Anesthesia Notes

A Anesthesia and Peri-Operative Medicine Alexander Huang, Lindsay MacKenzie and Pamela Lau, chapter editors Alaina Garbens and Modupe Oyewumi, associate editors Adam Gladwish, EBM editor Dr. Isabella Devito and Dr. Ryan Mai, staf editors Anesthesia Basics 6.0... .0.cecceceeesee2 Pre-Operative Assessment . History and Physical Pre-Operative Investigations Fasting Guidelines ‘American Society of Anesthesiology (ASA) Classification Pre-Operative Optimization 4 Medications Hypertension Coronary Artery Disease (CAD) Endocrine Disorders, Respiratory Diseases Aspiration Induction Agents 6 Intravenous Agents Volatile Inhalational Agents Muscle Relaxants and Reversing Agents Airway Management. Airway Anatomy Review Tracheal Intubation Rapid Sequence Induction (RSI) Difficult Airway Intraoperative Management..........+.+. 10 Oxygen Therapy Ventilation Tomperature Heart Rate Blood Pressure Fluid Balance and Resuscitation IV Fluids Blood Products Extubation ....0cc0cccceeeeeereeeee 7 Post-Operative Care... eseeeeeeeeeeee 7 Pain Management ........2+0+eceeeeee02 17 Regional Anesthesia . Definition of Regional Anesthesia Preparation for Regional Anesthesia Epidural and Spinal Anesthesia Peripheral Nerve Blocks Local Anesthesia ........cccceseeeeeee 21 Local Anesthetic Agents Local Infiltration, Hematoma Blocks Topical Anesthetics Obstetrical Anesthesia 2 Pediatric Anesthesia a Uncommon Complications 24 Malignant Hyperthermia (MH) ‘Common Medications.........-2..00+00+ 25 Intravenous Induction Agents Opioids Volatile inhalational Agents Depolarizing Muscle Relaxants Non-Depolarizing Muscle Relaxants Reversal Agents for Non-Depolarizing Relaxants, Local Anesthetic Agents nes 2 Toronto Notes 2011 ‘Anesthesia AIAD Anesthesia Anesthesia Barice/Pre-Operative Assessment Toronto Notes 2011 PS weird 6 A's of General Anesthesia 1. Anesthesis 2. Anxiolysi 3. Amnesia 4. Arefleia (muscle rlaxaion not always requised) 5. Autonomic Stability 6. Analgesia Types of Anesthesia general general anesthesia ‘Hota TV anesthesia (TIVA\ + regional * spinal, epidural * peripheral nerve Block = TV regional + local * Toca infiltration "topical + sedation ' monitored anesthesia care note that diferent types of anesthesia can be combined (e.g general + regional) me emer d + to identify the patients medical and surgical issues: to allow forthe arrangement of further ‘investigations, consultations and treatments for patients nol yel optimized; and to plan anesthetic techniques History and Physical History + indication for surgery + surgical/anesthetc Hx: previous anestheties/complicaions, previous intubations, medieations, rag llergies + PME * CNS: seizures, stroke, raised intracranial pressure (ICP), spinal disease ry diease (CAD), myocardial infarction (MI), congestive heat failure HE), hypertension (HIN), valvular disease, dysthythmias, peripheral vascular disease (PVD), conditions requiring endocarditis prophylans, exercise tolerance, CCS class, NYHA class (see Catdiology and Cardiovascular Surgery, C33 for NYHIA classification) ry: smoking, astima, chronic obstructive pulmonary dizeaze (COPD), recent upper respiratory tract infection (URTD, sleep apnea + Gk gastroesophageal reflux dteate (GERD), liver disease + renal: insufficiency. dialysis, CKD * hematologic: anemia, coagulopathie, blood dyscrasias * MSK: conditions associated with dificult intubations ~arthitdes (eg. rheumatoid arthritis), cervical tumours, cervical afections/abscess, trauma to cervical spine, Down syndrome, scleroderma, obesity conditions affecting neuromuscular junction eg myasthenia gravis) + endocrine: dsbetes, thyroid, adrenal disorders + other: morbid obesity, pregnancy, ethanol/other drug use «Flix: malignant hyperthermia, atypical cholinesterase (pseudocholinesterate), other abnormal Grug/anesthetic reactions Physical Examir + ofopharyax and airway assesement to determine the likelihood of dificult intubation + ability to assume “sifing postion” ~ upper cervical spine extension, lower cervical spine Alexion (asteses likelihood of dificult intubation) + no single tel i specific or sensitive ~ all ad in determining the ease of Mallampati Classification (Figure 1) * dayromental distance (the distance of the lower mandible inthe midline from the mentum to the thyroid notch) * with the adult patients neck fully extended, <3 finger Alfficut intubation eats (<6 em) i associated withToronto Notes 2011, Pre-Operative Assessment + mouth opening (<2 finger breadths is associated with difficult intubation) * tongue size * dentition, dental appliancee/proshetic caps ~ must inform patients of the raze possibility of damage + nasal passage patency (ifplanning nasotracheal intubation) «+ bony landmarks and suitability of anatomy for regional anesthesia (if relevant) 1 faced phyical exam ofthe CNS, CVS, and respiratory syten 1 general assessment of nutrition, hydration, and mental satus Pre-existing motor and sensory deficits "scs for TY, cental venous pressure (CVP), and pulmonary artery (PA) catheters Posse all 3 r=. Malan Glsifion of Upper Airway Vcaaton Pre-Operative Investigations Teo 1. Spestd indications fr Specie mvstiatons in he Pr-dperavo Paid im Tess ost Ta spy ora le ae Ore le renal er hapedseose marae, eum a sspced ater Bear Sasser relent seth Teo ope Sil oll sere Gers paged pint esi clceopares if screm peste) Ina, arr scout tay nding dhe, ha dase eevelnes and ype, eal seas, betes, tay anal as: gaxin or dr thay Creatine eater eg mapies aectngeetas, age >50, Fasting gucovoloval Dabs pean cay! spe) Pregnancy betes) Waren eitbouig oe tee Hear esse, yperansin, dade, thea amore CVA neal rage ra >, Eehocargrm CHE cadaryopety var aly. vied acres, tke of nosve elegy Chat raigaph ac play ise age 260 ‘re ences dE phe on eto SIT ‘andra Fasting Guidelines Fasting Guidelines Prior to Surgery (Canadian Anesthesiologists’ Society) + Shoure after a meal that includes meat, fried or fatty foods 1 Ghoure afer alight meal (euch ae toa, crackers and clea formula or nonhuman milk + hours afer ingestion of breaet mill or jello + hours afer clear Muids (water, black coffee, tea, carbonated beverages, juice without pulp) i) oF after ingestion of infant ‘Anesthesia A3 laptop (cer May Meaty etn 8888 Sy ee py hc nd eh a eet. ae ‘wat oscar mc (rome él ore nn ‘Srna et po endtentan te 2a Taner hee nenrgensoe| et i pevene 2 ate a ee ceo 8 ‘eer mn ee ‘hve and end ‘aes a up et Spssldenumtn ch alae Shoes gn, Tpoos pod araend wea ‘ended mo eet peateviMM Anesthesia isk Asosnet ‘fuer ptt tar th sel ete eve ade terete on [Link] ‘hola go Setanta beatae Sage POSE Ad eat ua Uecame mb Papo wi el te Ine prea pee nan wa to, ear en Watt eo ‘et ey ae > aero dient eine ‘we dan Pt ee are ‘Se eemtlpane es ges ‘enter Sees sho a ae ennai rg eho oa ‘nn vont eh redmperidcvos nelle ‘Setinbsby eae ee ee tgs id ee st cog Usenet anette ‘hilton pede vedeeac mst ss ate iret event seed Sie ete pe wae tees Pt ens ae bac Inca npn i nr ede (Sepa tee wat a tee epi re-Operative Astessment/Pre-Operative Optimization Toronto Notes 2011 American Society of Anesthesiology (ASA) Classification «+ common clasification of physical status at the time of surgery 1 a gross predictor of overal outcome, NOT wsed as sraliicaion for anesthetic risk (mortality + ASA I: aealthy, fi patient ‘+ ASA2Z:a patient with mild systemic disease eg. controlled Type 2 diabetes, controlled essential HIN, obesity, smoker + ASA 3:a patient with severe systemic disease that limit activity ¢g, stable CAD, COPD, DM, obesity 4 ASA 4: patient with incapacitating disease that i constant threat to lf, eg, unstable CAD, renal failure, acute respiratory failure 4 ASAS:a moribund patient not expected to survive 4 houre without surgery, eg. ruptured abdominal aortic aneurysm (AAA), head trauma with increased ICI « for emergency operations add the eter E ater lasifiation (eg. ASA 3E) Pre-Operative Optimization «+ in general, any Duid and/or electrolyte imbalance should he corrected prior to elective surgery «+ pay particular attention to cardiac and respiratory meds, narcotics and drugs with many side ‘fect and interactions + pre-operative medications to start + prophiylanie * Fisk of GE te: sodium citrate 30 mL PO ot ranitidine 150-300 mg PO 30 min to 1 how pre-op + Fisk of infective endocarditis, GUGU interventions antibiotics * risk of adrenal suppression: steroid coverage * risk of DVT: heparin SC * consider oral benzodiazepine for the anxious patient «optimization of co-existing disease: bronchodilators (COPD, asthma), nitroglycerin and beta-blockers (CAD risk factors) + pre-operative medications to stop * oral hypoglycemic: stop on morning of surgery * antidepressants (Cicyclies, MAOIS): stop on morning of surgery + pre-operative medication to adjust * insulin, prednisone, coumadin, bronchodilators Hypertension + mild to moderate HTN is not an independent risk factor for peri-operative cardiovascular complications te etalon Sag. 1987; 216187708) + targel sBP <180 munllg, dB? <110 mg 1 assess for absence/presence of end-organ damage and teat accordingly Coronary Artery Disease (CAD) + ACCIAHA Guidelines (2007) recommend postponing elective surgery 46 weeks fllowing an MI 4 this period carries an increased tsk of teinfarction/death ‘<3 months afler MI ~ 37% patents may reinfaret + 3-6 months after MI 15% + >6 months afler MI risk romaine constant al 5% + ifoperative procedure is essential, and cannot be delayed, invasive intra and post-operative ICU monitoring reduces the risk to 6%, 2% and 1% respectively for the above lime periods + mortality with perioperative MT is 20-50% + ination of peri-operaive bela-blockade in patents with increased risk of CVA * beta blockade should be contined if ready stated * initiate beta blockade if inducible ischemia, CAD or muluple cardiac risk factors and ‘undergoing high risk surgery * consider initiating beta blockade CAD or multiple cardiac risk factors and undergoing intermediate risk surgery * tecalment with beta-blockers should be optimized well in advance of any eurgeryToronto Notes 2011 Pre-Operative Optimization/Monitoring. Anesthesia AS Endocrine Disorders + diabetes melitus * hypoglycemia ‘ caused by drugs and surgical stresses and masked by anesthesia «+ prevent with dextrosefinrulin infusion and blood glucose monitoring + end organ damage: be awate of damage to CVS, renal and nervous systems, including selonomic neuropathy + hyperthyroidism "can experience sudden release of thyroid hormone (thyroid storm) + tecatment: beta blockers + pre-op prophylaxis, + adrenocortical insuliciency eg. Addisons, exogenous steroid use * steroid coverage suggested if steroid use of >1 week in past 6 months Respiratory Diseases + sethma * bronchospasm from intubation, delivery of inhaled anesthetics * pre-op inhaled salbutamol may mitigate risk + avoid non selective beta-blockers, caution with beta specific * cancelidlay clecive surgery for poorly controled asthma + smoking " adverce effects: altered mucus secretion and clearance, deressed smal airway caliber and altered immune response 1 abstain atleast # weeks pre-op possible * sf unable, abstaining even 24 hours pre-op has shown benefit, + corp * anesthesa, surgery and analgesia predispose to atelectasis, bronchospasm, pneumonia, prolonged mechanical ventilation and respiratory failure + caneelelay elective surgery for acute exacerbation * optimize with bronchodilators = inhaled corticosteroids = antibiotics Aspiration rick of aspiration in gastroesophageal (GE) ephincter incompetency, GERD or hiatus hernia avoid inbibiting away reflexes; reduce gastric volume and acidity employ rapid sequence induction if increased risk (see RSI, A8) ‘increased risk with laryngeal mask (instead of ETT) Canadian Guidelines to the Practice of Anesthesia and Patient Monitoring + an anesthetist present. “the only indispensable monitor + a completed pre anesthetic checklist: including ASA class, NPO policy Hx and investigations * aperi-operative anesthetic record: HR and BP gSmin, dove and route of druge and iuide 1 continuous monitoring * oxygenation + ventilation * circulation temperature ‘Metso. ears ak Routine Monitors for All Cases le + BP cuff, elemetry, pulte oximeter (0; saturation), stethoscope, temperature analyzer, eapnometer (end tidal CO, to assess adequacy of ventlation) robe, gas Elements to Monitor (Figure 2) «anesthetic depth * inadequate: blink reflex present when eyelashes lightly touched, HTN, tachye sweating + excessive: hypotension, bradycardia «+ oxygenation: pulse oximetry, inspired Q, concentration (£i0;) + ventilation: verification of correctly positioned ETT, chest excursions breath sounds, end tidal (CO, analy, end tidal inhaled anesthesia analysis + circulation: pulse, heart sounds, BE, telemetry, oximetry, central venous pressure (CVP), pulmonary capillary wedge pressure + Lemperature: temperature probe tearing oFAG Anesthesia hy cme ty, 2. Garin Outpt (0 Monitoring/Induction Agents Toronto Noter 2011 4 Jt. IN K NK KARAS Toe a NaninniC A? Arey Psuae Tastee ped! Figure 2 Typical Anesthesia Monitor Induction Agents + induction may be achieved with intravenous agents, wold agents or both Intravenous Agents «Table 11, 425 + the TV induction agents include a selection of non-opioid drugs used to provide amnesia and blunt relere, hese are initially used to draw the patient into the maintenance phaze of gener nesthesia rapidly, smoothly, and with hile adverse eects "eg, propofol, sodium thiopental or ketamine + propofol and ketamine ae also ued forthe maintenance phase of GA, Volatile Inhalational Agents + Table 13, 6 + general concepts of what agents ate discussed below * eg, sevollurane, desflurane isolurane, enfluran, halothane and nitrous oxide MAC (minimum alveolar concentration) + definition: the alveolar concentration of an agent atone atmosphere (atm) of pressure that wil prevent movement in 50% of patients in response to a surical stimulus (eg. abdominal incision) + often 1.213 times MAC will abate resposse inthe general population + potency of inhalational agents is compared using MAC {1 MAC values are roughly additive when mixing N,O with another volatile agent (Le. 05 MAC fof potent agent + 0.5 MAC of N,O = 1 MAC of potent agent however, thi only applics to ‘movement, nt other effects such as blood pressute changes and does not hold ove the entire NiO dose range) + MAC intubation: the MAC of anesthetic that wil inhibit movement and coughing dusing ‘endotracheal intubation, generally 1.3 MAC + MAC-block adrenergic response (MAC-BAR): the MAC necessary to bluat the sympathetic response (o noxious simul, generally 15 MAC «+ MAC-awake: the MAC of a given volatile anesthetic at which a patient will open their eyes to ‘command, usually 0.3-0.4 ofthe usual MAC valueToronto Notes 2011 Induction Agents/Airway Management ‘Anesthesia A7 Muscle Relaxants and Reversing Agents + depolarizing muscle eaants;succnylchoine($Ch) sn-depolarizing rocuronium, mivacurium,vercuronius 1 specific muscle relaxants are described in ore - Oy Semen ) (0) U\jg—tecstat y Yu Y Beslan i tr ‘cain peters Che eras pey q hamewatatheiecnt 5 ADK yeas Koh 3 Figur 3. Anatomy and Physiology of he Neuromuscular Junction NM) Muscle Relaxants oy + muscle rlaraion produces the fellowing desired eects 1. facilitates intubation 2 assets with mechanical venation 5. prevents muscle stretch reflex and decreases muscle tone 4, allows access tothe surgical eld (intracavitary surgery) «+ never use without adequate preparation and equipment to