Lec 2
Anaesthesiology
Clinical Anaesthesia I.C.U. Pain Management
General Neuroaxial Regional
♪ Anaesthesia: Temporary induced loss of sensation or awareness. It may
include analgesia, paralysis, amnesia or unconsciousness.
♪ Anaesthesiology: It’s the medical specialty that focuses on perioperative
medicine.
Premedication ( 6As ) refers to drug or group of drugs administered to
facilitate induction and maintenance of anaesthesia, generally it’s any approach (
pharmacological ) to optimize the patient status for any medical or surgical (
invasive or non-invasive procedure ).
Anxiolysis the most commonly prescribed drugs are benzodiazepine
(diazepam), they produce a degree of sedation and amnesia. Other drugs could
be opioids (Morphine).
Amnesia most patients request not to recall events of anaesthesia and
surgery, this could be done by benzodiazepine & opioids.
Anti-emetic nausea and vomiting may follow administration of opioids either
pre- or intra-operatively. Certain types of surgery ( Gynaecology ) associated
with higher incidence of Post-Operative Nausea and Vomiting ( PONV ).
Unfortunately, none of the currently used drugs can be relied on to
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prevent or treat PONV. Drugs such as metoclopramide, ondansetron, cyclizine
and dexamethasone.
Antacids ( modifying pH and of gastric volume ) patients are starved
adequately to reduce the risk of regurgitation and aspiration of gastric acid at
the induction of anaesthesia. Such as oral Sodium citrate 0.3 M ( 30 ml )
especially in pregnancy*, H2 blocker ( Ranitidine ), proton pump inhibitor (
Omeprazole ) and prokinetic (metoclopramide)*.
Anti-autonomic
1. Anticholinergic Antisialogogue reduce salivation ( glycopyrrolate ) and
Vagolytic to reduce bradycardia especially in children ( Atropine ).
2. Antisympathetic reduce the sympathetic reflex ( tachycardia and HT ) like
B-Blocker ( Esmolol ) and IV local anaesthesia ( Lidocaine ).
Analgesia the most important drugs; opioids ( morphine, fentanyl and pethidine
), NSAIDs, steroids ( dexamethasone )*
Majority of patients own their regular medications should be taken as normal,
unless instructed otherwise by the anaesthetist.
♪ Pre-operative starvation; Optimum starvation. Prolonged / or an adequate
starvation increases the risk of PONV.
Water, breast milk and clear fluids for 2 h.
Bottle milk and pulp juices for 4 h.
Solid food for 6 h.
Heavy ( fatty ) meals for 8 h.
Normal medication taken with small amount of water.
Chewing gum does not increase gastric volume and best treated as clear fluids.
Airway management
Maintenance of patent airway is the essential base for the safe and successful
conduct of anaesthesia. It is a skill required for all doctors as during
resuscitation. As anaesthesia frequently results in loss of airway patency and
this is most easily restored by a combination of the head tilt a jaw thrust.
When a holding facemask in position with the index and thumb, jaw thrust is
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achieved by lifting the angle of the mandible with the left three fingers of one
or both hands ( C & E ). The overall effect desired is that the patient’s
mandible is ‘lifted’ into the mask rather than the mask is being pushed into the
face.
Facemask
Commonly used type in adults is the BOC anatomical facemask, designed to the
contours of the face with the minimum of pressure.
Leakage of anaesthetic gases is minimized by air-filled cuff around the edge.
Masks made of variable sizes, smallest one provide good seal should be used.
Some masks have transparent body allowing identification of vomits, bleeding,
secretion and drooling, making them popular for resuscitation.
All masks should be disinfected* between each patient use. Alternatively single
use ( disposable ) masks are available.
Oropharyngeal ( Guedel’s ) airway
Curved plastic tubes flattened in cross-section and flanged at the oral end. Lie
over the tongue, preventing it falling back into the pharynx.
Available in variety of sizes suitable for all patients, from neonates to large
adults, respectively.
Estimating the size required by comparing the airway with the vertical
distance between incisors teeth and angle of mandible.
