General Anesthesia

POS April 14th 2009

Outline
1.Anesthesia Drugs / Monitors.
2. Anesthesia Events in the OR.
3. Anesthesia Consults.

Am I missing something ?
Miller - 6th ed, 3204 pages (subtract about
800 pages for regional / pain)
Sabiston 18th ed, 2353 pages.

Am I missing something ?

Miller 6th ed. , 3204 pages.

Sabiston 18th ed. , 2353 pages. Takes

five years to cover the

material

Am I missing something ?
Miller - 3204 pages. We

can cover
this in 60 to 90 minutes.

Sabiston 18 ed . 2353 pages.

And the POS exam is over !

Ill wake you up at the end.

Biggest change for you since 2008?

Biggest change for you since 2008?

Ask for 2 grams of Cefazolin preoperatively instead of 1 gram if the patient
is > 80 kg.

ANESTHETIC DRUGS /
MONITORS

Routine Monitors

ECG.
BP.
Oximetry (use the ear probe in shock).
End Tidal CO2 .

Temperature (axillary vs. core).

Future : Depth of anesthesia - BIS. (Bispectral
index EEG) - scale from 0 to 100
March 2008 ,NEJM negative BIS trial.

ETCO2
Continuous monitor in OR.
Monitor of position of ETT (after 6 breaths).
Monitor acute decrease - Cardiac Output,
Embolism.
Monitor acute rise - for M.H.

Intravenous Drugs
1 .Propofol - less hangover, good anti emetic . Very
easily contaminated. Pain on injection,
2 .Pentothal and Propofol - potent anti- convulsants
and ICP.
- BP
- resp depressants
3. Ketamine - maintains BP, maintains respiration, but
ICP. IM useage.

Neuromuscular Blockers Succinylcholine

Can cause excess K+ release in certain conditions
-ACUTE neuromuscular disease, burns > 20%.
IOP.
C / I in MH.
5 minutes to recover from metabolized by
plasma cholinesterase . Cannot reverse its effect
with other drugs

Nitrous Oxide
MAC - 104%.
Enlarges air containing closed spaces e.g.
obstructed bowel, middle ear, eye with SF 6 ,
pneumothorax, VAE.
Negative outcomes large studies
High FIO2 and wound infection
Not often used - air /oxygen

Vapours
All C / I in MH.
Lipid solubility important so awaken
quickest from Desflurane.
Pungency - Sevoflurane least (epiglottitis).
For inhalation induction /kids

Toxicity vapours

Halothane hepatitis (1:10 000)

Isolated single reports with other vapors.
Sevoflurane - possible nephrotoxic Fl - ion
Nitrous Oxide - Possibly rate of
spontaneous abortion (RR 1.3) and
congenital abnormalities (RR 1.2). ?Recall
bias,voluntary response.

Neuromuscular BlockersNondepolarizing Drugs

Cisatracurium, Pavulon, Rocuronium.

Safe in M.H. but can cause anaphylaxis.
Longer acting - 20 mins. to 90 mins.
Monitor with nerve stimulator (train of four)
But clinical testing e.g. head lift is best.
Can reverse action with cholinergic drug e.g.
neostigmine

ANESTHETIC INTRAOPERATIVE
EVENTS

ASA Score
1 - Healthy.
2 - Mild systemic disease, no functional
limitations.
3 - Severe systemic disease that limits activity.
4 - Incapacitating disease that is a constant threat
to life.
5 - Moribund, not expected to survive 24 hrs, with
or without surgery.
E - Emergency

ASA Difficult Airway Algorithm

Not possible to visualize any of the vocal
cords = difficult.
Mallampati score - one of many aspects of
airway assessment.
LMA rescue device but does not protect
vs. aspiration (Can be used as conduit for
FFOB).

Failed Intubation
Management depends on whether can
ventilate or not.
Different blades and smaller tube.
LMA , Bronchoscope , Bougie, Glidescope
Cannot intubate , Cannot ventilate - need
surgical airway.

