ANAESTHESIOLOGY

Dr. Ashique Ahmed

KEY CONCEPTS

An anesthetic plan should be formulated that will

optimally accommodate the patient's baseline
physiological state, including any medical conditions,
previous operations, the planned procedure, drug
sensitivities, previous anesthetic experiences, and
psychological makeup.
.
Contd…

Inadequate preoperative planning and

errors in patient preparation are the
most common causes of anesthetic
complications. Anesthesia and
elective operations should not
proceed until the patient is in optimal
medical condition
To be valuable, performing a preoperative test implies
that an increased preoperative risk exists when the
results are abnormal and a reduced risk exists when
the abnormality is corrected.

The usefulness of a screening test depends on its

sensitivity and specificity. Sensitive tests have a low
rate of false-negative results, whereas specific tests
have a low rate of false-positive results.
Contd..
If any procedure is performed without the
patient's consent, the physician may be
liable for assault and battery.
The intraoperative anesthesia record
serves many purposes. It functions as a
useful intraoperative monitor, a reference
for future anesthetics for that patient, and a
tool for quality assurance.
Definition of the Practice of
Anesthesiology
.

Which is the Practice of surgery:

Assessment of, consultation for, and
preparation of patients for
anesthesia, Relief and prevention of
pain during and following surgical,
obstetric, therapeutic, and diagnostic
procedures
Contd..
Monitoring and maintenance of normal
physiology during the perioperative period.
Management of critically ill patient.
Diagnosis and treatment of acute, chronic,
and cancer-related pain.
Clinical management and teaching of
cardiac pulmonary resuscitation Evaluation
of respiratory function and application of
respiratory therapy. Conduct of clinical,
translational, and basic science research.
THE HISTORY OF ANAESTHESIA

Anesthetic practices date from ancient times, yet the

evolution of the specialty began in the mid-
nineteenth century and only became firmly
established less than six decades ago. Ancient
civilizations had used opium poppy, coca leaves,
mandrake root, alcohol, and even phlebotomy (to
the point of unconsciousness) to allow surgeons to
operate. It is interesting that the ancient Egyptians
used the combination of opium poppy (morphine)
and hyoscyamus (hyoscyamine and scopolamine);
a similar combination, morphine and scopolamine,
is still used parenterally for premedication.
Con..

The evolution of modern surgery was hampered

not only by a poor understanding of disease
processes, anatomy, and surgical asepsis but also
by the lack of reliable and safe anesthetic
techniques. These techniques evolved first with
inhalation anesthesia, followed by local and
regional anesthesia, and finally intravenous
anesthesia. The development of surgical
anesthesia is considered one of the most
important discoveries in human history.
Effective General anaesthesia began in 1846.
Local anaesthesia originated in 1884 approx..
 Types of Anaesthesia:

General: You are unconscious and have no

awareness of the surgical procedure or other
sensation.

Regional: Your anesthesiologist inject medication

near a cluster of nerves to numb only the area of your
body that requires surgery. You may remain awake or
you may be given a sedative.

Local: A local anesthetic may be injected into the skin

and tissues to numb a specific location.
Preoperative evaluation and management :

1. Investigation of general condition of the pt.

2. Surgery should be specific according to the

general condition of the pt.

3. Evaluate the general history and clinical signs

4. Routine hematological and biochemical screens,

ECG and CXR are prudent inv. for the elderly pt.

5. Serum sample for transfusion cross match.

Preparation for anaesthesia :

1. History of

allergy
cough
asthma and smocking
chest pain

2. Investigation

a. Blood for TC ,DC ,Hb% ,ESR.

b. Blood sugar for random ,fasting,
post- prandial
Con..

C. Urine for routing examination—sugar and

pus cell and urine for cs.
d. Chest x ray..P/A view.
e. ECG
3. Special condition to be treated…

- Cardiovascular Disease

- Respiratory Disease

- Gastrointestinal Disease

- Metabolic Diseases

- Coagulation Disorder
- Neurological Disease
 4. Starvation before Surgery..

For about 4 to 6 hrs pt must be in empty

stomach. It should be used even with Elective
regional anaesthesia and also with light iv
anaesthesia for loss of laryngeal reflexes.

5. Preoperative drug and treatment..

- Sedation and analgesia

- Anti cholinergic agent, atropin are used to
dry respiratory and oral secretion.
- Prophylactic antibiotics are given
- Preoperative chest physiotherapy which
may help bronchodilator treatment.
Special condition to be treated…

Cardiovascular disease:

- Uncontrolled HTN, angina, arrhythmias, heart

failure and atrial fibrillation.

- Symptometic disorder of sino atrial condition

require pacemaker insertion before anaesthesia..
trans venous temporary pacing wire or external

pacing can be used.

-Recent MI is a strong contraindication to elective

anaesthesia. We should delayed until at least 6 month.
Con..

- Pt with valvular disease will need corrective

treatment of any preoperative infection . An
appropriate antibiotics, to avoid subacute
endocarditis.

