Criselle Angeli C.

Barcenas, MD, DPBA, FPSA, MMHA

DAY 1:
ANESTHESIA FOR THE SURGICAL PATIENT
Objectives
1.Understand the role of anesthesia in surgery William Morton (1846)
2.Describe the evolution of modern anesthesia  Dentist
practice  Practiced ether
3.Recall the pioneer anesthesiologists and their administration on a dog
contributions to the field of anesthesia  Used ether in teeth
extraction
Before the advent of modern anesthesia
 Opium :
 Alcohol  October 16, 1846- first public demo of ether as an
 Exposure to cold anesthetic for Johns Collins Warren (removal of
 Compression of peripheral nerves vascular mass in the neck)
 Constriction of carotid arteries
 Hypnosis Ether Demo

“..rushed away before they were completed. Nor did I

ever attend again, for hardly any inducement would
have been strong enough to make me do so; this
being long before the blessed days of chloroform. The
two cases fairly HAUNTED me for many a long year.”
-Charles Darwin

Horace Wells (1844) John Snow (1847)

 Dentist  The first anesthesiologists
 Used nitrous oxide on himself  Applied scientific methods
 In 1845- demo dental  Described the five degrees
procedure at Harvard of etherization
 Demo failed - committed suicide  Improved apparatus for
 First person to recognize and ether administration
use the only anesthetic from  Encouraged anesthesia as a
the 1800s that is still in use specialty
today (NO)  Created a standard of
excellence with other anesthesiologists (Joseph
Clover & Sir Frederick Hewitt)
Crawford Long (1842)  Improved apparatus for administering ether
 Physician  Mastered clinical techniques of anesthetizing
 Used diethyl ether (removal patients
of two neck tumors), a
popular recreational drug
 Published his work too late in
1848
ANAESTHETIST TO ROYALTY The twentieth century
 1853: Provided anaesthetic for the birth of Prince
Leopold John Lundy (1925)
“Dr. Snow gave that blessed chloroform and the effect was  Introduced the concept of balanced anesthesia
soothing, quieting and delightful beyond measures”  Directed Anesthesiology Dept. at the Mayo Clinic
for 28 yrs
 1857: Birth of Princess Beatrice  Established the first RR and BB
 1858: Prosthumous book  Authored the first textbook of modern anesthesia
“On Chloroform and other Anaesthetics”  Helped found the American Board of Anesthesiology
Snow is said to have given 11,0000 anaesthetics
without death Cyclopropane (1923)
accidentally discovered anesthetic properties

Charles Suckling (1953) - Produced halothane

HISTORY OF COCAINE
 the first local anesthetic Ross Tyler
 Ancient Incas chewed coca leaves  introduced enflurane (1972)
 Allegedly facilitate trephination of the skull by  isoflurane (1981)
dripping the saliva into the wound 
1990s: sevoflurane and desflurane were introduced
Albert Niemann (1860)
Synthesized the active alkaloid of the coca leaf and VIGILANCE- motto of American Society of Anesthesiologist
called it cocaine  Patient monitoring
 Patient color
Sigmund Freud (1884)  Depth of respiration
Wrote the famous monograph UBER Coca  Pulse rate

Karl Koller Harvey Cushing (1895)

 Instilled in his own cornea  First anesthesia records or “ether charts”
 Report its use as a local anesthetic  Introduced BP monitoring using
sphygmomanometer & stethoscope for breath
William Halsted & Richard Hall and heart sounds
 First to use regional blocks
 Experiment on themselves - became addicted Sir Ivan Magill – pioneered endotracheal intubation
Arthur Guedel – invented cuffed ETT
Leonard Corning Harold Griffith – popularized curare use
 Published the first textbook on anesthesia
 Coined the term spinal anesthesia
Anesthesiology Today – The Perioperative Physician
August Bier  No longer limited to the OR
Gave the first deliberate spinal anesthetic  Acute and chronic pain medicine
 Critical care medicine
 DAY 2:
PHARMACOLOGY IN ANESTHESIA
Pharmacokinetics: Administration
 Oral & administration – subject to first-pass effect
Learning Objectives
of
 Differentiate between pharmacokinetics and
 the portal circulation
pharmacodynamics
 IV or nasal or sublingual route- bypasses first-pass
 Classify the different types of anesthesia
 effect
administered to surgical patients
 Transdermal
 Categorize the drugs used in anesthesia
 Intramuscular
 Plan an anesthetic management approach of a
 Subcutaneous
surgical patient
 Inhalation
Pharmacokinetics vs. Pharmacodynamics

