Anesthesia Review Dwi

7/25/2019 Anesthesia Review Dwi

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Anesthesia Review

M. Dwi Satriyanto


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The Anesthesiologist


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Initial Assessment

ASA classification is part of the physical

examination of the patient.

Is graded classes 1- in order of increasingris! of mortality.


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ASA "lassification

"lass 1 #ealthy

"lass $ Mild systemic disease% no f&nc limitations

"lass ' Moderate to severe systemic disease%f&nctional limitations

"lass ( Severe systemic disease% constantly lifethreatening% f&nctionally incapacitating

"lass ) *ot expected to s&rvive with or witho&ts&rgery $(h

"lass +rgan Donor

"lass , ,mergency


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Monitoring

*oninvasive monitoring with

appropriate c&ff si/e.

Invasive monitoring 0A-line for electivehypotension% anticipation of wide variations

in % need for fre2&ent 3lood sampling.

"ommon sites are femoral and radial sites.Don4t &se rachial artery.


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Monitoring

,56 for detection of dysrhythmias% myocardialischemia% electrolyte a3normalities.

7eads 8$ and 8) together detect 9): of

intraoperative ischemia% allowing for earlyintervention.

&lse oximetry estimates level of oxygen 3inding3y hemoglo3in

Sa+$ of ;


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Monitoring

Temperat&re- Axilla% esophag&s% pharynx% 3ladder%tympani.

>rine o&tp&t- a meas&re of end-organ perf&sion?

@oley for all cases over $ hrs% to decompress3ladder 0lap proced&res.

Swan-6an/- for 78,D% "+% S8R.

"apnography- confirms ade2&acy of ventilation%,TT placement% estimates a"+$.

>nexpected rise in "+$ Malignant hyperthermia.


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Ind&ction of Anesthesia

I8 or mas! ind&ction of general anesthesia.

"om3ination of agents 3ased on patient

characteristics% and proced&re.

Incl&des an amnestic% analgesic% hypnotic% m&scle

relaxant% and a volatile agent.

Rapid se2&ence ind&ction.


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Rapid Se2&ence Ind&ction

re-oxygenate with 1


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Analgesic Agents

In 3ol&ses at ind&ction and 3efore incision% thenmaintenance as needed.

Additional doses 3ased &pon sympathetic response to

pain% li!e increased #R% .Fentanyl% a synthetic narcotic% onset $min% pea!)min. Meta3oli/ed 3y liver.

6ag is 3l&nted% minimal cardiac depression% can

ind&ce respiratory arrest.(< times potency of morphine% no cross allergytho&gh.


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Analgesics

Morphine- )min onset% pea! at $


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Analgesics

Ketamineincreases #R% %3ronchodilator% maintains spontaneo&sventilation. Increased "@.

Ill&sions% dysphoria.

*ot a respiratory depressant% can 3e soleanesthetic agent.

+ne of several ind&ction agents% good forchildren% contraindicated in head inC&ry.


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Sedative-#ypnotic Agents

Sodium thiopental% a 3ar3it&rate% ind&ces&nconscio&sness within '< seconds witho&tanalgesia.

,xcellent anticonv&lsant.

After single dose dr&g redistri3&tion into m&scle mayres&lt in rapid awa!ening.

Side effects hypotension 0in hypovolemia%heartfail&re% 3eta 3loc!ade% resp. arrest% decreases "@%meta3olic rate.

PentotalB


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Propofol% fast acting% no hangover 0great for

o&tpatients% antiemetic.

Rapid meta3olism 3y liver.

Side effects hypotension% 3l&nting of airway

reflexes helping in int&3ation% resp. arrest.

>sed for maintaining anesthesia% sedation in I">.1.1!"alm7E

1


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Etomidate% fast acting% minimal hypotension% great

for ind&ction.

Rapid meta3olism 3y liver% avoid contin&o&s

inf&sions as can ca&se adrenocortical s&ppression.

"an ca&se myoclon&s.


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Benzodiazapines% provide anxiolysis% hypnosis%amnesia% anticonv&lsant% s!eletal m&scle relaxant

properties.

*o analgesic properties here.

Versed most common% short acting% liver meta3%so watch itF.crosses placenta.

Ativan0lora/epam long acting.Flumazenil is a 3en/odia/apine antagonistFassociated with sei/&resE


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M&scle Relaxants

>sed to facilitate int&3ation.

D&ring a3dominal s&rgery.

Ghen movement can 3e devastating.Paralyzed but still feel and remember

everythingE

*o analgesia% hypnosis% or amnesia.

Diaphragm last to go down% first to recover.

*ec! M&scles first to go down% last to recover.


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M&scle Relaxants

Depolarizingand non-depolarizing.

Depolari/ing agents ca&se an initial

transient m&scle fi3er activation 3eforerelaxation occ&rs.