Operative procedures create an increase demand for

oxygen due to pain, surgical stress and loss of
temperature.
Pt with cardiac disease may need period of elective
postoperative mechanical pulmonary ventilation

The careful anaesthetist and surgeon plan such care

before surgery..
Special condition to be treated…

Respiratory Disease:

-In general surgical practice, respiratory

infection and asthma are the common
problem needing treatment before
anaesthesia.
- In chr respiratory failure, perioperative
physiotherapy, early mobilization and control
of infection.
- Measurement of oxygen saturation and
blood gas analysis should be done
preoperatively.
 - Post operative ventilatory support
should be anticipated.
- Regional anaesthesia is
advantageous in respiratory and thoracic
surgical procedure.

Gastrointestinal disease:

- Acid pneumonitis ,pneumonia and

even death occurred during operation due to
aspiration of gastric conten.

- Incase of emergency like bowel

obstruction, paralytic ileus –a rapid sequence
 of induction is conducted, in which the pt is
preoxygenated and cricoid pressure is
applied from the loss of consciousness until
the lungs are protected by tracheal
intubation.

- Bowel obstruction requies

preoperative nasogastric aspiration

- In increased risk of regurgitation –

use H2 blocking agent at least 12 hrs of
operation
 - Anaesthesia in presence of jaundice
carries a high risk of renal damage. Ensure
that no hypovolaemia occurs and a good urine
output is present before induction.

Metabolic disorder:

- Highly spesefic preanaesthetic

planning requries in presence of disorder like
Diabetes, adrenal suppression phaeochro-
mocytoma .

- For non insulin dependent pt –diet

and oral ADA will needed to modify before
operation.

- an iIV glucose infusion require if the

long acting hypoglycemic effect persist even
if the agent was omitted on the day of
surgery.

- For diabetic pt, rapid acting insulin is

likely to be necessary with close monitoring
and control of blood sugar levels.

- On the operative day, rapid acting

insulin by intervenous infusion is continued
until the pt has recover from the operation
 - During post operative period, short-
acting insulin is given continuously by
intravenous syringe pump

- The circulatory volume should be

manipulated independently by a separate
infusion of normal saline.

- Hourly measurement of blood glucose

should be maintained in postoperative time.
 Coagulation Disorder:

- Coagulation disorder need careful

assessment before surgery with a coagulation
screen of clotting factor and platelet
measurement.

- In disorder like DIC, fresh frozen

plasma or platelet may be given
perioperatively to control haemorrhage.

- Pt receiving warfarin need to stop

several days before operation and have
prothrombin time mesurment, until the INR
falls to about 1.5 from the theraputic range
of 2.0- 4.2. At INR of 1.5 , surgical
haemostasis should be achieved.

- When the risk of thrombosis and

embolism is high an intravenous infusion of
heparin can be use

Neurological disease:

- In cerebral disease, trauma and

respiratory obstruction- rise intracranial
pressure and can causes cerebral damage
 - Management of airway and ventilation
by endrotracheal intubation and artificial
pulmonary ventilation.

- Anticonvulsant drug must be continued

during surgery

- In peripheral neuropathies and

myopathies prolonged use of postoperative
ventilation should be necessary
 Starvation before surgery:

-In standard practice- 6 hrs

abstinence from food and 4 hrs abstinence
from fluid .

- this rules apply for prevent the loss

of protective laryngeal reflux.

-In case of children –a glucose drink

about 4 hours before operation to prevent
hypoglycaemia during operation.
 Consent for surgery and anaesthesia:

An informed consent should be

obtained by the team, preferable the
operating surgeon and the asaesthetist also.

- Ansaesthetist should explain

anaesthetic procedures, especially regional
and spinal techniques and discuss potential
sequelae.

- The document should must be in

written format.
Preoperative drug and Treatment:

a. Sedation and analgesia

-opioid analgesic agent are generally
first given during induction of anaesthesia by
iv chanel for rapid onset of action.
- for reduction of anxitey, oral short
acting benzodiazepines can be used 1-2 hrs
before operation
b. Anticholinergic agent like atropine
and hyosine are used to dry respiratory and
oral secretions.
- hyosine is pleaseanty sedative
without cardiac effect of atropine but it can
causes excessive sedation.
 c. Prophylactic antibiotic agent are used
d. Antithrombotic treatment is usually
initiated with the preoperative sedation in major
surgery.
-special attention must be given to high
risk pt such as women taking contraceptive and
hormone represent drug.
- it is ideal to stop the contraceptive
hormone 1 month before major surgery.

e. Preoperative bronchodilator treatment

with nebulization and O2 inhalation may be
indicated before sedation
Types of anaesthesia:

A. Local anaesthesia-

1. surface anaesthetics
- Xylocaine
- Cocaine
- Benzocaine
- Butocaine
- Tetaracaine

2. Infiltration anaesthetics
- Xylocaine
- Procaine
3. Nerve block

4. Spinal/intrathecal/ subarachnoid

5. Epidural

6. Intravenous

7. General anaesthetics

a. Volatile/ inhalation anaesthetic

- gases like
N2O,ethylene,cyclopopans
2. Liquid
- halothaen
- chloroform
- ethyl chloride
- vinyle ether
- dlethyl ether
- Trichloro ethylene

B. non-volatile/ iv anaesthetics
1. Steroidal- Na-hydroxy succinate
2. Non- steroidal- Thiopental sodium
ketamine
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