Pharmacokinetics or time dependecy of a drug Pharmacokinetics: Distribution

Factors affecting rate of entry of the drug to the tissues
 Describes the relationship between the dose of a
 Molecular size of drug, capillary permeability,
drug and its plasma or tissue concentration
polarity and lipid solubility
 What the body does to the drug
 Plasma protein and tissue binding
 Relates to: absorption, distribution, metabolism &
 Volume of Distribution (Vd)
elimination
 Tissue blood flow
 Fluid volume in which the drug distributes
Pharmacodynamics
 How the plasma concentration of a drug
translates into its effect on the body
 What the drug does to the body Pharmacokinetics: Metabolism
 Relates to: mechanism of action, therapeutic and The permanent breakdown of original compounds
toxic effects into smaller metabolites

Pharmacokinetics: Elimination
Drugs are:
 excreted unchanged by the body
 decomposed via plasma enzymes
 degraded in the liver
 Pharmacodynamics
Pharmacokinetics
Additive effect – a second drug acts with the first
Context-sensitive half time
drug and will produce an effect that is equal to the
 the time required for blood concentrations of a
algebraic summation of both drugs (1+1=2)
drug to decrease by 50% after its discontinuation
Synergsitic effect – two drugs interact to produce
 determined by the interaction of the duration of
an effect that is greater than expected from the two
administration, distribution and accumulation,
drugs’ algebraic summation (1+1=3)
and metabolism and excretion
Hyporeactivity- a larger than expected dose is
required to produce a response
Tolerance, desensitization, tachyphylaxis

Potency – dose required to produce a given effect

Efficacy – power to produce effect
Effective dose (ED50) – dose producing the desired
effect in 50% of the general population
Dose-response curves – show relationship between
the dose of the drug administered and the
pharmacologic effect of the drug

Pharmacodynamics
Agonist- a drug that causes a response (activates a
receptor)
 Full agonist – produces full tissue response
 Partial agonist – provokes less than the maximum Lethal dose (LD50) – dose producing death in 50%
response induced by the full agonist of animals to which it is given
Antagonist – a drug that does not provoke a response Toxic dose (TD50) – dose that elicits a toxicity in
itself, but blocks agonist-mediated responses 50% of humans to which it is given
Therapeutic index – ratio of TD50 to ED50
A drug with high therapeutic index is safer than a
drug with a low or narrow therapeutic index
 ANESTHETIC AGENTS

Types of anesthesia
 Local GENERAL ANESTHESIA: Unconsciousness & Amnesia
 Regional IV agents:
 General I. Barbiturates
II. Propofol
General Anesthesia III. Benzodiazepines
Triad of 3 major effects: IV. Etomidate
1. Unconsciousness (and amnesia) V. Ketamine
2. Analgesia VI. Opioid analgesics
3. Muscle relaxation VII. Non-opioid analgesics
DRUG MOA EFFECTS EXAMPLES ADVERSE ADVANTAGES/
NAME EEFFECTS DISADVANTAGES
 rapid & smooth  Anticonvulsants
GABA receptor agonists: Thiopental,
induction within 60 Hypotension,  protect brain during neurosurgery
Inhibit excitatory Thiamylal,
BARBITURATES secs Myocardial
synaptic transmission at Methohexit by ↓ cerebral metabolism
 wears off in 5 mins depression
the GABA receptor al
 fast onset of sedation,
Inhibits excitatory hypotension,  Low incidence of nausea and
short duration
PROPOFOL synaptic transmission Propofol irritant pain vomiting
 rapid recovery
at the GABA receptor on injection  Bronchodilatory properties
(choice for ambulatory surgery)
Peripheral
vasodilation,
hypotension,  Anticonvulsant
minimal  Rarely cause allergic reactions
Inhibit excitatory  Anxiolysis diazepam,
respiratory
BENZODIAZEPINES synaptic transmission at  Amnesia lorazepam,
depression
the GABA receptor (anterograde) midazolam
when used Flumazenil- reverses BZD effects;
alone antagonist
 DRUG MOA EFFECTS EXAMPLES ADVERSE ADVANTAGES/
NAME EEFFECTS DISADVANTAGES
 Less reduction in blood pressure
than thiopental & propofol,
inhibits excitatory  Rapid awakening
ETOMIDATE synaptic transmission at rapid induction - -
the GABA receptor  Pain on injection, nausea &
vomiting, adrenal suppression

