Surgeons and Anesthesia

Surgeons and
Anesthesia
Surgeons and
Anesthesia
S Ahanatha Pillai MD DA
Emeritus Professor
The Tamil Nadu Dr MGR Medical University
Chennai, Tamil Nadu, India
Former Professor
Department of Anesthesiology
Madurai Medical College and Government Rajaji Hospital
Madurai, Tamil Nadu, India
Foreword
Sam C Bose
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Surgeons and Anesthesia
First Edition: 2014
ISBN: 978-93-5090-837-2
Printed at
Sri Ramajeyam
Om Anandamayi Chaithanyamayi Sathyamayi Parame!
Dedicated to
Professor Dr T Subramaniam FRCS

Emeritus Professor
The Tamil Nadu Dr MGR Medical University
Chennai, Tamil Nadu, India
Honorary Clinical Professor of Surgery
Madurai Medical College and Government Rajaji Hospital
(1971–1987)
I had the great fortune of working with this legendary personality

A wonderful great human being with a loving heart to his fellowmen
A surgeon of high repute with compassion to poor patients
A renowned teacher with admirable virtues
Foreword
Who is better suited to write the foreword for a well-thought out book for
surgeons by an Anesthetist? Certainly, an Anesthetist!
But when a surgeon is asked to study the 236-page book and write
the foreword, it is a pleasure and honor. Pleasure, because one is
educated even in his eighth decade of life and over six decades of nodding
acquaintance with surgery since 1952.
A lesson which I learned is, in the first 10 years learn ‘how’ to do surgery,
second 10 years ‘when’ to do surgery, third 10 years ‘when not’ to do surgery
(these three were taught by the Jambavans of yesteryears), and finally
when ‘stop’ doing surgery!
In conclusion, I congratulate Professor Dr S Ahanatha Pillai for writing
this wonderful piece of educative manual throwing open the nuances of
high quality anesthesia wizardry for the benefit of future generation of men
and women of all specialties including ‘surgeons’!
Sam C Bose MS MCh

Former Professor of Plastic Surgery
Madurai Medical College
Preface
This small book is aimed at the young surgeons who would like to know
something about anesthesia while developing expertise in their own field.
I am fortunate to be in the field of anesthesiology from the ‘open drop
ether era’ to the modern-day anesthesia for about four decades and had
the fortune of working with three generations of surgeons specially, some
of the great stalwarts in surgery of yesteryears. Hence, I humbly feel fit to
write about the subject on the title Surgeons and Anesthesia.
There is a natural question, ‘Why should a surgeon know about
anesthesia?’ The answer is very straightforward and simple; surgery and
anesthesiology are very intimately related and interdependent fields, and
as anesthesiologists and surgeons work in the same team, each one must
have some orientation about the other’s work so as to give the best possible
service to the patient in the teamwork.
I brought out the book Anesthesia for Undergraduate sometime in 1995.
Since then, there had been a persistent request from many of my good
friends and colleagues belonging to various surgical specialties for a simple
and comprehensive book that deals with the basics of anesthesiology and
other important aspects related to anesthesia and operating department. I
am very grateful to all my esteemed colleagues, for their love to me.
My close association with my dear surgical colleagues was so pleasant
and enduring for the past four decades that the idea of this book was deep
in the back of my mind all these years. Now it is taking shape.
After a lot of thought and planning, keeping all their requirements in
mind, this book has been designed a little differently.
The topics and chapters have been chosen in such a way that it may
be useful to the postgraduates in surgery as well as practicing surgeons.
Preanesthetic assessment and preparation of the patient which would tell
upon the ultimate outcome of surgery has been adequately dealt with.
Without going deep into the subject, all the practical aspects are discussed
with their clinical relevance. This will certainly help the surgeons to easily
spot and identify the anesthesia-related problems in the perioperative period
so that remedial steps could be taken without delay; and if necessary, call
the anesthetic colleague for help.
Apart from discussing fundamentals of clinical anesthesia, less commonly
discussed topics such as surgical team, surgeon-anesthesiologist relations,
operation theater discipline, planning an operating department, asepsis,
sterilization of equipment, coordination of theater work, postanesthetic
care, etc. have been included. The chapter “Vital Organs Function and
Anesthesia” has been specially included that precisely deals with the
possible alterations in function of vital organs due to anesthesia.
x Surgeons and Anesthesia
Spinal anesthesia is being practiced extensively and is associated with

significant morbidity and mortality. There are innumerable misconceptions
about that technique; and for that reason, it has been dealt with more
elaborately.
All of us are aware; there is no substitute for ‘Asepsis’ in surgical practice.
But, in the modern era of antibiotics, there is a fear whether the concept of
surgical asepsis is slowly taking the back bench. So, it has been dealt with
more care.
It is not an attempt to tell anything new, but to discuss the already known
things to look at it in a little different angle so as to enjoy the intricate details
and to use them for the benefit of the patients.
I am very sure; this small book would make an interesting reading for
all my esteemed surgical colleagues.
S Ahanatha Pillai
Acknowledgments
I am extremely grateful to all my teachers, who always made me realize and

feel that teaching is a wonderful experience and inspired me to learn that art.
My loving students, both undergraduates and postgraduates, consistently
inspired me to continue teaching for more than four decades. I am grateful
to them, for their love to me.
My dear colleagues in various surgical specialties have contributed for
my development in many ways. Most of them loved me and encouraged
me in every endeavor.
I am deeply indebted to Professor Dr Sam C Bose, former Professor
of Plastic Surgery, Madurai Medical College, Madurai, a renowned great
teacher and a pioneer in the field of plastic surgery for being kind enough
to go through the book, make corrections and give constructive criticisms.
This book is adorned by the foreword from him. I consider this as a special
privilege and I do not have words to express my profound gratitude to him.
My dear younger colleague, Dr G Saravana Kumar, has gone through
the whole script carefully and made corrections and contributions. My love
is due to him.
I am very grateful to all those patients, the faces of whom I could not
remember who submitted themselves for anesthesia and permitted me to
learn anesthesiology for the past four decades and for all that they taught
me.
I owe my immense gratitude to Shri Jitendar P Vij (Group Chairman),
Mr Ankit Vij (Managing Director) and Mr Tarun Duneja (Director-Publishing)
of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for
publishing this book in a very presentable form in a short time. My boundless
thanks are due to Mr R Jayanandan, senior commissioning editor of
M/s Jaypee Brothers Medical Publishers (P) Ltd, Chennai Branch, for the
excellent and prompt coordination work he did with regard to this publication
as in my earlier four publications.
Contents
1. Introduction 1
Anesthesia 2
2. Anesthesiologist 7
Learning anesthesiology 7
Functions of the Anesthesiologist 7
Surgeon-Anesthesiologist Relations 11
Operating theater suite and theater discipline 13
Operating department Manager 16
3. Surgical Team 19
Members of Surgical Team 19
Job descriptions of Anesthetic Technician 23
Unskilled personnel working inside the operating room 25
Coordinator of the Team 27
4. Safe practice of Anesthesia 32
Ten Golden Rules of Anesthesia 33
Indian Society of Anesthesiologists 34
Safety in anesthesia 36
Accidents during Anesthesia 37
Anesthetic Records 40
Monitoring during Anesthesia 43
Monitoring the anesthetic machine 45
The cardiovascular System 45
5. Preanesthetic Assessment 48
The purpose of preoperative visit 49
Guidelines for Preanesthetic visit 49
Definition 51
History taking 51
Physical examination 52
Basic Laboratory Investigations 52
Grading of Risk (American Society of Anesthesiologists) 54
Fit for anesthetic 55
Informed Consent for anesthesia and surgery 57
Preoperative starvation 60
Canceling cases 61
Choice of anesthesia 62
6. Preanesthetic Medications (Premedication) 65
Definition 65
Preanesthetic Medication Drugs (Premedication Drugs) 66
Effects of Premedication 71
7. Clinical Anesthesia: Balanced Anesthesia 73
The Purpose of Anesthesia 73
Guedel’s classification of Anesthesia 73
The Triad of Anesthesia 75
Definition of Anesthesia 76
xiv Surgeons and Anesthesia
Balanced Anesthesia 77
Modern Anesthesia 78
Recovery from Anesthesia 83
Classification of Anesthesia 86
8. The Operating Department 87
Operating Department, Operating Suite, Operating Theater 89
Access Zones 89
Patient transport 91
Design 93
Construction 94
Lighting 94
Pendant services 99
Ventilation 99
Storage 102
9. Theater Asepsis and Equipments Sterilization 104
Operating theater environment and asepsis 104
History 105
Definitions 107
Theater Disinfection Schedule 107
Ultraviolet Rays 110
Ultraviolet Rays air cleaning system 110
Sterilization of Equipments 113
Cleaning and Sterilization 114
Gamma rays 128
10. Operating Table and Positions for Surgery 132
Positions for Surgery 134
Supine or Dorsal Recumbent Position 135
Trendelenburg Position 136
Gallbladder and Liver position 136
Lateral Position of Extension (Kidney Position) 137
Lithotomy Position 139
Position for Abdominoperineal Resection of Rectum 140
Supporting pads for positioning 143
11. Assessment of Blood Loss and Volume Replacement 144
Facts about Blood Transfusion 145
Assessment of blood loss during surgery 145
Recommendations from various authorities regarding transfusion 147
role of colloid solutions in blood volume replacement 147
Commonly used IV Fluids, their Composition and Indications 149
12. Vital Organ Function and Anesthesia 155
Anesthesia and liver 155
Anesthesia and Kidney 160
Anesthesia and Brain 166
Anesthesia and Heart 170
13. Recovery room: Postanesthesia Care Unit (PACU) 178
Postanesthesia Care 178
Recovery Room 179
The Transport to Recovery Room 180
The purpose of Recovery Room 181
Recovery Criteria 188
Contents xv
Clinical assessment of adequacy of reversal of NMB 189

Guidelines for Postanesthetic Care 192
14. Local Anesthetic Drugs and Regional anesthesia 198
Definition of Regional Anesthesia 198
Pharmacology of local Anesthetics 199
Structure of pharmacological relationship 199
Mechanism of action 200
Xylocaine 200
Bupivacaine 201
Toxic Reactions of Local Anesthetics 201
Techniques of Regional Anesthesia 203
15. Guidelines for Emergency Abdominal Surgeries 221
A Clinical Approach 224
16. Postoperative Nausea and Vomiting 225
Common recovery room problems 225
Factors that affect the incidence of PONV 228
Guiding principles 235
Index 237
Quotes
‘Eternal vigilance is the price of safety’

‘Primum non nocere’—‘first of all, do no harm’
‘Anesthesia is a science, but practiced as an art.’
‘Relief of pain is purchased always at a price. The price in both morbidity
and mortality does not greatly differ whatever the agent or agents used.’
— Ralph Milton Waters
‘The proper dose of any drug is enough.’

‘It is not the drug that is dangerous, but the man who administers it is.’
— Sir Robert Macintosh
‘It is a great mistake to suppose that nature always stands in need of the
assistance of art... Nor do I think it below me to acknowledge that, when
no manifest indication is pointed out to me what was to be done, I have
consulted the safety of my patients, and my own reputation effectually by
doing nothing at all.’
— Thomas Sydenham
‘All anesthesiologists, however experienced and however accident-free,

should be humble enough to recognize that they may make mistakes at any
time. These errors may be in technique, judgment or failure of vigilance.’
— John Alfred Lee
‘No hospital is too small for learning and no doctor is too wise not to be
benefited from the experience of others.’
‘It is a common mistake to believe that general anesthesia is dangerous
and conduction anesthesia (regional) is safe’.
Hospitalization
Hospitalization is a dehumanizing process. Even in the best of circumstances,

we move the patient into a strange environment, replace his clothes with
formless rage, percuss, palpate, and paw at his frightened frame, and
essentially remove his personal identity and individuality. With the exception
of planned pregnancy or cosmetic surgery, no one voluntarily commits
himself to hospitalization with the anticipation of attending a summer resort.
Hospitalization is painful to the psyche as well as to the corpus; it forces the
patient to adapt to an unfamiliar role of childlike dependency. Hospitalization
is also destructive to the family unit, which must suffer the pain of the loved
one as well as emotional and financial loss. Always remember that no patient
ever enters a hospital just to receive an anesthetic.
What then can we do as anesthesiologists to make the patient more
comfortable? Primarily, we must offer expertise. The patient has the right
to expect the summum bonum of anesthetic care. This translates into a
personal preoperative visit where the anesthesiologist, acting as a total
physician, can evaluate the patient’s physiologic and psychologic status
and where he/she can remediate, if possible, deviations from normal. The
anesthesiologist must employ a rational (i.e. nonautomatic) approach to the
choice of premedication and anesthetic drugs and technique, and flawless
performance of motor skills with gentleness and kindness.
The anesthesiologist must not take shortcuts in patient care, and must
monitor all parameters required to ensure patient safety in that particular
situation. And, the anesthesiologist must do all with the awareness that
although he/she is totally familiar with the operating room and the stress of
the perioperative period; for the average patient, an operation is a unique
and frightening experience.
There are two shibboleths to be emblazoned upon the white coat of
the anesthesiologist. The first is the motto of the American Society of
Anesthesiologists: vigilance. And, the second is the golden rule: ‘Treat
other people as you would like to be treated yourself’.
(The Epilogue from the book “Problem in Anesthesia: a case study
approach” by Mark B Ravin, MD)
Chapter
1 Introduction
Introduction
Anesthesia and surgery are intimately interlinked and interdependent specialties.
If we carefully look back into the past, surgery done without anesthesia was an
agony and surgical techniques could not develop because speed of surgery was
considered as an essential quality of a good surgeon.
Till middle of 18th century, nothing effective was available for improving the
situation. The dawn came only on 16th October 1846, when general anesthesia with
Ether was introduced by WTG Morton. The surgeons were eased of their technical
difficulties due to a struggling patient held down forcefully by the strong men who
were always the part of the surgical team in those days (Fig. 1.1).
Because the patient was quiet under good anesthesia, the surgeon could do the
surgical procedure without hurry to his satisfaction for the benefit of the patient.
This situation permitted the surgeons of that era to improve and reach perfection in
their techniques. Since then, both the specialties started developing simultaneously
and continued to improve the standards for the past two centuries into the modern
sophisticated status as we see today.
Anesthesiology is a science that provides relief of pain for the mankind. This
is the simplest way of defining this wonderful branch of medicine.
General anesthesia is a reversible, drug induced state of unconsciousness. This
is another definition though old and incomplete, explains what General Anesthesia
means.
Fig. 1.1: Surgery without anesthesia where the ‘Strong men’ hold down the patient
2 Surgeons and Anesthesia
Anesthesiology is a science, that is practiced as an art, which provides relief of

pain during surgery and in the postoperative period at the same time taking care of
the patient’s well being, simultaneously providing good working condition for the
surgeon. This gives adequate explanation about anesthesiology. The anesthesiologist
is a highly trained medical specialist and now anesthesiology is a major medical
discipline whose boundaries extend far beyond the act of an anesthetic.
Unfortunately, anesthesia has not found its place in many undergraduate
curricula. Only very few universities have included a little of the subject in the
syllabus of surgery in the recent years. Postgraduate surgeons are often not taught
anesthesia either, with the result many times the house officers and surgeons do
not have the chance to learn the basic information about anesthesia.
It is quite interesting to note that there are certain things described in the “Holy
Bible”, which have very high relevance to anesthesia.
After creating this beautiful world, God created our forefather, the first man
of this world “Adam” in his own resemblance from earth, blew into his nose and
gave life to him. But when he decided to create a companion for Adam, he did not
do it the same way. He did it differently. “He (God) made him (Adam) to go into
deep sleep, removed one of his ribs, covered it with flesh and blood, gave life to
it and thus created the first woman of this world ‘Eve’, because the father wanted
Eve to be the part and parcel of Adam.
Here the statement “He made him to go into deep sleep, removed one of his
ribs” is the words of Holy Bible. That means Adam was in a state that was similar
to a state of anesthesia—(the word anesthesia was not coined then) when he did
not feel any pain of removal of rib. (Rib resection)
Hence we may take that God almighty anesthetized Adam and did rib resection
on him to create Eve. So according to the Holy Bible, the first surgery known to
this world is “Rib resection” and that was done for showing God’s everlasting love
for mankind. Anesthesiologists and surgeons may feel proud about this.
Anesthesia
The meaning of the word ‘Anesthesia’ is given differently in different dictionaries.
• “A defect of sensation” (Bailey’s English Dictionary—1721)
• “Privation of the senses” (Encyclopedia Britannica—1771)
• “A sleep like state that makes painless surgery possible” (English Dictionary—
1751)
• “Absence of sensibility to external impressions, particularly touch” (Modern
English Dictionary).
Anesthesia is the basic requirement for any surgery to be conducted as, any
surgical procedure, however small, is certain to inflict pain on the patient.
All human beings irrespective of their socioeconomic status or any other
discrimination have their basic fear about two things; one is fear of pain and the
other is fear of death. In day-to-day life, the fear of pain persists even with a very
trivial injury, and in the event of illness, that too in an illness associated with need
for surgery, they develop these two fears together, that is fear of pain and fear of
Chapter 1  Introduction 3
possible death as a consequence of surgery. The patients when they are questioned
many times they refer to this and express this as “fear of the unknown”.
Though physiologically pain is a protective reflex to prevent movements
and further damage to injured tissues thereby promoting the healing process,
uncontrolled pain of severe degree of any cause is detrimental to the physiology
itself. Hence, relief of pain in any form is a heavenly blessing. So relief of pain
of surgery is essential both during and after surgery, otherwise irreversible damage
may be caused to the individual that may even be fatal.
“The relief of pain is purchased always at a price. The price both in morbidity
or mortality does not greatly differ, whatever the agent or agents used”
— Ralph Milton Waters
This statement of Ralph Milton Waters, who was one among the pioneers who
had contributed enormously for the development of anesthesia, is absolutely true
as anesthesia is a highly interventional specialty meaning thereby, the normal
physiology is modified for the sake of relief of pain and for the protection of the
patient from the ill effects of surgery. Though this modification of physiology is
done with an intention of protecting the patient from the likely damage by the
pain and reflexes induced by the surgical procedure, there is a limit for this
modification. This limit of modification of physiological status grossly varies from
patient-to-patient depending upon their physical and physiological status, when it
is crossed, certainly leads onto risks that may result in a fatal outcome.
Let us think about this;
Have we ever seen a man walking on the pavement suddenly becoming
unconscious for a few minutes and lying flat on the ground, then getting up and
walking again? Or have we ever seen someone traveling in our next seat in a bus
or a train suddenly stops breathing for a while and after sometime shakes his head
and starts breathing again?
Both these things can never happen during normal life, but during anesthesia
a patient is made unconscious and is paralysed. To prevent him from dying
the anesthesiologist takes over the respiration and ventilates him manually by
compressing a bag intermittently till he is back to normal to breathe on his own.
When the patient’s physiology is artificially modified and deviated from
normal, even if it is within the so called limits of safety, it means he is no longer
in a position to take care of him. Then it becomes the prime responsibility of the
anesthesiologist to take care of the patient, till he is able to do it himself.
In fact, over the past two centuries, the deep concern of all those involved in
surgical teamwork is only ‘Patient safety’.
Three aspects have to be taken into very careful consideration before
anesthetizing a patient.
1. The physiological status of the patient at the time of taking him up for anesthesia
and surgery.
2. The nature of surgery and the degree of modification of his physiology required
for that surgical procedure.
3. The choice of technique of anesthesia and the choice of drugs needed for that
purpose and their doses in accordance with the patient’s condition.
The situation can be explained in very simple words;

• Anesthetizing a patient means, the physiological protections available in the
normal conditions of life have been artificially removed to varying degrees.
Hence, even in the best of circumstances, with adequate support and monitoring,
he may still be exposed to the possibility of grave risk to life (risk of death).
• In normal healthy person, there is always a wide margin between life and death.
This is known as the ‘Safety Margin’. This is possible because of the normal
protective compensatory mechanisms available in physiology. So, a mild to
moderate insult to the physiology such as severe bleeding due to an injury,
may not kill a person, but the protective compensatory mechanisms are forced
into action to sustain the life for a fairly long time till an artificial support is
made available.
• During anesthesia, because of the modifications in the physiology which
we artificially make, for the purpose of performing the surgery, many of the
protective compensatory mechanisms are either removed or suppressed. This
situation inevitably makes the margin between life and death (the safety margin)
a little narrower. Hence a careful modulation of anesthesia within the available
narrow margin of safety is necessary to protect the patient from the possible evil.
• At this point we must remember that, when a patient suffers from a systemic
disease, then the compensations are likely to be reduced and so, the margin of
safety becomes narrower. The modulation of anesthesia has to be done very
precisely within this available small margin of safety which means that the risk
involved is higher. Depending upon the severity of the system derangement,
the margin gets narrowed further.
• Mild degree of derangements of multiple systems also tends to narrow the
margin to a severe degree. Hence, in multiple system diseases, the safety margin
may be extremely narrow, making the anesthetic management more difficult
and the risk of death imminent.
• Similarly, a severe systemic derangement also will tend to make the safety
margin very narrow.
• Here high degree of skill and experience is required for managing this type of
high risk patients.
• In anesthesiology, the aim will be to first carefully assess the margin of safety
and then modulate the anesthesia for the particular patient with the available
safety margin very meticulously and skillfully as walking on a tight rope with
a balancing rod.
• During the process of assessment and preparation, whenever possible, reversal
of the correctable problems is to be done such as correcting the dehydration with
fluid therapy, correcting the hemorrhagic anemia with blood transfusions, etc.
• After surgery, finally the patient is reversed from the effects of anesthesia
fully back to his original physiological status or if possible to a better status
because of fluid resuscitation, etc, so that he will be in safer condition with
less risk to life.
• In general, for good anesthesia much depends more on the skills of the
anesthesiologists than on the availability of expensive and complicated
equipments. In other words, safe and good anesthesia does not mean that it
has to be expensive.
Chapter 1  Introduction 5
The degree of modification in the safety margin has been explained in the
Figure 1.2.
Fig. 1.2: Schematic representation of ‘Safety margins’ available for various

type of patients
1. In a healthy person in normal life, the safety margin is very wide as all the
compensatory physiological mechanisms are functioning well and all protective
reflexes are fully active. Usually mild to moderate physiological insults
occurring in such individuals are well compensated and no risk to life is caused.
2. The same healthy individual, once anesthetized, cannot protect himself from any
untoward thing that is likely to happen. He becomes almost totally dependent on
the care of the anesthesiologist for the safety, because he loses the physiological
protection to a varying degree depending upon the type and depth of anesthesia.
This induces a potentially hazardous situation as long as he is under anesthesia
and also in the immediate postoperative period till his physiological protective
mechanisms are fully regained. Hence the safety margin of even a otherwise
healthy person is reduced considerably. That is the reason for grading a perfectly
healthy person undergoing anesthesia as Risk I.
3. If the patient is suffering from a mild systemic disease, the ‘Safety margin’ is
further reduced, making the anesthetic management difficult. Good degree of
skill is required to manage and wherever possible, less duration of surgery will
help to reduce the insult to the patient by anesthetic procedure.
4. When the patient has a severe systemic disease (Cardiac, respiratory renal
etc), the damage is so severe, that the patient’s system may not stand the stress
of anesthesia and the ‘Safety margin’ becomes still narrower. Very intricate
modulation of anesthesia is needed for this patient to prevent risk to life.
5. Mild derangement of multiple systems will have almost the same situation, but
as more than one system is deranged, the risk becomes higher and this further
narrows the ‘Safety margin’. So, the risk is higher than severe derangement of
one system.
6. When a patient is presented with multiple organ failure, he is said to be in a
‘moribund’ state (close to death). In such patients, literally there is no ‘Margin
of safety’ available for modulating the anesthesia. Even an attempt to induce
sleep with very small dose of ultra short acting barbiturate (thiopentone sodium)
may abolish all those feeble reflexes which sustain life till that moment and
cause cardiac arrest with no chance of revival. It is not worth attempting for
all known reasons.
Chapter
2 Anesthesiologist
Chapter Outline
Learning anesthesiology
v
Functions of Anesthesiologist
v
Surgeon-Anesthesiologist Relations
v
Operating suite and theater discipline
v
Operating department manager
v
The anesthesiologist is a person who is basically a clinician with deep knowledge

of basic sciences like anatomy, physiology, biochemistry and pharmacology which
he would be able to apply in appropriate clinical situations to safeguard the patient.
He must have a reasonably sound knowledge of the steps of surgical procedure
that makes him modulate the plane of anesthesia according to the steps of surgery.
Learning anesthesiology
“Anesthesia is a science but learned and practiced as an art.”
Anesthesiology bridges the gap between the basic sciences and clinical sciences.
Of all the disciplines, it is the one which is most suited for reinforcement of
information learned in biochemistry, physiology and pharmacology in the context
of a patient’s disease. Anesthesia practice is the ideal setting for teaching ventilatory
control and adequacy of respiratory exchange, circulatory monitoring, assessment of
level of consciousness and care of comatose, fluid replacement and all such clinical
aspects. Tracheal intubation, insertion of venous cannulae and spinal tap are also
logically taught on an anesthesia service. Postgraduate training in anesthesiology
differs from that in other fields because it must be individualized. Considering the
breadth of the surgical and obstetrics fields, this specialty has wide exposure to
many disciplines and has the advantage of receiving information from all.
Practically all hospitals still seek qualified anesthesiologists interested in
teaching and research as well as in clinical practice.
Functions of the Anesthesiologist

The duties of the anesthesiologist can be simply the following:
Taking care of the patient and protecting the patient from the possible untoward
events during anesthesia and surgery.
Giving the best possible pain relief for the patient.

