ANAESTHESIA

PRE OPERATIVE
ASSESSMENT
PRAVADI HP
ROLL NO.90
Goal of pre anaesthetic checkup
To identify the problem and to optimize the patient general
condition,so that patient can safely tolerate the surgery

Pre anaesthesia check up includes

• complete history taking
• physical examination
• systemic examination
• airway examination
Past Medical History

Hypertension-
Significance:
anaesthesia-sudden hypotension-disrupted autoregulation
of vital organs-hypoperfusion of brain,kidney,heart
Cutoff value:
BP<180/110mmHg can be taken for surgery
Management
Antihypertensives:
• Continued till the day of surgery to prevent rebound
hypertension
• ACE inhibitors,ARBs stopped prior to surgery due to risk of
orthostatic hypotension
• ACE inhibitors continued in minor surgery with min. blood loss
Diabetes
Significance:
if blood sugar increased;DKA, hyperglycaemic hyperosmolar
coma
if blood sugar decreased:
hypoglycemia
C/F;confusion,irritability,tachycardia,sweating
masked under anaesthesia—permanent neurological damage
Management:
Oral hypoglycemic agents,insulin
Drugs stopped:OHA and insulin skipped on the day of Sx bcz of
hypoglycemia
SGLT-2 inhibitors stopped 24hr prior to Sx bcz of
euglycaemic
ketoacidosis
Intra operative monitoring:
• Monitor blood sugar every 30mins
• Short acting insulin :if bloof sugar increased
dose;120-200mg/dl
onset;7-10 mins
duration;30mins
Epilepsy

Significance: epilepsy: abnormal excitation of brain cells.

falling back of tounge

hypoxia,hypercarbia,acidosis(ppt agents)

subsequent episodes

status epilepticus(permanent neurological

defect)
Management
Evaluation :
• After the first episode of seizure;
radiological investigations
start anti epileptic drugs,if necessary
• Known case of seizure on AED;
complete blood count
liver function test
• S/E of AED;bone marrow suppression,leucopenia,electrolyte
abnormalities, macrocytic anemia
• AED continued till the day of surgery
Thyroid disorders
Hypothyroidism : decreased BMR
Effect of anaesthesia-delayed metabolism of drug—delayed
recovery
Management : Thyroxin , continued till the day of surgery
Presentation of unprepared patient:
Myxedema coma
• severe bradycardia
• hypotension
• hypoperfusion
• delayed recovery
Hyperthyroidism: palpitation
Effect of anaesthesia: ppt supraventricular arrhythmia
Management: anti thyroid drug-
carbimazole,methimazole,propylthiouracil
continued till the day of surgery
Presentation of unprepared pt:
Throid storm
• sudden unexplained tachycardia
• hypertension
• hyperthermia
• atrial fibrillation/supraventricular tachycardia
Psychiatric disorders:
Continue antipsychotics till the day of surgery
Exceptions
[Link] inhibitors stopped 2-3 weeks prior to Sx
bcz older MAO inhibitors interact with meperidine
and ephedrine---hypertensive crisis
[Link](used in bipolar disorder)
stop 24hrs prior only if short acting m/s relaxants
aren’t available
current guidelines-continue lithium on day of Sx if
short acting m/s relaxants are available
Coronary Heart Disease
Significans:
[Link] thinners—aspirin,clopidogrel
• Stopped prior to Sx
• Reason:to avoid bleeding in closed cavities during regional
anaesthesia
• Complications of stopping blood thinner: re-infarction
• Prophylaxis: start low doses LMWH ,stopped 12hrs prior to Sx

[Link] other cardiac medications to be continued on day of Sx

Drug history
ATT; continue the drug bcz stopping it causes MDR
check LFT prior to Sx

Steroids; continue bcz sudden stoppage causes HPA axis

suppression

ART; continue
check LFT,serum electrolyte,CBC

NSAIDS; PCT-continue
COX2 inhibitors;stop prior 24hrs
stop all other NSAIDS 48hrs prior dur to increased
chance of bleeding,renal injury
Personal History
• Smoking: stop prior 6-8 wks
chronic smoking:
[Link]:sudden
unexplainedtachycardia,hypertension
Rx:bronchodilators
[Link]:stridor, low Spo2
Rx:100%O2 + larsons manouevre
propofol 10mg iv during extubation,if uncontrolled-quick acting
muscle relaxant(succinyl choline),then intubate

