ANAESTHESIA GUIDELINES

Anaesthesia main objectives during surgery are:

• To relieve pain
• To support physiological functions
• To provide good conditions for the operation
GENERAL CONSIDERATIONS
The facilities for administering anaesthesia must be:
• Available and in a state of readiness at all times
• Appropriate in quality and quantity
• Compatible with safety
Staffing requirement for anaesthesia
• Anaesthesia provider
• An assistant dedicated to the anaesthesia provider
• Adequate assistance in positioning the patient
• Adequate technical assistance to ensure proper functioning and servicin
g of all equipment
Before anaesthesia
Read the notes/ medical records of the patient
Assessment of the patient
• Identify the patient
• A standard history is obtained and an examination done
Emphasis is on the cardio-respiratory systems
• Investigations appropriately interpreted e.g., Hb
• Classify physical / health status of the patient
according to American Society Of Anaesthesiologists(ASA) Classification :
ASA 1: Normal patient
ASA 2: Patient with mild or well controlled systemic disease
ASA 3: Patient with systemic disease that is limiting activity but
not incapacitating
ASA 4: Patient with systemic disease that is incapacitating and a
Constant threat to life
ASA 5: Moribund patient not expected to survive in 24 hours with
or without surgery
Letter E is added in case of emergency condition e.g. ASA 1E
Prepare properly:
The workplace
Should be in a constant state of preparedness for anaesthesia
The drugs, equipment, instruments and materials to be used must
be known
These items should be available, checked and ready.
The patient
Aim is to make the patient as fit as possible in the given circumstance
before surgery
• Preparation is according to condition of the patient and nature of the
operation
• adhere to the process of obtaining informed consent
Ability of the patient to withstand the stresses and adverse effects of
anaesthesia and the surgical procedure will depend on how well prepared he is
Make a plan for anaesthesia based on the obtained information
SELECTION OF TYPE OF ANAESTHESIA FOR THE PATIENT
Consider
• Patient factors: medical state, time of last meal, mental state, wish of
patient if applicable
• Surgical factors: nature of surgery, site of operation, estimated durati
on of surgery, position in which the surgery is to be performed
• Anaesthetic factors: availability of drugs, experience of the anaestheti
c provider

During anaesthesia
Anaesthesia is administered (induction and maintenance)
The patient must be monitored meticulously:
• To ensure his/her wellbeing
• To detect dangerous signs as soon as they arise and appropriately treat
them
Expertise in resuscitation is obligatory
If in trouble ask for help

After anaesthesia
The patient
• Recovers from effects of anaesthesia
• Has stable vital signs
• Is returned to the ward in the fully conscious state, no worse, or if at
all possible, even better than before operation.

ALWAYS PAY ATTENTION TO DETAIL.

The anaesthetist, surgeon and theatre staff are on the same team.
Know your limits, seek help, consult or refer to higher level of care.

Types of Anaesthesia
Anaesthesia may be produced in a number of ways
General anaesthesia
Basic elements: loss of consciousness, analgesia, prevention of undesirable refl
exes and muscle relaxation
Regional or Local anaesthesia
Sensation of pain is blocked without loss of consciousness.
The conduction of stimulus from a painful site to the brain can be interrupted a
t one of the many points:
• Surface Anaesthesia
• Infiltration Anaesthesia
• Intravenous regional anaesthesia
• Nerve block/Plexus block
• Epidural Anaesthesia
• Spinal Anaesthesia

TECHNIQUES OF GENERAL ANAESTHESIA

Requirements for all:
• Take and record baseline vital signs
• Establish intravenous line and commence infusions
General anaesthesia with spontaneous respiration
Induce anaesthesia by:
• Intravenous route (adults)
Or
• Inhalation route (children, patient with difficult airway)
Maintenance
• Secure a clear airway using an oropharyngeal airway
• The mask is placed on the face
• Titrate concentration of inhalation against response of the patient
• Monitor, record every 5 min. or more frequently, BP, Pulse, Respiration,
Colour, oxmetry
Indication:
• This technique may be used for operations on limbs, perinium, superfial
wall of
chest and abdomen
• Suitable for operations lasting less than 30 min
General anaesthsia with controlled ventilation
Induce anaesthesia:
• Intravenous/ inhalation (see above)
• Tracheal intubation
-when spontaneously breathing (for children)
-or
-under relaxation by suxamethonium and laryngoscopy
-confirm correct tube placement by presence of breath sounds on both chest sides
-connect the breathing / delivery system to the endotracheal tube
Maintenance
• Titrate concentration of inhalation agent against response of the patien
t
• A selected long acting muscle relaxant is given
• Intermittent positive pressure ventilation is done
• Monitor vital signs (as above)
• At the end of the operation when the patient shows signs of respiratory
effort
Neostigmine is given to reverse the effects of the long acting musc
le relaxant
Indication: all operations that require a protected airway and controlled ventil
ation e.g. intraabdominal, intrathoracic and intracranial operations