maintain airway and ventilation, + blocks nicotini cholinergic eceptors in NM} + provides skeletal muscle paralyss, including the diaphragm, but spares involuntary muscles uch ae the heart and smooth muscle «+ nerve simulator ie used intraoperatively to asexs the degree of nerve block; no twitch response ‘cen with complete neuromuscular blockade teers a Ie rem a maar, A ge ran fst Sth tec wth Te teaed gay ins Reversing Agents for Non-Depolarizing Muscle Relaxants (e.g. neostigmine, pyridostigmine, edrophonium) «reversal agents are acetylchoinesterae inhibitors * inhibits enzymatic degradation of ACh; increases amount of ACH at nicotinic and muscarinic receptors, diuplacing non depolarizing muscle relaxant «anticholinergic agents uch as atropine or glycopyrtolate are simultaneously administered to reversal agents (ie. bradycardia salvation and increased bowel perisalis) PC WAU CUE iui Ai ‘way Anatomy Review + normal airway: nares “> natal cavities > nasal pharynx laryngeal pharynx - taceha 4 resistance to aslo through nasal partage account for approximately 23 of total airway resistance + pharyngeal airway extends from posterior aspect ofthe nse to cricoid cartilage pnepstate + the glotic opening (triangular space formed between the rue vocal cords) isthe narrowest segment of the laryngeal opening in adults «when infubating, the glltic opening i used asthe space through which one visualizes proper placement ofthe endotracheal tube (277) «+ the raches hepine a the level of the thyroid cartilage atthe level of 6 1 the trachea bsfureates int the right and left main bronchi atthe level of 75 ste on Figure 4 Landmarks for Intubation‘AS Anesthesia oe sob Figure 5, Anatomie Con in Larmngoscopy raat ‘Airway Management Toronto Noter 2011 Table 2, Methods of Supporting the Airway Mask Away MA) Endovacea Tbe [TH Aavatages + Bae + Easy ait “hes Pe Inietone * Novant ‘Let ary uumaiiatin + Eres aay Prey Realy a ne + Pret pat eatin 1 Fees up hands bs aera) + Alows ste psa votatn * Pimarvured sposanesy + Alows utigi,"Purorary vwrcrg patent ‘ale +s fr Paracel sein Uieadvntages) + kel piston LLOC + Risk gasie ipraion + fetoncanb ek Canridewtons + Cometonueamay = PPY>ZlemiiOnooded + Mud rat uly eee peony + Lined TA bity * Larygeszesmmay stare ake The delete + Cope elargeaeatage —_ ubaten exabaion ‘id lire free + Shmpathae ses o + Operate + Drophayegaltephayagel baton peer ay tee + False away oaoey + Dae NOT rte seat + Rule aid web jt een lara er gee edabrentl ation + Can use repo! asian + 33h ee: rasapbarygpl ry» Sing so Male £8. ey mang? Ferale: 70:80 sig ¢ Pedieage'} + &men megs Tracheal Intubation Equipment for intubation ‘oxygen source and slf-inflating bag face mask (appropriate size and one size larger and seller) oropharyngeal and nasopharyngeal airways endotracheal tubes (appropriate size and one size sn tracheal styles syringe for tube ryngoscopes lation Preparing for Intubation «filed attempts at intubation can make further attempts mote dificult due to tissue trauma + plan, prepare and assess for potential difficulties (see Pre-operative Assessment, A2) ‘ensure equipment is available and working (eg. test ETT cull, check aryngoscope light, machine check) «+ pre-onygenatelde breathe «+ may need to suction mouth and pharynx first .genate: patient breathes 100% 0; for 3-5 min or for Avital capacity Proper Positioning for Intubation + “sing positon’ lexion of lower C-spine (C5,6) i, bow head forward and extension of upper C-spine at atlanto (Cl)-occiptl joint, ce. nose inthe air + aligns the three axes of mouth, pharynx and larynx to allow visualization from the oral cavity to the glottis Figure ) + proper position for laryngoscope tp to vtualize cord i the epigltte valle + contraindicated in knowa/suspected C-spine fractue/insability Tube Insertion + ETT insertion can incite a significant sympathetic response duc toa “foreign body reflex” in the crachea, including: tachycardia, dysthythmias, myocardial ischemia, increased BP and coughing + amalpositioned ETT isa potential hazard forthe intubated patient " iftoo deep, may result in sight endobronchial intubation, which is associated with left-sided atelectasis and right-sided tension prcumothorax + iftoo shallow, may lead to accidental extubation, vocal cord trauma or laryngeal paralysis as a resul of pressure injury by the ETT call + the tip of ETT should be located a the midpoint ofthe trachea at least 2 cm above the carina and the proximal end of the euf should be placed at last 2 em below the vocal cords approximately 20-28 cm mark atthe right corner ofthe mouth for men and 19-21 em forToronto Notes 2011, ‘Airway Management Confirmation of Trach * visualization of ETT passing through cords "bronchoscopic visvalization of ET in trachea + indirect * end-tidal CO, in exhaled gas messured by capnograph * auscultate for equal breath sounds bilaterally and absent breath sounds over epigastzium * chest movement and no abdominal distention, * feel the normal compliance of lungs when ventilaing patient * condensation of water vapour in FIT visible during exhalation + refling ofreervoir bag during exhalation "AP or lateral CXR: EIT tp at midpoint of thoracic inlet and carina (lateral CXR mote sensitive and specific) 1 Placement of ETT Complications During Laryngoscopy and Intubation «+ mechanical * dental damage * laceration (lips, gums, tongue, pharynx, esophagus) + Taryngeal trauma * esophageal or endobronchial intubation + aceiental extobation * insufficient cuff inflation or culf laceration: results in esking and aspiration + systemic * laryngospasm + bronchospatm «+ esophageal intubation suspected when. * end-tidal CO, zero or near zer0 on capnograph * abnormal sounds during assisted ventilation + impairment of chest excursion * hypexia/cyanosis + presence of gastric contents in ETT * distention of stomech/epigastium with ventilation Rapid Sequence Induction (RSI) + indicated when patent has full stomach’ ¢, predisposed to regurgitation/aspzation: * decrease level of consciousness (LOC) * teauma * meal within 6 hours + sphincter incompetence suspected (GERD, hiatus hernia, nasogastric tube) * increased abdominal pressure (pregmancy, obesity, bowel cbstruction, acute abdomen) + pre-oxygenateldenstrogenate: patent breathes 100% O: for 3-5 minutes or for vial capacity breathe prior to induction of anesthesia (do NOT bag ventdate) + assistant performs Selick’ maneuver: pressure an crcoid cartlage to compress esophagus between carilage and CS to prevent rellux/aepiation + administration af induction agent immediately followed by fat acting muscle relaxant (eg. SCh) ‘intubateshorly after administration of muscle relaxant (approximately 45-60 seconds) with no bag: mask ventilation sn between induction and intubation + mist uze cuffed ETT to prevent aspiration of gastric contents + inflate cuff, verify correct placement of FTT, release crcosd cartilage pressure ¢ ventilate when ETT in place and cu inflated Difficult Airway «+ dificulties with bag-mack ventilation, supraglotic airway, endotracheal intubation, infraglottic airway or surgical airway + algorithms exist for dificult airways (e.g. Anesthesintogy 2005; 98:3273, Anaesthesia 200; 58875] 1 pre-op ascssment (history of previous dificult airway airway examination) and pre-oxygcnation important preventative measuret + sf diiclt airway expected, consider: * awake intubation * intubating with bronchoscope, trachlight lighted stylet), bre-optic laryngoscope, slidescope, etc + sfintubation unsuccessfl after induction: 1. CALL FOR HELP 2, ventilate with 1009 O, via bag and mask. 5 consider returning o spontaneous ventilation andlor waking patient ‘Anesthesia AS @ din toss wes oe oe irs e Stet © coaaenr ore DiplcedeTT Oorcten Precratbors spree