Hypotension,
DEXMETOMIDINE a2 adrenergic agonist sedative & analgesic -  Sedation in ICU, adjunct to GA
bradycardia
dissociative  Useful in acutely hypovolemic pxs
anesthetic, to maintain BP via sympathetic
cataleptic gaze stimulation;
inhibits excitatory w/ nystagmus,  Asthmatic pxs- bronchodilation
KETAMINE synaptic transmission at amnesia and analgesia delirium &  Less allergic reactions
the NMDA receptor hallucinations
while  Increase HR & BP (CI: CAD pxs);
regaining direct myocardial depression in
consciousness catecholamine depleted pxs
 GENERAL ANESTHESIA: Analgesia

OPIOID ANALGESICS NON-OPIOID ANALGESICS

I. Morphine I. Ketamine
II. Codeine II. Ketorolac
III. Hydromorphone III. Dexmedetomidine
IV. Meperidine IV. IV acetaminophen
V. Fentanyl (sulfentanil, alfentanil, remifentanil)

DRUG MOA EFFECTS ADVERSE OTHER DETAILS

NAME EEFFECTS
Remifentanil- rapid hydrolysis, recovery in
minutes
Act centrally on euphoria, Naloxone – pure opioid antagonist;
μ-receptors on sedation, reverses opioid
OPIOID
the brain & Spinal - constipation, overdose (resp depression)
ANALGESICS
cord resp Methylnaltrexone & Alvimopan- peripheral
depression opioid antagonist; reverse constipation S/E
without affecting analgesia

COX-1 – synthesis of several prostaglandins

& prostacyclin which protects gastric
reduces gastric mucosa, & thromboxane which supports
prostglandin bleeding, platelet function
NSAIDs:
formation via platelet COX-2 – induced by inflammatory reactions
KETOROLAC,
PARACOXIB
inhibition of the dysfunction, to produce more prostaglandins
COX enzyme acute kidney
(NSAID) injury Parecoxib- predominantly COX-2 NSAID
without causing GI bleeding or platelet
dysfunction
 GENERAL ANESTHESIA: Analgesia
DRUG MOA EFFECTS ADVERSE OTHER DETAILS
NAME EEFFECTS
When used as part of post-op analgesic
property,
constipation,
ACETAMINOPHEN centrally acting analgesic & antipyretic sedation,
it reduces amount of opioid required
resp depression
↓
reduced opioid side effects
COX-1 – synthesis of several prostaglandins
& prostacyclin which protects gastric
mucosa, & thromboxane which supports
reduces prostglandin gastric bleeding, platelet function
NSAIDs:
formation via inhibition platelet COX-2 – induced by inflammatory reactions
KETOROLAC, -
PARACOXIB
of the COX enzyme dysfunction, acute to produce more prostaglandins
(NSAID) kidney injury
Parecoxib- predominantly COX-2 NSAID
without causing GI bleeding or platelet
dysfunction
 NEUROMUSULAR BLOCKING AGENTS
 No amnestic, hypnotic or analgesic properties
 therefore pxs must be properly anesthetized first before its administration
 MOA: act on neuromuscular junction
Depolarizing NMB
DRUG NAME MOA EFFECTS ADVERSE OTHER DETAILS
EEFFECTS
Adv:
 Rapid onset (<60 secs)
& rapid offset (5-8 mins)
binds to Ach DisAdv:
receptors on the  Fasciculations causes post-op aches and pains
postjunctional
membrane in the Depolarizing post-op aches,  elevates serum K levels
SUCCINYLCHOLINE CI in pxs with burns & denervating injuries
NMJ NMB post-op pains
↓
↓ cardiac arrhytmias
causes depolarization  increase in intraocular and intragastric pressure
of muscle fibers  severe bradycardia in children
 Hydrolyzed by plasma cholinesterase or
pseudocholinesterase
 Can trigger malignant hyperthermia
Nondepolarizing NMB
 MOA: reversibly binds to postynaptic terminal in the NMJ and prevents Ach from depolarizing the muscle
 No fasciculations like succinylcholine
 Reversal agents: neostigmine, edrophonium, pyridostigmine