Aspiration
Risk factors - Morbid obesity, Pregnancy,
Massive ascites, Diabetes, Pain esp. trauma.
Prophylaxis H 2 blockers, Prokinetic agents,
Sodium Citrate.
Rapid Sequence Induction (RSI).
Presents as desaturation or wheezing.
Guidelines : 6 hrs for light meal (clear fluid and
toast) to 8 hrs. (meat) and 2 hours for clear
fluids.

Malignant Hyperthermia
Triggered by vapours and Succinylcholine.
Hypermetabolic state of muscles.
ET CO2 , tachycardia (metabolic storm).
Arrhythmias from K+ release VT,VF
Muscle rigidity and temp -LATE signs.
Rx- Dantrolene (2,5mg/kg up to 10mg/kg),

Airway fire
1. Ignition source cautery, laser, flammable
ointment alcohol based prep solution.
2. Fuel drapes , PVC ETT.
3. Oxidizer near surgical site Oxygen or Nitrous
Oxide.
Laser surgery, Tracheotomy.
Disconnect patient from machine, extubate and
extinguish with saline,ventilate or reintubate,
evaluate airway damage (rigid bronchoscopy).

Gas Embolism
Air, Helium, CO 2 .
Operative site above heart, low CVP.
Presents as ETCO2, SaO2, millwheel
murmur, BP, PA pressures.
Rx - D/C Nitrous, Trendelenburg, flood field,
aspirate from CVP catheter, left side down
(airlock RV), consider hyperbaric oxygen.

Latex Allergy
Multiple procedures, health care esp. dental
workers, spina bifida, food sensitivity.
Prevent - glass syringes, remove top of vial, 1st
case of day, premed optional.
Onset after 20 - 60 minutes.
Airway and 100% O2.
Volume.
Epinephrine - 0,1 micrograms / kg boluses

Massive Transfusion
All complications of 1 unit -TRALI,
Immunosuppression.
Hypothermia.
Hypocalcemia from citrate.
K + abnormalities (> 120 ml/ min).
Dilutional coagulopathy.

ABO Transfusion Reaction

Minimal signs under GA.

Hypotension.
Hemoglobinuria.
DIC ( oozy NYD ).
Blood for re XM and hemolysis workup.
Die from DIC and ARF.

Autologous donation

EPO and Iron supplementation.

Clerical error (1: 100 000).
Yersinia enterocolitica contamination.
May not be enough blood.
Anemia.

Hypothermia
Core and peripheral component ,with tonic
constriction normally.
1st hour rapid drop 1,5 C vasodilation.
2nd stage - slow linear decrease for 2 -4 hours of
1,5 -2,5 C as heat loss exceeds metabolic heat
gain . (radiation*,convection, evaporation,
conduction)
3rd stage - plateau after 2- 4 hours

Adverse Effect Hypothermia

Cardiac - RCT 35.4C vs. 36.7C in 300
patients undergoing abdo, vascular, thoracic
(JAMA April 9 1127, 1997 ).
Postop morbid cardiac events: 1,4%vs 6,3%
VT : 2% vs. 8%.
Infection - RCT 200 patients undergoing
colorectal surgery 34,7 vs. 36,6- 3 x risk
wound infection (NEJM 1996 334, 1209).

Adverse effects hypothermia

Blood loss - 500 ml greater 35,5C vs.
36,6C in THA ( Lancet 1996 347 289)
Coagulopathy - platelet dysfunction and
sequestration in liver, false negative normal
PTT as lab always warms blood to 37.
1 litre fluid or 1 unit blood temp 0,25C.
Forced air warming best method ($10)

Positional Injuries
Ulnar - commonest (male, >4hrs, BMI<20
or >40). 27% used extra padding.Often
delayed onset, at day 3. Occurs in regional
anesthesia also.
Brachial plexus- median sternotomy, steep
Trendelenburg with shoulder braces,prone
esp. head to opposite side (females)

Positioning
Arms < 90 when supine.
At side, neutral position.
On arm board supinate.
Chest roll risk brachial neuropathy.

DNR
Patient or SDM. 3 choices for OR:
1.DNR intact.
2. DNR partially rescinded .
3. DNR rescinded completely
Discuss specifics and goals - chest compressions,
pacing, defib, vasoactive drugs, postop ventilation,
postop ICU ( time limited).

