This document discusses several topics related to anesthesiology including: 1) Intraoperative management including rapid sequence induction and inhalation induction. 2) Recovery from anesthesia including reversal of neuromuscular blockade using anticholinesterase agents and postoperative care in the PACU. 3) Common postoperative issues like PONV treated with serotonin receptor antagonists, assessing and treating acute postoperative pain, and malignant hyperthermia triggered by volatile anesthetics and succinylcholine.

1. Anesthesiology
Intraoperative management,Recovery
from anesthesia,Malignant
Hyperthermia

2. Intraoperative management

3. Induction of general anesthesia
● The induction of general anesthesia is the most critical component of practicing
anesthesia.
● The goal of rapid sequence induction is to achieve secure protection of the airway
with a cuffed endotracheal tube while preventing vomiting and aspiration.
● Rapid sequence induction is performed as follows:
1. Proceed only after evaluation of the airway predicts an uncomplicated
intubation,
2. Preoxygenate the patient.
3. Rapidly introduce an intravenous induction agent, (e.g., propofol)
4. An assistant to the anesthesiologist presses firmly down on the cricoid
cartilage to block any gastric contents from being regurgitated into the trachea,
5. A muscle relaxant is injected and the trachea is quickly intubated. The assistant
is instructed not to release pressure on the cricoid cartilage until the cuff of the

4. Patients undergoing inhalation induction progress through
three stages :
1. Awake
2. Excitement
3. Surgical level of anesthesia
● Adult patients:excitement stage can last for several min, which
may cause hypertension, tachycardia, laryngospasm, vomiting,
and aspiration.
● Children:progresses to stage 2 rapidly.The benefit of
postinduction intravenous cannulation is the avoidance of
many presurgical anxieties, and inhalation induction is the
most common technique for pediatric surgery.

5. Recovery from anesthesia

6. Reversal of Neuromuscular Blockade
● The elimination of neuromuscular blocking agents from the body and resumption
of neuromuscular transmission takes a considerable amount of time,routine to
antagonize the neuromuscular block pharmacologically with the use of reversal
agents.
● Reversal agents raise the concentration of the neurotransmitter acetylcholine to
a higher level than that of the neuromuscular blocking agent.
● Use of anticholinesterase agents, which reduce the breakdown of acetylcholine.
The most commonly used agents are neostigmine, pyridostigmine, and
edrophonium.
● The common side effects of these three anticholinesterase agents are
bradycardia, bronchial and intestinal smooth muscle contractions, and excessive
secretions from salivary and bronchial glands.

7. The Postanesthesia Care Unit(PACU)
● All patients awakening from anesthesia are followed in a recovery room.
● As more serious surgeries are performed on older and sicker patients, the number
of patients requiring postoperative ventilation and medications to support their
circulation increases with age.
● Postoperative pain control with continuous epidural administration of local
anesthetics and narcotics demands close observation, because respiratory
depression can occur.
● In most hospitals, the number of intensive care beds is too small to accommodate
the increasing number of these patients.
● A variety of physiologic disorders that can affect different organ systems need to
be diagnosed and treated in the PACU during emergence from anesthesia and
surgery.

8. Postoperative nausea and vomiting (PONV)
● Transient, unpleasant event carrying little long-term morbidity.
● Aspiration of emesis, gastric bleeding and wound hematomas may occur with
protracted or vigorous retching or vomiting.
● Troublesome PONV can prolong recovery room stay and hospitalization and is
one of the most common causes of hospital admission following ambulatory
surgery.
● Agents usually administered for PONV are the serotonin receptor antagonists
ondansetron, dolasetron, granisetron, and tropisetron.

9. Pain: The Fifth Vital Sign
● Measure of pain intensity:(0 = no pain, 1 = mild pain, 2 = moderate pain, and 3
= severe pain) and a five-point measure of relief (0 = no relief, 1 = a little relief,
2 = some relief, 3 = a lot of relief, and 4 = complete relief).
● Acute postoperative pain and its treatment (or prophylaxis) is a significant
challenge for the health care professional.
● Recent development of new nonnarcotic analgesics, and a better
understanding of the side effects associated with pain medication of all types,
acute postoperative pain remains a significant concern for patients, and
represents an extremely negative experience for patients undergoing surgery.
● The American Pain Society has advocated the assessment of pain as the fifth
vital sign, along with temperature,pulse, blood pressure, and respiratory rate.

10. Malignant Hyperthermia

11. Malignant Hyperthermia(MH)
● Life-threatening, acute disorder, developing during or after general anesthesia.
● Triggering agents include all volatile anesthetics (e.g., halothane, enflurane,
isoflurane, sevoflurane and desflurane) and the depolarizing muscle relaxant
succinylcholine.
● Volatile anesthetics and/or succinylcholine cause a rise in the myoplasmic
calcium concentration in susceptible patients, resulting in persistent muscle
contraction.
● Classic MH crisis entails a hypermetabolic state, tachycardia and the elevation of
end-tidal CO2 in the face of constant minute ventilation.
● Respiratory and metabolic acidosis and muscle rigidity follow and
rhabdomyolysis, arrhythmias, hyperkalemia, and sudden cardiac arrest.

12. Treatment for Malignant Hyperthermia
● Discontinue anesthetics.
● Benzodiazepines (work fastest to control
hypermetabolic state).
● Dantrolene sodium (a calcium channel blocker
considered more definitive treatment, but onset of
action takes about 30 minutes.

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