Drona Foundation Course Salyatantra Note 6 2020-21

Sterilization, Anaesthesia, Trividha Karma

Q1. Define Anaesthesia and write its types. Explain spinal anaesthesia in
detail? (10 marks) (Amrita Feb 2016, July 2015)
Answer:
Anaesthesia is a state of controlled, temporary loss of sensation or awareness that is
induced for medical purposes. It may include analgesia, paralysis, amnesia and
unconsciousness.
Aims of Anaesthesia-

• To ensure a pain free surgery.

• To provide a motionless and unresisting field for surgery.
Types of Anaesthesia-
General anaesthesia (GA): The patient is unconscious and there is a generalised and
reversible depression of the central nervous system.
Regional anaesthesia: This involves injection of local anaesthetic agents in close proximity to
the nerves or nerve bundles supplying the site of surgery. Regional anaesthesia can be central
neuraxial block or peripheral nerve blocks.
Central neuraxial block: When regional anaesthesia is induced by injecting the local
anaesthetic agents around the spinal cord, it is called central neuraxial block.
Peripheral nerve block: When regional anaesthesia is induced by injecting the local
anaesthetic agents around nerve plexuses or individual nerves, it is called peripheral nerve
block.
The choice of anaesthesia depends on several factors:

• The site and duration of surgery.

• General condition of the patient
• Expertise of the anaesthesiologist and
• Preference of the patient
Regional anaesthesia has a small failure rate and certain surgeries may outlast the duration of
block provided by the regional block, in which case general anaesthesia may need to be
given. Thus even though the primary anaesthetic contemplated is regional anaesthesia,
patients must also be fit for general anaesthesia.
Spinal Anaesthesia-

• Injection of local anaesthetics around the spinal cord to produce a reversible blockade
of impulses that pass through it is called central neuraxial blockade.
• When the local anaesthetic is injected into the cerebrospinal fluid bathing the spinal
cord, it is called spinal anaesthesia (subarachnoid block).
Indication and Contraindication of spinal anaesthesia
Indications-Any surgery below the level of umbilicus
Contraindications-
Absolute- Patient refusal, Infection at the site of injection, Bleeding tendancies
Relative- Hypovolaemia, Severe stenotic valvular heart disease

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Position: The spinal anaesthetic may be administered with the patient in lateral or sitting
position.
Lateral: The patient lies either in the left or right lateral position. The back should be parallel
to the edge of the operating table and perpendicular to the ground. The legs should be flexed
at the hips as much as possible.
Sitting position: The patient sits on the table, with the back bent forward. He is allowed to
rest his arms on pillows. The back is cleaned with spirit and betadine and draped. Under
aseptic precautions, the vertebral spines are identified in the lumbar region. The highest point
of the iliac crest corresponds to L3-4 space. The L2-3, L3-4, L4-5 intervertebral spaces can
also be used. A space higher than this is not used as the spinal cord ends at L1 in adults. This
point is lower in children and should be borne in mind in paediatric spinals.
Complications: These may be classified into Minor and Major based on the reversibility and
seriousness of the complication.
Minor:

• Hypotension: This is treated with intravenous fluids to compensate for the vasodilatation.
If necessary, incremental doses of a vasoconstrictor may also be used.
• Bradycardia: If the cardioaccelerator nerves (T1-T4) are blocked. This is usually easily
treated with an anticholinergic such as atropine or glycopyrrolate. If profound, a small
dose of adrenaline may be required (very rare).
• Postdural puncture headache (PDPH): The incidence of PDPH depends on the size of the
needle used, number of punctures made, fluid status and ambulation. With finer (25 and
26# needles) and good hydration of the patient, PDPH is uncommon. This may be treated
with rest, increased fluid intake, plenty of coffee and NSAIDs. Rarely, an epidural blood
patch (vide infra) may be required.
• Respiratory depression: If the level of spinal anaesthesia is high and all intercostals
muscles are paralysed, respiratory depression may occur. However, diaphragm, the
principal muscle of respiration is supplied by the thick phrenic nerve which does not get
blocked easily. Any respiratory depression seen during spinal anaesthesia is more due to
hypoperfusion of the respiratory centre (due to hypotension). This can be treated with
respiratory support as required and stabilisation of blood pressure.
• Retension of Urine: Backache: This is not a problem of spinal anaesthesia per se but may
be due to faulty positioning during surgery.
Major:

• Infection: Arachnoiditis, meningitis

• Nerve injury: Cauda equine syndrome

Q2. What is the importance of premedication anaesthesia? Explain the

stages of anaesthesia? (10 marks) (Amrita Feb 2014)
Answer:
Premedication:
Premedication is the term given to the administration of certain medications prior to
anaesthesia. The drugs used for premedication and their objectives are as follows:

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1. To allay anxiety: Certain degree of anxiety is felt by most patients before surgery. A good
rapport developed between the patient and the anaesthesiologist helps relieve this anxiety.
Any of the following medications may be used.
Adults: (Night before and morning of surgery)
Tab Diazepam 0.1-0.2 mg/kg
Tab Lorazepam 2-4 mg orally
Children: To enable easy separation from parents.
Midazolam 0.5 mg/kg (maximum 10 mg) mixed with 5 ml of paracetamol syrup is given
orally 15-20 minutes prior to the procedure.
Tricolofs syrup, 100mg/kg, one hour prior to surgery
2. To relieve pain: If the patient has any painful condition that could get aggravated on
movement, a narcotic is often added to reduce the pain during shifting from the ward,
e.g.fractures. Morphine(0.1 mg/kg), pethidine(0.5 mg/kg) or tramadol(0.5-1 mg/kg) given
IM are often used.
3. To dry secretions: An anticholinergic such as glycopyrrolate (0.2 mg) is added if a
fibreoptic intubation is planned so that oral secretions do not hinder vision. Local
anaesthetic agents produce better local anaesthesia of the upper airway when the mucosa
is dry. It may be given intravenously just prior to surgery in ENT surgeries and oral
surgeries.
4. To help anaesthesia induction: Premedication with a narcotic provides analgesia and
helps induce anaesthesia more smoothly.
5. To blunt baroreceptor reflexes: A small dose of β blockers or clonidine may be given in
certain Patients to blunt baroreceptor reflexes during intubation.
6. To reduce gastric volume and acidity: Some patients are at risk of regurgitation of gastric
contents and aspiration. They may be premedicated with a prokinetic such as
metochlopramide (10 mg) and a H2 blocker such as ranitidine (150 mg orally).
Pantoprazole 40 mg may be given instead of ranitidine. The consequences of aspiration of
gastric contents depends on its quantity and acidity. Particulate matter, if aspirated can
cause mechanical blockage of the airways
Stages of anaesthesia
There are four stages of anaesthesia
Stage 1 : Stage of Analgesia
Stage 2 : Stage of Delirium and Excitement
Stage 3 : Stage of surgical anaesthesia
Stage 4 : Medullary or Respiratory paralysis
Stage 1: Stage of Analgesia

• Starts from beginning of anaesthetic inhalation and lasts up to the loss of consciousness.
• Pain is progressively abolished
• Patient remains conscious, can hear and see and feels a dream like state.
Stage 2: Stage of Delirium and Excitement

• Stage starts from loss of consciousness up to gain of rhythmical respiration.

• Respiration- Irregular and large in volume
• Heart rate and BP raises.
• Pupils- Large and divergent.
• Muscle tone increased- jaw may be tight
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• Patient may shout or struggle

• Involuntary micturation of defeacation
Stage 3: Stage of surgical anaesthesia

• Extends from onset of spontaneous respiration to respiratory paralysis

• This has been divided into four planes
➢ Plane 1: Roving eyeballs. This plane ends when eyes become fixed.
➢ Plane2: Loss of corneal and laryngeal reflexes
➢ Plane 3: Pupils starts dilating and light reflex is lost.
➢ Plane 4: Intercostal paralysis, shallow abdominal respiration, dilated pupil.
Stage 4: Medullary or Respiratory paralysis

• It is also known as overdose, occurs when too much anaesthetic medication is given
relative to the amount of surgical stimulation
• The patient have severe brainstem or medullary depression, resulting in a cessation of
respiration and potential cardiovascular collapse.