Rapid sequence induction of general anaesthesia

Also called crash induction
For patients with “full stomach” and at risk of regurgitation e.g. emergency su
rgery, distended abdomen.
Crash induction steps
• Establish an intravenous line and commence infusions
• Preoxygenation for > 3 min.
• Induce with selected intravenous anaesthetic agent
• Assistant applies cricoid pressure
• IV suxamethonium is given
• Laryngosopy is done
• Trachea is intubated and correct tube placement confirmed
• The cuff of the endotracheal tube is inflated then cricoid pressure rele
ased
• The position of the tube is fixed by strapping and an airway is inserted
.
Then connect to breathing circuit/ system to maintain anaesthesia.
Techniques for Regional anaesthesia
Detailed knowledge of anatomy, technique, and possible complications is importan
t for correct injection placement
Preoperative assessment and preparation of the patient should be done
Patient refusal and local sepsis are the only absolute contraindications
Select the appropriate technique for operation
Precautions:
• Discuss the procedure with the patient
• Identify the injection site using appropriate landmarks
• Observe aseptic conditions
• Use small bore needle which cause less pain during injection
• Select concentration and volume of drug according to the technique
• Aspirate before injection to avoid accidental intravascular injection
• Inject slowly and allow 5-10 min. for onset of drug action
• Confirm desired block effect then surgery commences
• The patient must be monitored throughout the procedure*****
Note
Supplemental agents should be available for analgesia or anaesthesia if techniqu
e is inadequate
Resuscitative equipment, drugs and oxygen must be at hand before administration
of any anaesthetic

The commonly used drugs in anaesthetic practice

General anaesthetic agents
1. Intravenous agents: thiopentone, ketamine, propofol
Thiopentone
• Solution concentration: 2.5% or 25 mg/ml
• Route: intravenous
• Dose: 3 to 5mg/kg body wt.
• Indication: induction of anaesthesia, anticonvulsant
• Contraindication: airway obstruction, shock, hypersensitivity to barbitu
rates, severe heart disease
• Side effects: drowsiness, depression of cardio respiratory system( in cl
inical doses)
• Complication: hypotension, apnoae (dose dependent), tissue necrosis in c
ase of extravasation of the solution

Ketamine
• Solution concentration: 50mg/ml, 10mg/ml
• Route: intravenous, intramuscular
• Dose: I.V. 1-2mg/kg body wt
I.M. 5-7mg/kg body wt
• Indication: induction of anaesthesia, maintenance of anaesthesia (infusi
on),
Analgesia
• Contraindication: hypertension, epilepsy, raised intracranial pressure e
.g. head injury
• Side effects: emergency delirium, hallucinations, increased salivation,
increased muscle tone
• Prevent salivation by atropine premedication, treat emergency delirium b
y giving diazepam

Propofol
• Solution (emulsion): 1% or 10mg/ml
• Route: intravenous
• Dose: 1-2.5mg/kg body wt titrated at a rate of 4mls/sec.
• Indications: induction of anaesthesia, maintenenance of anaesthesia
• Contraindication: hypersensitivity, hypotension, obstetrics, paediatrics
• Side effects: pain at site of injection
2. Inhalational anaesthetic agents
Halothane
A volatile liquid a room temperature
• Indication: induction of anaesthesia ( in children, patients with airwa
y obstruction)
Maintenance of anaesthesia
• Precaution: -always use at least 30% 0xygen with halothane,
-It is safe to avoid use of adrenalin to prevent high
incidence of arrhythmias
• Adverse effects which may occur include:
-Atony of the gravid uterus
-Postoperative shivering
-Severe cardiopulmonary depression
Ether
A highly volatile and inflammable liquid
• Indication: maintenance of anaesthesia
• Side effects: nausea and vomiting, increases salivation, irritates the a
irway
• Precaution: -Avoid sparks e.g. diathermy, in the ether risk zone
-Give atropine to prevent salivation