• Tobacoo: difficult intubation due to restricted mouth opening

• Alcohol: hepatic microsomal inducers
stop prior 24-48hrs
complication in post op: acute fulminant hepatic
necrosis

• Breast feeding: major Sx-drugs are secreted in breast milk-

express breast milk for 24hrs post Sx
minor Sx-short acting drugs not secreted in
breast milk
so continue feeding after 6-8hrs

Family History
Malignant hyperthermia
Allergic history
Causes anaphylactic shock

M/C drugs:Antibiotics>latex>muscle relaxants>LA

Pathophysiology: Ag+Ab---degranulation of mast cell---release

of histamine

C/F: sudden unexplained tachycardia

hypotension
wheeze
edema of face,lips,airways

Management: Adrenaline
Investigations
CBC: Hb cutoff: min 8g/dl----risk of post op complications
systemic disease(epilepsy,seizures,IHD,major
Sx) 10g/dl
(due to loss of blood)
severe disease(on ventilator,in ICU) 12g/dl
platelet count cut off:
[Link] anaesthesia
[Link] cavity spaces:1,00,000/microL
[Link] closed cavity:80,000/microL
[Link]: 80,000/microL
[Link] procedure(central venous
catheter):50,000/microL
indication for platelet transfusion;<20,000/microL , H/O
RFT
Indications;chronic kidney disease
H/O nephrotoxic drugs
H/O reduced urine output

LFT
Indications;H/O ATT, AED, chemotherapy

Coagulation studies
Indications; H/O bleeding disorders
on warfarin therapy
massive blood transfusion
Urine examination; hyaline cast, proteinuria(risk of kidney
injury)
Chest X ray; in COPD,pneumonia,pulmnory edema
Pre Medications
• To relieve anxiety and induce sedation; short acting

benzodiazepine(midazolam)
• Reduction of secretions; anticholinergics(to prevent
aspiration) [Link]
indications;children,mentally retarded pt, head and
neck Sx
• Decrease aspiration;
[Link] to Sx nil per oral
[Link] Sx; high risk of aspiration
NG tube/ryles tube aspiration
prokinetic agents ti increase gastric motility
[Link]
To reduce acidity;PPI,gastric acid neutralized by antacids
COMPLICATIONS
P R AT H V I
ROLL NO:89

R O L L N O : 8 9
GENERAL ANESTHESIA
DEFINITION: IT IS A DRUG INDUCED REVERSIBLE
PROCESS CHARACTERISED BY
 AMNESIA [unconsciousness]
ANALGESIA[loss of pain]
MUSCLE RELAXATION
PHASES
[Link] OF ANESTHESIA
oIV Infusion-Propofol[1- 2.5mg/kg]

- Ketamine[2mg/kg]
oInhalational drug-Halothane, Enflurane, Isoflurane.
 [Link] MANAGEMENT
Mechanical ventilation-
 Endotracheal tube –These are
inserted into Trachea and is used to
conduct the gases and vapors in
and from the lungs.
 Depending on the diameter it is
available in various sizes.
 It has cuff on one end which when
inflated stabilizes the tube in
position.
 Non cuffed tubes are also available.
[Link] Phase
It can be achieved with inhaled or intravenous anesthetic agents.
Inhaled agents are most common and include -
isoflurane ,desflurane and nitrous oxide

