Conduct of Anesthesia

‫لف بدل السيمنار‬.‫الدكتور طلب نعتمد هذا ا‬

Dr. Med. Khaled Radaideh 0

Conduct of Anesthesia
Objectives :
1. Inhalational induction. (procedure,
indications, difficulties and complications)
2. Maintenance of anesthesia.
2.1.Conduct of inhalational anesthesia with spontaneous
ventilation.
2.2 Difficulties and complications
2.3. Airway maintenance delivery of inhalation agents:
-face mask (when and how applied, signs of obstruction and
treatment)
-laryngeal mask (Insertion, indications, contraindications)
-tracheal intubation (Preparation, indications, complications)

Dr. Med. Khaled Radaideh 0

Conduct of Anesthesia
Objectives :
3. Anesthesia for tracheal intubation.
3.1. Inhalational technique for intubation.
3.2. Relaxant anesthesia.(indications)
3.3 Early and late complications
4. Conduct of extubation. (procedure,
Complications)

Dr. Med. Khaled Radaideh 0

 inhalational induction
Indications
1.young children.
2.upper air way obstruction,
e.g.epiglottitis
3.lower air way obstruction with
foreign body
4.bronchopleural fistula or
empyema.
5.no accessible veins
(neonates,infants &phobic)
Dr. Med. Khaled Radaideh 0
 inhalational induction PROCEDURE
Delivery tube may be preferred to young children, some favor allowing
child to play with mask before connecting anesthetic tube.
• The mask or hand is introduced gradually to the face from the side.
•While talking to the patient& encouraging him to breathe deeply the
anesthetist adjusts the mixture of gas flow &observes the patient’s
reaction.
•initially No2 70% in O2 is used.

Dr. Med. Khaled Radaideh 0

 inhalational induction PROCEDURE
•Anesthesia deepened by gradual introduction of a volatile agent.
(e.g.halothane1-3%).
• A single breath technique for patient’s who are able to cooperate.
•Observe the color of patient’s skin ,pattern of ventilation, palpate
peripheral pulses, monitor ECG& spo2.
•Insertion of an oropharyngeal airway, a laryngeal mask airway or
tracheal tube may be considered when anesthesia has been
established.

Dr. Med. Khaled Radaideh 0

inhalational induction
Difficulties and complications
1. Slow induction of anesthesia.
2. Airway obstruction and
bronchospasm.
3. Laryngeal spasm and hiccups.
4. Environmental pollution.

Dr. Med. Khaled Radaideh 0

Maintenance of anaesthesia.
Anesthesia can be • Depending on :
maintained using: ● Nature of surgery
1.inhalational agents. ● Provision of
Sevoflurane ,Isoflurane but also analgesia in the
Halothane 1-2 MAC may be employed in premedication
a mixture of nitrous oxide 70% in oxygen
● patient’s response
2. i.v. anesthetic agents. (ventilation
3. i.v. opioids (Fentanyl, Alfentanil, ,circulation, HR &
Remifentanil) rhythm).
(alone or combinations) • -Tracheal intubation
(TIVA: Propofol and Opioid) w/o muscle relaxants
may be employed.
Dr. Med. Khaled Radaideh 0
Maintenance of anaesthesia.
Anesthesia can be
maintained using:
1. inhalational agents.
2. i.v. anesthetic agents.
3. i.v. opioids
(alone or combinations)

-Tracheal intubation w/o muscle

relaxants may be imployed.

-Regional anesthesia may be

used to supplement any of these
techniques.
Dr. Med. Khaled Radaideh 0
Maintenance of anesthesia.
Conduct of inhalational anesthesia with spontaneous
ventilation.
Appropriate form of maintenance for :
1. Superficial operations.
2. Minor procedures which produce
little reflex or painful stimulation.
3. Operations for which profound
muscle relaxation is not required.

