drug
• Beta blocker
• ACEI/ARB
 general
anesthesia
General anesthesia (GA)

Nociceptive
input
Analgesia

Amnesia
Arousal
feeling Unconscious
Consciousness
Areflexia
Autonomic response
Relaxation
Somatic response
- muscle contraction
- movement
 Sequence of GA
Intubation

Induction Maintenance Emergence

Hypnotic
• Induction agents • Volatile anesthetic gas
• Opioids • IV anesthetic
• Muscle relaxants • Benzodiazepine
Analgesia
• Opioids
Relaxation
• Muscle relaxants Reverse
 Technique of GA
Induction Intubation Hypnotic Relaxation Analgesia

Total intravenous
IV IV Opioid
anesthesia (TIVA)

Balanced technique IV Relaxant Inhale Relaxant Opioid

Inhalation
IV Relaxant Inhale Inhale Opioid
technique

Undermask IV Inhale Inhale Opioid

Volatile induction
maintenance Inhale Inhale Inhale Inhale Opioid
anesthesia (VIMA)
 Anesthetic agents
• IV anesthetic agents

• Opioids

• Muscle relaxants and reversal

• Inhalation anesthetic agents

IV anesthetic agents

Inhibitory effect Excitatory effect

IV anesthetic agents
Thiopental (3 - 5 mg/kg IV)

• Rapid onset, Ultrashort acting

• pH 10.6 >> thrombophlebitis

• CNS : Coupling effect >> decrease CMRO2 & CBF

Anticonvulsant (1 - 2 mg/kg)
Contraindication
• CVS : Vasodilate >> decrease CO - Hypotension
- Acute intermittent
• RS : Hypoventilation, apnea porphyria
IV anesthetic agents
Propofol (2 - 3 mg/kg IV)

• Rapid onset and recovery

Contraindication
• Antiemetic effect - Hypotension
- Soybean/egg
• Pain on injection allergy

• CNS : Decrease ICP, CMRO2

• CVS : Hypotension, myocardial depression

• RS : Respiratory depression
IV anesthetic agents
Etomidate (0.2 - 0.3 mg/kg IV)

• CNS : Decrease ICP, CMRO2

• CVS : Hemodynamic stable

• RS : Minimize depress ventilation

• N/V

• Pain on injection

• Adrenocortical suppression >> adrenal insufficiency

IV anesthetic agents
Ketamine (1 - 2 mg/kg IV, 3 - 5 mg/kg IM)
• Dissociative anesthesia

• Potent analgesia

• Nystagmus

• Increase ICP and CMRO2

• Sympathetic stimulation >> Hypertension, tachycardia

• No respiratory depression but hypersecretion

Opioids
Postoperative pain control

*** Multimodal analgeisia***

 Muscle relaxants

Nondepolarizing NMBA Depolarizing NMBA

 Muscle relaxants
แบ่งตาม mechanism of action
• Depolarizing muscle relaxant : Succinylcholine
• Nondepolarizing muscle relaxant : Pancuronium,
Vecuronium, Rocuronium, Atracurium, Cisatracurium, Mivacurium

แบ่งตามระยะเวลาการออกฤทธิ์
• Ultrashort acting (5-10 min) : Succinylcholine
• Short acting (10-15 min) : Mivacurium
• Intermediate acting (20-40 min) : Vecuronium, Rocuronium,
Atracurium, Cisatracurium
• Long acting (40-60 min) : Pancuronium
 Muscle relaxants
CNS :
• Succinylcholine >> increase ICP

CVS :
• Succinylcholine >> bradycardia, hypotension

• Atracurium >> “histamine release” (vasodilate,

hypotension)

• Pancuronium >> “vagolytic effect” (tachycardia,

hypertension)
 Muscle relaxants
RS :
• Atracurium >> “histamine release” (bronchospasm)

Electrolyte imbalance :
• Succinylcholine >> hyperK (0.5-1 mEq/L) especially in
Burn, spinal cord injury Pt.