uation aden Sats pty fama secs 1 Ppa ees nse eae ind sed ts, ete Paint aoe 20, eet ie aren ey ‘omens parapet Seetetanl omental tea tomar sacle Sab fe nbc edie ‘abn SCL AS Tae spe Fen L500 a ra Feoodansbencder ph ‘Sect. ese tn ne ‘eanasttl 1s po Hiaasen Sse EIS ome Sane a ANRts Samaras SS Sneha NRO Wah para SHCFRAI NOR gd denne ne ana Camis cana eas Italie eater edrgotnaanan eset Melt soup ete ae ears sl ig WR Nein Fetes se Spey‘M10 Anesthesia es ‘Awol 0, Gas Equation ay = Foy Pel POCO, ‘Airway Management/Intraoperative Management Toronto Noter2011 + bag and matk venation inadequate 1. CALL FOR HELP 2 attempt ventilation with oral airway 3 consider/attempt LMA, 44. emergency invasive airway access (eg. rigid bronchoscope, crcolhyrotomy or tracheostomy) ey eM Ure ll Oxygen Therapy + in general the goal of oxygen therapy isto maintain oxygen saturation ($40; 290% + below an S20, 0f 908, a small deerease in saturation cortesponds to agge dap in PaQs (igure 6) + initbated patients, oxygen is delivered va the endotracheal the (STT) ‘in patients not intubated, there are many oxygen delivery systems available; the choice depends ‘on oxygen requitements(Fi0,) and the degree to which precise conitol of delivery is needed + cyanosis can be detected at a0); = 80%, frank cyanosis a $40, = 67% Low Flow Systems + acceptable tidal volume 800-700 mi zespeatory sate (RR) <25, consistent ventilation pater + provide Op at flows between 0-8 L/min + ution of oxygen with room aie results in a decrease in the inspired oxygen concenteaion (FiO,) + ap increase in minute ventilation (tidal volume x RR) results in a decrease in the inspire oxygen concentration | «eg nasal canula (prong) * ell oleated if llow rates 5-6 sin, at high lows drying af nasal mucosa * the nasopharynx acts as an anatomic rcervoir that collects O; * the delivered oxygen concentration (510) can be estimated by adding 9% for every addtional lize of O; delivered (eg. at normal tidal volume and RR, flow rate of 16 L/min ‘equate to FO, of 24-44%), Reservoir Systems «use a volume reservoir to accumulate oxygen during exhalation thus increasing the amount of ‘oxygen available forthe next breath «+ simple face mask (Hudson face mask) * covers patients nose and mouth ad provides an additional reservoir beyond nasopharynx * fed by small bore O, tubing at arate of at least 6 L/min to ensure that exhaled CO; is used ‘through the exhalation ports and not ebreathed 1 E10, 0f 559 can be achieved at O; flv rates of 10 L/min + non-rebreather mask "reservoir bag and a series of one-way valves direct gus low from the bag on inhalation and allow release of expired gases on exhalation, this allowing for oxygen accumulation during intubation +O, low sate of 10-15 L/min are needed to maintain the reservoir bag inflaton and should Acliver iO, >80% High Flow Systems + generates lows of up to 50-60 L/min eesfexceeds patient inspiratory low requirement elivers consistent and predictable concentration of 0; Venturi mask * delivers specific percentages of oxygen by varying the size of air entrapment * port determines the cxygen concentration (i.e. can vary to achieve 24%, 28%, 35%, 50%) + enables conteol of gas humidity Puritan mask * delivers the highest level of humidified oxygen, Ventilation tn patients given musde relaxants, venation ir maintained with postive pressure venation Pv) ifno muscle relaxant is given patients may have sullicent spontaneous respiraions to maintain ventilation, or asssted/contolled ventilation can be usedToronto Notes 2011, Intraoperative Management + eer ndcaons of mechanical vetlaton + scpratve posonlng ling reprory excursion (eg. prone, Tendlnbarg) + regu yperealiaion (lowe! intacrnal pes) 1 lnc pouie ca eran resure (PEEP 1 eed intnbracl prs eg epwencpl procedure + conplcton of mechani vena 1 dered 60, eee hyperventisin USSGeved duc deze venmur crn fom need nears peste 1 Gioia wth ver conection of don hypeterbi 1 oseomialpheumonaonlts «eRe 27 fr very modes Table 3. Causes of nr ative Hypor_and Hypocapnea iypecapnea Co Hpeenea (a) igen Tipe Hpstemia peters Drees eon tr Insrovedaesow ong ae reuacan ohpatesin earch fang cat Loni Ia sala vole Aoeshets beating ret ert it ryote “Rb a a eb iconbatien "sed edt Wier canary vie Temperature Causes of Hypothermia (<36,0°C) + intraoperative temperature losses are common (eg. 90% of intraoperative heat loss is transcutaneous), due to: "OR environment (cold room, IV fluids, instruments) * open wound. + prevent with inflated warming blanket and warmed IV uid (if giving platelet through a line that docs not go through warmer, warmer distorts viability of platelets) Causes of Hyperthermia (>37-5-38.3°C) ‘drugs (eg. alropine) blood transfusion reaction Infection/sepsis, medical disorder (eg. thyrotoxicosis) malignant hyperthermia (see Uncommon Complications, A24) cover zealous warming efforts Heart Rate Causes of Intraoperative Tachycardia + confirn itis sinus tachycardia vs. other shythms (eg alral brillation/ utter, paroxysmal arial tachycardia, accessory pathway syndromes, ventricular tachycardia) «+ causes of sinus tachycardia: * shock/bypovolemia/blood los * anxiety pain/light anesthesia, * fullbladder + febrile ness/sepsie * drugs (eg, atzopine, cocaine, dopamine epinephi pancuronium) + Addisonian criss, hypoglycemia, transfusion reaction, malignant hyperthermia ine, ephedrine isolurane, soproterencl, Causes of intraoperative Bradycardia ‘increased parseympatheti tone vs. decreased sympathetic one smust rule out hypoxemia, arrhythmias (se Cardiology and Cardiovascular Surgery, C12) baroreceptor reflex due to increased intracranial pressure or increased blood pressure vagal reflex (occulocardize reflex, carotid sinus rellex, airway manipulation) gs (eg. succinyicholine, opioids, edrophonium, neostigmine, halothane, digexin, beta-blockers) ‘Anesthesia ALL g suspect non wit ones Cause of vanperave Hypoxia Inadequate oxen sr eating yt denen, Savard rmabeted ET aks inthe amesore macnn, bee one ae ipeventaton Veit persion ina fears pane ‘ira pmo edu in expen caring apace ones eaten marie eso roms Femeorenay otal hit homeo Fern dessed 0G leds hypaeain, ebon reno ight cardi shnt petri (2°95 96) Impectn Octeomes “ilo te idee of Yeh rd chat aut pobrrgpstap‘AI2 Anesthesia Intraoperative Management Toronto Noter2011 @-r Blood Pressure Causes of Intraoperative Hypotension/Shock (sBP <90 mmHg or MAP <60 mm¥g) Invaepraive Shack a) hypovolemic/hemorthagic shock swocke * see Infectious Diseases, 1D24 Sosa Spal stock * most common form of shock, due to blood loss or dehyration ipo remage + class | hemosthage- 0-158 of blood volume ox <3% total body water (TW) © cane peel pect fg he to wihtndpolengd ahem in, + patient Fels cold, postural hypotension and tachycardia, cool/pale/moist skin, low VP, ‘decreased [Link] peripheral vascular tesistance, concentrated urine + teatment: rapidly infuse 1-2 [of balanced sl solutions (BSS), then maintenance Mids + class Zhemorthage: 15-308 of blood volume oF approximately 686 of TBW * thirst, supine hypotension and tachycardia, liguria or anuria + tealment: rapidly infuse 2 of BSS then re-evaluate continued needs ' class 3 hemorthage: 30-40% of blood volume ‘ mildly decreased perfusion to heart and brain ‘+ marked tachypnea, tachycardia, decreased [Link], confusion, ‘ treatment: rapidly infuse 21 of BSS + replace blood losses with BSS (1:3) or PRBCs, colloid (1:1) + maintain urine output >0.5 mb/kg/he * class d hemorthage:>40% of blood volume o approximately 9% of [BW * decreased perfusion of heart and brain + agitation, confusion, obtundation, supine hypotension and tachycardia, rapid deep breathing, anuria + treatment: same as dass 3 ) obstructive shock " obstruction of blood into or out ofthe heart * inexeased IVP