The Medical Students Anesthesia

Pocketbook
University of Texas Health Science Center Houston
Table of Contents
Contributors: Trent Bryson MS4, Tanner Baker MS4, Claudia Moreno MS4,
Darrell Wilcox MS3, and Allison DeGreeff MS3
2
Acknowlede!ents
"e the contributors would first and fore!ost like to thank the faculty at the University of Texas
at Houston for their su##ort$ uidance$ and teachins in hel#in us create this #ocket book% "e
would also like to thank the residents for their contributions to our learnin and skill
develo#!ent as well as in hel#in us revise the content to be as detailed$ succinct$ and accurate
as #ossible%
&
Anesthesia 'verview
Ada#ted fro! (A Medical Students Anesthesia Pri!er) by *oy +% Soto$ M, -roysoto.ucla%edu/
Introduction
0n !any #rora!s across the country$ !edical students are only ex#osed to two weeks of
anesthesioloy durin their third or fourth year% The student often attends daily lectures and
!iht be told to 1read Miller2s 3asics of Anesthesia1$ but often by the ti!e the student has finally
fiured out why we are doin what we2re doin$ the rotation is over$ and he or she leaves with
only a !ini!u! of anesthesia knowlede%
This #ri!er is intended to ive a brief overview of what we do$ when we do it$ and why we do it
for standard$ unco!#licated cases %%% the ty#es that you are bound to see durin your rotation% 3y
no !eans is the infor!ation contained co!#rehensive$ or intended to allow you to #ractice
anesthesia solo$ but it is intended to ive an overview of the 1bi #icture1 in a for!at that can be
4uickly read in one sittin$ and then referred to as needed% 5ee# in !ind that there are !any
ways to acco!#lish the sa!e thin in anesthesia$ and you will undoubtedly see techni4ues that
differ fro! what we2ve written here$ but our oal aain is to #resent you with a si!#le overview%
Anesthesia is a challenin and excitin s#ecialty$ but can also be extre!ely frustratin if not
tauht clearly durin the short ex#osure that !any !edical students et to the field%
Preoperative History and Physical
Unlike the standard internal !edicine H6P$ ours is !uch !ore focused$ with s#ecific attention
bein #aid to the airway and to oran syste!s at #otential risk for anesthetic co!#lications% The
ty#e of o#eration and the ty#e of anesthetic will also hel# to focus the evaluation%
'f #articular interest in the history #ortion of the evaluation are7
Coronary Artery Disease 8 "hat is the #atient2s exercise tolerance9 How well will his or her
heart sustain the stress of the o#eration and anesthetic9 Askin a #atient how he feels -i%e% S'3$
CP/ after cli!bin two or three flihts of stairs can be very useful as a 1#oor !an2s stress test1%
Hypertension 8 How well controlled is it9 0ntrao#erative blood #ressure !anae!ent is affected
by #reo#erative blood #ressure control%
Ast!a 8 How well controlled is it9 "hat triers it9 Many of the stressors of surery as well as
intubation and ventilation can sti!ulate bronchos#as!% 0s there any history of bein hos#itali:ed$
intubated$ or #rescribed steroids for asth!a9 This can hel# assess the severity of disease%
"idney or #i$er disease 8 ,ifferent anesthetic drus have different !odes of clearance and oran
function can affect our choice of drus%
%eflux Disease 8 Present or not9 Anestheti:ed and relaxed #atients are #rone to reuritation and
as#iration$ #articularly if a history of reflux is #resent% This is usually an indication for ra#id
se4uence intubation -succinylcholine ; cricoid #ressure/%
<
S!okin& 8 Currently s!okin9 Airway and secretion !anae!ent can beco!e !ore difficult in
s!okers%
Alcool Consu!ption or Dru& A'use9 8 ,rinkers have an increased tolerance to !any sedative
drus -conversely they have a decreased re4uire!ent if drunk/$ and are at an increased risk of