Giving an optimum and comfortable working condition for the surgeon, this
in turn can give three certain benefits to the patient.
–– Good comfortable working condition allows the surgeon to complete the
surgery faster—anesthesia and surgery time are remarkably reduced.
–– Comfortable surgeon handles the tissues minimally and gently which reduces
the postoperative pain and morbidity.
–– A comfortable surgery involves minimal or reduced blood loss and so, blood
replacement may be avoided or reduced.
For achieving all these, the anesthesiologist may have to struggle hard to
modulate the plane of anesthesia particularly when the patient is critically ill. It
needs extreme degree of concentration and skill.
The person contemplating to take up anesthesiology, must acquire certain
qualities that may be added as adjectives to fit into the specialty though these are
qualities desired for any speciality.
They are well defined qualities required for any specialist and more so for the
anesthesiologists; Good, Efficient (Skillful), Well-informed (knowledgeable) and
Safe
Good
He must be very kind and compassionate to the patients, working with human touch
and takes care of every patient with personal interest and involvement. He must
treat all the patients equal and show no discrimination for any reason.
In fact everyone is a VIP. We conveniently forget one clear fact that if there are
no patients there is no work for the doctor and if there is no patient for surgery in
the operating list there is no work in the operating room for that day. So the VIP in
any hospital premises can only be the patients and so also in the operating room
and treat every patient with respect.
Many anesthesiologists believe that they need not have any interaction with
the patients. This is absolutely untrue as communication is a basic skill one must
develop to be successful in any endeavor. The anesthesiologist must have the
capability of positive communication to the patient that matches their level of
intelligence to make them understand that he is there to take care of the patient.
Without effective communication with the patient the anesthesiologist’s job is only
half done and incomplete.
Actually positive communication is defined as the capability of forming the
correct sentences by using appropriate words and passing on to the right person
in the right time and in the right manner so as to transfer the information which
you wanted to pass on to him.
He must be very careful in choosing the word because an inappropriate word
may spoil the purpose of communication and may lead on to confusion in the
minds of the patients. It is essential to understand proper meaning of the word or
the definition of every technical word which he uses.
Chapter 2  Anesthesiologist 9
Efficient (Skillful)
He must be willing to learn the basic techniques very clearly and sincerely so as to
gradually acquire the necessary skills and refining them everyday so that as days
pass on his skill improves remarkably. So also, he must be updating his skill with
newer innovations in the field, if needed by attending training programs.
Well informed (Knowledgeable)

He must have very clear knowledge of basic sciences and must be able to apply the
knowledge in clinical situations suitably while managing the anesthetic procedure.
He must acquire adequate knowledge of anesthesia also in the course of time. He
must be willing to update it and strive hard for that with the available resources.
Safe
He must be deeply concerned with the safety of the patient. He must not compromise
the safety of the patient for any reason. Here it may be necessary to have extensive
lengthy discussions with the team mates about the risk and seek their cooperation
to establish safety.
The patient does not show any interest to know about the qualification of the
anesthesiologist and not even about his experience, but would like to know whether
he is a safe anesthesiologist and whether he will safeguard him from any possible
catastrophe during anesthesia and surgery.
To be safe he may imbibe the following three characters:
Discipline
He must maintain punctuality. Punctuality does not imply coming in time. Coming
sufficiently before time to check the equipments, keep the right drugs loaded in
syringes and start the work in the scheduled time is described as punctuality. The
work must be done in an orderly fashion so that no step is missed and no error is
happened.
Devotion
He must consider the work place as a place of sanctity. He must enforce maintenance
of silence as far as possible and not making unnecessary conversations not relevant
to the work.
Dedication
He must be willing to do any type of work for the sake of patients with fullest
involvement with a willingness to sacrifice his own comfort.
“The principal tasks of the anesthesiologist are to provide relief of pain for
patients during operation and optimal operating conditions for the surgeons, both
in the safest possible manner.”
To do this the anesthesiologist must be a competent physician and a clinical
pharmacologist, with a broad knowledge of surgery and the ability to utilize and
interpret correctly a variety of monitoring devices.
In addition to anesthetics, the drugs employed by the anesthesiologist include

opioids and antagonists, antisialagogues, barbiturates, tranquilizers, vasopressors,
vasodilators, antiarrhythmics, cardiotonics, antihypertensives, neuromuscular
blockers and antagonists, analeptic and steroids—to cite a few. In recent years, the
interaction of drugs and their pathway of elimination have assumed increasing
importance, not only from the view point of widespread drug usage by patients but
also because inhalation anesthetics, once thought inert, are now known to undergo
metabolic transformation, interacting with other drugs and body components.
Anesthesiologists must combine knowledge of patient’s disease, the drugs
taken, the demands of operation and the patient’s concerns in order to arrive at a
proper choice of agent and technique. Most monitoring devices in use in intensive
care units today are modifications and extensions of equipments first used by
anesthesiologists in operating suites. Recovery rooms arose out of the need for
continued individual patient care, and today both surgical and medical intensive
care units extend such attention to all critically ill patients. Blood pressure via
direct or indirect recording, electrocardiogram, heart and breath sounds; blood gas
analysis, central venous pressure, body temperature and pulmonary wedge pressure
are commonly measured during anesthesia.
Fluid replacement during operation is supervised by the anesthesiologist, who
establishes the routes of administration and the kinds of fluid given while keeping
track of blood loss and therefore determining the blood or blood component therapy
needed.
Anesthesiologists spend more time in the operating room than any other
group of physicians. It is logical; therefore, that many institutions have appointed
an anesthesiologist as chief of the operating room, responsible for day-to-
day scheduling and overall supervision of activities. This is the most difficult
responsibility, the anesthesiologists all over the world shoulder, particularly things
related to the maintenance of asepsis of operating suite which may even cause
slight friction among colleagues.
Since the introduction of muscle relaxants, unlike the ether era, patients were
paralysed and so the anesthesiologists had to ventilate the patients. By necessity,
anesthesiologists became respiratory physiologists and experts at managing
ventilatory inadequacy. New ventilators were devised, monitoring equipment was
introduced to ensure ventilatory exchange, and blood gas analysis was perfected.
Again, such expertize could not be restricted to the operating room.
Anesthesiologists began to be consulted in the intensive care and respiratory
care units, in the care of traumatized patients and those with neurological deficits.
In many hospitals today, anesthesiologists manage respiratory and inhalation
therapy services. In our country an appreciable number of anesthesiologists are
solely involved in these endeavors as ‘Intensivists’.
In many institutions Intensive Respiratory Therapy Units (IRCU) are run by
anesthesiologists only.
Intensive therapy related to the management of victims of poisoning either
suicidal or accidental are taken over by anesthesiologists in many hospitals.
Regular Pre-anesthetic clinics are run in many bigger institutions manned by
a team of anesthesiologists to have a protocol based pre-anesthetic assessment
of patients before posting them for surgery. This system works out very well
in many of our institutions for the past many decades.
Anesthesiologists were the vanguards in establishing the “Day Care Surgical
Services”. Operations performed on an ambulatory basis to minimize costs and
reserve available hospital beds for the critically ill and those requiring major
procedures. Anesthesiologists arrange the schedule, interview and instruct the
patients before the day of operation, admit and examine them, anesthetize,
supervise recovery, and discharge them. Anesthesia for outpatient is quite
different from in-hospital care; only reasonable risks for anesthesia can be
accepted, and only agents that dissipate rapidly can be administered.
Skill with the needle need not be confined to operation. Various neurosurgical
and circulatory illnesses are amenable to nerve blocks, which are of value
therapeutically, diagnostically and prognostically. Anesthesiologists have
established “Pain Clinics” to serve the patients suffering chronic pain of
varying etiology. This concept is accepted world over particularly for cancer
pain in terminally ill patients.
Obstetric analgesia is yet another field in which anesthesiologists have entered
in the recent days to provide pain relief during delivery to parturient mothers
thereby making child birth absolutely pain free. Though this service has been
well established and very well recognized in western countries, it is gaining
recognition in our country also evidenced by established labor analgesia set
up in some of the selected institutions.
Finally everyday, anesthesiologists face cardiorespiratory emergencies in and
out of the operating room. It is only natural that they should have organized
cardiopulmonary resuscitation team throughout hospitals, evolved rescue and
transport systems for cases of cardiac arrest and drowning, and trained firemen
and civilians in management of emergencies.
Surgeon-Anesthesiologist Relations
(From the writings of the famous author and a loved teacher Robert D. Dripps.,
in his own words)
Surgeons and anesthesiologists constitute a team of physicians dedicated to the
welfare of the surgical patient whose interest is best served if each member of the
team recognizes his or her responsibilities, yet remains aware of the problems faced
by colleagues. The anesthesiologist’s position on the team is clearly defined: he or
she must have a thorough knowledge of the patient’s medical history, the operation
proposed, and the risks involved. The stresses placed upon the bodily systems by
the contemplated anesthesia and surgical procedure must be understood. There
must be discussion with the surgeon and other consultants concerning unfamiliar
aspects of the patient’s disease. The surgeon should be informed of the patient’s
progress, not by routine recitation of vital signs but by instant transmission of
important information. A multitude of details must be constantly monitored that
would distract the surgeon’s attention from the technical problems of operation.
Care of the patient in the crucial immediate postoperative period must be closely
supervised while the surgeon is engaged elsewhere.
A surgeon should consult with the anesthesiologist before operation and discuss
the details of surgical management. It is unwise to insist upon unnecessary speed
in induction of anesthesia, since this can be detrimental to the patient. A particular
anesthetic or technique rarely should be demanded, as the surgeon may not know
the limits of an anesthesiologist’s capabilities or the potential for harm of certain
anesthetics and techniques. Cadaveric relaxation never is needed and cannot
be produced with genuine safety under any circumstance. Problems peculiar to
anesthesia must be realized and time allowed for their solution. On occasion the
surgeon must agree to rapid conclusion of the operation if the anesthesiologist
believes that the patient’s condition is deteriorating; development of malignant
hyperthermia is a good example.
A team is at its best when its members have worked together repeatedly. It
takes time for individuals to learn where they fit into the scheme of things and
how associates perform their particular tasks. Good team work arises from mutual
respect. A new member of the team must be proved worthy before acceptance on
the same basis as the others.
Surgical team works under variety of circumstances. In most operations there
should be little tension, but in difficult operations or those in which complications
arise; tempers may flare and harsh words may be exchanged. The care of the
patient may suffer as a result. Surgeon and anesthesiologist must visualize each
other’s predicament. Technically simple operations may be performed under trying
anesthetic conditions, while an intricate, difficult operation may be performed
without anesthetic incident. If irritability is displayed by any member of the team,
the others must assess the situation and minimize friction if possible. The operating
room is no place for verbal battle. Words spoken in anger can be withdrawn later
on, but if the patient has suffered, irreparable damage may ensue.
The inexperienced observer sometimes believes that the anesthesiologist
occupies a position subordinate to that of the surgeon. This feeling often arises from
lack of experience with the team performance of complex operations, although the
anesthesiologist may contribute to his subordinate status by failing to participate
fully in medical care. Evidence that an anesthesiologist is first a physician and
then a competent specialist will assure acceptance as an equal in the overall care
of patients.
Confusion often exists in the minds of both surgeons and anesthesiologists
as to medicolegal responsibility in anesthesia. A study of court rulings confirms
that surgeons are responsible for the anesthetic, only if administered by a nurse or
technician under their medical direction. Anesthetics given by anesthesiologists
constitute their legal responsibility.
One must summarize the essentials of surgeon-anesthesiologist relations as
comprising mutual professional confidence, understanding, frankness, honesty,
courtesy, and fair-mindedness.
Appraisal
Because of the intimate association with so many other specialty areas, a discerning
anesthesiologist is more likely than not to stay abreast of the advances in medicine.
The relationship with the basic sciences is close, perhaps more so than in other
specialties.
Some have charged that the practice of anesthesiology is too routine and
lacks intellectual challenge. This is a matter of individual opinion, for certainly
the authors of this text (Robert D. Dripps and Leroy D. Vandam) have not lacked
for challenges. Every branch of medicine has its share of routine. How much of
a pediatricians day is spent in examining normal infants and children, in giving
prophylactic injections, or treating respiratory infections? Obstetricians deal mostly
with normal women who will deliver without incident, and a day in an internist’s
office has more than its share of routine work. So with anesthesia! Most patients
will be healthy, undergo elective, uncomplicated operations, and recover from
anesthesia without incident. Few specialists, however, encounter such a high ratio
of stressful moments in which a wrong or a tardy decision may spell disaster.
Operating theater suite and theater discipline

Lot of ink has been spilt on this matter over many decades and every one knows
about it well. Still there is a need for discussing this aspect. The operating suite is
considered as the temple of the hospital complex. Strict discipline regarding the
entry, movements, and activities must be followed.
The operating room is the “Sanctum Sanctorum” of the hospital premises.
Only authorized personnel dressed in the specific clean robes specially meant
for that purpose are permitted to enter the operating room. Even the most
respected V.I.Ps of our nation cannot violate this basic rule.
Only the patients are considered as V.I.Ps in the operating room. In fact the
patients are the V.I.Ps in any part of the hospital premises.
No particular patient, based on social, economical, and political or alike
considerations is treated as special. All the patients are equally treated without
any discrimination of any sort and so among the patient there is no V.I.P. as far
as the operating room is concerned.
However, there are patients who are considered as “Medical V. I. Ps”. They
may belong to the lowest socioeconomic strata. The patient may be an ordinary
person such as a load man, suffering from an inguinal hernia and incidentally
he suffers from other coexisting medical illness like hepatic insufficiency,
renal impairment, cardiovascular problem like ischemic heart disease and old
treated pulmonary tuberculosis. He has to undergo a repair of the hernia that
got obstructed. Though he has to undergo only a simple surgical procedure, he
is medically considered as a V.I.P. in view of the coexisting medical problems
involving various systems. He has to be anesthetized by the senior most
anesthesiologist and operated by the most competent surgeon followed by
the best postoperative care.
No one should enter the operating suite without first washing his hands and
changing into clean protective clothing and footwear such as theatre sandals.
The main purpose of this is to prevent the transfer of pathogenic organisms
into the operating department. The rule must apply equally when there are no
operations in progress. (Medical Research Council, 1968; Ballenger et al., 1972;
Lidwell, 1984). Unfortunately, this practice is not very strictly followed in our
country even in some of the bigger centers. Personnel keep moving in and out
of the operating room in their own clothing without wearing cap and mask. This
has to be curtailed and stopped in the interest of the well being of the patients.
Personnel preparing the sterile instruments table for operations must cover their
hair and generally wear masks in addition to wearing suitable clothing and foot
wear. Visitors and other staff are similarly attired. The hair should be completely
covered with a closely fitting cap manufactured from a non-woven fabric.
Cotton poplin or polyester cotton are the most commonly used material for
theatre clothing; blue or grey color scrub suits (normal theatre wear), and
green color for operating gowns. But special fabrics like non-woven fabrics are
found to have superior resistance for bacterial permeation. White and Bailey
(1984) considered that “it was better to prevent the dispersion of bacteria
from people in theatre rather than allow the bacteria to be dispersed, and then
removed by air ventilation. Low airborne dispersion of bacteria from people
can be achieved by well designed clothing using fabrics effective in preventing
bacterial dispersion.”
Masks are probably the greatest potential source of infection. The traditional
four to six layers of muslin offer little protection as the mask soon becomes
saturated with moisture from the wearer’s breath. The most efficient mask is,
the one made from synthetic fibers. (Ford et al., 1967; Furunhasi, 1978; Meffin,
1980). These masks, which should be moulded to fit the facial contour snugly
when worn, actually filter the respirations rather than deflect as with ordinary
paper masks. It is claimed that such masks achieve 98 % efficient filtration
compared to 40% with muslin masks; however not all filtration masks are
equally efficient (Rogers, 1980).
When removing the mask, care should be taken to avoid touching that part
which has acted as a filter, for the hands can easily become contaminated with
microorganisms.
Masks should be changed at least every operating session and should never be
worn “around the neck”.
Loud talking among the members of surgical team must be avoided as that
causes more dispersion of bacterial contamination. It is always essential that
verbal communications among the operating team as well as the other members
of the team must be reduced to the minimum and preferably in the lowest
volume of voice or more acceptably, wherever possible, communication is
done by signs only.
Surgical hand disinfection (Scrub Up)

This is the term used for the preoperative disinfection of the surgeon’s,
assistants’ and scrub nurse’ hands. The scrub up procedure should be effective
against the resident flora as well as transient microorganisms.
Further, it is important that the surgical team’s hands remain as germ free as
possible for several hours during the course of lengthy operations. Studies
have shown that a large percentage of surgical gloves appear to be perforated
at the end of operation (Church and Sanderson, 1980). For this reason a method
adopted should achieve an immediate antibacterial effect with a sustained
activity lasting at least 2–6 hours (Reybrouck, 1986).
Present day opinion generally approves of a surgical scrub or wash which
lasts no longer than 5 minutes. Before the first case of the list, the conventional
scrub up technique using a nail brush (Fig. 2.1) and a detergent preparation
is followed by a rinse containing 1% chlorhexidine in isopropyl alcohol.
Prolonged scrubbing can cause excoriations of the skin and predisposes to
postoperative infection. It has been shown that the use of nail brush can be
limited to the nails only, provided an effective detergent preparation containing
iodophor (Betadine) or chlorhexidine (Hibiscrub) is used as pre-surgical
wash (White and Duncan, 1972; Murie and Macphersn, 1980; Rotter, 1981;
Reybrouck, 1986).
If brushes are used, for scrubbing up (which is absolutely essential in a tropical
country like ours for obvious reasons) they should be of a good quality soft
nylon bristle with grooved plastic backs and of a size which fits the hand easily
(Fig. 2.1). These should be finally sterilized in metal dispensers which fit in
wall brackets and permit the extraction of single brush without contaminating
the others. Alternatively, disposable combined sponge/nail brush is available,
impregnated with dehydrated chlorhexidine, iodophor, or wet with alcohol/
detergent.
Hand washing is the most basic yet most neglected of all the procedures.
Research in the US has revealed that 40% of medical and nursing staff followed
incomplete hand washing techniques. The resident bacteria on hands can be
greatly reduced by careful washing with soap and water. A hand rub with 4%
chlorhexidine, 10% povidone iodine, 70% ethyl alcohol are all effective.
An aqueous solution of antiseptic takes minimum of 3 min contact with skin
for disinfecting the skin whereas alcoholic solutions take one full minute for
that, so adequate time must be allowed for that. It has been established that
even with best hand wash, it is impossible to keep the surface of the skin free
from resident flora bacteria for more than 1 hour, as they come up to the surface
from the deep pores of skin.
It is important that no person should scrub unless free from upper respiratory
infection and skin lesion. Cuts and aberrations or infected pimples can endanger
the patient by increasing the possibility of postoperative infection.
Fig. 2.1: Nail brush with wooden handle and soft nylon bristles
The nail beds are good breeding grounds for bacteria. Cleaning under the nails
must be done with a suitable nail brush. When scrubbing up to carry out surgical
hand disinfection, care must be taken to ensure that all parts of the hands and
forearm are cleansed thoroughly, special attention being given to the nails and
between the fingers (Fig. 2.2).
Considering all the facts described above, the steps of hand wash may be
summarized in the following steps;
–– When using ordinary soap, the scrub up should last 5 minutes under running
water.
–– Less time is required when a detergent solution containing chlorhexidine
(Hibitane) or an iodophor (Betadine) is used. With these, the forearms and
hands are washed for 1 minute with a small quantity of the solution and
then rinsed with sterile water.
–– Particular attention is paid to the nails, utilizing either a sterilized nail brush
with a light friction which is then discarded.
–– The main wash should occupy a further full two minutes and consists of
reasonably vigorous massage of the hands and forearm up to elbow level with
a mixture of the solution and water. Care must be taken to ensure adequate
cleansing between the digits and skin folds.
–– Finally the hands and forearm are rinsed thoroughly under running water.
The taps are turned off with the elbow and the hands kept in an elevated
position to prevent water running down from the elbows. The hands and
forearm should then be rinsed or wiped with alcohol and dried with sterile
towel before assuming the sterile gown and gloves.
Operating department Manager

The senior nurse responsible for operating department services, usually a Head
Nurse with adequate experience of working in operating theatres, influences to a
great extent how working relationship is developed between members of medical,
nursing and technical team (Douglas, 1962; Clarke et al., 1984). This person should
be a good leader, experienced in all aspects of theatre technique, having managerial
skills and qualification of kindness, tolerance and total commitment.
The capacity to plan ahead with good judgment, and the ability to accept
constructive criticism is very important. There should always be a willingness to
adapt to new developments in surgery and theatre technique. The need for loyalty
to the patient and the other members of the team is obvious. The importance of
good communication between her and the members of the team cannot be over-
emphasized. She should tackle problems and contentious issues as soon as possible;
these should not be shelved, otherwise morale can suffer as a result of resentment
or misunderstandings. In short she should be a good ‘Manager’, but essentially a
good leader of a nursing and technical team.
Fig. 2.2: Steps of surgical hand scrub (Courtery: Royal Berkshire Hospital, Reading)
Further Reading
1. Ballinger WF, Treybal JC, Vose AB. Alexander’s Care of the Patient in Surgery, St.
Louis: Mosby, 1972.
2. Blowers R, Williams RFO, Mc Clucky, Garrard LP. Hospital Infection: Causes and
Prevention, 1966.
3. Chrch J, Sanderson PJ. Surgical glove punctures. Journal of Hospital Infection, 1980;
1:84.
4. Clarke, PE, Dixon E, Freeman D, Whitaker M. Nurse staffing and training in the
operating suite. The Design and Uses of Operating Theatres, edited by IDA. Johnston
and AR hunter. London: Arnold. 1984.
5. Douglas DM. Lancet, (1962);ii:245.
6. Ford CR, Peterson DE, Mitchell CR. American Journal of Surgery 1967;6:787.
7. Furuhashi M. Bulletin Tokyo Medical Dental University, 1978;25:7.

