6. I. WHAT ARETHE RISKS OF ANESTHESIA?
Sore throat
Postoperative nausea or vomiting
Dental damage
Corneal abrasion
Awareness
Brain damage
Death
7. PREOPERATIVE EVALUATION
II. PATIENT ASSESSMENT
Causes stress and physiologic effects
Past and current medical and surgical conditions
Who:
Anesthesiologist
nurse
Where:
In person
preoperative clinic
phone interview
web-based questionnaire
Healthy patients and emergency surgery – same day evaluation
8. Chief complaint
Age, height, weight
Surgical history
Previous anesthetics
Family history
Medications and allergies
Medical problems and systems review
PREANESTHETIC
EVALUATION
9. II. ANESTHETIC PLAN
Best approach:
Patient
Medical history
Proposed procedure
Ideal anesthetic:
Minimum physiologic trespass
Optimal surgical conditions
Comfortable
Expeditious recovery
10. II. NIL PER OS STATUS
Complications:
Regurgitation
aspiration
Exceptions:
Emergency surgeries
Trauma
Severe pain
Nausea and vomiting
Intestinal obstruction
RAPID SEQUENCE
INDUCTION
11. II. INFORMED CONSENT
Last step
Disclose pertinent risks
Allow questions
Legal guardian or medical proxy
12. SOAP-ME
S – suction
O – oxygen (pre-oxygenate with 100% FiO2 for 5mins)
A – airway (appropriately sized tubes, blades and oral/nasal airway)
P – personnel (RT, nurse, fellow/attending, sedation provider)
M – medications: premeds, induction, paralytic, rescue meds (epi,
atropine, fluids)
E – equipment: vent, ET, stylet, syringe, stylet, tapes, IV
14. III. INTRAOPERATIVE MANAGEMENT
Complications may occur at any time during anesthetic
Induction:
Unconscious
Cardiac and respiratory effects
Lower BP
Diminished upper airway muscle tone
15. III. MONITORING
Assess:
Oxygenation and perfusion
Breath sounds to detect airway problems
Body temperature
Routine noninvasive monitor
ECG
BP
Pulse oximeter
Capnography
Temperature
16.
17. III. INDUCTION
Babies and small children –
inhalation induction
IV induction is rapid and reliable
Combination of drugs
Propofol – most common, rapid
onset (<60 seconds)
Lidocaine
Agent Advantages Disadvantages Comments
Propofol • Rapid onset
• Short duration
• Rapid recovery
• No residual
effects
• Burns on injection
• Hypotension
• Can cause
respiratory
depression,
especially when
given with opioids
• Not an analgesic
• Most commonly used
induction agent
Methohexital • Rapid onset
• Short duration
• Postoperative
nausea and
vomiting more
likely vs. propofol
• Contraindicated
with acute
intermittent
porphyria
• Often used to induce
anesthesia for
electroconvulsive shock
treatment
Etomidate • Minimal
hemodynamic
effects
• Adrenal
suppression
• May increase
mortality
Ketamine • Minimal
hemodynamic
depression
(release
catecholamines)
• Maintains
respiration and
airway reflexes
• Has analgesic
effects
• Dysphoria and
hallucinations
• Hypertension and
tachycardia
18. III. INDUCTION
Muscle Relaxants
Agent Mechanism of
action
Onset Duration Side Effects Comments
Succinylcholine Depolarizing Rapid: 30-60 sec Short: 10-15min
Can cause
prolonges blockade
if given as an
infusion, in repeat
doses, or patients
with atypical or
absent pseudo-
cholinesterase
• Tachycardia
• Bradycardia
• Myalgia
• Hyperkalemia
• Rhabdomyolysi
s
• Malignant
hyperthermia
• Increased
intraocular
pressure
Almosst never used
in children
Pancuronium Nondepolarizing 4-5 min 75-90 min • Hypertension
• Tachycardia
Cecuronium Nondepolarizing 3 min 30-45min Duration may
increase with
repeat doses in
patients with renal
failure
Rocuronium Nondepolarizing 1-2 min 30-45 min
Cisatracurium Nondepolarizing 2-3 min 45 min
26. III. MAINTENANCE
Begins after induction when the airway is
secured.