distended neck veins, increased systemic vascular resistance, insufficient cardiac output (CO) + eg tension pneumothorax, cardiac tamponade, pulmonary embolism «cardiogenic shock * myocsedial dysfunction * increased JV, distended neck veins, increased systemic vascular resistance, decreased + eg, dysrhythmias, schemsa/infarct, eardiomyopathy, acute valvular dysfunction 4) septic shock. * Dactril, vital, fungal, endotoxins/mediators cause vasodilation and capillary leakage * associated with contamination of open wounds, intestinal injury o penetrating trauma, * fever, decreased TVP. wide pulse pressure, increased cardie output, increased HR, decreased systemic vascular resistance + pressors + initial treatment antibiotics, volume expansion «© spinal/neurogenic shock * decreased sympathetictone + hypotension without tachycardia or peripheral vasoconstriction (warm skin) £) anaphylactic shock "see Emergency Medicine, ERSO + acute/subacute generalized allergic reaction due to an inappropriate or excessive immune response (type I hypersensitivity) moderate reaction: generalized urticaria, angioedema, whecring, tachycardia = epinephrine (11000) 03-05 mg ~ antihistamines: diphenhydramine (Benadryl*) 25-50 mg IM = salbutamol (Ventolin®) Ice via nebulizer = severe reaction/evolution: severe wheezing, laryngeal/pulmonary edema, shock ABCs, may need ETT due to airway edema ~ epinephrine (1:1000) 01-03 mg IV (or via TT ifno IV access) to star, repeat as needed = antihistamines: Benadeyl* 50 mg V (-1 mghkg) = steroids: bydrocortsone (Solucorte) 100 mg TV (~1.5 mg/kg) or smedhyiprednisclone (Solumedrol*) 1 mg/kg IV gsh x 24h = large volumes of crystalloid may be required 8) drugs + vasodilators, high spinal anesthetic interfering with sympathetic outow b) other * transfusion reaction, Addisonian criss, thyrotoxicosis, bpothyroid, aortocaval syndromeToronto Notes 2011, Intraoperative Management ‘Anesthesia AIS Causes of intraoperative Hypertension «pain, anxiety due to inadequate anesthesia, + pre-custing essential hypertension, coarctation or pre-eclampsia 1 bypoxemia/hypercarbia bypervolemia drags (eg. ephedrine, epinephrine, cocaine, phenylephrine, ketamine) allergicfanaphylactic reaction ypermetabolic sates: malignant hyperthermia, neuroleptic malignant eyndrome (Gee Poychiatry S44), pheochromocytoma, thyroid storm (see Endocrinology. £35, E28) Fluid Balance and Resuscitation or + TOTAL REQUIREMENT = MAINTENANCE + DEFICIT + ONGOING LOSS +n surgical settings this formula must take nto account multiple factors including pre-operative fasting/decreaced Suid intake, increased losses during or before surgery uid shifting during surgery fluids given with blood products and medications What is the Maintenance? + average healthy adult requies approximately 2500 mi water/day 200 mUiday Gt losses + 800 mtday insensible losses (respiration, perspiration) +1500 mia urine (hewate of renal faite) «+ snereased requirements with fever, sweatin, Gl losses (vomiting, diarchea, NG suction), advenal insufficiency, hyperventilation, and polyurie renal disease + decreased requirements with anuria/oliguria, SIADH, highly humidified atmospheres, and CH {42:1 rue to calculate maintenance requirements (applies to crytallods only) 4 mbkg/hour rs 10 kg wan + 2 mLfkgihour second 10 kg #1 mbikg/hour for remaining weight >20 kg + maintenance electrolytes B + Na} mbghkgiday + Ki mEgkpiday +6. 50 kg patient maintenance requirements * iid = 40 = 20-+30 = 90 mUMhous = 2160 mL day " w + Na= 150 mbgiday (therefore 66 mEq/l) rae 05U baw SU ° hy, my aie 00 mEq/day (therefore 2: mEq.) (eae esmian bd + shove patients requirements roughly met with 2/3 DSW, 1/3 NS 07. Total Body Wat "eg 2/3 + 1/3 @ 100 mJhoue with 20 mBq KCI pe ire Division in 270 kg Adult What is the Deficit? «patients should be adequately hydrated pri to anesthesia + TBW = 60% oF 509 of total body weight for an adult mal o female, respectively (eg. for a70 kg adult male TBW = 70x06 = 42 1) + total Na content determines ECF volume, [Na} determines ICF volume ‘hypovolemia duc to volume contraction, exra-renal Na oss * Gk: vomiting. NG suction, drainage, fistula, diarchea + skinrexp: sensible losses (fever), sweating, burns + vascular hemorthage + renal Nand #0 loss “diuretics * hypoaldoseron + salt wasting nephropathies + renal HO loss * diabetes insipidus (central or nepheogenie) ' hypovolemia with normal or espanded ECF volume ‘ decreased cardiac output redistribution “ hypoalbuminemia:crthoss, nephrotic syndrome ~ capillary leakage: acute pancreatitis, rhabdomyolysis, ischemic bowel, sepsis, anaphylaxis «+ replace water and electrolyte as determined by patients needs + with chtonie hyponatremia correction must be done gradually over >48 hours to avoid CNS central pontine myelinalysie‘AM Anesthesia abi wr air ab eas ca 0 Fp: sek ct es epondacpalerer dest, ‘casei pt He eed hy totirec creak ere ed ‘eames nas iho ek San dettame revi ar re ee Pr ‘ev we ra ae ecko Fen al a in combed espe ‘dra pie pnt ke STO eon en pe fe IN SLIGS Hen ‘tans iter Nein a8 108 Leer ti apo ea cerpeed ‘Seventeen 2 beim. Cimino rds te Hranpesiapecpreayelottey fs tpn ee id Intraoperative Management Toronto Noter2011 iy Signe and Sy Till Deceased sinus sankey, ry racausmerbanes, try tng rece ses Nocerte Ogi ahora hotest, lame ke, 0) ‘nies, edn prpheral vis and hemacocenten, ay % rors Felner aria sed aramid CS son wth ori stored sera What are the Ongoing Losses? * Foley catheter, NG, surgical drains «third spacing (other than ECE ICP) * pleura, GL, retroperitoneal, peritoneal * evaporation via exposed viscera, burns + blood lose {ongoing lors due to surgical exposure and evaporative losses ‘minor surgery Seelkghhr eg laparoscopic surgery ‘intermediate surgery 6 eclaglhe eg open cholecystectomy fg. abdominal aneurysm repair IV Fluids «+ replacement fds include crystalloid and colloid solutions + improves perfusion but NOT O; earzying capacity of blood Crystalloid Infusion + salt-containing solutions that distribute within ECE + masntain euvolemia in patient with blood loss 5 ml crystalloid infusion per 1 mi. of blood loss for volume replacement (Le. 3:1 replacement). Controversy surrounds this as an initial vs maximal replacement cazget «+ afer 31 crytalloid replacement, switch to pRBCs + iflaege volUmes are tobe given, use balanced fuids such as Ringer’ lactate or Pasmalyte, as too much normal saline (NS) may lead to hyperchloremic metabolic acidosis, Colloid Infusion (sce Blood Products, A1S) + collected from donor blood (eh frouen plasms, albumin, RBCs) or synthetics [eg Ipydzoxyethel starch (HES) solutions] + diseibutes within intravascular volume +1: ratio (infusionblood loss only in terms of replacing volume 1 HES colloids remain in intravascular space (metabolized by plasma serum amylase and renally excreted), to available in Canada: Voluven' and Pentaspan* Table 5. Colloid HES Solutions Canceriwion — PasmaVohne ‘asinan Daly Dove Expansion ar w 7 we 230 8 was eat e Initial Distribution of 1V Fluids + H,0 follows ions/molecules to ther respective compartments Table 6 1V Fluid Solutions EF Ringers OSNSOASNS SWAN Plomaye tacate Eyl we mm a 7 x ‘ 4 5 a ‘ a Ma 3 a a mw 8 * eo, a a a inden noso met 2Toronto Notes 2011, Intraoperative Management ‘Anesthesia AIS Blood Products «see Hematology, H50 Fed Blood als RECA)» 1 URAC ~ aprox. 