8. le Bourdas E. Dimensions in Health Services, Toronto, 1975;52(2):27.
9. Lidwell OM, Macintosh CA, Towers AG. Journal of Hygiene, Cambridge, 1978;81:43.
10. Lidwell OM. Bacterial considerations in The Design and Utilisation of Operating
Theaters. Edited by ID. A Johnson and AR Hunter, London, Edward Arnold, 1984.
11. McKenzie N. The Professional Ethics and Hospital Service, 1971,5.
12. Medical Research Council. Aseptic methods in operating suite. Lancet, 1968;1:763.
13. Meffen K. The good and the bad. Nursing Mirror NATN Supplement, 1980.
14. Mitchell NJ, Evans DS, Kerr Ann. Lancet, 1978;I:696.
15. Murie JA, Macpherson SG,. Chlorhexidine in methanol for preoperative cleansing of
surgeons hands: A clinical trial. Scottish Medical Journal, 1980;25:309-11.
16. Nagai I, Kadota M, Takechi M, Kumamoto R, Nakano S. Studies on the bacterial
permiability of non-woven fabrics and cotton fabrics. Journal of Hospital Infection,
1986;7:267-68.
17. Reybrouk G. Hand wahing and hand disinfection: a review article. Journal of Hospital
Infection, 1986;8:5-23.
18. Robert D Dripps, Lery D Vandam, Introduction to Anesthesia (The Principles of Safe
Practice), 5th edn. WB Saunders Company, Philadelphia, 1977.
19. Rogers KB. An investigation into the efficiency of disposable face masks. Journal of
Clinical Pathology, 1980;33:1086-91.
20. Rotter ML. Povidone-iodine and chlorhexidine gluconate containing detergents for
disinfection of hands. Journal of Hospital Infection.1980;2:273-5.
21. Speers R, Shooter RA. Lancet, 1966;ii:469.
22. white JJ, Duncan A. The comparative effectiveness of Iodophor and hexachlorophane
surgical scrub solutions. Surgery, Gynaecology and Obstetrics, 1972;135:890-2.
23. Whyte B, Bailey PV. Reduction of microbial dispersion by clothing. Journal Parenteral
Science and Technology, 1984;39:No1.
24. Whyte W, Hodgson R, Bailey PV, Graham J. British Journal of Surgery 1978; 65: 469.
Chapter
3 Surgical Team
Chapter Outline
Members of Surgical team and their job descriptions
v
Unskilled personnel working inside the operating room
v
Coordinator of the team
v
“A surgical procedure should be planned so that the patient, with the least possible
risk and loss of time, will receive the greatest possible benefit.”
— Charles H Mayo
Safe surgical teams

In the operating room, where tension may be high and lives are at stake, teamwork
is an essential component of safe practice. The quality of team work depends on
the culture of the team and its communication patterns, as well as the clinical skills
and situational awareness of the team member. Improving team characteristics
should aid communication and reduce patient harm. (Safe Surgery Saves Life—A
WHO initiative 2009)
Members of Surgical Team

Surgery is never considered and described as an individual’s job, but is always an
example of a team work.
Anyone working in an operating suite or operating room must know about the
details of the other members working in that atmosphere. More important is to know
their designations and more precisely their job descriptions (responsibilities). This
is essential for achieving certain goals in the working environment:
To accomplish good interpersonal relationship
To extend excellent coordination during team work
To avoid intrusion into others work and causing inconvenience to them
To be watchful to render helping hand in others work, if asked for or in case
of necessities
The most important point is to prevent misunderstandings among the team-mates.
Various countries propose different number of essential Technical Members

of Surgical Team which may include Electrician, Biomedical Engineer and so on.
But in our country, the following members are considered essential, without whom
the surgical work may suffer to varying degrees. So, we shall consider the essential
members and their responsibilities in the team work in a little detail.
The team consists of many people with varying capabilities to put their efforts
together in the best possible way to achieve the best outcome of the work, which
means efficient and safe surgery. Though the number of persons involved in the
team may be more than ten in the sophisticated centers, we have to note that the
basic minimum of persons is five.
Every member must be able to contribute his best for the purpose of ultimate
successful outcome of surgery.
Schematic representation of all members of the surgical team and the unskilled
personnel working inside the operating room is shown in (Fig. 3.1).
The members of the team are:
1. The surgeon and his assistant
2. The anesthesiologist
3. An efficient, well trained nurse to assist the surgeon
4. An anesthetic technician
5. A nursing assistant.
Without the efficient contribution from all these people the surgical work may
be incomplete and inefficient.
Hence it is essential to know the “job description” of each one of the members
that makes one realize how the contribution from each member is highly significant
towards the outcome.
Fig. 3.1: Operating room with the members of surgical team

Chapter 3  Surgical Team 21
Job Descriptions—(Responsibilities)
Surgeon and his assistant
The Surgeon shall examine the patient in the outpatient department, make a
clinical diagnosis of the surgical disease, and order for relevant investigations
needed for the confirmation of the diagnosis.
After confirming the diagnosis, he discusses with the patient and his relatives
regarding the surgery to be performed and advises accordingly after explaining
the degree of risk involved. He shall explain the probable outcome of surgery
and the chances of recurrence of the surgical problem if any, etc. if the surgery
is elective.
If the surgery is to be done as an emergency procedure, he may explain to them
the need for the emergency surgery and the possible consequences if it is not
done immediately and advise them suitably.
Before the surgery, if the patient has any correctable problems like respiratory
infection, dehydration or any such medical conditions, he may institute
necessary treatment so that the patient may be presented for the proposed
surgery in a more fit condition to stand the stress of anesthesia and surgery.
At this time he refers the patient to the anesthesiologist with a clear note about
the surgical problem and the proposed surgery for assessment for the fitness
for anesthesia.
After getting this clearance, he may fix up the date for surgery and post him
on the list on that day.
On the day of surgery he brings the patient to the operating theater with
adequate preparations and under proper anesthesia he operates on the patient
and takes care of him in the postoperative period till the time of discharge
from the hospital.
The assistant surgeon would assist the surgeon in all these jobs from the
beginning till the time of discharge, so that he knows full details about the
patient.
Anesthesiologist
The Anesthesiologist shall examine the patient referred by the surgeon very carefully
for any undetected medical diseases like hypertension, respiratory problems, etc.
and if detected gives suitable advises for the correction of those problems.
Once these problems are corrected, he shall reassess the patient at a later date
for the appropriate anesthetic procedure for undergoing the proposed surgery. any
special instruction if needed and a clear note about the premedicant drugs, their
doses and the time of administration are written in the assessment note.
If considerable and significant blood loss is expected during surgery, he may
order for reservation of adequate number of units of compatible blood.
On the day of surgery he shall examine the patient again, administer the
preanesthetic medication in the right time, take up the patient, and administer
anesthesia, takes care of him throughout by continuous monitoring of his vital signs.
After the conclusion of surgery he shall reverse the patient from the anesthesia
carefully, assess his status by keeping in the recovery room (PACU) for sufficient
length of time.
He would give this care as long as needed, till his recovery criteria are normal
and then transfer him to the postoperative ward.
He shall visit the patient in the postoperative ward to ensure that the patient
continues to maintain normal vital parameters and everything is well.
In case of necessities he shall support the surgeon in giving postoperative care
of the patient such as cardio vascular support, ventilatory support, etc.
Assisting Nurse (Scrub Nurse)

The adjectives such as ‘well trained’ ‘skillful’ ‘dedicated’ are used while mentioning
about them. Each adjective has its significance in the patient care and overall best
outcome.
This nurse shall prepare adequate number of sterile trolleys with appropriate
instruments needed for the various surgeries in the operation list for that day.
Ideally, for every operation it is advised to prepare a sterile instrument trolley
for each surgery just before starting.
The scrub nurse is responsible for selecting, checking and arranging instruments
required on the table.
When a patient is anesthetized and ready for a particular surgery, she brings the
instrument trolley near the operating table and be ready for assisting the surgeon.
She will assist the surgeon for preparing the operation site by painting with
antiseptics, draping the patient for surgery and during surgery by handing over the
appropriate instrument for the need.
It is her duty to prepare the ligatures and sutures, having them ready immediately
when required.
A good scrub nurse will learn to anticipate the needs of the surgeon, often
having an instrument ready before it is asked for.
Sometimes it may be necessary for the nurse to act as surgeon’s assistant in the
absence of a house surgeon or assistant surgeon.
She is also responsible for accounting for all instruments, needles and swabs
or sponges at any stage of the operation, especially before any cavity (abdomen or
thorax) is closed, and must inform the surgeon that these items are correct, even if
the surgeon did not ask.
If the accounts are not tallying, she should warn the surgeon to recheck and
find out the missing item before closing and until then she shall not hand over the
sutures for closure to the surgeon.
This nurse has to be well trained as well as very efficient as the speed of surgery
as well as the efficiency of the surgeon could be greatly enhanced by the best
assistance given by her.
It has been universally well recognized that when dedicated and efficient
nurses assist the surgeon, even the most difficult operations could be successfully
completed faster with less strain. Their contribution to the outcome of surgery is
measureless.
Anesthetic Technician (Theater Assistant or Theater Technician)

Theater assistant is a paramedical personnel working in the operating room who
is coming under the category of Skilled Personnel. This means that he must have
certain prescribed training in a suitable atmosphere to acquire the necessary skills
for the job.
Many authorities have prescribed their job description as follows.
Job descriptions of Anesthetic Technician

The Anesthesia Technician (Theater assistant) works under the control of the
Anesthesiologist at all times.
He is a specially trained person with the technical knowledge about the working
of the machines and the other accessories and monitors that are used in the operation
theater.
He shall keep all the equipments in good working order at all times.
Basically, he is responsible for the maintenance of all the anesthetic machines
and the accessories in the theater.
He shall keep the anesthetic machine’s work top very clean and tidy.
He shall see and verify that essential equipments such as laryngoscope, endotracheal
tube, connector and catheter mount, malleable endotracheal tube introducer (stylet),
etc. are chosen properly and kept in order on the machine’s worktop.
He shall see that the necessary emergency drugs such as atropine, vasopressors,
adrenaline, bronchodilator and corticosteroids only are kept on it.
Any other drug specifically wanted by the anesthesiologist for the particular
case must be kept in addition.
He shall see that only objects related to anesthetic work are permitted to be
placed on the anesthetic machine.
Unwanted things like watches, cell phones and such other things should never
be allowed on it as these items occupy the space otherwise meant for other essential
life saving equipments and drugs. This may cause havoc during the times of crisis.
He shall keep ready all the equipments on the anesthetic machine that are needed
for anesthetizing the particular patient in concurrence with the anesthesiologist
and assist the anesthesiologist starting from the time of induction onwards to the
conclusion of anesthesia.
His assistance is specially needed during the time of induction to assist
intubation, securing the endotracheal tube, positioning the patient, etc. and
particularly during reversal of the patient from anesthesia for assisting in applying
oropharyngeal suction, extubation, etc.
Actually induction and recovery are the two common situations in anesthesia
where dangers are imminent as in the case of take off and landing of an aircraft.
Virtually he shall be there by the side of the anesthesiologist throughout the
procedure to hand over the necessary drugs and equipments as and when required.
Efficient and skilled assistance by an Anesthesia Technician (Theater assistant)
makes the conduct of anesthesia very comfortable and safe.
The anesthetic machine must be handled with adequate care and maintained
carefully so that at all times it functions perfectly. A malfunctioning machine means
disaster.
Though it is the primary responsibility of the anesthesiologist to maintain the
anesthetic machine well, in places where many machines are used, for the sake
of convenience one or two machines are left to the responsibility of the theater
technician for maintenance supervised by the anesthesiologist.
He has to do the following;

Everyday he must check the functioning of the machine with a protocol based
check list
Check the laryngoscope and accessories such as spare blades and bulbs
Check the endotracheal tube and their connections
Check the breathing systems for integrity of the components and check for
leaks particularly the reservoir bags
Check the contents of the cylinders attached to the machine
Check and ensure that there is adequate store of gases in the manifold room of
the central pipeline supply.
Nursing Assistant
This assistant’s job is taking care of the surgical instruments and assisting the
Nursing staff who is assisting the surgery.
In the course of any surgery, if the assisting nurse wants an additional
instrument, he shall take it from the sterile store of instruments (Bin) and hand it
over to the nurse and shall keep an account of that for final counting at the time of
completion of surgery.
When the day’s work is over he shall clean and decontaminate all the instruments
and pack them in bins and send them to the Central Sterilization Department for
autoclaving, get them back for the next days work.
These five people are the skilled members of the team, meaning thereby each
one has a special job to do, utilizing their skill fully for the best outcome of the
work.
Two more nursing staff will be usually present in bigger centers where the
workload is higher and multiple operating rooms work in one complex. They are:
1. The circulating nurse
2. The nursing supervisor
Circulating Nurse
Apart from the assisting nurse scrub nurse there will be one or two nurses in the
operating theater.
They are also known as theater runners. One stays in the operating theater,
watching the scrub nurse and ready to bring anything she requires during surgery.
The first circulating nurse also ties up gowns of washed up surgeons and nurses,
being careful to avoid touching any part of the gown other than the tapes.
He or she replenishes sterile warm or cold water in the lotion bowls and checks
the swabs, displaying them on counting rack in the required order. (Godfrey, 1983;
Shaw, 1984).
She will be dispensing articles from sterile bags or packs, she replenishes sterile
gowns and gloves on a sterile trolley or worktop reserved for the purpose.
The main duties of the second circulating nurse are:
To see that the instruments and trolleys are ready for the next case
Should help in placing the patient on the table, if a stretcher bearer or technician
is not available
She should also help the scrub nurse if the first circulating nurse has to leave
the theater
On no account, the theater must be left without at least one circulating nurse
The duties will of course, depend on the layout and system of particular
operating department
She must keep all the notes and X-rays relating to the patient available and it
is her duty to ensure that these are easily at hand for reference.
In some institutions, one or two anesthesia technicians or operating department
assistants (ODA) are posted to act as circulators to help the scrub nurse.
Nursing Supervisor
These are senior nurses belonging to the category of nursing tutors or supervisors.
One such person will be in charge of the supervising work done by the theater
nurses of two to three operating rooms preferably situated in the same complex
or at least on the same floor.
She makes regular visits to all theaters under her control in the morning
before starting the day’s work, organize the work pattern depending upon the
availability of the personnel.
She gets into the operating room where there is some deficiency, or a better help
is needed for a major difficult surgery and stays on until the problems are solved.
The most important aspect to be remembered at this juncture is, if one member
in one category is to be replaced (for any reason he or she has to be replaced) by
a person belonging to the same category and not by a person belonging to another
category. For example, a nurse should not be replaced by a doctor or a theater
assistant should not be replaced by a nurse and so on in the best interest of the
outcome.
The best outcome in any teamwork for that matter depends upon the total
involvement of each member of the team. Apart from that mutual understanding,
mutual confidence and mutual trust contribute very much for that.
Unskilled personnel working inside the operating room

Apart from the surgical team (Skilled members) there are some more people who
render their services inside the operating room. Though they are not skilled persons,
their services are essential, without which the routine work cannot be carried out in
the operating room. At all times these people must be made to realize how important
their work is for the ultimate benefit of the patient. They must also be appreciated
for their good work and treated with dignity and due respect.
At least there are three categories. They are:
Stretcher bearer
At least two persons must be posted for one operating room depending upon the
number of operating tables and the time taken for finishing the operation based on
type of surgery. It is essential that they must be physically fit to do this type of job.
General worker
At least one person must be available. They are meant for doing petty jobs
and assisting others in manual works such as shifting the patients, washing the
instruments, etc. Physical fitness is essential for them also as they have to do make
shift duties.
Sanitary worker
Ideally two persons must be posted for one operating room. Their job is to clear the
soiled linen from the operating room as soon the surgery is over. After each surgery,
they have to clean the surface of the operating table with clean cloths soaked in a
disinfectant solution, and wipe it dry and then to clean the floor in the same way.
After this the nursing assistant will cover the operating table with a clean sterile
cloth and keep it ready for the next operation.
However, these three categories of personnel can have their work exchanged
in case of necessity. It is essential to ensure the following basic aspect with regard
to the posting of these people.
They must be taught the basic discipline of the theater work and the steps needed
for maintaining the asepsis.
They must have the willingness to work in the operating room environment.
They must be posted regularly for quite a good length of time so that they
will get acclimatized to the routine of the operating room schedule. This helps to
improve their work efficiency.
A small set up in Indian scenario

Most of the time, the theater personnel may be working in a smaller setup with
the basic minimum facilities. In such situations, an elaborate staff pattern cannot
be expected. Lot of adjustments among the team members may be required. The
minimum staff requirement for safe and efficient functioning will be:
Nurse
She is either a qualified or a trained nurse with adequate experience in the
operating theater work and the principles of theater asepsis
She will be incharge of the operation theater and coordinates the entire work.
Nursing Assistant
He/she will be assisting the nurse-in-charge to run the operation theater
He/she must have basic knowledge of theater asepsis.
Anesthesia Technician
He will be incharge of the anesthetic machine and accessories and maintains
them.
He will keep things ready well before starting the operation and assist the
anesthesiologist and stay by his side to assist although the work
In smaller setups like this, usually the anesthesiologist will be a visiting
consultant
Every individual anesthesiologist will have his own pattern of working. So
also, the assistance required for each anesthetist may vary
The anesthesia technician may have to know the individual anesthetist’s pattern
of work and their requirement for managing anesthesia
He will set things ready accordingly
He will assist the in-charge nurse in the overall management of the operation
theater.
Stretcher Bearer
He is a physically fit person who can do the shifting and transferring of the
patient
He may be a general worker doing all assistance in the operation theater work.
Sanitary Worker
He will be doing the washing and cleaning of the operation theater after every
day’s work is completed
After completion of each surgery, he will collect the soiled linen and send for
washing
He will clean the operation table, wipe it with a cloth soaked in germicide or
antiseptic
Afterwards he cleans the floor and wipes the floor with germicide or anti-
infective solution.
The above mentioned five categories of personnel are essential for effective
functioning without compromising the safety of the patient. In such settings,
excellent cooperation, coordination, tolerance, mutual understanding and
involvement among the team members is possible.
In fact, in many of such small setups, good amount of major surgical works
are going on well.
Coordinator of the Team

For the safe sailing of a ship, there is a need for a captain to guide its course and all
activities in it. Similarly, for any team (surgical team) there is a need for a captain or
a coordinator. Now that, the surgical team comprises of members, each one meant
for carrying out very definite and distinct responsibilities, there is a definite need
for a coordinator whose job is to organize and streamline the daily work without
any flaw and misunderstanding among team-mates. The basic aim of any team is
to win the game.
Here the aim of the team is to do the proposed surgery in the best possible
way without compromising the safety, to reach the best outcome that is success.
So here, every member is as important as the other. Each has to contribute his part
in the best way thereby contributing for the successful outcome. There the matter
ends happily. No one should feel superior or inferior as far as his or her job is
concerned in the team.
Generally, the anesthesiologist coordinates the work in the operating theater.
As he is available in the operating suite almost every day, he has ample time to
spend for coordinating the work. For this reason, it is universally accepted as a
norm that the anesthesiologist takes over the big responsibility of managing the
theater activities, which is really a tough job. Usually surgeon could not do the
job of this coordination work, as he has other jobs to look after such as outpatient
clinic, review clinic, postoperative rounds on different days in a week and can not
be available in the operation theater.
On certain occasions, a senior experienced Theater Nurse or Head Nurse may
be taking up this responsibility.
Responsibilities of the Coordinator

