Recombinant DNA technology (Immunological screening)
The practice conduct of 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
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.
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.
15.
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.