Dr. Med. Khaled Radaideh 0

 Maintenance of anesthesia.
Difficulties and Complications
1. Airway obstruction (relieved by appropriate
positioning & equipment)
2.Laryngeal spasm
Cause: stimulation during light Anesthesia
Treatment: stop stimulation, gently deepen anesthesia
>>100%O2 is applied with face mask…
If severe >>100%O2 is applied with face mask…
i.v. suxamethonium and Reintubate the patient

Dr. Med. Khaled Radaideh 0

 Maintenance of anesthesia.
Difficulties and Complications
3. Bronchospasm
Cause: Allergy, smokers, Irritants, upper respiratory infection
Treatment: increasing the depth of anesthesia with additional
induction agent or volatile agent, or by administering IV or
endotracheal lidocaine 1-2 mg/kg. humidification and warming of
gases, bronchodilators
4. Malignant hyperthermia
(volatile Anesthetics, suxamethonium and amide local
anesthetics are triggering substances)
5.Raised intracranial pressure (accentuated by CO2
retention)
6.Atmospheric pollution (scavenging apparatus)
Dr. Med. Khaled Radaideh 0
 Maintenance of anesthesia.
Airway maintenance delivery of inhalation agents:
1. Via Face Mask
•Applied before and during and after lose of consciousness
at anesthetic induction and the selection of the correct fit is
important to provide gas-tight seal. (esp. short procedures).
the mandible is held into the mask by the anesthetics
(holding rather than pressing)
-the mandible is held foreword , helping to prevent posterior
movement of the tongue and obstruction of the airway.
•It has variants of type and size (00 to 6).

Dr. Med. Khaled Radaideh 0

 Maintenance of anesthesia.
Airway maintenance delivery of inhalation
agents:
Face Mask 1. Via

•Airway obstruction with Face Mask:

A. soft tissue in drawing in the suprasternal and supraclavicular
areas is evidence of obstruction of the upper airway.
B. noisy ventilation or inspiratory stridor provides further evidence
that airway obstruction requires correction.
•the patient’s head position during mask anesthesia is very
important
•maintenance of the airway may be assisted further by
oropharyngeal (Guedel ) or nasopharyngeal airways .
•Note: An appropriate stage of anesthesia must be reached before insertion
of the airway as stimulation of the pharynx will produce coughing,
laryngospasm or breath-holding.

Dr. Med. Khaled Radaideh 0

 Maintenance of anesthesia.
Airway maintenance delivery of inhalation agents:
2. Via Laryngeal Mask (LMA)
LMA insertion: appropriate depth of anesthesia is required .
1. Patient's head is extended.
2. Mouth is opened.
3. Pre deflated LMA is inserted into the Pharynx.
4. LMA is swept distally into the laryngopharynx.
5. Inflate the cuff.
6. Confirmation of the correct placement.
7. LMA is secured in place.

Dr. Med. Khaled Radaideh 0

 Maintenance of anesthesia.
Airway maintenance delivery of inhalation agents:
2. Via Laryngeal Mask (LMA)
Indications:
a.Provide clear airway without the need to support a mask.
b.Avoid the use of tracheal intubation during spontaneous ventilation .
c.in a case of difficult intubation , to facilitate subsequent insertion of a
tracheal tube.
Contraindications:
a. Full stomach or any condition lead to delayed gastric emptying.
b. Possible regurgitation .
c. Surgical access is Impeded By the cuff of the LMA .
d. Thoracic surgery.
e. an unusual position (Prone).

Dr. Med. Khaled Radaideh 0

 Maintenance of anesthesia.
Airway maintenance delivery of inhalation agents:
2. Via tracheal intubation.
Preparation:
1. he anesthetist must check the availability and function of the
necessary equipment .
2. should have a dedicated and experienced assistant
3. laryngoscopes of the correct size are chosen and the function
of bulb and batteries checked
4. patency of tracheal tube is checked .

Dr. Med. Khaled Radaideh 0

 Maintenance of anesthesia.
Airway maintenance delivery of inhalation agents:
2. Via tracheal intubation.
Indications:
1.provision of a clear airway .
2.Surgical procedures in which the anesthesiologist cannot easily control the
airway (e.g., prone, sitting, or lateral decubitus procedures)
3.head and neck operation ( nasotracheal tube).
4.Protecting the respiratory tract from aspiration of gastric contents
5.suction of the respiratory tract .