he#atic disease$ which can i!#act the choice of anesthetic aents%
=ndocrine7
Steroids > #atients with recent steroid use !ay re4uire #reo#erative steroids to cover secondary
adrenal su##ression%
Dia'etes 8 "ell controlled9 The stress res#onse to surery and anesthesia can !arkedly increase
blood lucose concentrations$ es#ecially in diabetics%
Tyroid > Hy#o?Hy#er !etabolic states affect the cardiovascular syste!$ renal clearance$ and
ther!oreulation%
Medications 8 Many !edications interact with anesthetic aents$ and so!e should be taken on
the !ornin of surery -blood #ressure !edications/ while others should #robably not -diuretics$
diabetes !edications/%
Aller&ies 8 "e routinely ive narcotics and antibiotics #erio#eratively$ and it is i!#ortant to
know the ty#es of reactions that a #atient has had to !edications in the #ast% The @A anesthesia
alleren is the non8de#olari:in #aralytics% The @2 class is antibiotics%
(a!ily History 8 There is a rare$ but serious disorder known as malignant hyperthermia that
affects susce#tible #atients under anesthesia$ and is heritable% Another heritable disorder is
pseudocholinesterase deficiency which affects succinylcholine duration and !ay re4uire
extended #osto#erative ventilation%
Anestesia istory 8 Has the #atient ever had anesthesia and surery before9 ,id anythin o
wron9
#ast Meal 8 "hether the #atient has an e!#ty sto!ach or not i!#acts the choice of induction
techni4ue -another indication for ra#id se4uence intubation/%
"hile a history of a difficult intubation !ay be the !ost reliable #redictor of future difficult
intubations$ the #hysical exa! is also i!#ortant to hel# #redict #otential #roble!s% Bor the
#hysical exa!$ the s#ecific areas which are of #articular i!#ortance to the anesthesioloist
include the cardiovascular syste!$ luns$ head?neck?u##er airway$ sins of #reexistin
neuroloical dysfunction$ and sins of coaulation dysfunction%
Many tests have been #ro#osed to hel# #redict difficulty with intubation$ but no sinle factor$
taken inde#endently$ has been able to acco!#lish this oal% However$ when !ulti#le factors are
taken toether$ the #redictive value is increased% The followin so!e s#ecific as#ects of the
head?neck?u##er airway exa! which can be used to hel# #redict difficulties that !ay be
encountered%
C
Head?Deck?U##er Airway exa!
(acial trau!a or defor!ities8 !ay !ake it difficult to #erfor! larynosco#y%
De$iated septu! or nasal polyps8 can #ose difficulty with nasal intubation or with insertin a
nasoastric tube$ #ossibly resultin in bleedin%
)eck ran&e of !otion8 the #atient needs to be able to assu!e the sniffin #osition -cervical
flexion and atlanto8occi#ital extension/ so that the oral$ #haryneal$ and laryneal axes are
alined which will facilitate viewin the lottic o#enin% Dor!al #atients should achieve &C
derees or !ore of atlanto8occi#ital extension$ which can assessed by observin the anle
traversed by the occlusal surface of the !axillary teeth when the head is fully extended fro! the
neutral #osition% ,ifficulty with intubation !ay be #redicted by a sinificant reduction in the
ability to achieve this deree of extension or if the #atient ex#eriences any #ain$ tinlin$ or
nu!bness durin this !ove!ent%
TM* !o'ility and de&ree of !out openin&8 this is i!#ortant for deter!inin the ade4uacy of
s#ace for !ani#ulatin the larynosco#e and endotracheal tube% Measure the inter8incisor
distance% An o#enin of E & c! or 2 finer breadths will likely not #rovide ade4uate s#ace and
!ay result in a difficult intubation% 0n addition$ ask the #atient to !ove the lower incisors as
hih on the u##er li# as #ossible -u##er li# bite test/% 0f the lower incisors do not reach the
ver!ilion border of the u##er li#$ this !ay be a sin of inade4uate translational !ove!ent of the
