GHAZI ALDEHAYAT MD

Ancient and Mediaeval times

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 Anesthesia
 CPR
 Acute Pain control
 Difficult Lines
 Evaluating critical patints

 Theatre
 Radiology
 Interventional radiology
 Cardiology
 ECT
 GI

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General Anesthesia
 Local Anesthesia
 Sedation

 Preoperative evaluation
 Intraoperative management
 Postoperative management

 Medical assessment of the patient.
 Decide the type of anesthesia.
 Establish rapport with the patient.
 Allay anxiety and decrease pain.
 Obtain informed consent.
 Ask for further investigation.
 Decide risk versus benefit .
 Prescribe medications.

History
 Indication for surgery
 Surgical/anesthetic hx: previous anesthetics/complications, previous intubations,
 Medications, drug allergies

• Medical history
 CNS: seizures, CVA, raised ICP, spinal disease, arteriovenous malformations
 CVS: CAD, MI, CHF, HTN, valvular disease, dysrhmias, PVD, conditions requiring endocarditis prophylaxis, exercise tolerance, CCS class, NYHA class
 Resp: smoking, asthma, COPD, recent URTI, sleep apnea
 GI: GERD, liver disease
 Renal: insufficiency, dialysis

 Hematologic: anemia, coagulopathies, blood dyscrasias
 MSK: conditions associated with difficult intubations
– arthritis, RA, cervical tumours, cervical infections/abscess, trauma to C-spine, Down syndrome,
 scleroderma, obesity
Endocrine: diabetes, thyroid, adrenal disorders
 Other: morbid obesity, pregnancy, ethanol/other drug use

FHx: malignant hyperthermia, atypical cholinesterase
(pseudocholinesterase), other abnormal drug reactions

Physical exams of all systems.
Airway assessment to determine the likelihood of difficult intubation

 Bony landmarks and suitability of areas for regional anesthesia if relevant
 Focused physical exam on CNS, CVS and respiratory
(includes airway) systems
 General, e.g. nutritional, hydration, and mental status
 Pre-existing motor and sensory deficits
 Sites for IV, central venous pressure (CVP) and pulmonary artery (PA) catheters,
 regional anesthesia

Investigations: According to( ranged from none to most comlicated)
 Age
 Surgery
 Medical condition
As clinically indicated
 Low risk – no further evaluation needed
 Intermediate risk – non-invasive stress testing
 High risk – proper optimization +/delaying/canceling procedure

 American Society of Anesthesiology (ASA) classification
 Common classification of physical status at time of surgery
 A gross predictor of overall outcome, NOT used as stratification for anesthetic risk (mortality rates)
 ASA 1: a healthy, fit patient (0.06-0.08%)
 ASA 2: a patient with mild systemic disease, e.g. controlled Type 2 diabetes, controlled essential HTN, obesity (0.27-0.4%), smoker

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ASA 3: a patient with severe systemic disease that limits activity, e.g. angina, prior MI, COPD (1.8-4.3%), DM, obesity
ASA 4: a patient with incapacitating disease that is a constant threat to life, e.g. CHF, renal failure, acute respiratory failure (7.8-23%)
ASA 5: a moribund patient not expected to survive 24 hours with/without surgery, e.g. ruptured abdominal aortic aneurysm (AAA).
ASA 6 : Brain death patient
For emergency operations, add the letter E after classification

 Medications:
 Pay particular attention to CVS and resp meds, narcotics and drugs with many side effects and interactions• prophylaxis.
 Risk of GE reflux: Na citrate 30 cc PO 30 mins hour pre-op.
 Risk of adrenal suppression – steroid coverage
 Risk of DVT – heparin SC,LMW Heparin, Mechanical methods.

 Optimization of co-existing disease ^ bronchodilators
(COPD, asthma), nitroglycerine and beta-blockers
(CAD risk factors)
 Pre-operative medications to stop:
 Oral hypoglycemics – stop on morning of surgery
 Antidepressants.
 Pre-operative medication to adjust:
Insulin, prednisone, coumadin, bronchodilator

 Decide, whether to proceed with surgery ,to send patient for further management or to cancel the operation.
 Discus anesthetic options.
 Decide which is the most useful for the patient.
 Informed concent.
 Risk stratification .

GENRAL ANESTHESIA
REGIONAL ANESTHESIA
LOCAL ANESTHESIA.