The first concern is about the number of patients in the operation list. It is imperative
that a patient posted for surgery must be operated as per schedule. Postponing a
planned surgery for want of time or anything else is a social crime and injustice
towards that individual. It must be avoided at any cost. It causes not only the
psychological stress imposed on the patient and his dear ones, but also may impose
unnecessary financial burden on them.
A planned surgery could be justifiably postponed only when there is genuine
reason concerning the safety of the patient such as a severe respiratory infection
with pyrexia. Thus, he would have acquired during his stay in the hospital and
manifests only on the previous day that was missed.
It is always essential that the surgeon consults the anesthesiologist before posting
the number of patients in the list as to how many surgeries could be performed.
This is necessary because there may be shortage of availability of personnel of
different categories such as anesthesiologists, nurses, theater technicians, and other
paramedical staff on a particular day. The shortage of personnel may seriously
restrict the number of surgeries that could be done on that day. If this aspect is
discussed on the day before operation, the number of surgeries as well as the type
of surgeries could be adjusted accordingly without causing inconvenience to any
one concerned.
In certain operating rooms, there may be provision for simultaneously taking
up only two patients under general anesthesia. If a list containing all patients to
be done under general anesthesia (GA) is posted, it will only seriously affect the
completion of the list successfully in time. It may result in postponing surgeries
inevitably. That may be because of want of adequate number of anesthetic machines
or adequate number of anesthesiologists to manage the patients.
If the coordinator looks into these aspects carefully and decides the planning,
it will go a long way in the smooth running of the operation theater.
Wherever possible the temptation of the surgeons to operate with inadequate
assistance must be curtailed. For example, operating without the help of a trained
nurse and taking the help of any other paramedical assistant in that place should
be discouraged.
Planning the operation list

As the day starts, as soon as he comes the anesthesiologist must look at the list of
operation and try to plan the order in which the patients may be taken up for surgery.
This is done with the view of operating all the patients in the list giving justified
priorities and finishing the operating list in time with the available resources
without compromising safety. This has to be done carefully taking the following
factors into consideration:
The number of operating tables available
The number of surgeons available
The number of assistant surgeons available to assist them
The number of trained nurses to assist the surgeons
The number of anesthesiologists; Here more than the number, their ability to
manage the cases must be considered.
The number of anesthetic technicians available to efficiently assist the
anesthesiologists
The number of anesthetic machines available; and so on.
These factors play very important role in managing the list efficiently and
finishing it in time. Proper planning involves deciding and fixing the order in which
the patients are taken up, the number of patients to be taken up in the first round
and among those how many under general anesthesia and those under regional
technique, etc.
Secondly decision on the major surgery to be taken up first in the list has to be
made. This is made after considering the type of procedure, the anticipated duration,
the degree of blood loss expected, the degree of intense care needed for the patient
based on his general condition and the expertise required for anesthetizing that
particular patient.
With the proper understanding of the real situation and good mutual
understanding and the willingness to do more service to the needy, the planning
of the operating list is never a difficulty.
Planning the team for different procedures

Allocation of team for different procedures means a lot in the overall performance
of the team as well as the outcome of surgery.
For example, a major intricate surgery requiring great skill and experience
of the surgeon necessarily requires an experienced anesthesiologist and senior
well- trained nurse to assist. The anesthesiologist cannot have any command
on the choice of the surgeon and his assistant. But he may explain the high risk
in view of the patient’s poor general condition and the difficulties involved in
anesthetizing the particular patient with the request to them to do the procedure
with the best assistance available and in the shortest time possible. In general,
there are no difficulties encountered in this aspect. But it is utmost important that
one must be extremely careful to see that in the process of making this request,
no one is made to feel that his efficiency or skill is judged inferior and gets hurt.
Similarly the nurse-incharge may be requested to assist that surgery or to allocate
the more experienced and skillful nurse for that case. This is a very difficult job and
requires very high degree of tact and communication skills. An anesthesiologist,
in the course of experience has to develop this, sometimes guided by his elders in
the profession.
Planning the postoperative care

Another important aspect is to decide where the particular patient is transferred
for the purpose of postoperative care. Based on different criteria used for judging
this and also by using his own experience and judegment, the anesthesiologist may
decide whether the patient has to be transferred to recovery room, postoperative
ward or first to the recovery room an then to an intensive therapy unit, etc. This is
always decided considering the safety only and not anything else.
Maintenance of Theater Asepsis

Though there are clear and well prescribed norms accepted universally for this
purpose, every theater complex must have their set protocol for maintaining the
asepsis in theater atmosphere for that institution, based on the availability of
infrastructure and personnel.
If aseptic environment is not strictly maintained in the operating suite including
the recovery area, any work in the operating room becomes less meaningful and
likely to be dangerous. All the routine related to the sterilization of equipments as
well as the theater atmosphere is strictly followed. The dressing code meant for
theater personnel must be followed very strictly irrespective of the cadre in order
to maintain asepsis. The rules should never be relaxed for any one for that matter.
Many times this enforcement may cause unpleasantness among the personnel
particularly when a senior member knowingly or unknowingly violates the aseptic
precautions and that fact is pointed out to him. It needs quite a bit of good tactics
to point out that to him. A statement like this may make things smoother. “Sir, it
looks as if you have forgotten to wear the mask in your hurry. Shall I bring one
for you?” If a senior person has come into the theater without changing to theater
robes, one may politely ask, “We are sorry that we have not kept theater robes for
you in the changing room sir, may I bring one now for you to change?”
Points for theater asepsis

Points
Theater must always be air conditioned
Ideally, the air entering must pass through bacterial filter (HEPA Filter)
This may require a little higher capacity of air conditioning machine to maintain
adequate flow of air
It is better to have a minimum of 7 air changes in an hour to keep the bacterial
load in the operating room atmosphere at an acceptable low level by the possible
contamination from the personnel working inside the theater
The ambient temperature must be maintained between 20 to 25° C
Daily cleaning of the theater after the day’s work and leaving the atmosphere
exposed to a standard sterilizing device such as ultraviolet light
Daily carbolising the theater
No one is permitted to enter the theater without changing to the prescribed
clean (sterile) theater robes and wearing cap and mask.
One of the most unclean parts of our body is the oral cavity with wide variety
of bacterial contamination and while talking micro droplets of oral secretions
loaded with bacteria will be thrown into the atmosphere contaminating the
atmosphere. To prevent this and to reduce this contamination, a well fitting
mask must be used covering both mouth and nose. Unnecessary conversations
must be avoided to reduce droplet spread from the mouth.
Similarly, hair of scalp is one part of the body that cannot be cleaned easily
and completely. There are two reasons for that. One is, the hair is always kept
exposed and the creams and the oil in the hair attract dust. The second and the
most important reason is that hair attracts more dust mainly because of the
accumulated static electric charges and is constantly gets contaminated. For
this reason if a hair falls on the operating field, the chances of severe infection
is very high. So to reduce these chances of infection the hair must be kept well
covered by a cloth cap that allows adequate ventilation to the scalp.
Frequent and unnecessary movements of personnel in and out of theater must
be avoided.
Further Reading
1. Bunker JP. The anaesthesiologist and the Surgeon Partners in the operating room, Little.
Brown Co, 1972.
2. Eckenhoff JE. Anaesthesia from Colonial times. Philadelphia, JB Lippincott Co, 1966.
Greene NM: Anaesthesiology and the University. Philadelphia, JB Lippincott Co, 1975.
3. Lidwell OM. Bacterial considerations in the Design and Utilization of Operating
Theaters. Edited by IDA Johnson and AR Hunter. London: Edward Arnold, 1984.
4. Medical Defence Union, Medical Protection Society, Medical and Defence Union of
Scotland., National association of Theater Nurses and Royal College of Nursing of the
United Kingdom. Theater Safeguards, MDU, MPS, MDU of S, NATN, RCN, 1986.
5. Meffen K. The good and the bad. Nursing Mirror. NYAN Supplement, 1980.
6. Nagai I, Kadota M, Tackchi M, Kumomoto R, Nakano S, Jitsukawa S. Studies on the
bacterial permeability of non-woven fabrics and cotton fabrics. Journal of Hospital
Infections, 1986;7:261-8.
7. National Association of Theater Nurses Guideline to the total patient care and safe
practice in the operating theaters, NATN, Harrogate, 1983.
8. Nimmo WS. British J Anaesthesia, 1990;64:7.
9. Reybrouck G. Hand washing and hand disinfection: a review article. Journal of Hospital
Infection, 1986;8:5-23.
10. Robert D Dripps, Leroy D Vandam: Introduction to Anesthesia. Philadelphia, Saunders
Company, 1978;1:1-8.
11. Vandam LD. Early american anesthetists: The origin of professionalism in anesthesia.
Anaesthesiology, 1963;38:264.
12. Vincent R. Br J Anesthesia, 1997;79:188.
13. Whyte W, Bailey PV. Reduction in microbial dispersion by clothing. Journal of
Parenteral Science and Technology, 1984;39:1.
Chapter
Safe practice of
4 Anesthesia
Chapter Outline
Ten Golden Rules of Anesthesia
v
Indian Society of Anesthesiologists
v
Safety in anesthesia
v
Accidents during Anesthesia
v
Anesthetic Records
v
Monitoring during Anesthesia
v
The cardiovascular System
v
Universally the primary consideration in anesthesia is “Safety”.

“Primum non nocere” which means “first of all do not harm” is the worldwide
accepted phrase for anesthesiology.
World Health Organization (WHO) has launched a Patient Safety initiative in
2009, ‘Safe Surgery Saves Lives’ to reduce the number of surgical deaths across
the world. In that the following observation is made under ‘Safe anesthesia’.
Three decades ago, a patient undergoing general anesthesia had an estimated
one in 5,000 chance of death. With improvements in knowledge and basic standards
of care, the risk has dropped to one in 200,000 in the developed world—a
40-fold improvement. Unfortunately, the rate of anesthesia associated mortality in
developing countries appears to be higher.
This statement indicates that there is a need to review and revise our concept
of ‘Safety in Anesthesia’.
Our aim is to do deeds that improve the patient’s condition and relieve his
sufferings and in that process not to do any harm. As accidents are always possible,
one has to be extremely careful to prevent them, by very strictly following certain
set protocols and guidelines.
The universally known and accepted ‘Ten Golden Rules of Anesthesia’
for safe practice of anesthesia briefs it well. It is all about the basic safety
requirements needed for starting anesthesia. Therefore, it may be recalled
here to emphasize the need for anticipation and preparedness for managing
the problems if they occur, though these rules have been formulated about four
decades ago.
Chapter 4  Safe practice of Anesthesia 33
Ten Golden Rules of Anesthesia

1. Assess and prepare the patient adequately. Assess him so that you will not
anesthetize who is asthmatic, acidotic, or grossly anemic, unknowingly. If he
is on any drugs that might interfere with anesthesia, you must know what they
are. Prepare the patient by; correcting dehydration, severe anemia, cardiac
failure or diabetes before you operate.
2. Starve the patient even for local anesthesia, so that, if he tries to vomit, his
stomach is less likely to be full. Local anesthesia may fail or may be inadequate,
so that you may have to give general anesthesia.
3. Anesthetize him on a tipping table, because he may still vomit, even if he
is supposed have been starved. So you must be able to tip him head down. If
you do this, his stomach contents are less likely to run into his lungs. If you
do not anesthetize him on a table, which does not tip, and if the patient vomits,
turn him immediately on to his side to protect his airway.
4. Check your drugs and equipments before you start, especially if you are
using less simple equipment. The equipment to preserve his airway must be
ready beside you.
5. Keep a sucker instantly ready, tested and working, so that if his pharynx
fills with vomit, you can suck it out. You will also need suction catheters.
6. Keep his airway clear, because it can easily get obstructed. One way to do
this is using Guedel’s airway. You will need a range of different sizes.
7. Be ready to control his ventilation. Because almost any anesthetic (including
ketamine) may stop him breathing, so that he needs ventilation. To do this you
will need a self-inflating resuscitator bag, a non-rebreathing valve and a face
mask. Although you can control his ventilation with these, it will be easier if
you can intubate him. So, have access to a laryngoscope, endotracheal tube,
an introducer, and suction catheters. Intubation is the only way you can be
sure to control his airway and prevent aspiration.
8. Have a vein open, because if the patient has an IV line or an indwelling needle,
you can treat some of the complications that may arise during anesthesia more
easily and give him both blood and fluids quickly. An ‘open vein’ is an essential
precaution in all major operations.
9. Monitor his pulse and blood pressure continuously, during the operation
and immediately after it, so that you are able to take the necessary corrective
action before it is too late. You must recognize cardiac arrest immediately.
One of the most effective ways to do this is to strap a pre-cordial stethoscope
to his chest and to keep the ear piece always in your year.
10. Always have some one in the room who can apply cricoid pressure
effectively and will be useful in an emergency.
The Indian Society of Anesthesiologists has formulated the guidelines for
minimum requirements for safe anesthetic practice in India in the Governing council
meeting on 20th October 1990, at Chennai after carefully taking into consideration
the restraints in the environment in our country as given below.
Indian Society of Anesthesiologists

Recommended minimum requirements for safe anesthetic practice in India.
Operation theaters: minimum requirements

1. Every operation theater, except where minor procedures are performed, must be
air-conditioned to keep the room temperature between 20–28° C and humidity
between 60–70% to minimize chances of wound infection, heat induced
complications to the patient and fatigue to theater personnel. Appropriate
changes may be necessary in theaters where neonates are operated upon. The
administrators should not think this facility is a luxury.
2. Operation theaters and intensive care units must have emergency lighting and
power supply arrangements through appropriate power generators. Alternate
methods for suction like hand or foot operated suction units must be available
in these areas.
3. Every hospital must designate one senior anesthesiologist working in the
hospital to advise the authorities on the following:
–– In planning/expansion of operation theaters and ICU
–– In the choice and maintenance of anesthetic, resuscitatory and monitoring
equipments for the hospital.
–– To organize and supervise the servicing and maintenance of anesthesia,
resuscitatory, ventilatory and monitoring equipments of the hospital.
–– And to guide and train personnel in managing acute emergencies and for
resuscitation.
Anesthesia care: principle

1. Anesthesia shall be administered only by a qualified anesthesiologist or a post
graduate/trainee in the department under the direct and continuous supervision
of a qualified anesthesiologist.
2. Every patient present for anesthesia must have a pre-anesthetic consultation or
evaluation by an anesthesiologist.
3. Basic staffing, equipments and drugs and protocols for safe administration of
anesthesia are essential requisites.
Staffing
1. A suitably trained or qualified theater assistant must help anesthesiologist in
all critical areas like operation theater, recovery ward and ICU.
2. The assistant must be exclusively available to the anesthesiologist until the
anesthesiologist indicates that he is no longer required. During induction,
maintenance or at the conclusion of anesthesia the assistant should always be
available to help the anesthesiologist.
Anesthesia record and machine

1. For every patient undergoing anesthesia, be it general regional, local or
intravenous sedation, the anesthesiologist should maintain an anesthesia chart/
record, complete and duly sign the same.
2. A check list in respect of the anesthesia machine shall be maintained. This
check list must be completed before starting the operation list.
3. Every operation theater must have as many number of anesthesia machines as
there are operating tables.
4. Every anesthesia machine must have incorporated in it oxygen supply pressure
failure warning device. It is also desirable to have an oxygen analyzer in addition
to oxygen supply pressure failure warning device in each anesthesia machine.
Basic equipments
1. Each operation theater must have the following:
–– Stethoscopes
–– Sphygmomanometer with adult and child cuffs
–– At least two laryngoscopes with three blades appropriate to the age of the
patients treated in the hospital
–– Suction apparatus and suction catheters exclusive for the anesthesiologist.
–– Appropriate face masks
–– A range of oropharyngeal and nasopharyngeal airways
–– A range of endotracheal tubes, connectors, introducers and catheter mounts.
Intraoperative monitoring
1. The best possible monitor is the anesthesiologist. Every patient undergoing
any type of anesthesia must be supervised by an anesthesiologist. He must be
present right from the time of the induction of anesthesia, to the conduct of
the whole anesthetic, termination of the procedure and transfer of the patient
to the recovery area.
2. Continuous monitoring of ventilation and circulation by clinical observations
must include the following:
–– Chest wall movement and movement of reservoir bag
–– Color and response to surgical stimulus
–– Auscultation of heart and breath sounds by a pre-cordial or esophageal
stethoscope
–– Pulse rate and blood pressure should be measured at least every 5 minutes
in every patient receiving any form of anesthetic or sedation.
3. Every patient subjected to anesthesia must be monitored by cardioscope. It
should be displayed before induction and continued until further surveillance
is deemed unnecessary.
4. Every operation theater suite must have in readiness one defibrillator.
5. In all pediatric patients the core temperature either by rectal or esophageal route
must be monitored both postoperatively as well as in the recovery ward.
6. Wherever necessary pulse oximetry and end tidal CO2 may be measured. The
same applies to neuromuscular function monitoring.
7. Monitoring of intra-arterial, central venous and pulmonary artery pressures
should be done only when indicated as they are all invasive methods.
The recovery area

1. The recovery area should be located in an area appropriate for the purpose close
to the place where the anesthetic was administered.
2. Ideally, every operation theater should have one recovery area or a group of
operation theaters in the same floor may have one recovery area.
3. The transfer of the patient to the recovery area must be supervised constantly
by an anesthesiologist who is also responsible to the patient until discharge
from the recovery room.
4. Monitoring of parameters must be continued in this recovery area employing
appropriate monitors where consider necessary. The recovery area must be well
equipped to ensure patient safety at all times.
5. A separate scoring chart must be filled up for every patient in the recovery area
and duly signed by the anesthesiologist.
A senior anesthesiologist is one with postgraduate degree of diploma with at
least 5 years of experience in the speciality.
Safety in anesthesia
Facts to be accepted
1. The topmost priority in anesthesia is only “safety” and all others come next.
2. “There is no shortcut for safe anesthesia.” Only proper understanding of the
underlying pathology and its effect on the various systems of the patient and
appropriately modifying the anesthetic technique and giving intense care in the
perioperative period are the ways for a safe anesthesia.
3. Giving a higher grading in ASA to cover up inefficiency of the anesthesiologist
or surgeon and to accept a bad outcome is considered as untenable.
4. In modern days of safe anesthesia, many surgeons have unrealistic expectations
about the comfort during surgical procedure as well as the duration of surgery.
They believe that the duration of anesthesia has no implication in the overall
outcome of surgery. At least in very ill patient, the prolonged anesthesia and
prolonged surgical handling has serious deleterious effect on the outcome.
5. Some anesthesiologists believe that continuous epidural with opioids to provide
postoperative analgesia will keep the patient pain-free and cheerful, but we must
understand that this blocks the pain pathway and thereby the pain perception,
but the morbidity related to the biochemical process of damage due to injury
and handling continues and will take a long time to heal.
6. Hence, long duration of surgery without due justification causes inevitable
increased handling of tissues, eventually resulting in manifold increase in
morbidity that cannot be justified by any means.
7. It is the prime duty of the anesthesiologist to give the best possible comfortable
working condition for the surgeon without compromising the safety of the
patient even to the slightest extent.
8. The surgeon must always remember that if a bad outcome ensues it will have
the primary impact on the surgeon’s image particularly in Indian context, though
everyone in the team is responsible.
9. The meticulous technique of surgery and the speed of surgery tell upon the
overall outcome.
10. Meticulous technique with unduly prolonged duration sometimes ends up in
bad outcome because of multiple factors particularly in a relatively very ill.
11. When an ordinary technique with a relatively good speed is employed without
unnecessary handling of tissues, that results in a good outcome even in a poor
risk patient.
12. Ideally a good technique of surgery and good speed counts.
Somethings that are not openly discussed in the work place considering courtesy,
have to be discussed tactfully with a open mind to take up the facts, in this situation
in the larger interest of the patients, without causing any ill effects or hurt to any
one concerned.
Here it is appropriate to recollect the statement made by the British surgeon
Sir William Heneage Ogilvie (1887–1971), about the four decades in a surgeon’s
life. Though as a surgeon himself he made the statement pointing to the surgeons,
this holds good to any specialty. The statement goes as follows;
The first ten years a surgeon leans—‘How to operate’
The second ten years he learns—‘When to operate’
The third ten years he learns—‘When not to operate’
The fourth ten years he learns—‘When to Stop’.
This clearly indicates that for anyone to acquire the wisdom of understanding
the point at which he has to stop the particular work, it takes at least three decades.
Accidents during Anesthesia