Metabolic :
• Succinylcholine >> malignant hyperthermia
 Muscle relaxants
Metabolite/Exc
Dose (mg/kg) Side effect
retion
Pseudocholineeste IICP, bradycardia,
Succinylcholine 1 - 1.5
rase hyperK, MH

Pancuronium 0.1 - 0.2 Liver/Urine Vagolytic effect

Vecuronium 0.1 - 0.2 Liver/Bile

Rocuronium 0.6 - 0.9 Liver/Bile

Hofmann
Atracurium 0.5 - 0.6
elimination
Histamine release

Hofmann
Cisatracurium 0.1 - 0.2
elimination
Reversal of muscle relaxants

Depolarizing NMBA :
• Pseudocholinesterase

Nondepolarizing NMBA :
• Anticholinesterase “Neostigmine” >> increase Ach

- Nicotinic recepter >> muscle contraction

- Muscarinic receptor >> bradycardia, bronchoconstriction,

hypersecretion, salivation

ให้ Anticholinergic drug (Atropine) ร่วมด้วย

Inhalation anesthetic agents
Hypnotic
Gas Analgesia
• Nitrous oxide Relaxation
Decrease BP
Volatile agent
• Halogenated hydrocarbon : Halothane
• Ether group : Isoflurane, Sevoflurane, Desflurane
 Inhalation anesthetic agents
Blood-gas solubility
Concentration effect
>> บอก onset

Alveolar ventilation

Minimal alveolar concentration (MAC) >> บอก potency

ระดับความเข้มข้นของยาดมสลบในถุงลมปอดที่ความดัน 1 บรรยากาศ ที่
ทาให้ผู้ป่วย 50% ไม่ตอบสนองต่อ surgical stimuli
Inhalation anesthetic agents

Side effect
Benefit
• Hypotension
• Nonflammable
• Potentiates neuromuscular block
• Hypnotic
• Increase CBF, ICP but decrease
• Low degree of respiratory CMRO2 >> uncoupling effect
depression VS IV agents
• Spontaneous ventilation >> rapid
• Potent bronchodilators shallow breathing

• Uterine atony

• Trigger malignant hyperthermia

Inhalation anesthetic agents

N2O

• Gas, no color, not irritate

• potent analgesia

• Second gas effect

• Diffusion > N2 34 times >> expand close space

• Diffusion hypoxia >> high FiO2 3 - 5 min

• Prolonged exposure >> BM depression, teratogen

Inhalation anesthetic agents

Halothane

• High potency (MAC 0.75)

• Good smell, not irritate airway

• Bradycardia, induced arrhythmia

• Induced hepatitis

• Increase ICP
Inhalation anesthetic agents

Isoflurane

• Not induced arrhythmia

• good muscle relaxation

• Slow onset/offset of action

• Irritate airway

• Coronary steal syndrome

Inhalation anesthetic agents

Sevoflurane

• Good smell, not irritate airway

• Fast onset/offset of action

• Not induced arrhythmia

• good muscle relaxation

• Low flow >> Compound A (nephrotoxic)

Inhalation anesthetic agents

Desflurane

• Most rapid onset/offset of action

• Not induced arrhythmia

• good muscle relaxation

• Irritate airway >> bronchospasm

• Tachycardia
Intubation
Sniffing position
• Flexion at lower C-spine
(neck)
• Extension at atlanto-
occipital joint (head)

Case C-spine injury

• Manual in-line stabilization
 Intubation

Risk of aspiration
• Rapid sequence induction with cricoid pressure

Difficult airway
• Awake intubation/VDO laryngoscope
• Expert consultation

Severe maxillofacial injury/Fx base of

skull
• Avoid nasal intubation
Confirmation of ETT placement

• เห็น endotracheal tube ผ่านเข้าไประหว่าง vocal cord

• ใช้ stethoscope ฟังเสียงการหายใจที่ปอดด้านบนและชายปอดทั้ง 2 ข้าง
• เห็นทรวงอกขยายเท่ากันทั้ง 2 ข้างตามจังหวะการช่วยการหายใจ
• สังเกตเห็นไอน้ําเกิดขึ้นภายใน endotracheal tube เวลาหายใจออก
• สังเกตการเปลี่ยนแปลงของ oxygen saturation
• Capnograph
• fiberoptic bronchoscope
• chest x-ray
 regional
anesthesia
 Contraindication to RA
Absolute Relative
contraindications contraindications

• Patient refusal • Systemic sepsis

• Infection at injection site • Increased ICP
• Untreated hypovolemia • Skeletal anomalies
• Coagulopathy • Neurological disease
• Local anesthetic allergy • Fixed CO state ex. AS

• Unco-operative Pt.