MUSCLE RELAXANTS
Used to provide muscle relaxation to facilitate a procedure
Precaution before using a muscle relaxant:
• Have means of supporting the airway and respiration
• used in a patient who is unconscious e.g. general anaesthesia, or sedat
ed
Short acting muscle relaxant
Suxamethonium:
Solution concentration: 50 mg/ml
Action: fast onset and short duration
Route: intravenous or intramuscular
Dose: 1-2mg/ml
Indication: muscle relaxation for short procedure e.g. tracheal intubation, redu
ction of fracture
Contraindications: airway obstruction, hyperkalaemia conditions e.g. tetanus, bu
rns >3days old.
Long acting muscle relaxants
Pancuronium:
Solution concentration: 2mg/ml
Action: slow onset and long duration (45 min.)
Route: intravenous
Dose: 4-6 mg initially thereafter 2mg or 0.08- 0.1mg/kg
Indication: muscle relaxants for long procedure e.g. laparotomy
Atracurium:
Solution concentration: 10mg/ml
Action: duration=20 – 40 min.
Route: intravenous
Dose: 0.3- 0.6 mg/kg
Indication: muscle relaxation for operation of intermediate duration

LOCAL ANAESTHETIC AGENTS

Lignocaine:
Solution concentrations of lignocaine commonly used:
• Topical- larynx pharynx 2-4% (20-40mg/ml) or 10% (100mg/ml)
• Infiltration 0.25- 0.5% (2.5- 5mg/ml) with adrenaline 1:2000000
• Nerve block 1-2% (10- 20mg/ml) adrenaline 1:2000000
• Spinal 5% (50mg/ml) hyperbaric solution
Action: fast onset
Plain lignocaine 40 – 60 min
Lignocain with adrenaline 60 – 90 min
Dose: lignocaine with adrenaline 6-7mg/kg body weight
Plain lignocaine 3mg/kg body weight
It is important to calculate the volume of lignocaine that could be used safely
Note: lignocaine toxicity-
• Signs and symptoms
CNS stimulation followed by depression
o Stimulation –restlessness, tremor, convulsions
o Depression – semi consciousness, coma
• Treatment
Give sufficient/ titrate IV diazepam to control convulsions
Thiopentone may be used e.g. 50mg
Oxygen is given
Support airway, breathing and circulation as indicated
Admit the patient to ward to continue treatment and observatio
n as needed.
Bupivacaine:
Solution concentration 0.5% (5mg/ml)
Action: slow onset but long duration 4-6 hours or longer
Dose: 2mg/kg body weight
Indication: all regional anaesthesia, but hyperbaric solution for spinal.
Other drugs:
Analgesics, Naloxone, Noestigmine,Atropine, Diazepam

Drugs for managing the following condition:

Anaphylaxis, Cardiac arrhythmias, Pulmonary oedema,
Hypotension, Hypertension, Bronchospasm, Respiratory depression,
Hypoglycaemia, Hyperglycaemia, Adrenal dysfunction,
Raised intracranial pressure, uterine atony. Coagulopathies