Increases Acetylcholinesterase
↓
Increases Ach levels
↓
Increases availability of Ach in NMJ
↓
return of motor function

 Reversal agent: Suggamadex, a chelating agent (Rocuronium & Vecuronium)

 INHALATIONAL AGENTS

Minimum Alveolar Concentration (MAC)

 Measure of anesthetic potency or ED50 of an inhaled agent
 Dose required to prevent movement in response to skin incision in 50% of patients

The higher the MAC, the less potent the agent is

Agent MAC (%) Advantages Disadvantages

 Analgesia  Sympathetic stimulation
NO 105  minimal cardiac & resp depression  expansion of closed airspace
 no odor, rapid  PONV
 Effective in low concentration  Cardiac depression & arrhythmia
Halothane 0.75  minimal airway irritability  hepatic necrosis
 inexpensive  slow elimination
 Muscle relaxation  Strong smell
Enflurane 1.68  no effect on cardiac rate and rhythm  seizures

 Muscle relaxation  Strong smell

Isoflurane 1.15  No effect on cardiac rate and rhythm  slow uptake and elimination
 Bronchodilation
 Rapid induction and emergence  Coughing
Desflurane 6
 high cost
 Rapid induction and emergence  High cost
Sevoflurane 1.71  pleasant smell  metabolized by liver
 ideal for mask induction
 LOCAL ANESTHETICS
Amides
 Have amide linkage between a benzene ring and a hydrocarbon
chain that, in turn, is attached to a tertiary amine
Esters
 Have an ester linkage in place of the amide linkage
 Metabolized in liver
 Hydrolyzed by plasma cholinesterase → allergic potential
 DRUGS: Lidocaine, bupivacaine, mepivacaine, prilocaine, ropivacaine
 DRUGS: Cocaine, procaine, chloroprocaine, tetracaine, benzocaine

Equianesthetic Duration Site of
Agent Equianesthetic Duration Site of
concentration (%) (min) Metabolism Agent
concentration (%) (min) Metabolism
Prilocaine 1 100 Liver/Lung
Procaine 2 50 Plasma
Lidocaine 1 100 Liver
Chloroprocaine 2 45 Plasma
Mepivacaine 1 100 Liver
Tetracaine 0.25 175 Plasma
Bupivacaine 0.25 175 Liver
Ropivacaine 0.3 150 Liver
Etidocaine 0.25 200 Liver
Local anesthetics: MOA Lidocaine
Reversible block of the transmission of neural impulses when placed on or near  Local anesthetic
a nerve membrane by stabilizing sodium channels in their closed state,  Can be given intravenously to reduce post-op pain
preventing action potentials from propagating along the nerve  reduce opioid requirements & shorten time to recovery of bowel function
Lidocaine toxic dose: 5 mg/kg