• Complicated surgery
Neuraxial block

Peripheral
nerve block

Local
infiltration
Spinal block
Spinal block
Spinal block

Prepare & Monitoring

• EKG
• NIBP
• SpO2

Positioning
• Lateral
• Sitting
Spinal block
Local anesthetics
 Local anesthetics

onset potency duration

Local anesthetics
Local anesthetics
 Complications of RA
Local anesthetic systemic toxicity (LAST)
• Prevention
- max dose calculation
- add epinephrine
- incremental injection of LA
- device : ultrasonography

• Management
- stop injection immediately
- A-B-C
- stop cerebral excitation
- antidode : Lipid emulsion
 Complications of RA

Hypotension
• Prevention & Treatment
- Preloading IV fluid 10 - 20 ml/kg
- Vasopressor : ephedrine, norepinephrine

Bradycardia
• Mechanism
- High block (cardiac accelerator fiber : T 1 - T4)
- Benzold Jarisch reflex

• Treatment : Atropine
 Complications of RA

Postdural puncture headache (PDPH)

• Mechanism
- CSF leak >> decrease ICP >> traction/stretching pain
sensitive and vascular structure

• Risk factors
- Young, female, pregnancy
- Large spinal needle
- Type of needle >> sharp tip
- Multiple attempts
- Needle bevel is vertical to dural fiber
 Complications of RA

Postdural puncture headache (PDPH)

• Clinical presentation
- headache in upright position
- throbbing pain at frontal/occiput area
- onset 24 - 48 hr
• Treatment
Supportive : - Fluid intake > 3 L/day
- pain control : paracetamol, NSAIDs
- bed rest
Specific : - epidural blood patch
 Complications of RA

Nausea/Vomiting
• Mechanism
- unopposed vagal activity
- related with hypotension

• Treatment : antiemetic drugs, treat hypotension

Urinary retention
• Mechanism
- urinary sphincter spasm, overdistension of bladder
- last until regression to S3

• Treatment : intermittent cath, retained foley’s cath

 oxygen
therapy
Indication for Oxygen therapy

- Prevent and correct hypoxemia

Hypoxemia
- Decrease cardiopulmonary working

- Hypoxemic hypoxia
- Abnormal O2 transport
Tissue hypoxia
- Circulatory hypoxia
- Histotoxic hypoxia

- Enhance absorption of air space :

Miscellaneous - CO poisoning
- Hyperbaric oxygen therapy
Oxygen therapy in Hypoxemia

1. Prevent and correct hypoxemia

• Cause : • Low PiO2
• Impaired pulmonary gas exchange
• Low mixed venous oxygen saturation

• Goal : keep PaO2 > 60 mmHg, SaO2 > 90%

2. Decrease cardiopulmonary working

• Hypoxemia >> work of breathing หัวใจทางานมากขึ้น

>> heart failure ได้ในผู้ป่วยที่ cardiac reserve ต่า/ MI
 Oxygen delivery devices

1. High flow system/fixed performance device

• FiO2 คงที่ แต่ total flow ต้อง 3 เท่า minute volume

• Venturi mask, Aerosol mask, T-piece, air O2 blender

2. Low flow system/variable performance

device
• FiO2 ไม่คงที่ ขึ้นกับรูปแบบการหายใจ, ขนาด reservoir

• Nasal cannula, Face mask, (simple, non-rebreathing)

 Device Flow oxygen (LPM) FiO2

1 0.24
2 0.28
3 0.32
Nasal cannula 4 0.36
5 0.4
6 0.44

6 0.4
Simple mask 7 0.5
8 0.6

6 0.6
7 0.7
Partial rebreathing
8 0.8
mask 9 > 0.8
10 > 0.9

Non-rebreathing
≥ 10 1
mask
 basic
life
support
advanced
cardiac
life
support
Do your best !
ABCD management
- jaw thrust
- O2 supplement
 Diagnosis

PEA : chest compression >> adrenaline

Aerosal mask
(when flow ≥ peak inspiratory flow)
( สายเป็น corrugate >> ไม่หักพับ)
 Chest compression

Endobrionchial intubaton
Multimodal analgesia
Absolute NPO
Aspiration prophylaxis
 Rapid sequence induction

Multimodal analgesia
 C-A-B

Hypersecretion
mcg

1,100

2,200 psi -> 622 L

1,100 psi -> 31 1 L
31 1 L >> 6 LPM : 31 1/6 = 50 min

Size E : K = 0.28
1,100 x 0.28 = 308 L
308/6 = 50 min
protection
Chest compression
 SVT

• Synchronized cardioversion 50 – 100 J

• If regular narrow complex, consider
Hypotension << Adenosine 6 mg IV [normal BP]
- If not response >> cardioversion

Anaphyllaxis criteria
• Unknown allergen : skin + Respi/Cardio
• Likely allergen : 2 of 4 systems
(skin/Respi/Cardio/GI)
• Known allergen : BP drop
 Pulseless VT

1 st shock: IV
2nd shock: Epinephrine, intubation, capnograph
3rd shock: Amiodarone
Correct reversible causes

PEA