TMF$ which is also necessary for successful larynosco#y%
Dentition8 0t is i!#ortant to note the #resence of dentures$ #oor dentition$ loose teeth$ or ca#s$
which !ay not tolerate diital !ani#ulation or !ay be at risk of da!ae when the larynosco#ic
blade is inserted into the !outh% ,entures should be re!oved before surery% 0n addition$ the
#resence of #ro!inent !axillary incisors !ay result in obstruction of the view of the lottis%
Conversely$ edentulous #atients are enerally easy to intubate$ but !ay #ose difficulty with !ask
ventilation%
Ton&ue+,roparynx8 ,irect larynosco#y allows visuali:ation of the larynx by dis#lacin the
tonue anteriorly into the !andibular s#ace$ which !oves the tonue out of the line of siht% A
nor!al si:ed tonue will enerally fit easily into the s#ace between the two !andibular ra!i%
However$ if the tonue is too lare -!acrolossia/ or the !andible is too s!all -!icronathia/$
there will likely be difficulty with #ro#er visuali:ation of the lottis% The Malla!#ati
classification is a !ethod to assess the tonue si:e in relation to the si:e of the oro#harynx% The
test is #erfor!ed by havin the #atient sit with their head in the neutral #osition$ and then o#en
their !outh as wide as #ossible and #rotrude the tonue as far as #ossible% They should not
#honate$ as this can elevate the soft #alate and alter the view% A Class & or < view !ay be
associated with difficult larynosco#y%
G
The si:e of the !andible can be assessed by !easurin the thyro!ental distance% This is the
distance fro! the !entu! of the !andible to the thyroid cartilae% A thyro!ental distance of G
c! -a##roxi!ately & finer breadths/ or less$ as often seen in #atients with a recedin !andible
or a short neck$ !ay indicate a #ossible difficult intubation% Alternatively$ the sterno!ental
distance -fro! !entu! to sternal notch/ can also be used$ which assesses the si:e of the
!andible and neck% A sterno!ental distance of E A& c! !ay also #oint to difficulty with
intubation%
Binally$ a #hysical status classification is assined$ based on the criteria of the A!erican Society
of Anesthesioloists -ASAA8C/$ with ASA8A bein assined to a healthy #erson without !edical
#roble!s other than the current surical concern$ and ASA8C bein a !oribund #atient$ not
ex#ected to survive for !ore than twenty four hours without surical intervention% An 1=1 is
added if the case is e!erent% The full details of the classification scale are also detailed later%
IVs and Premedication
The two skills you should take the o##ortunity to #ractice while on your rotation are 0H insertion
and airway !anae!ent?intubation% =very #atient -with the exce#tion of so!e children that can
have their 0H2s inserted followin inhalation induction/ will re4uire 0H access #rior to bein
brouht to the o#eratin roo!% The key to success with 0H #lace!ent is #re#aration and #atience%
All of us have successfully found and cannulated a vein$ only to find that we left the ba of 0H
fluid or the ta#e across the roo!% Dor!al saline$ Iactated *iner2s solution$ or other balanced
electrolyte solutions -Plas!alyte$ 0solyte/ are all co!!only used solutions intrao#eratively%
Many #atients are understandably nervous #reo#eratively$ and we often #re!edicate the!$
usually with a ra#id actin ben:odia:e#ine such as intravenous !ida:ola! -which is also
fabulously effective in children orally or rectally/% Metoclo#ra!ide$ 3icitra$ and?or an H2
blocker are also often used if there is a concern that the #atient has a full sto!ach$ and
anticholinerics such as lyco#yrrolate can be used to decrease secretions%
Room Setup and Monitors
3efore brinin the #atient to the roo!$ the anesthesia !achine$ ventilator$ !onitors$ and cart