‘There are no safe anesthetic drugs; there are no safe anesthetic techniques; there
are only safe anesthesiologists.’
Accidents don’t happen everyday
Accidents can happen either due to our mistakes or due to others mistakes.
To prevent we have to follow the safety rules meticulously and also that others
have to do the same.
In Anesthesia everyone in the operating team has to follow the discipline and
the rules, so that safety is ensured and accidents prevented. Our entire anesthesia
practice should be ruled by the application of carefully considered decisions made
on the basis of previous systematically analyzed experiences. That is, after all
medical audit.
“All anesthesiologists however experienced and however accident free should
be humble enough to recognize that they may make mistakes at any time. These
errors may be in technique, judgment or failure of vigilance.”
—John Alfred Lee.
Can there be anyone who can be called as accident-free anesthesiologists?
This again is extremely difficult in these modern days for the following reasons.
Average life expectancy has gone up, so more geriatric patients with various
system disorders are presented for anesthesia.
Increased health care is available, so patients with multi-organ failure may be
presented to anesthesia.
In other words, severely ill patients with a very high risk for anesthesia who
were considered “Unfit” for anesthesia in olden days are frequently coming up for
surgery. These patients in olden days either did not live up to that age or they were
deemed “Unfit”.
So we have to sort out and analyze the ways of conducting a safe anesthesia.
No one should feel or declare that he is accident free anesthesiologist because
accidents occur accidentally—as they are unexpected in spite of adequate care
and caution.
Accidents can be due to factors related to;
1. The anesthesiologists
2. Equipments and drugs
3. Monitoring
4. The patient.
We shall see all that one by one.
The anesthesiologists
Even after careful selection and training, there is the need for continuing
education.
Surveys of mortality and morbidity often reveal the poor assessments and
inadequate treatment or resuscitation of the patient before surgery.
Delegation to a junior colleague or assistant may be inappropriate.
Regular audit, morbidity and mortality meetings contribute to safe anesthesia.
Stylized training is useful for infrequent but particularly hazardous situations,
for example, difficult or failed intubation, cardiac arrest, unexpected cyanosis,
anaphylaxis and malignant hyperpyrexia.
As with pilots, computer based simulators have been developed.
The use of artificial intelligence in patient’s management such as a sophisticated
simulator complete with mannequin, anesthetic machine and monitors are
available.
However, there is little formal assessment of practical skills in anesthesia,
neither of trainees nor their trainers.
With attention to details, it should be possible to prevent the minor error turning
to a disaster. No anesthesiologist (particularly a trainee) should be persuaded
to treat a patient beyond his capabilities.
The anesthesiologist works in a complex environment and so his behavior will
be influenced by some factors that are out of his control, such as climate, economy
and even architecture. The provision of a safe environment depends in part on
hospital administrator, although advised by the professionals.
The anesthesiologist needs to prepare for the unexpected and be alert.
Commonsense says a reasonable amount of sleep and rest is necessary before
taking a patient’s life into his hands. This is a legal requirement in New York State.
Sleep deprivation causes mood changes, but functional impairment is not always
apparent. But relatively easy tasks that are so important to the safety of anesthesia
require a high level of personal arousal to perform well.
All anesthesiologists must have skilled assistants. CEPOD (Confidential Enquiry
into Perioperative Deaths) has revealed that at least 14 deaths have been caused
simply because the anesthesiologists worked without such help from skilled assistant.
Equipments and Drugs
The anesthesiologist must understand the working of all equipment, and be
satisfied that it has been properly maintained. both equipment and drugs must
be checked before use.
Accidental disconnection of parts of the breathing circuit is an ever present
hazard. Ill fitting connectors must be discarded. Even minor leaks can have
serious consequences.
Some safety features are incorporated in modern anesthetic machines; inability
to deliver hypoxic gas mixtures, limits on CO2 flow, built in monitors.
In the future, features such as digital control of gas flow and vaporizers, self
check and servo control of vapour concentration within a circle may provide
additional safety. But correct usage of such equipment will be always crucial.
The anesthesiologist must be satisfied that the drug to be injected into a patient
is the one intended and prepared at the correct dilution.
New drugs require special vigilance and are marked by an inverted black
triangle in British National Formulary and in MIMS.
Monitoring
Monitoring has made a big contribution to the safety in anesthesia. Many countries
have introduced minimum standards of monitoring. These usually include the
continuous presence of an anesthesiologist in theater or briefly in the anesthetic
room if the intervening door is open.
Monitors of the anesthetic machine (oxygen failure alarm, inspired oxygen
concentration, ventilator disconnect alarm.) and of the patient (circulation—ECG, pulse,
blood pressure; respiration—bag movement, capnography, pulse oximetry; temperature;
neuromuscular transmission) such standards are legally enforced in certain states.
Time and motion studies of anesthesiologist in the operating theater reveal
much time is not spent observing the patient, and an implicit reliance on monitors
and their alarms.
The judgment of the anesthesiologist is the most important. Anesthesiologists
must know the limitations of the monitors, set appropriate alarm limit know how
to check that they are working correctly and be able to interpret the data.
An excessive number of monitors may lead to distractions, complacency and
a blind adherence to ‘standards’. Alarms frequently sound when there is in fact no
danger to the patient.
The patient is exposed to as much danger in the postoperative recovery room
as in theater. The CEPOD report shows that many hospitals don’t have adequate
recovery facilities. There must be a safe hand over of patient to recovery staff.
The patient
The anesthesiologist plays an important role in ensuring that the correct operation
is performed on the correct patient. A Medic Alert bracelet warns an attending
doctor of hazards such as allergies, sensitivity to suxamethonium or susceptibility
to malignant hyperpyrexia.
Anesthetic Records
It is absolutely essential that a record should be kept of all administrations of
anesthesia
It is a telltale evidence for the type and quality of care given to the patient
intraoperatively and to identify whether there were any problems or
complications during the course.
Its value is in three aspects; to contribute to patient care, teaching and medico-
legal reasons.
Patient care
Though it consumes about 11% of an anesthesiologist’s time, it stimulates
vigilant anesthesia.
It is an aid for audit of an anesthesiologist’s work.
To analyze and correct any defect in management of the case.
teaching
Similar to audit it is used to teach the learners how a case has to be managed.
Medico-legal reasons
In case litigation arises, this is considered as a very valuable document to
support the anesthesiologist
There are many anesthetic records available designed and supplied by various
companies, which are suitable for general use in any operating room
Nosworthy’s cards are in use for many decades and are periodically updated
with the addition of newer agent and techniques
An institution may design their own anesthetic charts according to their
convenience. A model Anesthesia Chart is shown in (Figs 4.1A and B).
Much harm may be done to an anesthesiologist’s defence of a civil claim if his
record is not full, accurate, contemporaneous and legible. Although patient care
should always take precedence over record keeping, events should be recorded as
soon as possible after they happen. Any correction should be made in such a way
that will not arouse suspicion that the record has been falsified. Handwritten records
are still effective and common.
The simplest record should contain the patient details, date and time of
operation, the surgeon and the assistant, the anesthesiologist, operation
performed, technique of anesthesia used and the drugs, record of vital signs
such as pulse and blood pressure, oxygen saturation (Figs 4.1A and B).
Intravenous fluids administered, the type of fluid, the duration of administration
in the order must be recorded.
Vital signs are recorded every 5 minutes as a routine, but this can be extended
as 15 minutes interval in straight forward cases and it should not be extended
further which means inadequate care and record.
If the BP and pulse have been checked every 10 minutes and has not been
recorded, the court of law takes that it has not been done.
Blood loss is estimated carefully and periodically recorded and the total loss
estimated at the end.
Quantity of blood replaced in terms of units, the time of starting and the time
of completing the transfusion along with a note of any reaction.
Finally the details of the total volume of blood loss, the total volume replaced,
any deficit, any further transfusion needed in the postoperative period all must
be noted clearly.
In some hospital the anesthetic charts incorporate carbon copies, which may
be retained in the department for official records and the original is sent with
the case sheets with the patient to postoperative ward.
Fig. 4.1A: The first page of an anesthesia chart

Fig. 4.1B: The second page of anesthesia chart
Many of the monitors have printer facilities, are connected to the computers that
give printouts after every case, these printouts, though not equivalent, to the
“Black Box” flight recorder, yet considered similar to that. Anesthesiologist’s
have been noted to fail to record manually the extremes of blood pressure that
are captured by the automatic recorders.
Instructions to the postoperative recovery room nurse must be very clearly
written without any chance for ambiguity of meaning. Wherever possible these
instructions are verbally communicated to the concerned nurse.
In every case, after completion, the anesthesiologist should write with his
own handwriting, the details in the anesthesiologist’s register provided in the
operating room, by filling in the columns. This register also is a very valid
document of proof, in case of litigation.
Monitoring during Anesthesia

Anesthesia represents a high insurance risk, because anesthesiologists manipulate
the physiology of cardiovascular and respiratory systems and administer
potentially lethal drugs for reasons which are not primarily therapeutic;
consequently, when a serious accident occurs, it may result in death or permanent
neurological damage. In addition, when minor morbidity caused by anesthesia
or anesthesiologist may be regarded by the patient as unacceptable when it does
not appear to be related to the primary illness. This explains the strong need for
preventing even the least morbidity by careful steps and monitoring.
It has been adequately emphasized about the absolutely essential need for intra
operative and postoperative monitoring in all the textbooks of anesthesia as well
as in all the forums where anaesthesiologists gather for scientific discussions. But
unfortunately there is always a universal doubt whether it has been carried out in
the way it is expected. Hence the need for an elaborate discussion here!
“High index of suspicion is a characteristic of a safe anesthesiologist”
“There is no monitor ever known that can match a human monitor”.
The word ‘monitor’ is derived from the Latin verb ‘monere’ which means—
to warn. As the derivation suggests, a monitor can only warn. No mechanical
or electrical device can replace conscientious observations of the patient by the
anesthesiologist. Information from the monitoring equipment requires clinical
interpretation. The user must know the basic principle on which the monitors work.
Varying levels of complex monitoring are appropriate during anesthesia in
different clinical situations; for instance, major cardiovascular surgery and dilatation
and curettage represent opposite ends of the monitoring spectrum.
The primary equipment for clinical measurement and monitoring is the hand,
eyes, and ear of the attending doctor. The anesthesiologist should develop a sixth
sense, a subconscious mental computation of observations, time and experience
which warns of impending events and prompts action to meet the needs of the
patient.
An anesthetized patient is in a state of almost total dependency in general
anesthesia and near total dependency in regional anesthesia. This is because his
physiology is modified and normal protective reflexes are either depressed or
abolished leaving the patient without the protection of nature. Then it becomes
imperative that it is the primary responsibility of the person who modified it , to
take care or the patient from the imminent dangers due to the lack of reflexes till
the reflexes are regained and he is able to take care of himself, in other words , till
he is normal with normal reflex activity.
Though the first documented general anesthetic was in 1846 and surely some
patients would have succumbed due to anesthetic mishaps, the first death attributed
solely to anesthesia occurred 2 years later. Fifteen year old Hannah Greener had
been “crying continually and wishing she were dead, rather than submit” to the
removal of ingrowing toe nail. Shortly after induction she had a cardiac arrest. This
illustrates two points.
Firstly, disasters can and do happen to young fit patients during the most
minor procedures.
Secondly, since the earliest years of anesthesia, mishaps have been common.
Our mistakes being rare, we must learn from the errors of others.
We may also hope to learn from their wisdom. One of the first dedicated
anaesthesiologist, Joseph Thomas Clover, claimed in 1871 to have administered
over 11000 anesthetics without a death. He explained his success simply. “It was
my habit …to watch the pulse as well as the breathing….” This “habit” would
have prevented most anesthetic mishaps to date. As anesthetic techniques develop,
new problems emerge and the need for changes in monitoring.
Facts about Monitors

The first and main monitor is always the anesthesiologist.
There is a basic difference between a human being and a machine. He can
monitor the whole of the patient’s condition and follow the course of the surgery,
anticipating problems and correcting them when they occur.
By contrast, even the most sophisticated electronic monitors are inherently having
their limitations. They can only monitor one aspect of the patient’s condition.
They require power for operation, need maintenance, occasionally develops
faults and are prone for errors.
A correctly set monitor saves lives by drawing attention to a problem before it
is too late to correct it. Thus it warns the observer of adverse events.
In addition, some monitors provide information which is not otherwise
obtainable. Examples include inspired and expired oxygen, carbon dioxide
and vapour concentration.
It is not appropriate to attach every available monitor to each patient. Rather
we choose monitors to enable to detect and treat likely adverse events. For a
cardiac cripple undergoing major surgery it may require direct measurement of
systemic and pulmonary artery pressure, which is an unacceptably dangerous
mode of monitoring for a healthy patient undergoing a minor surgery.
Some monitors, however, are so useful and so safe that they should be used in
all patients example being Pulse Oximeter.
Demerits of Monitors
Monitors may distract and confuse particularly when there are too many.
Each additional monitor distracts attention from the patient and from the other
monitors. A normal looking ECG trace for example, may delay recognition that
the patient has become pulseless.
All patients undergoing anesthesia are at risk. Most disasters stem from failure
to recognize some simple problem, for example a ventilator disconnection. Most
such problems can be detected by relatively simple, safe, monitoring, which is
therefore recommended for all patients.
The first set of standard to be published was that of Harvard Medical School
System in 1986. The American Society of Anesthesiologists endorsed a similar set
of recommendations the following year. The Association of Anesthetists of Great
Britain and Ireland published its own recommendations in 1988 and these were
revised in 1994.
Most important is that monitoring begins before induction and continues until
after recovery, with the anesthesiologist present throughout. Monitoring is clinical
observation supplemented by a variety of techniques including Oximetry, Capnography
and Electrocardiography, as well as intermittent determinations of blood pressure.
This represents the minimal acceptable provision of care for anesthesia in
developed countries. Medico-legally and ethically, it would be difficult to defend
a practice which fell short of these standards.
Monitoring the anesthetic machine

Oxygen failure alarm and analyzer to ensure that inspired gas mixture contains
at least 33 % of O2.
Airway pressure monitor to ensure that the patient’s airway is not subjected to
very high pressure that causes damage to lungs (Barotrauma).
These are the non-expensive yet very useful monitors in patients that must be
employed in all anesthetic machines.
Monitoring of the patient

Circulation:
Noninvasive BP, ECG Pulse Oximetry.
Respiration:
During IPPV, airway pressure, ventilatory volume, capnography, disconnection
alarm, and pulse oximetry.
Metabolic status:
Capnography, blood glucose, acid-base balance.
Neuromuscular transmission:
Peripheral nerve stimulator—when muscle relaxants are used.
Of these universally accepted basic minimum mandatory monitoring are;

Noninvasive BP
ECG
Pulse oximetry
Capnography.
The cardiovascular System
ECG
Valuable information concerning cardiac rhythm may be obtained by monitoring
the electrocardiogram. Most ECG machines calculate the ventricular rate. This
should not distract the anesthesiologist from monitoring the peripheral pulse rate.
Fig. 4.2: The CM5 ECG lead configuration
Modern ECG monitors are very reliable and less subject to interference. As the
technique is noninvasive, simple and accurate, it is now a mandatory monitoring
in UK that it is used in all patients undergoing anesthesia, no matter how minor
the surgical procedure.
Standard lead II monitoring is used widely. However, the CM5 lead
configuration (Fig. 4.2) has been advocated for routine intraoperative monitoring
because it reveals more readily ST segment changes produced by left ventricular
ischemia. This configuration is achieved by placing; the Right arm lead over the
manubrium sterni, the Left arm lead on the V5 position over the left ventricle, and
the indifferent lead over the shoulder.
It is important to appreciate that the ECG is an index of electrical activity
only. It is possible for a normal electrical wave form to exist in the presence of a
negligible cardiac output. Consequently, information from the ECG should be used
in conjunction with data acquired from monitoring of perfusion.
Monitoring the circulation

Maintenance of perfusion to the vital organs is one of the principal tasks of the
anesthesiologist during surgery. Adequate perfusion is dependent on adequate
venous return to the heart, cardiac performance and arterial pressure. Direct
measurement of cardiac output requires invasive procedures. However, adequacy
of cardiac output and circulating blood volume may be inferred from observation
of the following variables:
Peripheral pulse
Arterial oxygen saturation
Peripheral perfusion
Urine production
Arterial pressure
Peripheral pulse
Regular palpation of peripheral pulse is one of the simplest and most useful
methods of monitoring during anesthesia and is mandatory for even the most
minor surgery. Information may be obtained by observation of the rate, volume
and rhythm.
Pulse plethysmography: Automated devices are available for monitoring peripheral
pulsation. Usually it is available with sophisticated models of pulse oximeters. Pulse
monitors provide a guide to the pulse pressure. Thus an increased signal may be
seen in peripheral vasodilatation or increased cardiac output, and low pulse pressure
is seen during vasoconstriction or low cardiac output states. The exact mechanism
of plethysmography is described elsewhere later.
Arterial oxygen saturation: Pulse oximetry

Pulse oximeters measure the arterial oxygen saturation and the pulse rate
noninvasively and accurately within 2% variation.
Further Reading
1. Adams AP. Recent Advances in Anesthesia. In: Atkinson RS and Adams AP (Eds).
Edinburgh: Churchill Livingston, 1992:17.
2. Atkinson RS, Rushman GB, Davies NJH (Eds). Lee’s Synopsis of Anesthesia. 11th
edition; Butterworth Heinemann. England, 1993;19:356-60.
3. Gravenstein JS, Hozler JF (Eds). Safety and Cost containment in Anesthesia. Boston:
Butterworths,1988:2.
4. Risk Management in Anesthesia. Int Anaesthesiol Clin,1989;27:3.
Chapter
5 Preanesthetic Assessment
Chapter Outline
The purpose of preoperative visit
v
Guidelines for Preanesthetic Visit
v
Definition
v
History Taking
v
Physical Examination
v
Basic Laboratory Investigations
v
Grading of Risk
v
Fit for Anesthesia
v
Informed Consent for Anesthesia and Surgery
v
Preoperative Starvation
v
Canceling Cases
v
Choice of Anesthesia
v
Good patient care starts at this level as far as anesthesia is concerned.

Undergoing a surgery is a relatively dehumanizing process. We move the patient
into strange environment, replace his clothes with formless rags, percuss, palpate
and paw at his frightened frame and essentially remove his personal identity and
individuality. It is painful to the psyche as well as to the corpus; it forces the patient
to adapt to an unfamiliar role of childlike dependency. We must always remember
that no patient ever enters a hospital just to receive an anesthetic. We have to
make the patient comfortable by making preoperative visit to assess physiological
and psychological status and correct any deviations in them, prescribe rational
premedicant drugs with gentleness and kindness. We must never take shortcuts in
patient care and must monitor all parameters for patient safety. We must realize
that surgery is a unique and frightening experience to the patient.
At one time, the crucial phase of a surgical illness was thought to be the
operation—the chance of survival depending upon the patient’s response to
anesthesia. A common question often posed was whether a patient in poor
physical condition could tolerate the anesthetic. This concern has now undergone
modification. Anesthesia is still of major importance, to be given with skill and good
judgment but it is the quality of pre and post anesthetic care that largely determines
whether the outcome will be satisfactory. This overall approach to anesthesia has
led to a decrease in the number of intraoperative complications and to a reduction
in postoperative morbidity and mortality despite the extremes of age and the greater
severity of disease in patients coming to operation.
Chapter 5  Preanesthetic Assessment 49
Participation of anesthesiologist in preparation of the patient for operation
improves the outcome because; the anesthesiologist is knowledgeable in
the pathophysiology of the disease as it pertains to the action of anesthetics.
Anesthesiologists must establish their reputations with the expectation that they will
be asked to consult on operability and to help prepare the patient for the procedure.
The attitude this is “their” patient must be eliminated. That will go a long way in
dispelling the notion that anesthesiologists lack responsibility in patient care.
It is proper for the anesthesiologist to write brief notes about the assessment.
Specific mention about the anticipated problems such as difficult airway and
the requirements for managing them all must be included. Many a times lack of
assessment of airway had ended up in inability to intubate and inability to ventilate
situation leading to catastrophe.
These records carry lot of benefits both in clinical and legal point of view.
Particularly a rapid review of the record just before starting anesthesia will certainly
bring to mind all those problems observed during assessment.
The purpose of preoperative visit

Establish rapport with the patient, so that the anesthesiologist is not appearing
as a stranger to the patient
Obtain a history and perform a physical examination
Order for special investigations if needed
Assess the risk of anesthesia and surgery and in absolute necessity postpone
the surgery. ‘It needs lot of wisdom to overcome the temptation to take up the
patient for surgery at any cost’. One’s ego should not do it
Institute necessary preoperative management
Prescribe premedication and plan the anesthetic technique management.
Premedication is essential even in a day care surgery and it varies with
individual patient, procedure and the technique of anesthesia.
Guidelines for Preanesthetic visit

Every patient should be seen by the anesthesiologist before operation.
Only in dire emergency (such as multiple injuries in road traffic accidents)
when a patient is received in severe shock, where resuscitation is started and
immediately taken up for surgery, there would be little time available for this.
In all other circumstances there will be some time available for visiting the
patient to do rapid examination and giving preanesthetic instrucions.
For this reason it is necessary that patients be admitted to the hospital early
enough to permit a complete examination.
Past and present hospital records should be reviewed with attention focused on
prior experiences and the physiologic alterations induced by disease. The ability
to tolerate the adverse effects of anesthesia and operation depends largely upon
the normality of respiration and circulation and on the homeostatic functions
of the liver, kidneys, endocrines and central nervous system.
There is no substitute for talking to patients, listening to their problems
and acquainting them with the procedure planned. Thus the visit is a subtle
educational process for both patient and anesthesiologist; the patient learns what
anesthesia has to offer, and if misconceptions exist they can be dispelled. The
interview must be unhurried and tactful; if the patient is eating or receiving
special therapy it is better to return at another time. If visitors are present they
must be asked to leave before examination.
If a patient has not yet informed of the decision to operate, anesthesia can
be described as though it were to take place in the future. It is best to avoid
discussion of matters in the surgeon’s domain. Questioning should proceed
along lines of past anesthetic experiences, familial problems with anesthetics,
routine use of drugs, and unusual reaction to drugs and the concurrent illness.
While assessing the patient’s emotional state, one should look for physical
characteristics that may cause technical difficulties during anesthesia. The
individual with a short and stout neck readily develops respiratory obstruction
once unconscious; the athlete requires more medication than the asthenic. If
there are lose or caries teeth or delicate dental work, the patient should be
warned that dislodgement or damage may occur upon airway insertion and
a note to that effect should be written on the chart. Patient should be told to
remove dentures and leave them in the room so that they may not be broken
or misplaced.
Questioning pertaining to the patient’s cardiopulmonary reserve must be
carefully asked.
Simple pulmonary function tests may be performed. His exercise tolerance
may be assessed by questioning abut his profession and daily work pattern or
asking him to walk fast in the corridor or walk up a flight of stairs to detect
shortness of breath or claudication.
If regional anesthesia is planned it is essential to inspect and palpate the site
selected for injection of spinal or caudal anesthesia.
Once the preliminaries are over, the patient is told of the plans of anesthesia,
if the patient wishes to know about it and is intelligent enough to understand
things. Some patients will accede readily, while others may show concern
about many things such as, fear for face masks, postoperative vomiting or
pain. Some will object to spinal anesthesia for fear of headache or backache,
etc. explanations and reassurance usually settle most of these problems. Most
patients accept physician’s advice when confidence is inspired.
Patient must have good sleep during the previous night. Anxious patient may
be adequately supported with suitable medications to induce sleep with an
advice to go to bed early.
When the anesthesiologist leaves the patient, a summary of the preliminary data
is recorded on the case sheet or anesthesia chart, a physical status category is
assigned, preanesthetic orders written. From medico-legal point of view, this
summary is more meaningful than simply signed anesthesia fitness.
Finally anesthesiologist must develop enough judgment of their own to make a
surgical diagnosis and to predict the effect of the surgical position and operation
on physiologic processes.
As experience is gained the anesthesiologist will find that the preanesthetic visit,
above all else, sets the stage for a safe course both during and after surgery.
Because anesthesia by itself is interfering with the basic physiology and
modifying it for the purpose of performing the surgery, to know how much of
modification can be done safely, we have to assess the physical and physiological
status of the patient and look for any diseases affecting any system from which the
patient suffers already.
Definition
Preanesthetic assessment is the process of evaluating the physical and physiological
status of the patient who is likely to be submitted for anesthesia and surgery, by
doing a careful clinical examination aided by relevant laboratory investigations and
thereby assessing the capability of the patient’s systems whether it can withstand
the stress of anesthesia and surgery.
Accordingly the risk for anesthesia is graded so that appropriate planning and
modifications are made regarding the anesthetic and surgical techniques.
Incidentally assessing the psychological status of the patient is absolutely
essential as that has implication on the preoperative medication and the choice of
anesthetic techniques and drugs.
Routinely the following practice is done:
Looking at the patient’s general condition to assess whether he looks normal,
healthy, and fit
A careful short history taking to get relevant information related to anesthesia
Examination of cardiovascular system
Examination of respiratory system.
History taking
Listen to the patient carefully what he has to tell us, before putting any question
to him.
Ask about habits particularly such as smoking, chewing tobacco, alcohol, etc.
History of past illness especially the following:
Chronic diseases like tuberculosis, bronchial asthma, hypertension, epilepsy,
etc.
Jaundice within the past 3 months
Recent infective diseases
Any medications taken currently for any ailment and the details.
History of any allergy