200m 5 (= it + TUBE ceases Ho by aps. 10 gL na Ekg 1 RBCs maybe sins wh eae dense viesy Caedang Accel vast) lesen ‘ernie’ sma Simic Toma Seite Soma + Cala str ones + Dain‘ ease tase on intl Sod vans, promi ‘getter ads, patent sts Massie i rset ue sas, ston = > x Heed lel Feige RBCs» Reet! bd lane wth oes wn RCS + May eras complexions fects, le ra FBV = Tha x70 mLg = 800m + baie oa wants igs ia ‘te lelat nen yer el invari og TO gh or sn we] = 150 9 + Alea tohonlees arstsinin elect pracedrs, bt ony adequate Hb and einen + Pept atest suger lp 6st >1 wee ele suse) Nop Products» Freeh azn pena vom = 709 "Cnt als clting re a singe cose namallemalees + Cae rove ken ue ceaguin tr pet lenis, imam Attias «eo + Cpr = 150220 84900 = 2 ML * CmansFcters an, A Sregen 160 + Fades + Thin rea a + Usdin embactpenia masse rss, ingated ptt hein Il abo 1091, Rs el ave + bars * Sete ntarsclrvume pander + Eytogin “Cane ure ty trite rrp Transfusion Reactions Immunosuppression «some studies show associations between peri-operative tranefusion and post-operative infection, cater eancer recurrence, and poorer ouleame Nonimmune + infectious risks: HIV, hepatitis BYC, Epstein-Barr virus (EBV), cytomegalovirus (CMV). brucellosis, malaria, salmonellosis, measles, syphilis bypervolemia electeoyte changes: inereased K in stored blood ‘Etional coagulopathy “lutional thrombocytopenia bypothermia citrate toxicity hypocalcemia 4 iron overload‘AIG Anesthesia ‘i Ronin Ce he ‘ile ors a enti amrosa Pay soy tse Semetac esac meee oe venereal T Pant ea apne ode ‘realms near tg. tas Meaty ra ‘arn ad de strane sy # so a ‘ater ete g ‘nthe eran Tg ots boalseage nen ‘eset mn gunman hese “tandem ured Sin a Man avs Anse macy ato Dei nay ay [nnd atin a Shee toa ra. ends ie my sedi ‘ing tee ew net eerste gy vgn a Teta weber a Sev etter hosters tin Siegal hab gH dike a, iets At ag 80 evar ube weet Svar erent ney {porn wee apap et ikon Intraoperative Management Toronto Noter2011 Immune Transfusion Reactions * Awd oi, Prevention Mater EC wie wan Now honatie: Febrile Nowhemehie: ‘Aerie Now het: Aoapiylctd Transtsen Palate este Langa RAL Honelyie Auto fiavaseaer hana) Hemel Delayed (extavesuer hana) + Matern ue ‘alg eles bso nner pena + Mast cle sce wth Fister + Usa ccrsnpresxpene (ea. ele vars, ries) “Ing dticieptet with sec eas csv Ipteranng beet ‘immune camps ait ruc, tops, esophi,adeanlemet System sever sete Aertarsfoien 48, Feral, «oer Eempenrs wth gh * Femetnaneaiogie palmer era ‘ mmunaage cus: et fad vee orexcae fale + Bing of doe Ab ai reepent WOO; crea ceased capa perneiy + Cosby re incrathiy with recent bt + Oton au eel ere * ns ceed PEs esrayedby avon of Eempenent sytem + ABD carpal creer Cauee, ater REC AA systems cane reve + Casey rr inearathy wth repent bed * Greay mi, eseeey sexes hse Dilly cis anes ‘Thelolt antes at time a aden toe abedeece ara este maps, rte vo sete creased du to “Rl tf bea rete orbateral contason Mis 0} deren nate sd ge atppetes + Sev span, ge antptes, arthur, a Sympanatic tees vgs maybe >a wn reresnet ag stveng Nase Ti aig, ace, malas hypalersion ces and 1 Obes ly, new carlo ef Irene win hes stint + hen asi sia + Mi stn vantascn ate NE ‘ntti + Ait rst pt ech Medea tse: sop tants Utkanoname andtank, NV arthiamine,suetoeeut sccascaly ith ve spine, jelcerisene, Wis, + Less conman lene ole, oral nyc and bonis Popa: anthsanns 15.40 stint inca pre arstsin, washed ghettos ze A + Rar ptrtiay hl * Crh supa wit is, ‘Aap tari apans, calechlannes etepe) dies npetsan, neal oho ledarway edema abana. + Rept enistce ts nde het pa shock adden dent Eat eri define ané an Ipdantbdis “Faure tenis ste ie of lyk wasrededyeraes BCs toe al tt rm i decent dee + Oscus2-4 harps anstsion “Reston des: miles ‘a sve hype ‘Chester canst wth ete palroay ea ba puny {etey and wedge press a ddonted Tins “Usa ress wit 4 hs wih Oy mschancl elaien spprte ove cs, ches race pets, fain deen whee hyperemia bret, ie ledge ‘alae + etin2s0.00 + Sp arstsion “Nt ada, cere rede ut daze ~ cee heh, direct, aonb reat using Fh coen fndresmth, nen pogo ‘uae «Campane ester, repeat tron Rh sone and earch suhag + Manage onsen wih Bs, iaps, sas aus «Campane eaten. FF rye) Deca inrees senstinda + Scparive BC antes by eis Hod trwfusenrpreqaney + haere une, te 0 2 aes pest stain *Dret oenbs,atemamiten pretanstan pce om he pate nd rrr ges canary slsToronto Notes 2011 Extubation/Post-Operative Care/Pain Management Anesthesia AI7 med by rained, experienced personnel because reintubation may be required * patent must no longer have intubation requirements + patency: airway must be patent * protection: patient must have intact airway reflexes + patent must be oxygenating and ventilating spontaneously + laryngospasm more likely in semiconscious patent must ensure adequate LOC + general guidelines * ensure patent has normal neuromuscular function and hemodynamic statue * ensure patient is breathing spontaneously with adequate rate and tdal volume * allow venulation (spontaneous of controlled) with 100% O; for 3-5 minstee * suction secretions from pharynx * deflate cull remove ETT on inspiration (vocal cords abducted) * ensure patient is breathing adequately after extubation * ensure face mask for O; delivery avalable + proper positioning of patient during transfer to recovery oom (eg, lateral decubitus, head levated) * aspiration + Taryngospasm late * transient vocal cord incompetence * edema (glotc, subglotic) + pharyngtis, tracheltis Post-Operative Care + pain management should be continuous from OR to post-anesthetic unit (PAU) to hospital ward and home «pain service may assist with agement of post-operative inpatients Post-Operative Nausea and Vomiting (PONV) + hypotension and bradyeardia must be ruled out {pain and surgical manipulation also cause nawsea + often treated with dimenhydrinate (Gravol"), metoclopramide (Maxeran*) (not with bowel obstruction), prochlorperazine (Stemeti"), andansetron (Zoran), granisetron Type anette yu) eta aps Post-Operative Confusion and Agitation Doe PrPspai Naone «ABCs frst! ~ confusion or agitation can be caused by away obstruction, hypercapnes, = hypoxemia «+ neurologic status (Glasgow Coma Scale, pupils), residual paralysis from anesthetic + pain, distended bovee/bladder ‘ earfanxiety/separation fom caregivers/tanguage barriers + metabolic disturbance (bypoglycemi, hypercalcemia, hyponatremia ~ especially post-TUI Grog eftet(etanine anticholinergic) see Sah ern elie patents are mare uscepublee post-operative lium ea EST 2p synaSats acon TUE DE und Stl ovearnah eee eperepeeoreny st tgs a Definitions + nociception: detection, transduction and transmission of noxious ¢ pain: perception of nociception which occurs in the brain, arene ee ‘Acute Pain gnc sn + pain of short duration (<6 weeks) usually azvocialed with surgery, trauma or acule illness often plese Sssocited with inflammation tae en eee + ‘eval limited to the area of damage/trauma and resolves with healing ‘een eh a‘AIS Anesthesia (WH Anges ater ae Pin Decuranonten ae NSAIDs wth Caution in ants wt ey ie Seabee {porary 5. Pane, Sr eestor ammon Sie ecto Opa Theses wed vein 2 comstgaon 4 Sen ‘ate $.Aedemipn inary ton Tesora apesion _ PEA Pramas 4 centaur nee pe Adracages of POA Baer pan ane Fear sae ets ecru ant esi 4 Pain Management Toronto Noter 2011 ‘nm poere Sensory eax see - txe W_ Srl dose LA ested sly < can se) ne) Caminaus nisin Use of cater ewe orcas isin None trreestnelans Camplisons Fale rig aioe twee Hts ypatesin Badywialcara gabe eked Sralyearilewtac sympa Meson (ony Tet Tt ie hapa Epil or sbwaioidhersons iad rubs ere ciel beeen can rouceS-ginleaache (SF sl rts ndany te bone ages uy ase) oman Systran avers} SPs onan into Cath campeon sean ki, scl or uted cert con Deuce Combined Spindel Conbrs the els lpi real ntrse Hockde of pil neon eget ih rere Contraindications to Spinal/Epidural Anesthesia + absolute contraindication "lack of proper equipment or properly trained personnel lack of IV access = allergy to LA * infection at puncture site or underlying Useuee + coagulopathies ed ICP * sepsiaybacteremia * hemodynamic instabisty/uncorrected hypovolemia, + elative contraindicatons ‘bacteremia = pre-existing