!ust be checked and set u#% The anesthesia !achine !ust be tested to ensure that the aues and
!onitors are functionin #ro#erly$ that there are no leaks in the as delivery syste!$ and that the
backu# syste!s and fail8safes are functionin #ro#erly%
The !onitors that we use on !ost #atients include the #ulse oxi!eter$ blood #ressure !onitor$
and electrocardiora!$ all of which are ASA re4uire!ents for #atient safety% =ach are checked
J
and #re#ared to allow for easy #lace!ent when the #atient enters the roo!% Kou !ay see so!e
!ore co!#licated cases that re4uire !ore invasive !onitorin such as arterial or central lines%
0n the o#eratin roo!$ the anesthesia !achine can su##ort non8invasive and invasive !onitors%
"hile in the !aLority of cases$ non8invasive !onitorin is sufficient$ exa!#les and indications
of invasive !onitors include7
Arterial lines for continuous blood #ressure !onitorin > usually radial$ but can be
brachial$ fe!oral$ etc%
o Used in any case where wide swins in blood #ressure are ex#ected$ where tiht
control of blood #ressure is needed$ in cardio#ul!onary by#ass cases$ or when
there will be the need for !ulti#le blood as analyses%
Central venous lines for !easurin CHP8 ty#ically 0F or subclavian
o Used in any case when there is the need to closely !onitor the intravascular
volu!e status or there is a need to evaluate riht ventricular function%
Pul!onary artery catheter for !easurin "ede #ressure -IH=,P/
o Used to deter!ine *AP$ PA$ IH=,P$ C'$ and Pv'
2
% These !easure!ents are
hel#ful when faced with #oor left ventricular function$ valvular disease$ recent
M0$ A*,S$ !assive trau!a$ !aLor vascular sureries$ or when there is a critical
need to accurately assess the intravascular fluid volu!e or the res#onse to blood
#ressure interventions%
Transeso#haeal echo -T==/ > used in !any CH cases
o Used to evaluate reional wall !otion abnor!alities indicative of !yocardial
ische!ia$ to evaluate stroke volu!e?eLection fraction$ to evaluate cardiac valvular
function$ to look for intracardiac air$ to !onitor chanes in cardiac function$ or to
evaluate ade4uacy of intravascular fluid volu!e%
The anesthesia cart is set u# to allow easy access to intubation e4ui#!ent includin endotracheal
tubes$ larynosco#es$ stylets$ oral?nasal airways and the !yriad of drus that we use daily% A
#ro#erly functionin suction syste! is also vital durin any ty#e of anesthetic%
"hen it co!es to drawin u# the initial drus$ there are < cateories of drus that should be
ready for each case7 induction aents$ sedation?analesia drus$ reversal aents$ and e!erency
drus% At ti!es$ the s#ecific drus !ay vary de#endin on the case$ but the followin are !ost
co!!only used% The first & cateories should be drawn u# in #re#aration for the case$ but the
e!erency drus are often already #re#ared%
-nduction A&ents
M
Iidocaine -AN/ -AO!?!I/ > ,raw u# in a Ccc syrine
Pro#ofol -AO!?!I/ > ,raw u# in a 2Occ syrine
*ocuroniu! -AO!?!I/ > ,raw u# in a Ccc syrine
Sedation+Anal&esia Dru&s
Hersed -A!?!I/ > ,raw u# in &cc syrine
Bentanyl -CO!c?!I/ > ,raw u# in Ccc syrine
%e$ersal A&ents
Deosti!ine -A!?!I/ > ,raw u# in Ccc syrine
+lyco#yrrolate -O%2!?!I/ > ,raw u# in Ccc syrine
.!er&ency Dru&s -PAt Her!ann$ these drus are already #re#ared and should be found in
#lastic ba/
PPhenyle#hrine -AOO!c?!I/ > 0n AOcc syrine
P=#hedrine -C!?!I/ > 0n AOcc syrine
PSuccinylcholine -2O!?!I/ > 0n AOcc syrine
Atro#ine A!?!I > 0n &cc syrine

'ther #re#arations that can be done before the case focus on #atient #ositionin and co!fort$
since anesthesioloists ulti!ately are res#onsible for intrao#erative #ositionin and resultant
neuroloic or skin inLuries% Heel and ulnar #rotectors should be available$ as should axillary rolls
and other #ads de#endin on the #osition of the #atient%
Q