Local anesthetics: TOXICITY Cardiovascular System Toxicity

absorption into blood or inadvertent direct IV Hypotension → increase P-R intervals (heart block) Local Anesthetic: ADDITIVES
injection →ventricular arrhythmias→cardiac arrest Epinephrine(Vasoconstrictor)
↓  reduces local bleeding, onset is faster
CNS & Cardiovascular toxicities Bupivacaine  quality of block is improved, duration is longer
toxic dose: 3 mg/kg (very cardiotoxic)  less toxicity bec less local anesthetic will be
absorbed into the bloodstream
CNS Toxicity Calculation of toxic dose
Should not be injected into body parts w/end arteries
Restlessness→tinnitus→slurred Ex: Bupivacaine 0.5% for a 50kg person
speech→seizures→unconsciousness 0.5%= 5mg/mL; 3mg/kg, Bicarbonate
Earlier than cardiovascular toxicity therefore TD= 3mg x 50 kg= 150 mg  Increases pH
Management: benzodiazepine/thiopental for seizure 150mg ÷ 5mg/mL = 30 mL  favors nonionized uncharged form of
airway management 30 mL is the upper limit of infiltration  the molecule
(endotracheal intubation)  speeds onset of block
 DAY 3:
PRE-OPERATIVE EVALUATION
American Society of Anesthesiologists physical
Clinical Scenario status classification system
A 65-year-old man with hypertension, familial hypercholesterolemia, type 2
diabetes mellitus, and angina pectoris presented for resection of a sigmoid
colon tumor. Stress imaging demonstrated an anteroseptal region of ischemia.
Coronary angiography showed a critical lesion of the left anterior descending Score Mortality (%)
coronary artery and a 50% stenosis of the proximal circumflex coronary I 0.1
artery. II 0.2
Percutaneous transluminal coronary angioplasty with Drug-Eluting Stent (DES)
III 1.8
implantation was performed successfully on the left anterior descending lesion
IV 7.8
6 weeks before surgery. The patient was maintained on metoprolol, aspirin,
and clopidogrel therapy.Clopidogrel was discontinued 7 days before V 9.4
surgery. What are the anesthetic considerations for this patient?
“E” –emergent surgery
LearningObjectives
•Explain how to evaluate a patient prior to surgery
•Classify the different kinds of surgical patients
•Discuss the risk assessment of patients with comorbidities Airway Evaluation Vitally important!
– to recognize patients in whom endotracheal Intubation may be difficult
Preoperative Evaluation before administering medications that induce apnea
• PREOPERATIVE VISIT
a. Anesthesiologists determine the medical status of patient
 Detailed medical history, current drug therapy, complete PE, lab results
 Previous exposure/experience with anesthesia, family history
of problems with anesthesia
 History of atopy, concurrent medications
 PE targetedat CNS, CV, lungs and airway
b. Plan of anesthetic care
c. Discuss the plan with the patient/legal guardian

• RISK ASSESSMENT
a. Is the patient in optimal medical condition for surgery?
b. Are the anticipated benefits of surgery greater than the surgical and
anesthetic risks associated with the procedure?
Airway Evaluation Vitally important!
Other predictors of difficult intubation
• Functional capacity is measured in metabolic equivalents (METs)
 Short neck, Immobility of the neck
 Patients unable to attain 4 METs considered to have poor functional
 Interincisor distance<4cm
status
 Large overbite- inability to shift the lower incisors in front of the upper incisors
 METs including walking up a flight of stairs, climbing a hill,
 Small mandible
or walking on level ground at 3 to 4 miles per hour
 Thyromentaldistance<6 cm
 Obesity

Cardiovascular Disease
• regarded as the most important risk associated with anesthesia and surgery
• revised cardiac risk index (RCRI) patient and surgical factors
1. history of ischemic heart disease
2. congestive heart failure
3. cerebrovascular disease
4. diabetes requiring insulin
5. chronic kidneydisease with baseline creatinine greater than 2
6. whether the surgery is in a high-risk area
(major vascular, intraperitoneal, or intrathoracic)