Here many times an illiterate patient is asked the question “Do you have any
allergy?” Immediately he comes out with an answer “Yes sir, I am allergic to egg.”
Usually the doctor gets annoyed thinking that he is giving an irrelevant answer. In
fact, he gives very valuable information that he has allergy for some kind of food
and is likely to have allergy for drugs also.
Physical examination
Observe the patient when he walks towards you. This provides much
information that a routine examination cannot give
Look whether tall or short, well built or thin built, big frame or small frame,
obese or normal
Look whether he has any obvious deformity like limping, kyphoscoliosis,
gross asymmetry, any structural anomalies, etc. and all these must be given
adequate importance
Look for facial expression whether normal, has painful expression, or
melancholic (may be drug induced or disease induced).
Cardiovascular System
Blood Pressure: Both in supine and upright posture
Pulse: Feel in all palpable peripheral vessels and note the points given here.
Count for one full minute. Counting the pulse for shorter time there is a chance
of missing an occasional ectopic beat. Concentrate on the following three
characters:
–– Volume
–– Rate
–– Rhythm (arrhythmias can be due to cardiac causes or electrolyte imbalance).
Auscultation of heart sounds: All the four areas of pre-cardium to rule out any
abnormality or murmur.
Respiratory System
Observe whether the patient is breathing effortlessly
Look for tracheal deviation
Look for any chest deformities, abnormal or restricted movements, etc.
Auscultate all the areas of lung and if no abnormal sounds are heard, then it is
taken as the respiratory system is normal
Breath holding time must be > 20 seconds (Sabroz’s test).
Central Nervous System

Ascertain that the higher functions are normal
Look for any psychiatric illness.
This has significance when we look for recovery criteria as we need patient’s
cooperation.
Basic Laboratory Investigations

Hb%
Urine—albumin and sugar
Blood sugar
Blood urea
Serum creatinine
In elderly patients—ECG and X-ray chest should be done.
Hemoglobin
It indicates the general health of the patient. At least 10.4 g % (70%) is considered as
a baseline value for a normal person. It is an arbitrary value. If all other parameters
are normal, a small deviation in this value can be accepted without any untoward
effects, provided the proposed surgery itself does not cause a severe blood loss.
Urine Albumin
No normal patient should have albumin in urine. If present, three different
specimens must be taken and tested to confirm it. If positive, that indicates renal
damage. This patient needs a careful evaluation by doing elaborate renal function
tests, so as to assess the degree of damage and the available renal function.
This is important because, many times until about 35 % of functioning nephrons
are present a patient with mild to moderate renal damage may not have any clinical
manifestations at all.
Urine Sugar
If urine sugar is positive, test three specimens and confirm it. Then suspect diabetes.
Blood Sugar: Normal value is 80 to 120 mg%.
If the value is above 140 mg % repeatedly it is significant. If urine sugar is
positive and blood sugar level also is elevated, GTT may be done for proper
evaluation of diabetic status that needs adequate control before surgery.
Uncontrolled diabetes involves very grave risk.
Blood Urea
Normal value is 20–45 mg%.
It is a poor indicator of renal function. If more than 45 mg %, it does not
indicate poor renal function. There are various other non-renal reasons for elevated
blood urea. It may be elevated in dehydration, hyper metabolic state, etc. The test
inevitably has large margin of errors and technical error is always possible.
Serum Creatinine
Normal value is 0.9–1.2 mgs.
More sensitive test, if it is persistently raised it indicates that there is reduction
in renal function and necessitates elaborate renal function tests.
Routine tests but not indicated for all patients

In elderly patients aged above 60 years, it is always advisable to have ECG and
X-Ray chest.
ECG: Irrespective of the age of the patient, if the patient has history of cardio
vascular diseases either congenital or acquired, needs an ECG for evaluation
of the cardiovascular status at that time. ECG helps in assessing cardiovascular
status particularly in identifying problems like chamber hypertrophy, ischemia,
conduction defects, etc.
X-ray chest: Irrespective of the age, if the patient is suffering from any chronic
respiratory illness such as bronchial asthma, or gives history frequent respiratory
infections or similar illness X-ray chest is indicated.
This is needed to assess the condition of bony cage of the chest and the lungs.
It also gives idea of any increase in the size of heart by heart shadow.
Many of the elderly patients may present with emphysematous changes in
relation to their age, with a “Fixed Barrel” shaped chest. There may be minimal or
no chest wall movement. This status is clinically very significant as these patients
easily develop post operative pulmonary complications.
The purpose of all these elaborate examination and investigations is to identify
whether any particular organ as kidney or liver is affected and to do relevant
investigation to assess the functioning capability of the organ (available function)
and to assess its ability to stand the stress of anesthesia and surgery so as to make
suitable modification in the technique of anesthesia, the drugs and their dosage.
Based on these information an assessment of the risk involved in the patient
is classified as follows as per the norms prescribed by American Society of
Anesthetists (ASA).
Grading of Risk (American Society of Anesthesiologists)

ASA classification does not predict outcome, but it indicates preoperative status
and suggest the degree of skill and care required to deal with the case.
ASA Grading—physical and physiological status for anesthesia/surgical risk.
ASA Grade I Normal Healthy—absolutely fit individual. Anesthesia is the only
risk.
ASA Grade II A patient with mild systemic disease—but not affecting the normal
activity.
For example: A diabetic patient on control only with diet and
exercise.
ASA Grade III A patient with severe systemic disease—that limits activity but
is not incapacitating. There may be problem during moderate to
severe stress.
For example: A diabetic patient controlled with diet, exercise
and oral hypoglycemic agents.
ASA Grade IV A patient with incapacitating systemic disease—that is a constant
threat to life. The disease affecting the systems to the extent of
restricting the activity within the household. Only restful life is
possible.
For example: A diabetic patient with complications like
retinopathy, neuropathy, nephropathy, atherosclerosis, IHD,
stroke etc, with multiple organ derangement.
ASA Grade V A moribund (close to death status) patient who is not expected
to survive for another 24 hours with or without surgical
intervention.
Fit for anesthetic

This is a vague concept. But usually implies that a patient who;
Is not unduly old
Lives a normal life
Is free from serious signs and symptoms of diseases
Is not receiving drug treatment for abnormalities
Has reasonable exercise tolerance for his age
Is not unduly over weight
Appears emotionally stable.
In the light of more detailed ASA status analysis the global concept of “fitness”
is outmoded. Physical status is close to, but not the same as “Risk”.
Described norms for the classification of ASA Gr. I, II, III, IV and V are a little
complicated and is not accepted by all the anesthesiologists in the world but it still
continues.
This scoring system is an arbitrary one. All authorities do not agree with this
Grading System because it has the following lacunae and fallacies.
The age of the patient has not been given any significant consideration. We
know that with the process of advancing age there will be progressive decrease
in organ function. So geriatric patients have different risk for anesthesia when
compared to a younger patient for the same surgery
The type of surgery and its magnitude has not been considered. Different
surgeries involve different risk factors
The degree of blood loss related to a particular surgery has not been considered
Competence of the surgical team in managing the case has not been considered
The competence of the anesthesiologist is not considered
Finally if the patient suffers from an advanced malignancy with cachexia that
has not been taken into consideration.
All the above said factors can grossly modify the grading of risk and the outcome
of the anesthetic and surgical work.
Questions are often raised concerning the chance of survival or the risk involved
in undergoing anesthesia. In 1954, Beecher and Todd found that anesthesia played
a primary or contributory role in the death of one patient in every 1500 operations.
On the other hand, in a later study Dripps and his coworkers (1961) reported an
incidence of anesthetic related death as one in 780 for spinal and one in 259 for
general anesthesia. The disparity in figures arises in part from the difficulty in
defining death caused by anesthesia and in making a distinction between the effects
of the patient’s disease, the operation, and the anesthesia.
In the stand point of the individual, “Risk” encompasses many variables. In
addition to the factors already mentioned, risk might involve the technical skills
of the anesthesiologist or surgeon, socioeconomic factors in home or hospital
environment, extremes of atmospheric conditions, or duration of operation.
Too often a patient is called a “poor risk” only after a catastrophe has taken
place; this may represent a conscious or subconscious effort on the part of a
physician to conceal errors in diagnosis or management. From a statistical or
prognostic stand point, therefore, the term “Risk” is untenable and improvement
in patient care does not lie in attempting to establish the degree of risk.
A solution to the problem is found by categorizing the relative physical

conditions of all patients as representing constants among the many variables of the
surgical experience. For example, when physical status is quantified, prognosis and
therapy for heart disease are aided immeasurably by a functional classification. Thus
the classification of the American Heart Association bears relevance to anesthetic
problems. Such a classification is helpful in designating the resilience or reserves
of the cardiac patient approaching operation, but it does not apply to other types
of diseases. For the purpose of anesthesia, therefore, the classification of physical
status adopted by the American Society of Anesthesiologists is most helpful.
So far, the risk grading was done for the surgical patient considering only the
patient factors. Now it has been established and recognized by authorities all over
the world that the risk factors are clearly contributed by the quality of infrastructures
related to the health care providing system and quality and competence of health
care providers (specialists).
Who can deny the fact that a patient graded as Risk III, when taken up by a
well experienced, skillful and careful anesthesiologist emerges out of anesthesia
relatively safer as his risk is remarkably reduced by the skill and experience, than
when taken by a relatively less experienced person.
Similarly a patient graded as Risk III when operated by an experienced and
skillful surgeon who understands the gravity of situation, comes out of the operation
successfully, the patient’s risk has been considerably diminished by the surgeon’s
skill.
A very poor risk patient operated in an operating theater with all modern
facilities for monitoring of vital functions and equipments for supporting vital
function does well than when operated in a place with poor facilities. Here, the
support available has reduced the risk.
Similarly a poor risk patient taken care in the best postanesthetic care unit
(PACU) fares very well when compared to a patient who was given an ordinary
level of postoperative care.
In general, it is accepted that patients with poor general condition may not do
very well as the patients with good general condition. Though it is easy to discuss
about the physical condition as good, poor etc, clinically it is not that easy to
ascertain the condition. But many investigators made it clear, almost as a rule,
death in a better physical category was deemed preventable from the stand point
of anesthetic management.
Patients with organic heart disease who compensates sufficiently to carry
out their daily jobs, usually tolerate anesthesia well, provided it is carefully
administered and overdosage, hypoxia, hypercarbia and hypotension are avoided.
Physical status therefore provides us with a common language and a method
of examining anesthetic morbidity and mortality. Here is a means of assessing the
relative safety of new techniques of anesthetics upon an unchanging background of
the patient’s physical competence. A poor risk classification must alert the surgical
team to employ greater safeguards. Lastly physical status provides a means whereby
one anesthesiologist’s experience can be compared with others against a common
background.
As experience is gained, the anesthesiologist will find that the preanesthetic
visit, above all else, sets the stage for a safe course both during and after operation.
To simplify this grading and understand it better, the following explanations
may be helpful.
Grade I is a patient, in whom the conduct of anesthesia may be without any incident
in the normal course of events.
‘This comparable to a man walking on a wide, well paved passage’
Grade II is a patient in whom anesthesia means definite chances of problems due
to their already deranged or compromised systems. These problems can be avoided
by careful planning.
‘This is comparable to a man walking on a narrow, uneven, irregular footpath,
where he may stumble in spite of being careful.
Grade III is a patient in whom anesthesia involves manifold increase of chances
for problems even in the hands of experienced anesthesiologists.
‘This is comparable to a man walking in the jungle where the path is not very
clear and safe’
Grade IV is a patient in whom almost surely we anticipate problems during
anesthetic procedure and we prepare and keep things ready to manage them. Still
the worst may happen even in the hands of experienced and skillful persons.
‘This is comparable to a man walking by using a balancing rod, on a rope tied
between two poles. Unless the balancing is “Simply perfect”, the man is sure to
fall down’.
Grade V is a patient in whom anesthesia and surgery are invariably impossible.
‘This is comparable to a man walking blindfolded and trying to cross a road
with heavy traffic. If he attempts that, he is sure to die.’
A proper assessment of the possible defects in the systems of the patient with
anticipation and preparation for the management of all the possible difficulties that
may be encountered during anesthesia will do a good deal for the benefit of the
patient.
Informed Consent for anesthesia and surgery

Now, an increasing public awareness and often unrealistic expectations about
anesthesia and surgery without morbidity and mortality have led to increased
litigations and related interest in patient safety.
“Any intentional touching of a person without his consent constitutes an assault
or battery”. In fact no patient can be examined without his consent. In our country
this may not be practicable though law states this.
Anesthesiologist administering anesthesia without written informed consent
signed by the patient commits an assault and he is liable for paying damages except;
In an emergency situation where the patient is unconscious
Legally designated minor
Mentally incompetent
When he is under the influence of alcohol.
“Consent for surgery need not be taken as the consent for anesthesia.”
Separate consent for anesthesia must be obtained or very clearly mentioned in

the consent for surgery.
The potential for litigation should never be underestimated, nor the stressful
effect it can have upon the doctor. It must be remembered that “Every patient is
potentially litigant”. There is a very fine, delicate line between satisfaction and
dissatisfaction. For any reason when this line is crossed, then every chance that the
physician is sued in the court of law for compensation either for psychological or
physical damage believed to be caused to him. As a matter of fact, no patient could
be examined without his consent, if done, it is a violation of fundamental right
under common law and the hospital and doctors may be sued. So when a patient
turns litigant, there is a need for a legally valid document to prove in the court of
law that the physician has done everything in the best interest of the patient and in
the best possible way. That is why an informed consent is got signed by the patient
and his relative before undergoing any procedure.
There are two questions in this regard; who is to be informed? and what is to
be informed? The simple answer is;
Inform the people responsible for accepting the treatment.
Inform the salient features of the treatment, including demerits and likely
dangers.
The basic responsibility of a physician towards the patient is to give him first
hand information about his illness without exaggerations so that he realises the
need for the advice and treatment suggested in proper sense. When a patient needs
surgical intervention it is always essential to explain the matter to him without
causing anxiety, and ask him to come for discussion with his close relative who is
responsible and interested in his well being.
When the patient and his relatives are explained about the modalities of
treatment available and the one suggested for the particular patient and the
reasons for choosing that must be clearly described in simple language for them
to understand.
In Western countries, it is emphasized, that ‘the substantial risk of grave
adverse consequences’ is explained to the patient, unless there is ‘some cogent
reason why the patient should not be informed.’ This cannot be taken as such
in our country, because many times the patient may not be fit to take decisions
physically, mentally and sometimes financially. If the physician feels that on
psychological reasons, it is not wise to discuss these matters with the patient, and
it is not advisable to disclose some details to him, the close relative may be asked
to come alone and the details are given to him.
All these are done only for making them understand and believe that the
physician is genuinely interested in the welfare of the patient. In the course of
discussions, the financial aspect including the likely duration of hospital stay and
the overall expenditure likely to be incurred in that all may be clearly explained.
Carefully avoid any exaggerations regarding any aspect of the treatment; such as
‘There wont be any pain at all’, ‘You may go back to work on the third day’, ‘You
may have to spend a small amount of money only’, are some of the examples of
exaggerations that are likely to mislead the patient who gets dissatisfied. After all
these discussions, the patient may be asked to give consent by signing the prescribed
form for consent. If the patient can’t read, the relative will read the contents and
make him understand, make a note of it in the form itself and gets the signature.
In many hospitals a bland statement carrying no significant information about
the type of surgery, anesthesia, the expected morbidity or complications is written
and the patient is asked to sign in that not even telling him that it is the consent for
surgery he is signing. The following is an example.
‘I hereby give my whole hearted consent to undergo the operation, and if any
problem or danger occurs in the course of the operation, neither the hospital
nor the doctors will be held responsible for that’.
Signature of the patient
This type of consent form is commonly used and the patient’s signature is got in
that. Such type of consent carries little meaning and has no legal value in the court
of law in case of any litigation. If the hospital and the doctors are not responsible,
who else is responsible?
A statement and consent of the following sort will be more sensible and
meaningful, and will stand in the court of law.
Consent for anesthesia, surgery and other necessary procedures
I have been examined by Dr. ………………………………(Surgeon) and he has
diagnosed that I have……………………………(the surgical problem) and after
discussion with me and explaining the essential aspect of the disease and the need
for surgical treatment in detail, he advised me to undergo the surgery. Subsequently
I have been examined by Dr. ………………………… (Anesthesiologist), to assess
my fitness for administering anesthesia for conducting the proposed surgery and
he clarified my doubts in relation to anesthesia and explained.
After having understood that, believing and knowing fully well that these
doctors will take care of me in the course of the treatment, I give my consent and
submit myself for the above said treatment.
I know that in the medical field it is not uncommon to come across unforeseen
events happening in the course of a procedure and in case any such event occurs
in my case, I authorize these doctors to resort to suitable remedial measures to
combat that.
I have carefully read the above statement and affix my signature.
Signature of the patient
Signature of the relative

All these hold good for an emergency surgery also, but the time available is
limited and that also must be explained to the patient’s relative.
Who is eligible to give consent?
It is important that the patient must give consent before premedication, as
premedicated patient is unfit to give consent and such consent is invalid
Any one of 16 years of age or more and of sound mind may give valid consent
Below the age of 16 years, the parent or guardian is required to give consent
If the parent or guardian cannot be contacted, the consent may be sought from
the court of law, in an emergency surgery from the District Medical Officer.
Who is not fit to give consent?

Patient who is drowsy or semiconscious due to any reason
Patients who suffer mental instability
Patients who are in shock or severe pain
Patients who can not understand the language in use (English).
In these patients, the parents, next of kin, guardian or court of law can give the
consent.
Jehovah’s witnesses
Though this sect of believers in Christianity were not living in our country earlier,
now quiet a considerable number of them are living to the extent of having frequent
conventions. the 2nd convention was held in Madurai on 12th November 2005
and, subsequently in the following years attended by lakhs of followers. The facts
about them must be known to the surgical team, so that when a patient belonging
to this sect comes for any surgery, suitable modifications in the approach may be
made without hurting their belief.
Their interpretation of the Scriptures has caused them to believe that ‘blood is
sacred’ and therefore a Christian must “abstain from blood”. In addition, the
Bible says that the blood removed from a body is to be disposed of, not stored
for later use. This, rules out all blood transfusions for a patient belonging to
the sect of Jehovah’s witnesses.
They may refuse to accept transfusion of blood or blood components. In elective
operations, an adult patient in good mental fitness has lawful right to demand
that he need not be given blood. In return the anesthesiologist or the surgeon
may elect to refuse the patient for care and therapy.
In an emergency, an appeal may be made to the court for an emergency writ.
In case of a minor child, the court can give a verdict to order for transfusion
against the will of the parents.
Preoperative starvation
Preoperative starvation for many hours before induction of anesthesia has been
practiced from the days of ether anesthesia. That was because of the following
reasons:
Ether was probably the only anesthetic used commonly
Ether is an emetogenic agent and almost all the patients vomited after operation
With ether anesthesia the patient is likely to be semiconscious or drowsy
during recovery
Vomiting that occurs during recovery; particularly of solid food material from
stomach had proved very dangerous
Many patients died because of aspiration of stomach contents into the airway.
It is essential to remember that the stomach is never empty even if the patient
starves for more than six hours as there is continuous of gastric acid secretion
which amounts to at least 25–50 ml/h. Excessive starvation and dehydration are
to be avoided especially in children that may cause severe hypoglycemia and
hypotension during anesthesia and cause postoperative nausea and vomiting.
It has been established that the delay can be as long as 12 hours if food is
ingested after a severe injury particularly solid food. Hence if the preoperative
starvation is taken lightly and is not strictly followed, it can cause preventable
deaths related to anesthesia. Moreover there are some factors that cause enormous
delay in gastric emptying time.
Anxiety and fear
Multiple injuries
Severe pain
Opioids (narcotic like morphine) premedication
Atropine and glycopyrrolate premedication
Pregnancy. Any pregnant woman particularly in late pregnancy is considered
as full stomach patient
Increased intracranial pressure due to any reason
Any pathology that causes intestinal obstruction. There may be retrograde flow
of intestinal contents into the stomach.
Attempts are made to hasten the gastric emptying by using “prokinetic” drugs
like metoclopramide 10 mg either by IV or IM route about 45 minutes before
induction of anesthesia.
It certainly helps in faster emptying by increasing the tone of lower esophageal
sphincter relaxing the duodenal sphincter and increasing the normal peristaltic
movements of the stomach. However this does not give any assurance of emptying
the stomach in patients with a full meal just before anesthesia. Hence preoperative
starvation is essential and cannot be dispensed with.
Similarly attempts are made to decrease the volume of gastric secretion and
neutralizing the acidity to bring the pH to a higher value by adding an alkalinizing
agent. 0.3 % sodium molar citrate orally given in a dose of 30 to 60 ml is likely
to neutralize the acid and raise the pH above 5, so that even if it is aspirated will
not cause acute acid pulmonary aspiration syndrome (Mendelson’s Syndrome).
Practical and simple norms for preoperative starvation

For elective surgeries;
Overnight starvation and taken up as the first case in the list.
Six hours for solids
Four hours for milk
Two hours for clear fluids.
Bigger children may become uncomfortable if they wait without taking food
and fluids. Hence it is accepted and advised that up to 10 ml/kg of clear fluid can
be given safely one hour prior to anesthesia. Most of it is absorbed rapidly from
the stomach leaving the stomach almost empty at the time of induction.
Canceling cases
The paramount concern is the safety of the patient.