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Initially inserted upside down as far as the hard palate then rotated 180⁰, and
then fully inserted until the flange lie in front the teeth, or gums in an
edentulous patients.
Equipment for tracheal intubation
Laryngoscope; with a curved ( Macintosh ) blade and a functioning light.
Tracheal tubes; either cuffed ( adults ) or un-cuffed ( children ), with a
variety of sizes. The internal diameter is expressed in millimeters and the
length in centimeters.
Syringe; to inflate the cuff.
Catheter mount; elbow connector ( 90⁰ ), connecting the tube to the
anaesthetic system or ventilator tubing.
Stethoscope; to check the correct placement of the tube by listen the breath
sounds during ventilation.
Extras
1. Semi-rigid introducer ( Stylet ) to help mould the tube to a particular
shape.
2. Magill’s forceps designed to reach the pharynx to remove debris or direct
the tip of the tube.
3. Bandage or tape to secure and fix the tube.
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Tracheal tube
Manufactured from plastic.
Single use to eliminate cross-infection.
Available in 0.5 mm interval, long enough to be used orally and nasally.
Most tube with radio-opaque line, so the position could be visualized by X-ray.
In adult sizes enhanced with a cuff to prevent regurgitation and leakage of
anaesthetic gases.
The cuff is inflated by injecting air via a pilot tube, at the distal end there is a
one-way valve to prevent deflation and a small ‘balloon’ to indicate when the
cuff is inflated.
Un-cuffed tubes used in children up to 10 years of age as the narrowing in the
subglottic region provides a natural seal.
Steps for oral intubation
1. Pre-oxygenation All patients who are to be intubated are asked to breathe
100% oxygen via a close-fitting facemask for 2-3 mins. This provides a
reservoir of oxygen in the patient’s lungs, reducing the risk of hypoxia if
difficulty is encountered with intubation. Once this has been accomplished,
the appropriate drugs will be administered to render the patient
unconscious and abolish laryngeal reflexes.
2. Positioning the patient’s head is placed on a small pillow with the neck
flexed and the head extended at the atlanto-occipital joint, the sniffing
‘the morning air’ position. The patient’s mouth is fully opened using the index
finger and thumb of the right hand in a scissor action.
3. Laryngoscopy the laryngoscope is held in the left hand and the blade
introduced into the mouth along the right side of the tongue, displacing it
to the left. The blade is advanced until the tip lies between the base of
tongue and the epiglottis, the vallecular. Force ( by upper limb not by wrist )
is applied to the direction of the handle of the laryngoscope is pointing.
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4. Intubation the tracheal tube is introduced into the right side of the mouth,
advanced and seen to pass through the vocal cords. The tube is then held
firmly and the laryngoscope is removed, and the cuff is inflated sufficiently
to prevent any leak during ventilation. Finally the position of the tube is
confirmed and secured in place.
Complication of tracheal intubation
Hypoxia Unrecognized oesophageal intubation.
Trauma Directly during laryngoscopy; damage to lips, teeth, tongue, pharynx
and larynx. Or indirectly to the cervical spines and cord during manipulation
especially to traumatized patients or those with pre-existing degenerative
diseases.
Reflex activity HT, arrhythmia, vomiting and laryngospasm. Happened in light
anaesthetized or poorly prepared patients.
Cricoid pressure ( Sellick’s Manoeuvre )
Regurgitation and aspiration of gastric contents are life-threatening
complications of anaesthesia and every effort must be made to minimize the
risk. Preoperatively, patients are starved to reduce gastric volume, drugs given
to increase pH. At induction of anaesthesia ( especially in emergency cases ),
cricoid pressure provides physical barrier to regurgitation. As the cricoid
cartilage is the only complete ring of cartilage in the larynx, pressure on it,
anteroposteriorly, forces the whole ring posteriorly, compressing the
oesophagus against the sixth cervical vertebral body, thereby preventing
regurgitation. An assistant, using thumb and index finger, applies pressure
whilst the other hand is behind the patient’s neck to stabilize it. Pressure is
applied as the patient loses consciousness and maintained until the tube has
been inserted, the cuff inflated and the correct position confirmed.