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M&scle Relaxants 0Depolari/ing

Suinylholine% provides rapid depolari/ing

3loc!ade. Mimics acetylcholine% '< seconds%

short d&ration )-1< min.

Rapidly meta3oli/ed 3y plasma

pse&docholinesterase.

The only oneE


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M&scle Relaxants 0Depolari/ing

1 in '


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Malignant #yperthermia

"om3o of volatile anesthetic pl&s s&ccs.

@irst Sign is Increased end-tidal "+$.

Acidosis% m&scle spasm.

#ypertension% arrhythmias.

#ypoxemia% hyper!alemia

Tachycardia% pyrexia.

Myoglo3in&ria.Tx I8!antrolene "#mg$%g% cool% Dc volatileagent.


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*on-Depolari/ing

Mivac&ri&m

Roc&roni&m

8ec&roni&mAtrac&ri&m

anc&roni&m

All inhi3it acetylcholine at *MH.

*o fascic&lation% or increase in potassi&m.


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*on-Depolari/ing

Mivauriumdependent on pse&docholinesterase.

&ouronium% fast% &sed when s&ccscontraindicated.

Panuronium% inexpensive% &sed for prolongedparalysis% tachy% prolonged in renal.

All potentiated 3y hypo!alemia% calcemia%hypermagnesemia.

Monitored 3y peripheral nerve stim&lation.

To reverse% &se 'eostigmine 03loc!s acetylcholinesterase pl&s anticholinergic agent 0to

co&nteract 3rady at end of s&rgery.


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Airway

Mas%ventilation &sed at time of ind&ction.

"an 3e sole means of airway in patients withminimal ris! of aspiration.

8entilation also facilitated 3y oral or nasalair(ay0tong&e% awa!e patient.

)MAlodges in hypopharynx s&perior to larynxpreventing soft tiss&e o3str&ction of airway."ontraindicated in aspirators% paraly/ed% need forcontrolled ventilation.


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7MA


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Airway

Endotraheal *ntubationallows for vents&pport% oxygenation% relative protection ofairway.

"onfirm position 3y chec!ing 3ilateralchest rising% condensation in ,TT% ,nd-tidal"+$% 3ilateral 3reath so&nds.

@i3eroptic laryngoscopy in diffic&ltint&3ations.


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Inhalation Anesthetic

Afterind&ction anesthesia is maintained

with a volatile anesthetic.

rovides hypnosis% amnesia% some degree ofanalgesia and m&scle relaxation.

Differ in 3lood sol&3ility% potency% side

effect profiles.


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Inhalation Anesthetic

Minim&m Alveolar "onc. 0MA" is the

smallest concentration at which )


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Inhalation Anesthetic Agents


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8olatile Agents

#alothane

,nfl&ran

Isofl&raneSevofl&rane

Desfl&rane


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Side ,ffects of 8olatile Agents

#ypotension via cardiac depression 0halothane

or vasodilitation.

Arrythmogenic 0halothane potentiated 3y

epinephrine.

Enfluran contraindication for epilepsi

*sofluraneleast cardiac depressant% most coronary

artery dilation.


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Side ,ffects of 8olatile Agents

Rapid% shallow 3reathing res&lting in decreased

min&te ventilation% 3ronchodilation.

l&nts hypoxic drive

Impair cere3ral a&to reg&lation% or a3ility of 3rain

to maintain cere3ral 3lood flow over a wide range

of s.

*soflurane&sed in I" patients+alothanerarely ca&ses #epatitis.


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*itro&s +xide

*ot potent% re2&ires large inhalation

concentrations.

Insol&3le in 3lood

Minimal cardiac depression% changes little. *o

m&scle relaxant properties li!e volatile agents.

*ot 3ronchodilator% increases 8R.

May expand air cavities 3y diff&sing in faster thandiff&ses o&tF.. Avoid in middle ear occl&sion.


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Regional Anesthesia

Spinal Anesthesia% 7'-7( interspace. @ree flow of"S@ confirms s&3arachnoid placement where local isinCected.

Anesthesia occ&rs in min&tes% lasting &p to $ hrsdepending on agent and dose.

7evel of sympathetic 3loc! higher than sensory 3loc!%this in t&rn a3ove level of motor 3loc!.

Sympathetic 3loc! res&lts in hypotension.#igh spinal res&lts in respiratory depression.

Motor recovers 3efore sensory.


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Spinal


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Regional Anesthesia

In Epiduralanesthesia% a catheter is placed

in epid&ral space allowing for contin&o&s

inf&sion to relieve postoperative pain.@inal level of sensory 3loc!ade depends on

volume in,etednot dose.

+nset slower than spinal.


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,pid&ral


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Anesthesia Review Dwi