The decisions about the fitness for surgery are usually left to the anesthesiologist.
This calls for very skillful judgment. Occasionally in the interest of the sick patient,
calculated risks may have to be taken with agreement of the patient’s relatives and
the patient. Many times the patient may not be in a position to decide.
For an inexperienced anesthesiologist there will always be a temptation to take
up every patient for anesthesia. It needs lot of experience and wisdom to curtail
the temptation and the less experienced person may seek the opinion and advice of
a more experienced colleague available nearby without feeling inferior about it. Our
entire anesthesia practice should be ruled by the application of carefully considered
decisions made on the basis of previous systematically analyzed experience.
Operations may be cancelled:
Because of the inadequate preparation of the patient, that may prove hazardous.
The anesthesiologist must be sympathetic but inflexibly firm when there is a
grave risk.
Because of the risk arising from the poor condition of the patient, the
anesthesiologist must ask, ‘Is there any way in which this patient’s condition
can be improved? ‘Is it possible to postpone the surgery?’ If the answer is yes,
the operation may be postponed.
If not, the question becomes ‘Do the probable benefits of the surgery justify
the risk of anesthesia?
If the answer is “No”, then would a different type of anesthesia be suitable?
If the answer to this negative, due to shortcomings in patient’s health, shortage
of facilities in the hospital, shortage of intensive care or nursing staff, etc.
the anesthesiologist has the right to refuse anesthesia either temporarily or
permanently. He also has the right to postpone an anesthetic (even in an
emergency case) if he thinks that the patient’s condition can be improved by
a delay. CEPOD (Confidential Enquiry Into Perioperative Deaths) found that
only one in 20 of their ‘out of hours’(night and weekend) cases were true
emergencies and concluded that many patients are put at unnecessary risk by
being operated on as emergencies.
In this situation, the anesthesiologist may well be faced by an angry patient, an
enraged surgeon or both. He may be accused of work-dodging, cowardice or
even incompetence. He will be asked for the results of many tests to justify his
clinical judgment. When insulted, he should resist the temptation to insult in
return. He should offer sympathy and constructive advice, e.g. referral to another
unit with more facilities. It must be remembered that one is not refusing the
patient an operation, but only an anesthetic in particular set of circumstances.
Subsequently the patient may be offered to another anesthesiologist (often of
less experience) without any hint of previous cancellation. It may be humbling
to discover that another anesthesiologist has ‘got away with’ the risk that one
originally thought was unjustifiable. It is not a matter for regrets.
Choice of anesthesia
It is common mistake to believe that general anesthesia is “dangerous” and regional
anesthesia is “safe”.
In a general hospital, about 70–75% of surgery is performed under general
anesthesia, and the remainder is performed under regional or local anesthesia.
Operations about the head, neck, chest, and abdomen are best performed under
general endotracheal anesthesia, since with this method the airway is free and under
control at all times. However, the final decision concerning the type of anesthesia to
be employed rests with the anesthesiologist in consultation with the surgeon.
“The surgeon should not demand or insist on a particular technique of
anesthesia, as he may not know the limitations of the technique or the capability
of the anesthesiologist to manage the particular technique”
—John Alfred Lee
In many circumstances such a demand may prove fatal.
In one incidence, the surgeon suggested that he can operate on a patient
with perforative peritonitis if the anesthesiologist could give epidural. The
anesthesiologist was not well versed with the technique and was not confident and
competent. But without telling that, he attempted to give an epidural. Unfortunately
he ended up in a ‘total spinal’. He was neither competent to give epidural nor did
he know how to manage a ‘Total spinal’. The result was the patient developed
cardiac arrest from which he couldn’t be resuscitated.
This is not an uncommon scenario, which should be avoided by clear and honest
communications.
The anesthesiologist must consider various factors before choosing the type of
anesthesia.
Age
In infants and children, obviously, general anesthesia is the method of choice.
In adults general, regional or local techniques may be chosen depending upon
the situation.
Physical status
Preoperative disease: some diseases like poliomyelitis, myasthenia gravis,
etc. The use of muscle relaxants may be problematic. In patients who receive
anticoagulant therapy, it s wiser to avoid regional techniques.
Severe impairment of vital functions: particularly reduction of pulmonary or
cardiovascular reserve, dictates careful choice of techniques.
Emotional, mentally ill, uncooperative, senile, or disoriented patients may
better be managed by general anesthesia.
An obese patient with short neck: Usually thick neck easily develops airway
obstruction after induction of anesthesia and also in postoperative period.
Adequate planning and precaution must be taken if general anesthesia is
contemplated. If possible regional technique may be safely employed.
Type of surgery
Lengthy operations require general anesthesia.
In addition procedures done in prone, lateral, or other awkward positions require
general endotracheal anesthesia to secure satisfactory control of airway and
ventilation.
The skill and the requirement of the surgeon

The presence of electrocautery, the need for muscle relaxation in abdominal
operations, the use of epinephrine solution during ear, oral, or plastic surgery, and
the skill of the surgeon are the important factors in selecting the anesthetic agent
and the technique.
The skill and preference of the anesthesiologist

An anesthesiologist who is experienced in a variety of anesthetic techniques and
drugs may apply his experience to solve the problem of choice of anesthesia. In
some situations, a particular technique and drug may be preferable than any other
in the hands of a particular anesthesiologist. Following the study of all the factors,
indications, and contraindications, the final selection of techniques and agents is
often a matter of personal experience and preference.
The patient’s wishes

A few patients insist on general anesthesia in spite of the surgeon’s assurance that
the operation could be performed under regional or local anesthesia. The patient’s
wishes are respected only if his condition permits it and the success of surgery
will not be jeopardized.
Teaching purpose
In teaching institutions the operations last longer and general anesthesia is the
choice, particularly for lengthy procedures. In these operative situations, the
instructor and resident physicians are more relaxed and can speak freely, without
the need to choose their words carefully to avoid alarming the patient. If regional
or local anesthesia is selected, however, the patient is well sedated.
Further Reading
1. Bodlander FMS. Deaths associated with anesthesia. Br J Anesthesia, 1975;47:36.
2. Brown DL (ed). Risk and Outcome in Anesthesia. Philadelphia: Lippincott, 1988.
3. Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality.
1961;178:261.
4. Lee’s Synopsis of Anesthesia, 11th edition. Butterworth-Heinemann Ltd, London.
1993;5:85.
5. Maxwell H. Preparation for anesthesia (Stevens AJ ed) Clinical Anaesthesiology,
1986;4:473.
6. Medico-Legal Reports. Appearing in Court. London: Medical Protection Society, 1989.
7. Palmer RN Anesthesia. Consent, Confidentiality. Disclosure of Medical records.
London: Medical Protection Society, 1987;43:675.
8. Textbook of Anesthesia, Aitkenhead AR, Smith G (Eds), Third Edition, 1996;18:305-15.
Chapter
Preanesthetic Medications
6 (Premedication)
Chapter Outline
Definition
v
Pharmacological Aspects
v
Premedicant Drugs
v
Effects of Premedication
v
During preanesthetic rounds, the following factors are considered and a decision
is made on the conduct of anesthesia.
Mental and physical status of patient
The patient’s problems
The surgeon’s requirements
The anesthesiologist’s own skills.
Based on the above factors a rational premedication is decided. Anesthesia is
said to have begun when these medications are given. Wise choice of medication
can pave the way for an uncomplicated anesthetic and postoperative course;
improper choice can lead onto an unsatisfactory experience for all concerned.
Definition
This is a medication comprising of a drug or more drugs chosen as per the need
of the patient in precisely calculated dose and administered preoperatively in
appropriate time and by suitable route, before induction of anesthesia. The purpose
is to have their beneficial effects on the systems of the patient in preoperative,
intraoperative and postoperative periods.
this is essential for the safe conduct of anesthesia.
This is known as pre-anesthetic medication, which may be administered by
oral, IM (Intramuscular) or IV (Intravenous) route as per the requirement of the
particular patient.
The purposes are:
To alley the fear and anxiety
To relieve the pain—if the patient is suffering
To support pain relief during anesthesia (background analgesia)
To induce sleep before anesthesia (basal narcosis)
To dry up the secretions (reduce the secretions) of salivary glands and
tracheobronchial tree—which may interfere with gaseous exchange
To suppress the undesirable reflexes from anesthetic or surgical procedures

To prevent vagal stimulation by the reflexes and its effect on heart.
Timing
Oral premedication 2 hours prior to induction
Intramuscular premedication 45 minutes prior to induction
Intravenous premedication A few minutes prior to induction
(Intravenous premedication is usually given only in dire emergency for patients in
shock, where IM drugs will not be absorbed)
Preanesthetic Medication Drugs (Premedication Drugs)

Two Groups
I. Anticholinergic/antisialagogue/vagolytic/parasympatholytic
II. CNS Depressants
Usually one drug from each group is chosen in appropriate dose and combined.
I. Anticholinergic: Antisialagogue; Vagolytic

Atropine sulphate – Dose 0.6 mg. IM
Hyoscine hydrobromide – Dose 0.4 mg. IM
Glycopyrrolate – Dose 0.2 mg. IM
Atropine sulphate and Hyoscine Hydrobromide are the alkaloids derived from
the plant ‘Atropa Belladona’
They cross the ‘Blood Brain Barrier’ and cause central nervous system effects
Hyoscine causes CNS depression
Atropine causes CNS stimulation
Glycopyrrolate is a synthetic drug. Does not cross the ‘Blood brain Barrier’.
So, does not cause CNS effects. Causes less tachycardia.
II. CNS Depressants

Tranquilizers – Relieve the anxiety (also known as ‘Ataractics’ or ‘Anxiolytics’
e.g.: Diazepam, Promethazine, etc.
Sedatives – Make the patient drowsy.
e.g: Diazepam (in larger dose), Barbiturates, etc.
Hypnotics – Induce sleep.
e.g: Diazepam (in still larger doses)
Analgesics – Give relief of pain.
e.g: Codeine, Thebaine, etc.
Narcotics – Give relief of pain and induces sleep.
e.g: Morphine sulphate, Pethidine hydrochloride, Pentazocine,
Buprenorphine, Fentanyl, Alfentanil, Sufentanil, etc.
Tranquilizer
It is a drug that depresses the central nervous system very minimally so that
the patient’s cognitive functions are not affected but his excitement or anxiety
is relieved.
Chapter 6  Preanesthetic Medications (Premedication) 67
He appears more calm and quiet. For example Diazepam in a dose of 2 mg
orally causes calmness of mind without affecting other higher functions.
So the tranquilizer is prescribed for those who have minimal anxiety and no
pain preoperatively.
Sedative
It is a drug that depresses the central nervous system a little more than the
tranquilizer, in the sense that it makes the patient drowsy so that he does not
show much interest in the environment.
Any visual or auditory inputs may not disturb him. For example Diazepam in
a dose of 5 mg orally causes depression of central nervous system to the extent
of making the patient drowsy.
Here inevitably cognitive functions are also depressed. So a sedative is
prescribed for a patient who is more agitated than simple anxiety but has no
pain preoperatively.
Hypnotic
It is a drug that depresses the central nervous system more than a sedative, that
it induces sleep in the patient so that he is totally cut off from the environment
is not aware of things happening around him.
For example Diazepam in a dose of 10 mg orally makes the patient to go into
sleep very smoothly.
So a hypnotic drug is prescribed for a patient who is severely apprehensive
with manifestations of sympathetic stimulation, tachycardia and hypertension.
This clearly indicates that the degree of central nervous system depression
required during the preoperative period differs with individual patients depending
upon their psychological build and so the choice of the drug and its dosage must
be tailored according to the individual.
Analgesic
It is a drug that relieves the pain.
This may be a drug acting on the central nervous system by blocking the pain
perception at various levels or on the peripheral mechanisms related to the
pain perception.
Its effect on the level of consciousness is either relatively very minimal or
absent, depending on the type of drug used. For example, codeine phosphate one
of the opium alkaloids (Papaver somniferum) acting on the central mechanism
of pain perception, has good analgesic property with negligible effect on the
wakefulness when compared to the other opium alkaloids.
Similarly, the Non Steroidal Anti Inflammatory Drug (NSAID) like Diclofenac
Sodium relieves pain by acting mainly on the peripheral mechanisms by
inhibiting the synthesis of Prostaglandin E and also has their direct analgesic
effect on the higher centers.
So the analgesic drug is prescribed for a patient preoperatively when he suffers
pain. Other non-analgesic central depressant drugs like diazepam do not help.
Narcotic
It is a drug that acts on the central nervous system and induces sleep as well
as provides analgesia.
Morphine was the first narcotic known to the world and it was derived from the
plant Papaver somniferrum. It is the main alkaloid from that plant. Narcotics
are now known as opioids for this reason.
They are known also as Narcotic Analgesics, now better known as ‘Opioids’.
Morphine Sulphate
The name derived from the Greek word—‘Morpheus’ the God of dreams (the
son of Somnos the God of sleep)
It is the drug that was known as the “Queen of Analgesics” and was the “yard
stick” for measuring the potency of other opioids. Its dose for an average
healthy adult is 10 mg.
Pethidine Hydrochloride
It is the first synthetic opioid
It is 10 times less potent than Morphine and the dose for an average adult is
100 mg.
Now it is clearly established that there are specific opioid receptors in central
nervous system both in brain and spinal cord as well as peripheral nerves. These
receptors have been sub typed and each having specific pharmacological effects
related to analgesic effect as well as side effects such as nausea, vomiting, etc.
CNS depressant drugs

Clinical significance
When prescribing a central nervous system depressant drug, one has to properly
assess the patient’s requirements. For example, if a patient is suffering from severe
pain preoperatively, a sedative or a hypnotic given to him is not only meaningless
but also highly detrimental for the management.
A non-analgesic drug like diazepam, administered to a patient, suffering pain
makes him violent and uncontrollable, because, these drugs depress the more
vulnerable delicate neurons of the Inhibitory Centers of brain which have inhibitory
control over the more powerful and resistant excitatory Centers and so these centers
lose the inhibitory control and patient will react to the pain without any control
and will become uncontrollable. So a careful choice of the drug as well as the dose
must be done based on the clinical situation.
A wrong choice means mismanagement from the beginning.
Points to remember while prescribing opioids:
The dose noted against each drug is the equipotent dose of Morphine 10 mg
The analgesic potency will be the same but the respiratory depression caused
by this may be more.
Extreme caution is exercised in prescribing these drugs considering other
factors which contribute for respiratory depression or else fatal depression
may be caused.
So also, the side effects such as nausea, vomiting, histamine release,
bronchospasm, constipation, etc. are related to its action on the specific
receptors.
The classification of Narcotic Analgesics

Natural and Semisynthetic
Natural Alkaloids of opium:
Morphine sulphate – 10 mg.
Codeine phosphate – 30 mg.
Papaveratum – 20 mg.
Semisynthetic alkaloids
Diamorphine hydrochloride – 5 mg.
Dihydrocodeine – 50 mg.
Dihydromorphinone – 2 mg.
Synthetic agents
Piperidine derivatives:
Pethidine HCl (Mepiridine) – 100 mg.
Phenoperidine – 2 mg.
Fentanyl – 0.1–0.2 mg. (100–200 mics)
Alfentanil – 0.25–0.5 mg. (250–500 mics)
Sufentanil – 0.005–0.01 mg. (5–10 mics)
Lofentanil – 0.005 mg. (5 mics)
Remifentanil – 0.05 mg. (50 mics)
Diphenylheptane derivatives:
Methadone hydrochloride – 10 mg.
Dextromoramide acid tartrate – 5 mg.
Mixed Agonist/antagonists:
Pentazocine tartrate – 30 mg.
Buprenorphine hydrochloride – 0.3 mg.
Butorphanol – 2 mg.
Among these different drugs, the most commonly used drugs are Morphine,
Pethidine, Pentazocine, Fentanyl, Sufentanil and Remifentanil.
What is the effect of intravenous atropine?
Intravenous antisialagogues (Atropine) does not produce the drying of
secretions instantaneously, but it takes about 10 to 15 minutes for establishing
the drying effect.
Induction, laryngoscopy and intubation will hardly take 1 to 2 minutes, so
before the drying effect starts, the instrumentation of oral cavity will be over.
But it will certainly cause unnecessary tachycardia.
Where do we use intravenous premedicant drugs?
For patients in shock:
Intravenous route is used only in emergency as in shocked patients where
peripheral perfusion is closed down; Perfusion to the muscles will be almost
totally absent.
Intramuscular (im) route is not advised particularly for CNS depressants and
Opioids because no absorption of the drug from the muscle occurs at the time
of induction. It forms a ‘depot’ of the drug in the muscle.
But when the perfusion improves after volume resuscitation during anesthesia
and surgery, improved absorption may occur later and cause high blood levels
when it is added to the intraoperative supplementations resulting in serious
Central nervous system depression which may be fatal.
Therefore, even opioids must be given in small increments titrating just the
right dose which provides the desired level of analgesia.
In these patients, intravenous atropine is seldom required as in severe
hypovolemia as the perfusion to gland is almost stopped, it stops secreting
saliva and the oral cavity is dry.
Intravenous atropine will induce tachycardia in a patient who is already in
compromise with severe compensatory tachycardia resulting in reduced
ventricular filling time and reduction in cardiac output.
Useful hints about Preanesthetic medication

The right drugs are chosen, to fulfill the needs of the individual patient.
The correct dose is calculated taking into consideration the weight of the
patient, his general condition, cardiovascular and respiratory reserves, status
of his liver and kidney functions etc. neither more dose or less dose should be
given as both are detrimental.
After giving the premedication, adequate time is permitted for absorption of
the drug to achieve the necessary blood levels before induction of anesthesia.
In a normal patient 45 minutes must elapse after intramuscular injection.
When the patient suffers severe pain, always use an analgesic drug (opioid)
in premedication.
Non-analgesic central depressant drugs (sedatives like diazepam) may depress
the higher functions (inhibitory neurons) which help the patient restrict or hold
down his reaction to pain. This will result in exaggerated reaction to pain make the
patient restless and the patient may become uncontrollable, so adding an analgesic
is essential.
The right route is chosen, with right timing for adequate action
For elective surgeries—IM 45 minutes prior to induction
For small children—oral 2 hours prior to induction
Only in life threatening emergency or shock—iv along with induction agents.
Here again the drying effect will be insufficient and it takes about 15 minutes
to get established.
Effects of Premedication
After giving a premedication, it is necessary to give at least 45 minutes for the drug
absorbed to achieve the peak blood level before anesthesia is induced. The graph
I shows how the peak is reached and the plateau is maintained.
Fig. 6.1: The ‘basal analgesia’ provided by pethidine (opioid) premedication
Note:
Premedication pethidine 50 mg IM was given and waited for 45 minutes
Blood level the drug reaches the peak in about 45 minutes and maintains a
plateau
This plateau of drug gives basal analgesia lasting for varying periods based
on the metabolic status (hypermetabolic or hypometabolic)
On this basal analgesia, intraoperative IV analgesic supplementations can be
done as and when required.
Figure 6.1: Shows that;
Induction is done 45 minutes after giving pre-medication of pethidine 50 mg
with Atropine 0.6 mg by intramuscular route.
By waiting for 45 minutes after premedication, the peak blood levels of
premedicant drugs are reached.
This is important and advantageous particularly with narcotic analgesics which
maintain the “Basal Analgesia”.
Once the peak level is reached, there is a very gradual decrease in the blood
level depending upon the rate of metabolism that maintains a plateau which
may last for a few hours. It is known as ‘Basal Analgesia’.
This basal analgesia can be easily boosted by IV supplementation of analgesics
at the time of incision and also whenever the analgesic requirement increases
according to the steps of surgical procedure.
In a normal individual, a premedication given by intramuscular route gets
absorbed slowly and steadily so that the blood level of the drug reaches a peak
by about 45 minutes with minimal variations due to the pharmaco-dynamics
and pharmaco-kinetics of the drug. Since then the peak level slowly declines
in the form of a plateau that goes on for a few hours, again depending upon the
metabolism and elimination of the drug.
In hypometabolic state, the plateau will be more horizontal and longer, e.g.
myxedema.
In hypermetabolic states, the plateau will decline very fast, e.g. hyperthyroidism
This plateau maintains a basal analgesia in case of analgesic (a basal sedation
or hypnosis in case of sedatives) that gives an advantage in the management
of intraoperative analgesia.
Intravenous supplementation with small increments of analgesics will maintain
adequate analgesia which is easy to modulate.
In severely ill patients, the peak is reached late and the plateau is high and
almost horizontal (Fig. 6.2).
The premedication of Pethidine 50 mg IM was given and waited for 45 minutes
Because of poor peripheral perfusion due to dehydration and metabolic
impairment the drug was absorbed very slowly.
So, there is a delay in reaching the peak blood level—more than an hour and
the peak is higher than normal.
This higher peak reached very late develops a plateau which is almost horizontal
and maintained for a longer period because of poor metabolism and delay in
elimination.
This may lead to relative overdose and cause delay in recovery.
Fig. 6.2: Effect of opioid premedication in severely ill patient
Figure 6.2: Shows that;

In a severely ill patient with dehydration and depressed metabolism the
absorption is delayed, the peak level is reached very late and the plateau will
be almost horizontal-lasting longer.
This leads onto a situation where the intensity and duration of the drug effect
is likely to be more causing dangerous depression.
So there is a need for reduction of the dose of premedication and also the dose
of supplementation during anesthesia.
Chapter
Clinical Anesthesia:
7 Balanced Anesthesia
Chapter Outline
The Purpose of Anesthesia
v
Guedel’s Classification of Anesthesia
v
The Triad of Anesthesia
v
Definition of Anesthesia
v
Balanced Anesthesia
v
Modern Anesthesia
v
Recovery from Anesthesia
v
Classification of Anesthesia
v
The Purpose of Anesthesia