Patients with coronary stents

• delay elective surgery for 30 days after bare metal stent placement
and 1 year after drug eluting Stent (DES) placement
• Delay semi-elective surgery for 180 days
• Patients on β-blockers and statins- drugsmust be continued
• Patients with ICDs - determine whether electromagnetic interference
is likely to occur during the planned procedure
Pulmonary Disease Endocrine Disease
• Patients with asthma & COPD • Diabetic patient
 exercise tolerance and the frequency and severity of exacerbations  Hemoglobin A1c level should be obtained
should be evaluated  Type 1 and type 2 diabetes should bedifferentiated
 Focused history: prior admissions,intubations
 Preop bronchodilators  careful monitoring of their blood sugars in the perioperative setting:
 Most inhaled anesthetics are bronchodilators  Increase risk for periop myocardial ischemia,stroke,renal
 Desflurane- airway irritant dysfunction/failure, inc mortality
 Impaired wound healing
• Patients with OSA
 Identified preoperatively, obtain  Hyperglycemia- stress response tosurgery
sleep study Standard of care: AVOIDANCE OF HYPO/HYPERGLYCEMIC EVENTS
 Should not be extubated until
they are completely awake Metabolic & Endocrine Diseases
 Treat with noninvasive positive • Hypothyroidism
pressure ventilation in the
postoperative period Delayed gastric emptying, adrenal insufficiency, hypovolemia
• Obesity Compute BMI = wt(kg)/ ht (m)2
Renal Disease BMI >28 kg/m2 – increased perioperative morbidity
• Patients with chronic renal disease Problematic:IV access, application of monitors, airway management,
 Close attention to perioperative transport of px, ventilation (OSA), incrisk of aspiration,
fluid management and acid-base adjusting doses of drugs
and electrolyte homeostasis
 Drug dosing adjusted (opioids &
NMBs) PREOPERATIVE FASTING
 Cisatracurium- muscle relaxant  to mitigate the risk of
of choice aspiration of gastric
 Suggamadex- not recommended contents
 a rapid sequence
Hepatic Disease
• Patients with hepatic dysfunction induction (RSI) and
 Short-acting agents are preferred intubation
 Hypoalbuminemia can considered in patients who are
paradoxically increase the free at higher risk for aspiration
plasma levels of drugs
 Thrombocytopenia and regardless of fasting status
coagulation factor deficiency: symptomatic GERD, achalasia,
 Increased risk of bleeding gastroparesis, or dysmotility
 Relative contraindication
to spinal or epidural Patients with Advanced Directives
anesthesia
• Patients with substantial ascites: managed as if they have a full stomach  Patients with do not resuscitate (DNR) and/or do not intubate (DNI)
 preoperative discussions with the patient and their family clarify the
patient’s wishes
 DAY 4:
INTRAOPERATIVE MANAGEMENT
Learning Objectives
1. Discuss how to properly insert an endotracheal tube
2. Discuss knowledge ofthe structural landmarks for a spinal tap
3. Discuss principles of anesthesia in intraoperative & postoperative period

ANESTHETIC MONITORING

INTRAOPERATIVE MANAGEMENT
Induction
 Patient becomes
 Unconscious
 rapidly apneic
 myocardial function is usually depressed
 vascular tone abruptly changes
 Most critical component of practicing anesthesia
 Majority of catastrophic anesthetic complications occur

IV induction - smooth, high level of px satisfaction

Rapid sequence induction(RSI)
to achieve secure protection of the airway with a cuffed ETT
without ever mask ventilating a patient
Inhalation induction - 3 stages
(Awake, Excitement, Surgicallevel of anesthesia) pedia usually
AIRWAY MANAGEMENT AIRWAY MANAGEMENT: Preparation
 Face Mask  Evaluation of the airway (History & PE)
 Laryngeal Mask Airway (LMA)  Ventilation Equipment
 Endotracheal Tube (ETT) with cuff  Placement of Monitors
 Oraland nasal airways
AIRWAY MANAGEMENT:: Ventilation Equipment
Difficult Airway algorithm 1. Face Mask
2. Oral & Nasal Airway
3. Endotracheal Tube
4. Laryngoscope
5. Laryngeal Mask Airway
6. Flexible Fiberoptic Bronchoscope
7. Bonfils Rigid Bronchoscope

ENDOTRACHEAL TUBE
Tube size depth
Men- 8.0 mm ID 23 cm at lips
Women- 7.0 mm ID 21 cm
Children- (16 + age)/4 12 + (age/2)

