anesthesia

1. The pracTice conducT of
anesThesia
Dr. Mohamed Ibrahem El
said
Lecturer of Anesthesia
Zagazig university

2. Balanced anesthesia =
narcosis loss of consciousness
+ amnesia loss of memory
+analgesia loss of pain
+ relaxation loss of ms. tone
Anesthetic management
Preoperative management
Intraoperative management
Postoperative management

3. Preoperative management

4. A. Preoperative • History
• Examination
• Investigation
• Premedication
A. Intraoperative • Monitoring
• Position
• Choice of anesthesia
• Induction
• Maintenance
• Fluids
• Extubation and recovery
A. Postoperative • Transfer to ward or ICU
• Pain management
• Postoperative complication

5. Preoperative managment
History
Preop. Visits + written preoperative note
History of current disease
Other Diseases ( HPT . DM ....
Drugs NSAI & Aspirin ,Anticoagulants,
Steroids, Oral contraceptive pill, Magnesium
Previous anesthesia history
Problems intra /or postoperative.
Anesthetic record.
Family history
Hereditary diseases.
 Anesthetic history.

6. Last oral intake

7. Special habits
Smoking
 Vascular disease of peripheral, coronary
and cerebral circulation
 lung carcinoma.
 Effect of nicotine ..tachycardia and HPT
 Increase in CO hemoglobin decrease O2
delivery to the tissues.
 Six fold increase in postoperative
respiratory morbidity
 Should be stopped 6 weeks or at least 12
hrs before surgery

8. Examination
A full medical examination primarily by the surgeon
and documented in the patient record
The anesthesiologist emphasize on cardiovascular,
respiratory and airway examination in addition to other
relevant finding.
General examination
 Nutritional state
 Fluid balance.
 Skin and mucus m.(anemia –perfusion-jaundice )
 Temperature

9. Cardiovascular exam.
 Dyspnoea, fatigue, chest
pain.
 Pulse :rate, rhythm, volume
 Neck veins
 Blood pr.
 Heart sounds
 L.L edema
Respiratory exam.
 Cyanosis ( peripheral or
central).
 Cough
 Tachypnoea
 Tracheal shift
 Auscultation of all the
lung fields

10. Nervous system
 Documentation of the level of consciousness
 Documentation of any cranial or peripheral nerve
lesions
Skeletal system
 Documentation of any sk. Ms. dysfunction or
syndromes
Airway examination
 Teeth exam. ( dentures, loose teeth, protruding
upper incisors)
 Prediction of difficult airway (for ventilation or ET
intubation)

11. ASA rating
ASA rating Description of patient Mortality(
%)
Class I A normally healthy patient. 0.1
Class II A patient with mild systemic disease. 0.3
Class III A patient with moderate systemic
disease.
3
Class IV A patient with sever systemic disease. 15
Class V A moribund patient who is not expected
to survive 24 h with or without
operation.
30
Class VI A brain dead patient.
Class E Add as suffix for emergency operation.

12. Investigation
 Performing routine tests in all surgical patients as a
screening tool is inefficient, unnecessary, and
expensive
 Any disease discovered in history and examination
 fully investigated
 Investigation which will not affect decision  waste
of resources
 It is a misconception that routine tests provide
medico-legal protection.
 Young healthy adult can undergo anesthesia safely
without investigation

13.  Every organization decide its guideline
 Guidelines for testing can maximize the yield and
prevent waste of resource and time
 Tests should be done, not done, or considered –
may depend on
Age band
Complexity of intended surgery;
ASA grade
Nature of co-morbidity if ASA III.

14. Eleven tests are considered :
1. CBC
2. ECG.
3. Chest X-ray.
4. PT ,PTT ,INR
5. urea, creatinine, and electrolytes.
6. Random serum glucose
7. Urine analysis
8. Blood gases.
9. Lung function (peak expiratory flow rate, forced vital
capacity, and forced expiratory volume).
10.Pregnancy test.
11.Sickle cell hemoglobin test.

16. Premeditations Preop. Drugs before induction
1-5 min for i.v. drugs
30 – 60 min for i.m. drugs
60 – 90 min for oral drugs
Benzodiazepines anxiolysis and relief anxiety
Anticholinergics  antisialagouge + decrease vagal
reflexes
Antiemetics  Nausea and vomiting
Prophylaxis against aspiration
Antihistaminics allergy
Opoid  analgesia + stress response
Others anibiotics .. Bronchodilators ..

17. Intra-perative managment
• Monitoring 
• Standard monitor = anaesthetist + ECG +
pulse O2 + NIBP +end tidal CO2
• Position  supine . Prone . Lateral .....
• Choice of anesthesia  general , regional or
combined , local ...
• Induction  according to the case =
inhalational or intravenous
 Intravenous
 Smooth = routine i.v + ms relaxant +fasting
 Rapid sequence induction = full stomach+
succinyle or rocuronium + cricoid pressure.
 i.v line + preoxygenation + slow injection

18. • Inhalational
 Indication 
Young uncooperative
Difficult cannulation
Airway obstruction
Difficult airway
 Agent used  fluthane or sevofuorane
 Single breath technique = one vital capacity with bag
filled with  fluthane 5 % or sevoflurane 8 %
 Breathing with O2 :N2O 70:30 then increase O2 :N2O
to 30:70 then Add 0.5 % inhalational every 3 – 5
breath
• Intramuscular
• Rectal induction

19. • Maintenance
• Inhalational maintenance + spontanous ventilation
• Relaxant anesthesia + M.V.
• Fluids  table 4/2/1 rule
1: Deficit =Preoperative Fluid Losses
4/2/1 rule X hours of fasting
4/2/1 rule: 4 cc/kg/hr first 10 kg,
2 cc/kg/hr for the second 10 kg
1 cc/kg/hr for every kg above 20.
2: Maintenance = same
4/2/1 rule X hours of operation
3: Anticipated Surgical Fluid Losses
Minimal tissue trauma = 2-4 cc/kg/hr
Moderate tissue trauma = 4-6 cc/kg/hr
Severe tissue trauma = 6-8 cc/kg/hr
4: Unanticipated Fluid Losses
3 cc of crystalloid = 1 cc of blood
loss.
lap pads = (100-150 cc each)
4x4s = (10 cc each).
Deficit + maintenance + loss = ½ in 1st
hour , ¼ 2nd
hour , ¼ in 3rd
hour

20. •Extubation and recovery 
• Awake extubation is the Role  all patient + full
stomach.
• Deep extubation in Cardiac, asthmatic, CNS
patient.
C - Postoperative 
•Transfer to ward or ICU.
•Analgesia.
•Manage complications.