Q3. Describe the types of anaesthesia, explain stages, procedure and

complications of general anaesthesia.(10 marks) (Amrita Feb 2017)

Answer: Types of Anaesthesia: Refer Q1, Stages of Anaesthesia: Refer Q2

Procedure:
Before Procedure: Before having an operation, the anaesthetist will look the medical history
and will ask whether anyone in the family of the patient has had problem with anaesthesia.
Should also ask about the patient’s general health and lifestyle, including whether they: have
any allergies, smoke or drink alcohol, are taking any other medicine
During Procedure: The medications of anaesthesia should deliver through an intravenous line
in arm. Sometimes may given a gas to breath from a mask. Children may prefer to go to sleep
with a mask.
Once the patient were asleep, should insert a tube into patient’s mouth and down to the wind
pipe. The tube ensures oxygen and protects lungs from blood or other fluids, such as stomach
fluids. The patient should given muscle relaxants before inserting the tube to relax the
muscles in the patient’s wind pipe.
The anaesthesia care team monitors the patient continuously while they are asleep. They
adjust the medications, breathing, temperature, fluids and blood pressure as needed.
After The Procedure: When the surgery is complete, the anaesthesiologist reverses the
medications to wake you up. The patient probably feels groggy and a little confused when
they wake up. They may experience common side effects such as Nausea, Vomiting, Dry
mouth, Sore throat, Muscle aches, Itching, Shivering, Sleepiness, Mild hoarseness
Complications Of General Anaesthesia:

• Pain, Nausea and vomiting, Cardiovascular collapse, Respiratory depression

• Aspiration pneumonitis, Hypothermia, Hypoxic brain damage, Nerve injury
• Embolism, Backache. Headache

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• Idiosyncratic reactions related to specific agents- eg, malignant hyperpyrexia with

suxamethonium’succinylcholine-related apnoea
• Iatrogenic- eg: pneumothorax related to central line insertion.
• Death

Q4.Write in detail about pre-anaesthetic assessment of the patient and pre

anaesthetic medication (10 marks) (Amrita July 2015)

Answer:
Preanesthetic assessment is a medical checkup and laboratory investigation done by
an anaesthesia provider to assess the patient’s physical condition and any other medical
problems or diseases the patient might be suffering from. The goal of assessment is to
identify factors that significantly increase the risk of complications and modify the procedure
appropriately. The aim is to identify the appropriate anaesthetic techniques to be used to
ensure the safety of preoperative care, optimal resource use , improved outcomes and patient
satisfaction , while considering the individual and person related risk factors and
circumstances. The preanaesthetic assessment involves the consideration of information from
various sources that include the past medical records, interview, physical examination, as
well as results from medical and laboratory tests.
A mnemonic for anaesthetic assessment, to ensure that all aspects are covered.
A-Affirmative history, Airway
B- Blood haemoglobin, Blood loss estimation and Blood availability, breathing
C-Clinical examination, co-morbidities
D-Drugs being used by the patient , Details of previous anaesthesia and surgeries
E-Evaluate investigations, End point to take up the case for surgery
F-Fluid status, Fasting
G-Give physical status, Get consent
Pre-Anaesthetic Medication: Refer Q2

Q5. Define sterilisation and explain chemical sterilisation? (5 marks)

(Amrita Feb 2016)
Answer:
The process by which any living organism present on a material is completely
destroyed or terminated is called Sterilisation.
Methods
a) By heat – dry or moist
b) By chemical antiseptics
c) By mechanical means – viz filteration etc
Heat: Adequate heat is most certain and rapid method of sterilisation (causes hydrolysis and
breakdown of bacteria proteins). Higher temperatures, produce rapid sterilisation.
Dry Heat- It is used for sterilising glasswares etc . This is not suitable for sterilising culture
media, rubber connections, fabrics eg: mask, towels etc. Dry heating can be done by flaming,
incineration or hot air ovens (160°C for one hour)
Moist Heat-