neurological disease + Sortc/mtral valve stenosis (se. fixed cardiac output sates) 1 previous spinal surgery, severe kyphoscolisis * Severe/unstabe psychiatric disease or emotional instabilityToronto Notes 2011 Regional Anesthesia/Local Anesthesia Peripheral Nerve Blocks generally used for post-operative analgesia; sometimes uses for intra-operative anesthesia relatively safe 1 2 eardinal rules: 1, Avoid intrancural injection 2, Avoid neurotoxic agents eg, brachial plexus bloc, femora n ‘an be ultrasound: guided to prevent neural jury Contraindications to Peripheral Nerve Blockade «allergy to local anesthetic (LA) + patient refusal, ack of cooperation 1 Tack of resueitation equipment lack of 1V access + certain ypes of pre-existing neurological dysfunction (eg, ALS. MS) local infetion at block sit Local Anesthesia Local Anesthetic Agents (LA) + 4c¢ Table 17 for list of local anesthetic agents Definition and Mode of Action + Livre drug that Block the generation and propagation of impulees in excitable tissues: nerves, skeletal muscle, cardiac musee, brain «+ La bind to receptor (on the cytoroic side ofthe Na chan, ic lipid soluble), inhibiting Na fax and thus blocking impulse conduction «+ diferent types of nerve fibres undergo blockade at diferent rates Absorption, Distribution, Metabolism + LA readily crosses the blood-brain barrier (BBB) once absorbed into the bloodsteeam {exter type LA (procaine, tetracaine) are broken dovn by plaema and hepatic esterases metabolites excreted via kidneys «+ amide-type LA (idocaine, bpivicaine) are broken down by hepatic mixed (P4509 systema}; metabolites excreted via Kidneys Selection of LA + choice of LA depends on * onset of action: iniluenced by pXa (the lower the pKa, the higher the concentration ofthe base form ofthe LA and the faster the onset of action) + duration of desired effects: influenced by protein binding (longer duration of action when protein binding of LA is strong) * potency: ‘membrane more easly) * unique needs (eg sensory blockade with relative preservation of motor function by bupivicaine at lov doses) + potential fr toxicity ‘Systemic Toxicity black of excitatory fibres NS elects (in order of appe * numbness of congue, perioral * disorientation, drowsiness * tinnitus * visual dinurbances + muscle witehing,temors * convulsions, siaures * generalized CNS depression, coms, respiratory arrest VS effects codiation, hypotension * decreased myocardial contractility ce) (Figure 10) ogling, metalic taste ‘block, digital ing block, ete function oxidases enced by lipid solubility (agents with high lipid solubility penetrate the nerve ‘ce able 17 for max doses, potency and duration of action for common LA agents ‘occurs by accidental intravascular injection, LA overdose, of unexpectedly rapid absorption (CNS elects frst appear to be excitatory due to initial Block of inbibitory fibres; then subsequent ‘Anesthesia A2L Figure 10. Local Anesthotic Systemic Toxicity‘A22 Anesthesia Wher Notte Us Lael Amst ‘Agen UA th Eieshne “Finges, Tos Pen Hose TW tote edt Maylene Spee tour ec Ge Ht ‘aarp ae a 8 Siti anode ak ‘stp ote 800 Seen spoon pet ey ere fede Inui Faas mdi ‘ihe eee stent ta ‘coed ‘deri ne ecto manned mene ny ceeds (eect an enenn gae pre omer aetna Feet ne esa ep ‘epg eb pars ‘unten oe te {ax tees. msm ees ‘euirace tas etry ‘cae nm nga oped (Yar nmaanpnepe Inet res ‘malt edie ‘plgngrle mane datee ‘remlin, peanracon pat ere bratty fen ‘pee ne gee ‘Gren ep soca. a er iso ‘tpt pst nea doa cnt Geter ra ‘Mee opps ney Local Anesthesia/Obstetrical Anesthesia Toronto Noter 2011 * dose-dependent delay in cardiac impulse transmission ‘ prolonged PR, QRS intervals. « sinus bradycardia + CVS collapse reatment of systemic toxicity * easly recognition of signs * 100% O,, manage ABCs + diazepam or sodium thiopental may be used to increase seizure threshold * ifthe seizures are not contrelled by disrepam or thiopental, consider using succinylcholine (stops muscular manifestations of seizures, facilitates intubation) + manage arshythmias + consider ntralipid® 20% to bind local anesthesia in cxculation Loc: Infiltration, Hematoma Blocks Local Infitration + injection of tissue with local anesthetic agent (LA), producing a lack of sensation in the ‘inflated azca due to LA acting on nerve endings + suitable fo small incisions, suturing, excising mall lesions + can use fiely large volumes of dilute LA to sitrate a lange area + low concentrations of epinephrine (1:100,000-1:200,000) cause vasoconstriction, thus reducing bleeding and prolonging the effects of LA by reducing systemic absorption, Fracture Hematoma Block ‘special type of local insltration for pain control during manipulation of certain fractures hematoma created by fracture is infleated with LA to anesthetize surzounding Gases sensory blockade may be only partial sno muscle relaxation Topical Anesthetics various preparations oflocal anesthetics avalabl fr topical use, may be a mixture of agents, eg, EMLA cream isa combination of2,5% lidocaine and procaine mist be able to penetrate the skin or mucous membrane oO Physiologic Changes in Pregnancy Laieway * upper airway becomes edematous and fiable * decreased FRC and increased O, consumption “> desaturation 2. cardiovascular system * increased blood volume > inereased RBC mass» mild anemia * decreased SVR proportionately greater than increased CO ~ decreased BP + prone to decreased BP due to aortocaval compression 3. central nervous system * decreased MAC due to hormonal effects * increased block height dc to engorged epidural veins 4. gastrointestinal system delayed gastric emptying * increased volume and acidity of gastric id * decreased LES tone * increased abdominal pressure * combined, these lead (oan increased risk of aspiration IO Uc) Options for Analgesia during Labour 1. paychoprophylaxis Lamaze method patterns of breathing and focused atlention on fixed object 2. systemic medication * easy to administer, but risk of maternal or neonatal depression * common drugs: opioids (morphine, meperidine) 3. inhalational analgesia, * cary to administer, makes uterine contractions mote tolerable, but does not relieve pain completely 1 50% nitrous oxideToronto Notes 2011, ‘Obstetrical Anesthesia/Pediatric Anesthesia 4 regional anesthesia * provides excellent analgesia with minimal depressant effects + hypotension isthe most common complication + maternal BP monitored q2-5 min for 15-20 min aftr initiation and regularly thereafter * epidural usually given at preferentially Blocks sensation, leaving motor fanction intact Options for Caesarean Section 1 regional spinal or epidural 2. general used if containdications or time precludes regional blockade Potential complications of anesthesia in Caesarean section: + aspiration under general anesthesia: due to increased gastroesophageal reflux ‘hypotension andjor fetal distress: caused by aortocaval compression: corrected by turning patient into the left lateral decubitus (LL.D) position or using lft uterine displacement (LUD) Snintentional total spinal anesthesia TAvinduced seizures due to intravascular injection of LA post-dural puncture headache nerve injury (are) ediatric Anesthesia Respiratory System «in compariton to adulls, anatomical diference in infants include (Figure 11) * Targe head, shor trachea/neck, large tongue, adenoids and tonsils + narrow nasal passages (obligate nasal breathers until § months) * narrowest part of airway a the level of the cicoid ve, loti in adults * epiglotis is longer, U shaped and angled at 45 degrees carina is wider and isa the level of "2 (F4 im adults) + physiologic diferences include * faster RR, immature respiratory centres which are depressed by bypoxia/hypercapnea (airway dlorare occurs inthe neonate atthe end ofexpiralion) ' Tess oxygen reserve during apnea ~ decreased total lung volume, vital and functional reserve ‘apacily together with higher metabolic needs greater ViQ mismatch - lower ung compliance due to immature alveoli (mature a8 yeas) + greater work ofbreathing greater chest wall compliance, weaker intercostals diaphragm. fd higher resistance to airow «+ a pediateie breathing unit i zequit forall childzen <20 kg Cardiovascular System « blood volume a birth is approximately 80 mol k; transfusion should be started if>10% of blood volume lst «+ children haves high pulse rate and low BP + CO is increased by increasing IR, not stroke volume because of low heart wall compliance: therefore, bradycardia > severe compromise in CO. Temperature Regulation + vulnerable to hypothermia + minimize heat loss by use of warming blankets, covering the infants head, humiiication of inspired gases and warming of infused solutions Central Nervous System + the MAC of halothane is increased compared tothe adult (1. 