Management of the surgical patient with special condition

Internal haemorrhage
• As may occur in ruptured spleen, ruptured tubal pregnancy
• An emergency condition with unstable vital signs
• Invasive surgical intervention in whatever state the patient is in is li
fe saving
• Do not delay operation in attempt to stabilize the patient as this may n
ot be achieved
• Prompt resuscitative operation is required which includes:
1. Establish an IV line and infuse fluids rapidly
2. Rapid sequence induction of general anaesthesia
-Use drugs with no or minimal cardiac depression
3. Laparotomy to achieve surgical haemostasis
Intestinal obstruction
Preoperative fluid therapy
• Fluid deficit, the electrolyte abnormalities and acid-base disturbances
must be corrected
• Replace on going fluid losses e.g. vomit, fistula, NG- tube drainage
• Give maintenance fluid
• Duration, depending on urgency of surgery, may be as long as 6 hours to
achieve cellular hydration
• Monitoring outcome
The following signs will show the effectiveness of the therapy
-Pulse rate a gradual decline
-BP may rise
-Urine output good if it is 0.5 to 1ml /kg/hr
-CVP arise of 2-3 cmH20 with rehydration
-CNS patient more rational
-Mouth less dry
-Skin turgor increased
• The fluid to use: balanced solution e.g. Ringers Lactate. Physiological
saline may be used.
Operative fluid therapy
• Blood loss, fluid aspirated from the gut and other fluid losses must be
replaced
• Maintenance fluid be given 5ml/kg/hr
Postoperative fluid therapy
• Replace all fluid losses
• Maintenance fluid
• Monitor for adequate rehydration
Co-existing medical conditions
Principle:
The medical condition must be stabilized as much as possible before surgery
Preoperative management
• Establish whether condition is stable or unstable
• If unstable then control or correct the condition
Operative and postoperative management
• Anaesthesia technique based on condition of patient and nature of surger
y
• Maintain the stable condition
Hypertension
Diastolic of 90 mmHg is acceptable
If poorly controlled patient may have
• Vasoconstriction and hypovolaemia
• Exaggerated vasoactive response to stress leading to hypotension or hype
rtension
• Hypertensive complications under anaesthesia
Management
• Control hypertension preoperatively
• Take antihypertensive drugs on schedule even on the day of operation
• General anaesthesia technique is preferred
• Ensure adequate-depth of anaesthesia and analgesia
-oxygenation
-ventilation
-circulatory volume replacement
Anaemia
Condition of reduced 02 carrying capacity, patient prone to hypoxia
Heart failure may occur
Hypotension or hypoxia can cause cardiac arrest
This should be corrected to acceptable level depending on urgency of surgery
Regional anaesthesia is the preferred method
If general anaesthesia - is used avoid myocardial depressant,
-use small doses of drugs
-use high oxygen concentration
-intubate and ventilate except for very shor
t procedures
-replace blood very carefully
-extubate patient when fully awake
-give o2 in the postoperative period
For the sickle cell anaemia the above also apply as well as avoiding use of tour
niquet
Asthma
Avoid drugs and other factors likely to trigger bronchospasms
Regional anaesthesia is the preferred method
If general anaesthesia select drugs accordingly, maintain adequate depth of ana
esthesia
Diabetes mellitus
Achieve control using standard treatment preoperatively
If diabetic ketoacidosis -delay surgery even in emergency for 8-12 hours
-correct and control all associated distu
rbances
Hyperglycaemia under general anaesthesia is safer than hypoglycaemia
Patient should be operated early in the morning where possible
Regional anaesthsia is the method of choice where applicable
Minor surgery
Stop usual antidiabetic dose on the morning of surgery
Start infusion of 5%dextrose infusion rate of 2ml/min in theatre
Monitor blood sugar
Usual medication is resumed as soon as the patient is able to take orally
Major surgery
Control on sliding scale of insulin
Infusion of 5%dextrose started on the morning of surgery
Or
Glucose insulin potassium infusion
Monitor blood sugar ≤200mg/dl
CARDIOPULMONARY RESUSCITATION
(CPR)
Recognition of cardiac arrest
Assume cardiac arrest if patient is:
Unresponsive and Apnoeic or has an abnormal breathing pattern
Note:
The central (carotid) pulse check is inaccurate and has been omitted as a reliab
le sign of cardiac arrest
Reversible causes of cardiac arrest
Hypoxia Tension pneumothorax
Hypovolaemia Tamponade cardiac
Hypothermia Toxins
Thrombosis (coronary or pulmonary
During CPR
• Give 30 chest compressions immediately before any rescue breaths are att
empted
• For chest compressions, position hands at centre of chest
• Compression: Breaths ratio is 30:2
• The person delivering chest compressions should change every 2 minutes w
ith minimum delay so that quality and performance of compressions is maintained
• Equipment for airway, breathing and circulation support applied when ava
ilable
• Attempt / verify:
- IV access
- Airway and oxygen
• Give uninterrupted chest compression when airway secure
• Give adrenaline every 3-5 minutes
• Correct reversible causes
• Consider amiodarone, atropine, magnesium
ADULT CPR
In health facility resuscitation
Note:
Resuscitation in a health care setting should encompass both basic and a
dvanced life support
Basic life support should be continued until advanced life support is av
ailable and effectively applied
CPR termination when
Patient improves
Or
Irreversible cardiopulmonary arrest established