[Link] Relaxation: Muscle relaxants –Suxamethonium

chloride[1.5 mg/kg]
[Link] -[Link] off the anesthetic agents.
[Link](2.5mg) is commonly used along
with atrophine.
 Intraoperative complications of GA
Due to LARYNGOSCOPE Due to ETT
Trauma to Lips, INJURY TO THE VOCAL CORDS
TEETH
INJURY TO THE TRACHEA
BLOCKAGE OF TUBE-Secretions ,foreign body,
TONGUE
Blood clot.
TONSILLAR PILLAR Bronchospasm-(coughing can lead to reduced lung volume
EPIGLOTTIS and causing bronchoconstriction, or vagus nerve activation.
VOCAL CORDS treated with bronchodilators(salbutamol) ,steroids.
 Other Complications
[Link]-(due to induction agents causing reduce Cardiac
output and SVR)treated with fluid replacement, vasopressors
(epinephrine, norepinephrine)
[Link]- antiarrythmic drugs (Lidocaine,digoxin) in severe cases
defibrillation ,cardioversion is done.
[Link] Infarction-Immediate treatment with Oxygen, nitrates,
beta blockers, and prompt cardiac intervention.
[Link] and Hypothermia- Anaesthesia can affect the body’s
ability to regulate temperature, leading to shivering and hypothermia.
[Link] hyperthermia
A rare life threatening reaction to certain anesthetic agents, leading to
a rapid rise in body temperature and severe muscle contractions.
Treatment-Immediate administration of Dantrolene(skeletal muscle
relaxant) ,cooling measures and supportive care like oxygen and IV fluids.

[Link]’s syndrome
It is due to regurgitation of the acid from the stomach causing the
aspiration of acid leading into bronchospasm ,Pulmonary edema and
circulatory failure.
Treatment-Oxygen, suction, hydrocortisone,
aminophylline(bronchodilator), antibiotics.
Ryles tube aspiration and ventilation support.

[Link]- A severe allergic reaction that can lead to shock,

respiratory distress, or cardiac arrest. MANAGEMENT-Immediate
 Spinal Anaesthesia
It is the injection of LA in the
subarachnoid space(between pia and
arachnoid)
Spinal cord ends at lower border of L3
vertebrae in children and or lower border
of L1 vertebrae in adults.
The spinal anaesthesia can be peformed
safely in L2-L3 intervertebral space in
adults and L4-L5 space in children.
• The drug acts on nerve roots.
• Lower abdomen and lower limbs are
anaesthetized and paralysed.
• Drugs used-Lignocaine-5% in 7.5%dextrose
• Bupivacaine-0.5%in 8%dextrose
• INDICATIONS:
• [Link] surgery of lower limbs and
pelvis.
• [Link] of lower abdomen
• [Link] and obstetrics
surgeries.
COMPLICATIONS OF SA
[Link]-

The incidence of bradycardia in SA is 10%

Due to sympathetic blockade reduces the venous return to the heart.
It should be treated with atropine.

[Link] Paralysis
Severe hypotension leading to medullary ischaemia.
Immediate management required-Intermittent positive pulse
pressure ventilation(IPPV)
[Link] and Vomiting.
due to hypotension causing central hypoxia.
Management: Treat hypotension
keep oxygenated the Patient,
Give Antiemetic(ondansetron)

[Link]
It is very uncommon complication of spinal anesthesia mostly due
to aseptic techniques.
Treatment –IV Antibiotics
 Conservative
Treatment-Bed
rest ,adequate
hydration,
analgesics,
epidural blood
patch.
 Epidural Anesthesia

 It is a potential space between dura anteriorly and

ligamentum flavum posteriorly which has got negative
pressure inside.

 Touhy needle is used for epidural anaesthesia.

 An epidural catheter is placed in the space and

fixed.

 0.5% Bupivacaine or
2% xylocaine with adrenaline is used
Other complications:
• Allergic reaction to the anesthesia
• Bleeding around the spinal column
(hematoma)
• Infection in your spine (meningitis or
abscess)
• Seizures (accidental intra-arterial
injection,or accidental dural puncture)
• Difficulty urinating .
 NERVE BLOCK ANAESTHESIA

It is a type of regional anesthesia that involves injecting

medication near nerves to reduce pain.
It can be used for pain relief during and after surgery.

Complications:
• Nerve injury- rarely
• Bleeding or infection at the injection site
• Pneumothorax(intercostal nerve block or brachial plexus nerve
block)
• Facial paralysis(inferior alveolar nerve block)
• Damage to surrounding structures.