0.75% adult, 0.87% neonates, 1.29 nan) + the neuromuscular junction is immature for the fet A weeks oflife and thus there isan sncreased sensitivity to non-depolarizing relaxants + parasympathetics mature at birth, sympathetics mature at 4-6 months -* autonomic imbalance + fan brain is 129 of body weight and receives 34% of CO (adult 29 body weight and 4% CO) Glucose Maintenance «infants lee than 1 year can become seriously hypoglycemic during pre-operative fasting and. postoperatively if feeding ¢ nol zecommenced a8 soon as posible «fer 1 year children are ale to maintain normal gcse homeostasis in excess of 8 howe ‘Anesthesia A23 Neccoptve Paice in abr an aber Latest eva elton se taanens “sw are serra ‘priced 100) aber 2 Smale paren LeysAM Anesthesia Pediatric Anesthesia/Uncommon Complications Toronto Noter2011 Pharmacology « higher dose requirements because of higher TBW (75% vs. 60% in adults) and greater volume of distribution « barbiturates/opioide more potent due to greater permeability of BEB 1 msde relaxants * non-depolarizing + immature NM], variable response * depolarizing ‘ must preleeat with atropine of may experience due to PNS > SNS (alt dries oral secretions) ‘+ more susceptible to arrhythmias, hyperkalemia, chabdomyolysis, myoglobinemia, macseter spasm, and malignant hyperthermia, PLC ey lier) Malignant Hyperthermia (MH) found bradycardia, sinus node arrest. + hypermetabelic disorder of skeletal muscle + due to an uncontrolled increase in intracellular Ca (because ofan anomaly ofthe ryanodine receptor which regulates the Ca channel inthe satcoplaseic reticulum of skeletal muscle) + autosomal dominant (AD) inheritance 1 incidence of1-5100,000, may be associated with skeletal muscle abnormalities such as Aysteephy or myopathy «anesthetic drugs triggering MH crises * volatile anesthetics: any drug ending in" ane” + depolariaing relaxants: succinylcholine (SCh), decamethonium Clinical Picture + onset: immediate or hours after contact with trigger agent * increased oxygen consumption * increased end-tidal CO; on capnograph, + tachycatdia/dysthythmia * tachypnea/cyanest| + increased temperature (late sign) * hypertension + diaphoresis * tesmus (master spasm) common but not specific for MH (occuts in 1% of children given SSCh with halothane anesthesia) + tender, swollen mules due to thabdomyolyis * teunk or total body rigidity Complications + death 1 disseminated intravascular coagulation (DIC) 1 muscle necrosislweskness + myoglebinurc renal failurethepatic dysfunction + electrolyte abnormalities (eg. hyperkalemia) and secondary archythmias DARDS + pulmonary edema Prevention «suspect ME in patients witha family history of problems/death with anesthetic + danirolene prophylaxis no longer routine 1 avoid all rigger medications (ase regional i possible) and use “lean” equipment + central body temp and end-tidal CO, monitoring Malignant Hyperthermia Management [Sased on Malgnant Hyserhemia Associaton fhe US. (HAUS Guides, 208 1. nolfy surgeon, discontinue volatile agents and secinylcholin, hyperveaiate with 100% ‘xygen at flows of 10 T/nia or more; halt the procedure as soon as possible Uhdmserdameice?smgke | 2 dantzolene 25 mg/kg rapidly 1V, through large-bore IV if possible ene, * repeat unt there is control of signs of MH, sometimes up to 30 mg/kg is necessary + pete ae 3. bicarbonate 1-2 mlghkg ifblood gas values are not avallable for metabolic acidosisToronto Notes 2011, Uncommon Complications/Common Medications Anesthesia A25 4, cool the patents with core temp 239°C. * lavage open body cavities, stomach, ladder, rectum, apply ice to surface, infuse cold saline 1V * stop cooling if temp is <38°C and fallin to prevent drill 0 <36°C 5. dysehythmias usually respond to teatment of acidosis and hyperkalemia * azo standard drug therapy except Ca channel blockers as they may cause hyperkalemia and cardiac arrestin presence of dantrlene 6. hyperkalemia + treat with hyperventilation, bicarbonate, glucose/insulin, calcium, + bicarb 1-2 mbgfkg IV, calcium chloride 10 mg/kg or ealcium gluconate 10-50 mag fr lfe- threatening hyperkalemia and check glucose levels hourly 7. (llow ELCO;, electrolytes, blood gases, CK, core temperature urine output and colour with Foley catheter, coagulation studies * {CK andior potassium rises more than tansiendy or urine output fills to ess than (0.5 milkgih, induce diuresis to >1 milkg/he urine to avoid myoglobinuric renal failure jadiaepines, opioid, and propofal ‘ipo Pentoal®, sega open sum hiportan] (Nese), dazopan (Veo), loagpam Av] te ~Ayhnalbye__ Ute sher acing Hebabiale— hype» Pheveyeine POP devabve— + Bowatiapees evacive ation ‘ lhbtoy at ABAsypapee + Dns Cc apefallatg * aya’ on AVDA, pate aed + Causes iene he inhiiry ‘Deceased cevbalmeatalc —CABAandszressgghtimc sci obwrecgers rere fetes GABA fale Beedfews cerned «Dressel rata Tras reeeed 82 Pouce ata ar kk TER decrees SU, deceased deresed seston decwesed CPR ineesed SUA. raveased coy muscle lata ees BR and ce ods eras 0, tereses BR cecrared low nerenedmyacaral » Mielec aeressin Oca, ONS repay ckzressen,borchal mea mule ration Inicio Irducon * oct + Nojr tna, ysl ete * Ure sdton, are and Naniennoe Canal canal states sstinabeeasesymgatoninis ais Told inatoaus nse caval Caen + Alergy eas) + Ategy a bates + Keaiv dey + Maka spit depresion * Prewhacmol eat saten Unconlld ngtenen sick catde + Todt retin cause ceceacdP in fdewtar false tM an yhyeae ct ese) + Pe, eres, stats aetimaus, «Haye pho pete * Pretoria TN increase Dosing + Nidan. 25-20 agg ss» natin: 2Srghg THR + Widutin 2 ma + Dns han Sint en vith pi rere TVA + Uncraius aboa 10t * Dsecatin 1s,aalgesa, + Duran of acon gt rh + Unseen 1 mn ‘Late S mn ammovaanduseonccairss in sonevha rei Lat bmn + Recaron whee rater Tes Styndshes arene + Uncen fr 1015 ri ‘Deresedgosopcedan, + Gyn ne anager 40a, armesilr recovey ne NV + Postap sedatenasts ors ake wana Speci + 030% deen? eto + Combing wihrocunim cnuses + Highiniflenefemergmee + Angas rz (Aree) Canine vsosiion preeptas atom rercton fi eamng oval congener, 0.2m et 1 Rese bing at si by bey ersten lene) 1s repeat wh mii na rig wih ase Peeatwih dyspyitete alr) yf Bmines. tera rson + Miah aloha este lec fet + deceased ek slowerbeplets‘AI6 Anesthesia ‘Common Medications Toronto Noter2011 Tabla 12. Opioids jon PEA Doe PoA Lect Morptine 0308mgh o203m@ Ornate Featany, 209% 209 Sites Hpdemerpbane 0.192094 asia 0miutes awe oc Du Speci Coins Mertine O23 msia Medes 10rin) Mocante(-5H) vane ese bang tweens? Mopeds (Demer) 23mgkg Nedewo[i0nin) — Nodinte(248) Baten, alata ess pasa cents tan ‘erp, maa bald spmayease seus Cade OS mpi oN) Lae(2080min) Moderate) Pry pene cae ote aee Hidemerphone 1030 49k Node [IS min) Marte (45) (Oisaie™ Featany 0yot@ upid(