Awareness
MAC. 50% dont respond in to pain in a
grossly purposeful manner. Use surgical
incision as stimulus.
Sandin 18 / 11785 ( 0,15%). Trauma, OB,
CV surgery.
B Aware trial . 2 vs. 11 cases using BIS
(bispectral index)

Laparoscopic Physiology
CVS - Trendelenburg or reverse
- tachycardia from venous
return,CO2
- bradycardia from insufflation
Resp - PCO 2 , atelectasis, subcutaneous
emphysema, pneumothorax, CO2
embolus,venous stasis

Laparoscopy
Hypothermia
Impaired renal flow
ICP

PONV
Risk factors female, nonsmoker, volatile
agents, nitrous oxide, opioids, laparoscopy,
middle ear, strabismus, breast surgery.
Prophylaxis Serotonin antagonists e.g.
Ondansetron.
- Dexamethasone 4 - 8 mg IV.
- Dimenhydrinate.

Anesthesia Consults

Risks of Anesthesia
CEPOD - Mortality rate total contribution :
1. Patient factors 1: 870.
2. Surgical factors 1: 2860.
3. Anesthesia 1: 185,056 totally.
Anesthesia partially 1: 1430.
Fleisher - 564 267 outpatient , ASC , Office. Had a
mortality of 25 -50 / 100 000.
Newland - intraop arrest 1/14 000.( 1/10 000)

Myocardial ischemia
Risk of surgery - High ,intermediate and
low.
> 4 Mets.
Beta blockade preoperatively- Atenolol, 200
patients - Noncardiac surgery. NEJM 1996
335, 1713.
Bisoprolol in vascular patients - NEJM
1999, 341, 1789.

POISE Trial
Beta blockers decreased myocardial
infarction , but increased stroke rate and
overall mortality likely from decreasing
blood pressure.
Risk / Benefit now much more uncertain

AHA guidelines
Five risk factors (Lee or RCRI):
-

History CAD
History heart failure
History of CVA
Renal insufficiency
Diabetes

Stents and elective surgery

Bare metal minimum safe Plavix duration
before discontinuation is 30 days.

Drug Eluting - only safe to stop Plavix

after 365 days

Respiratory Disease

GA - FRC
GA - Diaphragmatic function
Shapiro score
Po2 on room air <50, Pco2 45
Active wheezing
Site of surgery especially upper abdomen
and thorax

Respiratory disease
Quit smoking > 8 weeks does resp
complications (14.5% vs. 33% in 200 ACB)
(Prospective, Mayo Clinic Proc 1989 ,64
609).
<48 hrs COHB levels and ciliary activity.
1-2 Weeks to sputum.
PFT- only to diagnose,not prognosticate.

AJRCCM Mar 1 2005.

Respiratory disease
Laparoscopic approach- better ABGs, PFT.
Epidural may be better- Meta analysis
showed less atelectasis.
Lung expansion manoevres postop work

Herbal remedies
CVS - Ginseng, Ephedra, St. Johns Wort,
dietary hyperadrenergic
Bleeding - Ginko, Vit E, Ginger
Hepato and nephro toxic
Natural herb CPS
www.herbnet. com

OSA
3 Scoring factors:
1. Severity - AHI (6-20, 21-40, >40).
2. Invasiveness surgery.
3. Narcotic needs postoperatively.
CPAP use or not?
Ward, ward with 24 hr oximetry, Step-down

Summary
Think ICU post-op especially for the
emergency list patients (sepsis).
Consult for multiple Lee cardiac risk
factors.
OSA beware need for step-down bed.
Being available and in the OR at the
beginning and end of the case is greatly
appreciated and noticed.

Sickle Disease
Hb AS -Trait - <40% S -only sickle at
extremes of O2 and temp, not anemic
Hb SC - 50%S -eye, hip , pregnancy
borderline anemia
Hb SS Disease > 80 %S, anemic
Get HBS < 40%
Keep warm and hydrated and oxygenated

MaVs Trial
496 patients for vascular surgery receive
metoprolol or placebo 2 hrs preoperatively
and for 5 days.
Blinded.
No difference in CV deaths or nonfatal MI
CJA 2004 51 .

Ann Int
Med Nov
2001