PLACEMENT OF MONITORS
Standard ASA monitor
 NIBP
 ECG
 Pulse Oximeter
 Capnograph (ETCO2)
 Temperature
 Induction of Anesthesia: RISK FACTORS
ENDOTRACHEAL INTUBATION Risk Factors for aspiration of gastric contents
 Insertion of an endotracheal tube  Full stomach (<8H fast)
 under direct visualization  Trauma
 by looking thru the mouth with a laryngoscope  Intra-abdominal pathology
 directly at the vocal cords (direct laryngoscopy)  Intestinal obstruction, inflammation
Indications:  Gastric paresis (drugs, diabetes, uremia, infection)
 Airway protection  Esophageal disease
 Maintenance of patent airway  Symptomatic reflux
 Pulmonary toilet  Motility disorders
 Application of positive-pressure ventilation  Pregnancy
 Maintenance of adequate oxygenation  Obesity
 Predictable FiO2  Uncertainty about intake of food or drink
 Positive end-expiratory pressure
Induction of Anesthesia: POSITIONING
Induction of Anesthesia
 Most critical component of practicing anesthesia

Induction of Anesthesia: TECHNIQUES

Intravenous (adults)
Preoxygen→IV induction→mask ventilation→NMB→intubate

Rapid Sequence (high-risk for aspiration)

Preoxygen→IV induction→NMB→intubate
(Sellick Maneuver on the cricoid cartilage)
Neutral postion Sniffing position elevated
Inhalation (Pedia)
Mask inhalation→intubate NASAL AIRWAY PLACEMENT ORAL AIRWAY PLACEMENT

Combined (adults)
Preox→IV induction→ask ventilation→intubate
  Signs of correct placement
 Chest rise with each ventilation
 Condensation at the ETT
 Equal breathsounds on auscultation (no gastric gurgle)
 ETCO2
 Reservoir bag filling and compliance
 Direct visualization of the tube passing thru vocal cords
 Fiberoptic confirmation
 Chest X-ray

When attempt at intubation fails

 Return to face mask ventilation
 Reassess situation (position, blade)
 Cancel case, consider feasibility of other options
 Return to spontaneous ventilation, awakening the patient
 Call for help

When mask ventilation becomes inadequate

 Non-surgical airway ventilation
 Emergency surgical airway (cricothyroidotomy)

LARYNGEAL MASK AIRWAY

CORMACK-LEHANE GRADING OF GLOTTIC EXPOSURE

 Spinal & Epidural Anesthesia
4 P’s
SpecialConsiderations: Pedia Preparation (drugs, equipment)
 Differences in airway anatomy with the adult Position
 Large head tends to flex short neck and obstruct airway Projection
 Disproportionately large tongue Puncture
 Larynx more cephalad
 Epiglottis is longer and stiffer, lies more horizontally
 Narrowest point of the airway is the cricoid cartilage
 Shorter trachea
 L-sided endobronchial intubation as likely as R-sided

Complications
 Teeth, lips, gums may be injured
 Coughing, laryngospasm, bronchospasm and vomiting (aspiration)
If inadequately anesthetized Spinal Cord
 Hypoxemia, hypercarbia
 Hypertension, tachycardia, dysrhythmias
 Increased ICP, CRMO2
 Esophageal intubation- most feared complication
 Airway obstruction, laryngeal edema

Extubation
 Deep (anesthetized) or awake
 Muscle relaxants reversed
Sustained 5-second head lift
 MONITORED ANESTHESIA CARE
 Procedural sedation
Puncture: Spinal anesthesia  When a patient undergoes a procedure under local anesthesia
under the care of an anesthesiologist who can provide sedation as
indicated

POSTANESTHESIA CARE UNIT
 For close monitoring of postoperative patients
 to prevent or expedite the management of a variety of serious
complications

 After the block has been placed, strict attention must be directed to
the patient's hemodynamic status with blood pressure and heart
rate supported as necessary
 The level of anesthesia should be assessed by pinprick or
temperature sensation
If the anesthesia is not rising high enough, the table may be tilted to
influence spread of a hyperbaric or hypobaric local anesthetic

 Hyperbaric vs. Isobaric anesthetic solutions