Dr. Med. Khaled Radaideh 0

 Maintenance of anesthesia.
Airway maintenance delivery of inhalation agents:
2. Via tracheal intubation.
Indications:
6. Surgical procedures within the chest, abdomen, or cranium
7. Protecting a healthy lung from a diseased lung to ensure its continued
performance (e.g., hemoptysis, empyema, pulmonary abscess)
8. Severe pulmonary and multisystem injury associated with respiratory
failure (e.g., severe sepsis, airway obstruction, hypoxemia, and hypercarbia of
various etiologies)
9. Positive-pressure ventilation

Dr. Med. Khaled Radaideh 0

 Conduct of Anesthesia
Anesthesia for tracheal intubation :
It can be done:
a. Under general anesthesia (either i.v. or
inhalational +\- muscle relaxation).
b. Awake Intubation under local anaesthesia
using (topical spry ,transtracheal spry and
superior laryngeal nerve block).

Dr. Med. Khaled Radaideh 0

Conduct of Anesthesia
Anesthesia for tracheal intubation :
Inhalational technique for intubation:
o Adequate depth of anaesthesia is necessary
to depress the laryngeal reflexes and to
provide muscles relaxation.
o Using halothane in concentrations up to 4%
may provide the necessary depth.
oThe adequate depth can be confirmed when
there is predominance of diaphragmatic
breathing.

Dr. Med. Khaled Radaideh 0

Conduct of Anesthesia
Anesthesia for tracheal intubation :
Relaxant Anesthesia for intubation:
• After i.v. or inhalational induction of anesthesia ,
muscle relxant (example: suxamethonium short
acting depolarizing agent) may be used to provide
muscle relaxation for intubation.
Isuxamethonium is administered in a dose of 1 to
1.5mg/kg.
• Assisted ventilation is maintained via the face mask
until muscle relaxation occurs(except in emergency
patients and those likely to regurgitate).
• Then the mask is removed and laryngoscopy &
intubation performed . The anesthetic circuit is then
connected to the tracheal tube and anesthetic
maintained at a depth appropriate for surgery.
Dr. Med. Khaled Radaideh 0
 Conduct of Anesthesia
Anesthesia for tracheal intubation :
Indications of Relaxant Anesthesia for intubation:
It provides muscle relaxation, permitting anesthesia for
major abdominal, intra peritoneal, thoracic or intracranial Operations
,prolonged operations, prolonged ventilation.

Dr. Med. Khaled Radaideh 0

 Conduct of Anesthesia
Complications of tracheal intubation :
Early Complications
a.Trauma to lips and teeth.
b.Jaw dislocation.
c.Damage to larynx and vocal cords.
d.Nasal intubation may produce epistaxis , trauma to pharyngeal wall.
e.Obstruction or kinking.
f.Bronchial intubation.
g.Arrhythmias, hypertension.
Late Complications
h.Tracheal stenosis(rare).
i.Damage to tracheal mucosa from a cuffed tube.
j.Trauma to vocal cords may result in ulceration and may require surgical
removal.

Dr. Med. Khaled Radaideh 0

Conduct of extubation.
Positioning :
May take place with the patient supine if the
anesthetist is satisfied that airway patency can
be maintained by the patient in this position
and there is no risk of regurgitation , but in
patients at risk of regurgitation and potential
aspiration , the lateral position is preferred .

Dr. Med. Khaled Radaideh 0

Conduct of extubation.
Procedure :
Oxygen 100 % replaces the anesthetic gas
mixture before extubation to :
- avoid the potential effects of diffusion
hypoxia .
- provide a pulmonary reservoir of oxygen
Tracheobronchial suction via the tracheal tube
is carried out using a soft sterile suction
catheter should be performed before tracheal
extubation to remove gastric fluid
Extubation is performed preferably during an
inspiration.
Dr. Med. Khaled Radaideh 0
 Conduct of extubation.
Procedure :
•Preoxygenation precedes suctioning as the oxygen
stores may be depleted by tracheal suction
•After extubation , the patient ability to maintain
the airway is ensured , the ability to cough and
clear secretions is assessed Administration of
oxygen is continued by face mask .
•The patient airway is supported until respiratory
reflexes are intact .

Dr. Med. Khaled Radaideh 0

 Conduct of extubation.
Complications :
a.Laryngeal spasm
b.Regurgitation/inhalation
c.Hemodynamic` changes (Extubation is
accompanied by transient hypertension
and tachycardia in most adults.)
d. Glottic edema (Tracheal and laryngeal trauma
may result in glottic Edema)

Dr. Med. Khaled Radaideh 0

Conduct of Anesthesia

THANK YOU

Dr. Med. Khaled Radaideh 0