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a) Boiling at 100°C is a common method for sterilising syringes etc.

b) Steam is the most effective moist heat sterilisation technique. Low temperature steam is
used for sterilising material like blankets, tubes etc. Steam at temperature above 100°C is
used in autoclave.
c) Ultra violet radiations, infra red radiations, cathode rays and gama rays have
considerable disinfectant action.
Chemical Sterilisation:
Chemical agents cause protein coagulation and disrupt the cell membrane of pathogens.

• Crezol, Lysol are mainly used for surgical instruments, for disinfecting hands etc
• Formalin is used for fumigating operation theatres, preserving specimens etc
• Chlorine for water disinfection
• Iodine for skin disinfection
• Alcohol (spirit) is used for disinfecting skin before injecting or before any operations.
• 2% glutraldehyde (cidex) is used for sterilising cystoscopes etc
• Ethyle oxide gas is widely used to sterilize disposable plastic syringes.

Q6. What is disinfection? Write different method of sterilisation. (5 marks)

(Amrita Aug 2017)
Answer:
The process by which any living organism present on a material is completely
destroyed or terminated is called sterilisation. When physical methods are used, the word
sterilisation is used and when chemical agents are used, the word disinfection is used.
Methods Of Sterilisation: Refer Q5

Q7. Define anaesthesia. Explain briefly about general anaesthesia.(5 marks)

(Amrita Feb 2019)
Answer:
Anaesthesia: Refer Q1
General Anaesthesia
The term general anaesthesia includes:

• Hypnosis (sedation)
• Amnesia
• Analgesia
• Muscle relaxation
General anaesthetic agents are of two types: Inhalational anaesthetic agents or intravenous
anaesthetic agents.
Inhalational Anaesthetic Agents
• Volatile anaesthetics: The volatile anaesthetic agents need a vaporiser to caliberate and
deliver the vapour accurately in measured doses, e.g. halothane
• Nonvolatile anaesthetics: e.g. nitrous oxide
Classification:
I. Agents of mainly historical interest
1. Ethyl Chloride
2. Chloroform

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3. Trichloroethylene
4. Cyclopropane
5. Methoxyflurane
6. Enflurane
II. Agents in occasional use:
1. Diethyl ether
III. Agents in clinical use:
1. Halothane
2. Isoflurane
3. Sevoflurane
4. Desflurane
5. Nitrous oxide
IV. Agents undergoing clinical trials- Xenon

Q8. Describe Trividha Karma in detail and discuss its importance in

surgical practice. (10 marks) (KUHS Mar 2018)
Answer:

• In Ayurvedic classics there are various types of treatment and Shastra chikitsa is one
among them.
• Sastra karma is divided into 3 parts known as Trividha Karma.
1. Purva Karma 2. Pradhana Karma 3. Paschat Karma

त्रित्रिधं कर्म - पूिमकर्म, प्रधानकर्म, पश्चात्कर्ेत्रि; िद्व्यात्रधं प्रत्युपदे क्ष्यार्ः || ( Su. Sut 5/3)

- According to Acharya Sushruta, Purva Karma means preparation of patient along with
collecting all the materials needed during the Pradhana karma. Ashtaviddha Shastra Karma is
included in Pradhana Karma. Paschat Karma includes post operative care. Sushruta divided
surgical activity into three parts i.e., pre- operative, operative and post-operative based on
sound scientific principles.

POORVA KARMA

- It is a first step of any surgery or basic requirement to perform a operative procedure.

- Poorva karma includes collection of materials required, preparation of patient and
preparations done by surgeon.
- Poorva karma is described as a pre-operative preparation to overcome the operative and
post-operative complications.