May use various IV or inhaled agents
The goal of anesthesia
ensure unconsciousness and amnesia
Immobility
muscle relaxation
blunted sympathetic reflexes
Inhaled Anesthetics
Agent Comment
Desflurane Most insoluble agent of the potent agents. Most rapid wake up. Pungent
aroma can irritate airway.Causes sympathetic stimulation during induction.
Isoflurane Most potent and most soluble of the currently used agents. Slowest
emergence, especially after longer cases. Pungent aroma. Can cause
tachycardia during induction
Nitrous oxide Not potent enough to produce anesthesia on its own. Often used in
combination with other potent agents
Sevoflurane Pleasant arome. Good choice for inhalation induction. No sympathetic
stimulation
27. Opioids
Opioid Onset Duration Comment
Remifentanil Rapid Brief Rapidly hydrolyzed by
nonspecific esterases.
Does not accumulate even
with prolonged
administration
Fentanyl 1-2 min (maximum effect
within 30 min)
15-20 min Small doses have a short
duration because they are
rapidly redistributed from
central to peripheral
tissues. Larger doses or
repeat injection causes
accumulation of drug in
the peripheral tissues
producing longer duration
of analgesia
Hydromorphone 15-30 min (maximum
effect may not occur for
up to 150 min)
Duration: 3-5 hr
28. III. EMERGENCE
Review patient’s hemodynamics and temperature
Degree of residual neuromuscular blockade
Ensure adequate analgesia for the transition to recovery
While assessing readiness for emergence, the anesthesiologist begins to decrease
or discontinue IV or inhaled anesthetics.
Timing of these changes depends on the type of drugs given and the duration of
the administration
29. CRITERIA FOR EXTUBATION
Awake and responsive
Stable vital signs
Reversal of paralysis
Good hand grip
Sustained head lift for 5 seconds
Negative inspiratory force ≥20mmHg
Vital capacity > 15ml/kg
30. IV. POSTOPERATIVE CARE
Transfer care to recovery room nurse
Requires effective and clear communication to avoid error and harm
The person assuming the care must respond and confirm that he/she heard and
understands the relayed information
Must be hemodynamically stable and normothermic
Unstable patient is better left intubated, ventilated and sedated until stable
-General anesthesia is a process whereby the patient is rendered unconscious in a reversible, controlled manner.
-unconsciousness is induced by binding to specific receptors throughout the brain, brainstem and spinal cord
-anesthetics most likely make patients unconscious by acting on the brain, while immobility results from effects on the brainstem
**complete paralysis can produce immobility in response to surgical stimulation, although paralysis without unconsciousness can lead to awareness with recall, an uncommon but potentially horrifying complication
**muscle relaxation provides optimal conditions for endotracheal intubation and improves surgical exposure during intra-abdominal and intrathoracic procedures
Even while paralyzed, the body can mount a robust SYMPATHETIC RESPONSE to surgical stimulation with hypertension, tachycardia and tachypnea. The last element of general anesthesia aims to controll these changes
Most anesthesia consent forms include a list of possible complications.
Some of these are..
-nausea and vomiting – common but transient
-dental damage and corneal abrasion – less common but self-limited or repairable
-awareness, brain damage, or death – rare but catastrophic
**awareness – happens 1 in 10,000 patients, and patient with awareness with recall are at increased risk of this complication after a subsequent anesthetic
** death due to anesthesia is very rare, occurring in fewer than 1 in 100,000 anesthetics
So in the OR, we use this acronym para guide natin kung okay na ang usual set-up
The World Health Organization has developed a checklist called “the WHO Surgical Safety checklist” used in operating rooms worldwide to increase safety and reliability
Eto po ung routine q&a pagpasok natin ng OR