Airway management
 Endotracheal intubation( Body cavities, Full stomach, prone position, compromised, Very long operations,
Airway involvment )
 Laryngeal mask Airway( peripheral, No indication for
ETT)
 Mask( very short, no indication for ETT)
Ventilation
 Spontaneous ( No muscle relaxant)
 Controlled ( With muscle relaxant)

 PREPARATION
 monitoring
 position
 Intravenous fluid
 Warming
 CONDUCT OF ANESTHESIA
 PERIOPERATIVE MEDICINE

 Monitoring: according to paitent medical condition and surgery proposed
 Basic: ECG, NIBP,SpO2, EtCO2, Temp,FiO2,
Anesthetic gases, Airway pressure, The presence of anesthetist all throug procedure.
 Others: Nerve stimulator, Invasive Bp, CVP, CO, BIS,
PA Catheter, TEE, UO
Lab tests, ABGs, CBC, LFT , Coagulation, TEG

 Anesthesia defined as the abolition of sensation
 Analgesia defined as the abolition of pain
 “Triad of General Anesthesia”
 need for unconsciousness
 need for analgesia
 need for muscle relaxation

Hypnosis
(unconsciousness
Analgesia
)
Muscle
Relaxation
Induction
Intravenous(eg:T hiopentone,Prop ofol)
Inhalational( sevoflurane,Halo thane)
Systemic( opiods,
Fentanyl,Remifen tanil,Alfentanil)
Depolarizing
(suxamethoniom
Non
Depolarizing
)
(steroids, vecuronium)
Benzylisoquinolo nium Cis atracurium)
Maintinance
Inhalational
Intravenous
Recovery
Discontinue
Systemic:
(opiods,NSAIDS)
Regional(
Epidural,Spinal)
LA
N2O
Non
Depolarizing
Goo ) Multimodal) d Analgesi
Opioids,Regional
, Local
NSAIDS
Parasetamol
Reversal by
Anticholinstrases
( Neostigmine,)&
Atropine

 Thiobarbiturates
 Uses for iduction, decrease ICP, Status epilepticus
 CNS: Hypnosis within 30 seconds ,decreased intracrainial pressure.
 CVS depression, hypotension, tachycardia
 Respiratory depression, spasm
 CI: porphyria
 Arterial injection

PROPOFOL ( Deprivan)
 USES: induction, maintenance, sedation in the ICU, sedation
 Contra indicated in children.
 CNS: Hypnosis within 30 seconds ,decreased intracrainial pressure.
 CVS: depression more than Thiopental
 Respiratory: Depression, no spasm
 Caloric load in the ICU, propfol infusion syndrome

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Ketamine
Phencyclidine
Uses, shock, burn, field.
CNS, dissociation, hallucination, analgesia,
Increased intracrainial pressure.
CVS Stimulation, hypertension, tachycardia
Respiratory, less depression.

 Etomidate
 Stable cardiovascular
 Steroid depression

Halothane
Enflurane
Isoflurane
Sevoflurane
Desflurane
N2o
Xenon

Anesthesia induced by inhalational effec
Tdifferent in their potency, indicated by MAC.
Different in rapidity of induction and recovery.
Common pharmacological properties,
CVS depression with tachy or bradycardia
REP Depression.
CNS increased intracranial pressure

Fentanyl
Morphine
Alfentanl
Remifentanil

 All have almost the same pharmacodynamics of ,
Morphine, Analgesia, Sedation , Respiratory depression, Nausea and vomiting, meiosis, constipation.
Different in their pharmakokinitcs.

Depolarizing
Suxamethonium
Short acting, rapid onset,
Many Side effects, hyperkalemia, arrythmias,
Muscle pain ,Scoline apnea.

Non Depolarizing:
Aminosteroid ; organ metabolism
Benzylisoquinolonium: Histamine release,
Long acting

Lidocaine, lignocaine,xylocaine
Bupivacaine ( marcaine)
Cocaine
Procaine

 Regional ( spinal , epidural)
 Local
 Different side effects
 Marcaine CI by intravenous
 LA toxicity. Maximum doses,
 Perioral numbness, tinnitus, conulsions, resp depression, Cardiac arrest
 Treatment, ABC, symptomatic, intralipid( propofol)

Neostigmine
Atropine

Basic ( ECG, BP, SPO2, EtCO2) Observation
Advanced ( IBP , CVP, CO ….ETc

Awarness
Definition
Types
Effect
Causes
Manegment

Thank you