अतोऽन्यतमं कमम चिकीर्मता वैद्येन पव

ू म
म ेवोपकल्पययतव्यायन भवन्न्त, तद्यथा-
यन्रशस्त्रक्षारान्ननशलाकाशङ्
ृ गजलौकालाबूजाम्बवौष्ठपपिुप्रोतसूरपरपट्टमधुघत
ृ वसापयस्त्तै
ल- तपमणकर्ायालेपनकल्कव्यजनशीतोष्णोदककटाहादीयन, पररकर्ममणश्ि न्स्त्ननधााः न्स्त्थरा
बलवन्ताः || (Su.Su 5/5)

Agropaharana - Collection of Materials Required

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Collection of materials such as Yantra, Shastra, Kshara, Agni, Salaka, Srnga, Jalauka, Alabu,
Pichu, Prota, Sutra, Patra, Patta (cloth), Madhu, Ghrta, Vasa, Paya, Taila, attenders those who
are affectionate and strong.

Contra-Indication for oral intake before Surgery

- In diseases such as Mooda garbha, Udara, Ashmari, Arshas, Bhagandara, Mukha roga,
surgical operation should be done when the patient has not taken any food.

Procedure of Poorva Karma

On the day and time having auspicious stellar constellation, Agni, Brahmana, and
physician should be worshipped first with offering of curd, rice and gems; then perform
sacrificial rites and chant hymns. The patient is then given light food and made to sit facing
east; surgeon should sit opposite to patient and perform the procedure.

PRE-OPERATIVE PROCEDURES

• The Pre-Operative period runs from the time the patient is admitted to the hospital to the
time the surgery begins.

Steps-
• History Taking • Examination • Investigation
• Informed Consent • Nil by Mouth • Care of Bowel
• Preparation of Part • Administrations of Anaesthesia.

Pre operative investigations-

- Blood routine - RBS - CT, BT - HIV, HbSAg, VDRL, HCV
- Urine routine, microscopy - Chest PA view X Ray

Rule out previous history of

- DM, HTN, DLP, Asthma, TB, myocardial infarction,

PRADHANA KARMA
According to Susrutha, the pradhana karma contains ashtavidha sasthra karma

PASCHAT KARMA ििः

शस्त्रर्िचार्म,शीिात्रिरद्भिरािुरर्ाश्वास्य, सर्न्ताि् पररपीड्याङ् गुल्या, व्रणर्त्रिर्ृद्य(ज्य), प्रक्षाल्य
कषार्ेण प्रोिेनोदकर्ादार्, त्रिलकल्कर्धुसत्रपमः प्रगाढार्ौषधर्ुक्ां नात्रित्रिग्ां नात्रिरूक्षां ित्रििं
प्रत्रणदध्याि्; ििः कल्केनाच्छाद्य, घनां कित्रलकां दत्त्वा, िस्त्रपट्टे न बध्नीर्ाि्; िेदनारक्षोघ्नैधूमपैधूमपर्ेि्,
रक्षोघ्नैश्च र्न्त्रै रक्षां कुिीि|| (Su.sut 5/15)

After incising the knife should be taken out, the patient comforted by sprinkling cold
water on face; the area around incision should be kneaded by fingers and massaged mildly,
washed with Kashaya, cleaned by swab, then a wick made from paste of Tila added with
honey, ghee should be inserted into the wound, another thick Kavalika (pad of cloth) placed
over it and then tied up with bandage; then exposed to fumes of drugs which relieve pain

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Rakshaa Karma
Rakshaa Karma means protective measures. It is recital of certain mantras for the
quick recovery of the patients.

Vranitagara/ Aatura aagara

- Achrya Susrutha in Agropaharaniya adhyaya tells that soon after Raksha karma, the
patient should be shifted to aatura aagara.
- In Vranitopaasaniya adhyaya Susrutha tells that the chamber were the patient resides
should be free from dirt, sunlight, and heavy breeze, so that the patient will not suffer
from physical, mental and traumatic disorder.
- Fumigation of Aatura aagara should be performed using drugs like Sarshapa, leaves of
arista (nimba) added with Gritha and Saindava.

Vranitopasana- care of the wounded

- On the 3rd day of surgery, the bandage should be removed, wound is cleaned, medicated
and again tied with bandage.
- Dressing should not be removed on the second day, by removing it on second day the
wound develops hardness, heals after long time and produces severe pain.
- For faster recovery, patient should avoid Viharas like Vyayama, Vyavaya, Harsha,
Krodha, Bhaya, Divaswapna and Aaharas which are Amla, Ruksha Teeshna and Ushna.

POST-OPERATIVE PROCEDURE

The post-operative period begins from the time the patient leaves the operation room
and ends when the patients resume with normal life.

Position of Patient

- Foot end elevation is done to relive anaesthesia as soon as possible.

- Pillows should not be placed underneath the head in spinal anaesthesia, to avoid
headache.

Diet

- If the operation is not performed on the gastro-intestinal tract, fluid may be allowed from
the evening of the day of operation.
- Fluid must be given in a very restricted manner – started with a sip of water and
gradually increased to a glass of fruit juice.
- On next day of operation, semi-solid food are allowed and from the third day normal diet
is allowed.
- If the operation is done on the gastro-intestinal tract, patient is always given an IV drip
and is continued till his intestinal peristalsis returns to normal.
- Later the fluid is started by mouth and gradually replaced with semisolid and solid foods.

Antibiotics- Given to prevent post-operative infections. Type and duration depends upon the
surgery performed.

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Antacids - To prevent excess gastric secretion and gastric irritation.

Analgesics- Given to relieve pain at operation site.

Anti-emetics

- Given to avoid nausea and vomiting.

- Record BP, Pulse and GRBS
- Monitored/recorded, to access patient’s condition on post operation.
- Input and Output chart: of IV Fluids and Urine.

Drain

- It removes the separating fluid from the cavity, so that raw surface can collapse and
come into contact with each other which will enhance the rapid healing.
- Amount of collection in 24hrs along with date and time is noted.
- Drain is removed if collection is less than 10ml

Catheter

- Used during and after surgery to monitor the urine output.

- After operations to prevent postoperative retention.
- It is removed after 24hrs.

Care of wound

- If there is no soakage in the operated wound, the dressing should not be changed till the
time of removal of stitches.
- If there is collection and discharge, dressing is done daily.
- Unnecessary change of dressing may cause infection and delay wound healing.
Normally, in healthy adult, without any post-operative complications, the stitches are
removed on 5th day of operation on the head and neck, on 8th day for operation on
thorax, and abdomen

Q9. Write a note on spinal anaesthesia. (5 marks) (Amrita Feb 2019, Feb 2017)
Ans: Refer Q1
Q10. What are the indications, contraindications and complications of
spinal anaesthesia? (5 marks) (Amrita Aug 2018)
Ans: Refer Q1
Q11. Write about sterilisation. (5 marks) (Amrita Feb 2014)
Ans: Refer Q5
Q12. Explain different sterilisation methods. (5 marks) (Amrita Feb 2018)
Ans: Refer Q5
Q13. Describe the types of anaesthesia. (5 marks) (Amrita Feb 2017)
Ans: Refer Q1

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Q14. Write about anaesthesia in brief. (5 marks) (Amrita Feb 2014)

Ans: Refer Q1
Q15. Explain Poorva Karma and its importance in the surgical practice.
Ans: Refer Q8 (5 marks) (KUHS Apr 2017)
Q16. What do you understand by Poorva Karma. Describe in detail.
Ans: Refer Q8 (10 marks) (KUHS Mar 2019)
Q17. Explain Trividha karma. (5 marks)
Ans: Refer Q8 (Amrita Feb 2014, Amrita Aug 2018, Amrita Feb 2017)
Q18. Write about poorvakarma in Surgery. (2 marks) (Amrita Aug 2014)
Ans: Refer Q8
Q19. Write a short note on Trividha karma. (2 marks) (Amrita Aug 2018)
Ans: Refer Q8

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