To give the relief of pain of surgery to the patient
To provide optimum operating condition for the surgeon
Both of these must be achieved in the safest possible manner.
There is a misconception in the minds of modern physicians that ‘Ether’ is
an old anesthetic drug and as it is no longer in use, one need not know anything
about it. But the fact is, even in modern anesthesia we talk about the various planes
of anesthesia referring to the depth of anesthesia needed for a particular surgical
procedure, and if that is not achieved, the surgeons could not comfortably do the
procedure and the patient’s systems may be subjected to unnecessary stress.
To understand what is really meant by term ‘the depth of anesthesia’, whether
one likes it or not he has to understand the original classification of the stages and
planes of anesthesia described by Arthur E. Guedel.
He has described the various physiological changes that occur during anesthesia
and the physical signs which take a definite pattern with each stage when Ether
alone is used.
Hence it is essential to know the Guedel’s classification of anesthesia before
going any further to understand modern anesthesia.
Guedel’s classification of Anesthesia
Stages and Planes of Surgical Anesthesia

Though Ether was in clinical use since 1846, only in 1920 Arthur E. Guedel
recorded his observations of the changes in physical signs that occurred in such
an orderly sequential pattern when the patient inhaled progressively increasing

concentrations of ether vapor thereby the patient was taken into surgical anesthesia.
He mainly observed:
Level of consciousness
Size of pupils and their reaction to light
Degree of reflexes suppressed
Degree of muscle relaxation
Type of respiration.
The original classification of Guedel was a little complicated and difficult to

understand. So, Later in 1926 Mushin and Laycock, refashioned the orthodox
classification and made it simpler.
Stage I Stage of induction
Conscious with disorientation
Stage II Stage of reflex hyperactivity with analgesia
Unconsciousness may supervene.
Stage III Stage of surgical anesthesia
Unconsciousness—analgesia—reflex suppression
(The Triad of Anesthesia)
This is the time (stage III) , when surgery could be performed on the patient
The stage III (surgical Anesthesia) is further divided into 4 planes.
Plane 1 Superficial surgery could be done (involving skin, superficial fascia up
to deep fascia), e.g: Suturing skin lacerations.
Plane 2 Deeper work could be done (involving depth up to muscle layer, but
not retracting the muscles), e.g: Herniorraphy.
Plane 3 Deeper surgeries could be done (involving retraction of muscles and
exploration of body cavities), e.g: Laparotomy.
Plane 4 Overdosage—characterized by irregular respiration, cardiovascular
collapse and dilated non-reacting pupils (patients would require
cardiovascular and respiratory support).
Stage IV Bulbar paralysis with apnea (respiratory arrest).
In fact every one who is learning anesthesia must learn how to administer
anesthesia with ether using an open drop method with the help of a Schimmel
Busch mask and an ether dropper bottle. This will make them see and understand
the Guedel’s classification practically.
Unfortunately, in the modern set up, with an environment of regular use of
diathermy and sophistications like laser, the use of Ether may be impracticable.
Hence, ether is rarely being used nowadays and not many people have acquaintance
with its use.
However, at least there must be a demonstration of this anesthesia in a suitable
environment, done by a senior teacher on a fit young patient undergoing an
otherwise simple surgery so that every learner has a chance to see and understand
the stages and planes of anesthesia described by Guedel. The various signs of
Guedel’s classification of anesthesia are tabulated in Table 7.1.
Chapter 7  Clinical Anesthesia: Balanced Anesthesia 75
Table 7.1: Physical signs Guedel’s classification of anesthesia
Ether inhalation for surgical anesthesia depending upon the plane required may
vary from 3% to 13%. From the above discussions, we can understand that a good
surgical anesthesia has some characteristics.
Patient is unconscious
Respiration regular and adequate
Pupils moderately dilated and reacting
Reflexes are suppressed adequately (pain is abolished and surgical stimuli are
suppressed)
Muscles are reasonably relaxed.
Good Surgical Anesthesia

We have to understand that surgical anesthesia has to be modulated between plane
1 and Plane 3 of the Stage III. Whatever be the technique of anesthesia we use, any
surgery does not require the same depth of anesthesia throughout the procedure;
always needs modulation according to the requirement based on the degree of tissue
handling and reflexes induced by that process.
The Triad of Anesthesia

Obviously achieving surgical anesthesia with ether, we observe three essential
things.
The patient is unconscious
He is not feeling the pain of surgery (analgesia)
The reflexes induced by the surgical procedure are suppressed adequately. (This
aspect was originally assessed by the degree of muscle relaxation).
These three aspects were originally known as ‘The Triad of Anesthesia’ where
unconsciousness is inevitable.
But in modern anesthesia we don’t rely entirely on one inhalational anesthetic
agent like ether. Multiple drugs are being used, and so the unconsciousness
induced inevitably by ether can be modified as ‘hypnosis’ (sleep). This means, the
unconsciousness can be eliminated and the patient may be kept in a state of good
sleep.
Now condensing all that we have discussed so far about anesthesia, we
can understand that general anesthesia comprises of only three aspects that are
commonly known as “The Triad of anesthesia”.
1. Hypnosis – Keeping the patient in good degree of sleep by using a
drug which induces sleep and continuing it throughout,
e.g. Thiopentone sodium, Diazepam, Midazolam, etc.
2. Analgesia – Relief of pain by using analgesics or narcotics (opioids),
e.g. Morphine, Pethidine, Pentazocine, Fentanyl, etc.
3. Reflex suppression – Mainly by muscle relaxants supported by analgesics.
(Once pain induced by surgery is relieved by analgesics, the further reflexes
are caused usually by tissue handling and retraction of muscles).
There is a need for further explaining ‘Reflex suppression’.
The causes of reflexes during surgery and managing them scientifically are
discussed below. Reflexes may be caused by;
The pain inflicted by the surgery: This will be suppressed well with the adequate
doses of analgesics given for pain relief.
The handling of tissues: This may also mediate reflexes by stimulating pain and
thereby the sympathetic system. Good analgesia suppresses that also.
The handling of viscera: This mainly causes autonomic reflexes only as the
viscera do not possess somatic pain fibers. Depending upon the innervations,
it may stimulate either sympathetic or parasympathetic. The predominance of
sympathetic or parasympathetic varies with different situations and patients.
Theses reflexes are suitably suppressed using either anticholinergic or anti-
adrenergic drugs.
The retraction of muscles during surgery: This may stimulate reflexes mediated
through muscle spindles. During retraction of abdominal muscles, along with
the muscle spindles being stimulated, the parietal peritoneum which is densely
innervated with pain fibers is also stimulated by the broad surfaces of the
retractors to cause pain.
This situation is suppressed first by additional dose of muscle relaxant that
relaxes the muscle well so that the retractors do not badly stimulate the pain fibres
of parietal peritoneum. Then, if needed it can be further suppressed by adding a
little analgesic.
Having an orientation of the stages and planes of anesthesia and ‘The Triad of
Anesthesia’, modern anesthesia could be defined as follows.
Definition of Anesthesia
Carefully controlled reversible modification, modulation or depression of various
modalities of C.N.S. (pain perception, wakefulness, motor activity, respiration,
reflexes, etc.), ANS, (vasomotor tone, heart rate, etc.) and peripheral Nervous
System, (Mainly in Regional anesthesia), by using small, incremental, titrated
doses of various pharmacological agents to achieve a specific physiological goal.
The goal being, the protection of the patient from the detrimental effects of various
reflexes caused by pain of surgery, handling of tissues and viscera, and retraction
of muscles.
The key words are: Reversible, small, incremental, titrated doses.
The reversibility is obviously essential; otherwise anesthesia will end up in a
disaster. For that purpose, the right dose of the required drugs for the individual
patient for the specific procedure must be used, neihter bigger nor smaller dose.
Balanced Anesthesia
Balanced anesthesia based on the ‘Triad of Anesthesia’ can be well realised from
the (Fig.7.1).
The term ‘Balanced Anesthesia’ is used very frequently by anesthesiologists
and it has a very high significance in the overall outcome in a surgical patient.
The components of the ‘Triad’ are numbered as: (1) Hypnosis (sleep); (2)
Analgesia; (3) Reflex suppression.
Among the triad of anesthesia ‘Hypnosis’ or ‘Sleep’ is ‘the base’ on which the
other two components are being balanced (Fig.7.1).
The other two of the ‘Triad’ namely ‘Analgesia’ (pain relief) and ‘Reflex
suppression’ (suppression of reflexes caused by handling of tissues, viscera,
retraction of muscles, etc.) has to be balanced depending upon the requirements
of the particular surgery.
The ‘hypnosis’ or sleep is induced at the time of ‘induction’ of anesthesia and
has to last throughout the ‘duration of surgery’ up to the time of ‘recovery’. At
no time during surgery the patient is allowed to be awake.
The hypnosis is depicted as ‘the base of the triangle’ and incidentally the base
of the triangle indicates the duration of surgery. The apex of the triangle is the
point on which there is a balancing rod, on either side of which ‘Analgesia’
and ‘Reflex suppression’ are to be balanced.
Fig. 7.1: Balanced anesthesia showing the ‘Triad of Anesthesia’

In any surgery ‘Pain’ is the main component and so the number 2 in the Triad
is always ‘Analgesia.
In many minor surgical procedures the main aspect to be managed is only
pain and further reflex stimulation may be negligible or absent. This means
the adequate pain relief manages the balance well. Hence the number 3 of the
triad is always ‘Reflex suppression’.
Various surgeries induce varying degree of pain and reflexes. No two surgeries
of similar magnitude induce the same type of reflexes as well as pain due to
various reasons related to the technique, degree of handling, individual patient
variance, etc.
Hence based on the assessment of the degree of pain and degree of reflexes
induced during surgery, a fine balance is maintained by supplementing analgesia
or using methods of suppressing the reflexes as the case needs.
If the balancing is done perfectly, there will be no damage to the systems of
the patient.
This assessment is done by using the clinical parameters and monitors and it
requires good knowledge and experience.
After assessing the status of the patient, planning the technique of choice is done.
When ‘General anesthesia’ is contemplated, the drugs and the doses of drugs
appropriate for that individual patient are the chosen so that the right doses of drugs
that does not adversely affect the systems are administered and that ‘The Triad of
Anesthesia’ is achieved without causing overdosage. In other words, the right doses
in appropriate time are used and not a higher or lower dose.
In modern anesthesia, the concept is to achieve the ‘Triad of Anesthesia’ not
with one single drug, but with many drugs in smaller increments as required
(polypharmacy). Each drug usually takes care of one aspect of the ‘triad’. The major
advantage of the use of multiple drugs in such combination is that, the individual
drug in smaller doses gives the maximum benefits without causing side effects.
Definition of ‘Balanced Anesthesia’

Achieving the “Triad of Anesthesia” by using small, incremental, titrated doses of
various pharmacological agents, thereby gaining maximum benefit of each drug,
at the same time avoiding their side effects.
Modern Anesthesia
How to orient the orthodox stages and planes of the anesthesia described by
Guedel in modern ‘Balanced Anesthesia’?
Normally a patient is premedicated with an opioid and a vagolytic such as
atropine sulphate. For example, the patient is given injection Pethidine 50 mg with
injection Atropine 0.6 mg combined and given intramuscularly.
The patient is made to wait in the waiting room for about 45 minutes for the
premedicant drug to get absorbed from the muscles to reach the peak blood level.
(see the Fig.6.1 in the Chapter 6 Preanesthetic medications).
In modern anesthesia the Stage I and the Stage II can be very easily and
conveniently skipped and by-passed by the practice of intravenous induction of
anesthesia. This is usually achieved by injecting thiopentone sodium, an ultra short
acting barbiturate, intravenously in a dose of 5 mg/kg as 2.5% solution, very slowly
which induces sleep smoothly in one arm-brain circulation time, i.e. in less than
30 seconds.
In this process, Stage I (stage of induction) and Stage II (stage of excitement
or stage of hyperreflexia) that are seen with inhalational induction particularly with
ether are quietly skipped.
This is immediately followed by intravenous injection of a short acting muscle
relaxant suxamethonium in a dose of 1–2 mg/kg. This is a depolarizing relaxant
(the only one available) which produces excellent relaxation of all the skeletal
muscles of the body in 30 to 60 seconds lasting for about 5 minutes. The patient
will become apneic, when he will be ventilated with 100% oxygen through a mask.
By these steps, the patient is now taken to the Stage III, Plane 1 and passes
on to Plane-2, because the ‘Triad of Anesthesia’ is well established.
Hypnosis – is achieved by Thiopentone.
Analgesia – is achieved by the ‘Basal Analgesia’ already caused by
the opioids in the premedication.
Reflex suppression – is achieved by the excellent muscle relaxation by
suxamethonium.
Now the patient is subjected to laryngoscopy commonly using Macintosh curved
blade laryngoscope and after visualizing the larynx, intubation of the trachea is
done with appropriate size tube needed for the patient.
Here it has to be remembered that with the endotracheal tube in trachea, the
plane of anesthesia required for tolerating the tube without inducing reflexes from
glottis is Stage III, Plane-2.
At that time, the patient is fully paralyzed and is not breathing (apneic). He has
to be ventilated artificially. So the endotracheal tube is secured with adhesive tapes
and then the tube is connected to a breathing system of an anesthetic machine and
artificially ventilated by intermittent positive pressure applied on a reservoir bag
(IPPV) using a mixture of 40 % oxygen and 60% nitrous oxide.
Soon the effect of the short acting muscle relaxant suxamethonium starts
wearing off and the patient will show attempts of respiration. It is the time to
switch over to longer acting muscle relaxant of non-depolarizing type such as
Pancuronium, Vecuronium, Atracurium, Rocuronium etc to continue the muscle
relaxation.
At this time analgesics have to be supplemented in small increments
intravenously to boost the ‘Basal Analgesia’ that already exists (Fig.7.2). By this,
the patient is brought in a perfect stage of ‘Balanced Anesthesia’ with all the ‘Triad
of Anesthesia’ properly balanced in Stage III, Plane-3.
Though nitrous oxide is a very weak analgesic, it has synergism with the
analgesia provided by the ‘basal analgesia’ and ‘boosted analgesia’ and enhances
the degree of analgesia (Fig.7.2).
At this stage, the surgeon may be permitted to make the skin incision and
proceed.
Fig. 7.2: Boosting of basal analgesia with small incremental dose of analgesic
Premedication of pethidine 50 mg was given IM and waited for 45 minutes

The “Basal Analgesia” with its peak reached about 45 minutes after premedica
tion and a normal plateau
Induction is done 45 minutes after premedication
Analgesia is boosted soon after induction with 20 mg of Pethidine IV
This creates an elevated blood level and maintains a new raised plateau
With the new plateau, analgesia will be sufficient for skin incision
Subsequently, depending upon the need of surgery, and pain inflicted and the
reflexes induced, supplementation of analgesic for boosting the plateau is done
in increments of small doses (10 mg)
This will maintain a smooth modulation of analgesia needed without causing
overdosage
The inset shows the modulation of level of analgesia like a smooth curve with
variable peaks.
Shall I start? —the surgeon asks the anesthesiologist before making the skin
incision. It this question necessary?
Before starting the incision it is customary that the surgeon asks the
anesthesiologist “shall I start?” Many times this is done as a formality and even
before the anesthesiologist nods his head or even if he is engaged seriously in doing
something else for the patient, the surgeon makes the incision and proceeds with
the surgery. Most commonly, by this time (from the time of induction to the time
of incision) the plane of anesthesia sufficient for making skin incision would be
established. So, everything goes on well and no problem is encountered.
Some view this with an element of ego. Looking at it with ego or doing it just as
a formality; both may be avoided in the interest of the patient. If everything is not
fine with the plane of anesthesia at the time of starting the surgery, it would cause
serious effect on the systems. Particularly sympathetic stimulation with its effect
on cardiovascular system would make anesthetic management difficult throughout
the procedure. This may cause increased oozing or bleeding from the beginning
of surgery and creat unpleasant working condition for the surgeon and may prove
detrimental to the patient.
Hence, it is essential to understand the real significance of this question and
wait for the anesthesiologist saying ‘OK’ or ‘wait a minute please’.
The only implication is that even though the patient is induced into anesthesia, he
might not have reached the right plane of anesthesia necessary to make an incision.
If the incision is made when the patient is in inadequate plane of anesthesia,
(the preferable plane is just above plane 2) the incision itself induces severe
reflex sympathetic stimulation leading on to tachycardia and hypertension
that may be grossly detrimental to the patient particularly if he suffers from a
cardiac problem like ischemia.
Sometimes, for making the skin incision it may be adequate, but to proceed
further it may need a little additional supplementation of drugs or a little time
(a few minutes) for the drug given already to act on the receptors to produce
the desired effect.
Very rarely, immediately after induction, the anaesthesiologist might have
encountered an unforeseen problem or complication that he might be busy in
managing.
It is quite natural that the team has to wait, till things are back to normal.
The following discussion with an example may help in understanding the need
of different planes for different steps of surgery.
Taking the case as P.G.J with vagotomy, as an example the points of various
steps of surgery with their requirements of plane of anesthesia are marked in the
form of a graph in (Fig.7.3).
Medical management of acid peptic disease with excellent drugs available and
now it is rare to see a patient with the disease progressing to a stage of cicatrizing
ulcer causing duodenal obstruction. But the procedure of “Posterior Gastro-
jejunostomy with Vagotomy” is considered as a major abdominal surgery that does
not involve significant blood loss. So that is taken as an example.
In this example, a normal otherwise healthy individual is posted for posterior
gastrojejunostomy and vagotomy (Fig.7.3).
Skipping stages I and II, Stage III is reached by intravenous induction,
suxamethonium for relaxation and intubation of moves the patient to Stage
III Plane 2.
With the endotracheal tube in position—the plane required for tolerating the
tube without inducing reflexes—is stage III plane 2.
Subsequent management of anesthesia will be by modulating the plane between
plane 2 and plane 3 depending upon the need of surgical procedure.
This could be achieved by intravenous supplementation of incremental
analgesics or muscle relaxants depending upon the need.
If pain is the cause for inducing reflexes intravenous incremental supplementation
of analgesic is done to boost the basal analgesia.
Fig. 7.3: Graph II Schematic representation of various planes of anesthesia required

for various steps during ‘PGJ with Vagotomy’ surgery
In spite of good analgesia, if muscle retraction causes reflexes, intravenous

increments of muscle relaxants are given. Thus the balancing of analgesia and
reflex suppression are managed.
There may be other reflexes due to the surgical stimuli such as ‘Vagal reflex’
causing bradycardia which will be managed by incremental doses of atropine.
Similarly other reflexes will have to be controlled.
This graph shows intravenous induction and muscle relaxant almost immediately
takes the patient to Stage III plane 2.
The plane of anesthesia is modulated from plane 2 and 4.
Please note that in modern anesthesia, plane 4 of surgical anesthesia can be
safely reached without any untoward effects whereas in anesthesia with ether
only—plane 4 indicates overdosage. In fact, this is the greatest advantage of
balanced anesthesia (see the definition).
The starting points of the steps of the procedure like skin incision, laparotomy,
vagotomy, gastrojejunostomy, (anastomosis) peritoneal closure and skin closure are
indicated—where the real modulations have been made on the plane of anesthesia
according to the requirement of the procedure.
At the conclusion of anesthesia N2O is cut off, the sleep is lightened and that
makes the patient slowly to wake up. That is shown as recovery.
The endotracheal tube is still tolerated as the plane of anesthesia is still plane 2.
Now the residual neuromuscular blockade is reversed by Neostigmine and
Atropine.
This lightens the plane of anesthetic to plane1; the patient is almost awake and
doesn’t tolerate the endotracheal tube.
Gradually reflexes recover completely and the patient will be fully awake with
active protective reflexes and regular adequate spontaneous breathing.
At this point, after oropharyngeal suctioning, extubation is done (endotracheal
tube is removed).
The relationship of the various abdominal incisions and

requirement of relaxants
In the modern days, the anesthetic requirements for various surgeries are highly
complex and individualized. Particularly requirement in relation to the muscle
relaxation is highly variable with every procedure and the individual patient. There
cannot be a generalized pattern in this aspect of anesthesia. Moreover there can be
individual variations with the surgeons regarding their requirement for relaxation
for the same procedure.
Facts to be remembered
Muscle relaxants per se do not kill a patient, but lack of ventilation after a
relaxant will.
It is quite impossible to be dogmatic about the dose of relaxant.
Cadaveric relaxation is never required for any surgery and it cannot be achieved
with genuine safety.
Blocking all the neuromuscular junctions in the body is never needed and is
not compatible with life.
It is estimated that blocking about 50–60% of neuromuscular junctions produce
excellent relaxation needed for any known major surgeries.
All abdominal surgeries don’t need the same degree of relaxation; there is a
gross variation with different incisions made for exposure. In the increasing
order it may be,
–– Roof top incision
–– Right or left sub costal muscle cutting incision
–– Transverse incision in pediatric patients (muscle cutting)
–– Mid line incisions (upper or lower)
–– Para median incisions (upper or lower)
–– Grid iron incision (McBurney’s).
The anesthesiologist may discuss with the surgeon about the details of the
procedure, the likely duration of surgery, the incision he proposes to make and the
type of assistance he is going to have and based on all these decide the degree of
relaxation needed and the drug to be used.
It may be emphasized here that it is unsafe to demand for more relaxation when
the anesthesiologist has already crossed the limits. There may be other reasons
other than inadequate relaxation for the difficulty the surgeon encounters.
Recovery from Anesthesia
Definition
“It is the period from the cessation of administration of anesthesia to the time when
the patient is awake with active protective reflexes”.
Therefore, for recovery from anesthesia the key words are awake and active
protective reflexes.
It is the prime duty of the anesthesiologist to ensure that the patient has
recovered from anesthesia adequately, as he (anesthesiologist) only induced him to
sleep or unconsciousness. If only the patient is awake with all protective reflexes
he may be sent to the postoperative ward.
There are certain recovery criteria proposed by various authorities to ensure
adequate recovery. Some have proposed even twenty criteria. When we look into
them many of them are difficult to ascertain as the patient may not be cooperative
or may not be intelligent enough to understand them. There is no documentation to
prove that one set of criteria is superior to the other. Taking all the criteria proposed
by various authorities and the essential aspects of them, putting them in a nut shell,
we get the following five recovery criteria. If we are sure that all the five recovery
criteria are satisfactory, we may send the patient to the postoperative ward.
The five recovery criteria
1. Fully Awake
Patient must be fully awake. He must respond to a conversational volume of
voice by opening the eyes. He must not be too drowsy. An unconscious patient
should not be sent to the postoperative ward.
2. Fully Oriented
Patient must be fully oriented with time, space, etc. He must be able to tell his
name, his profession, his native place, the name of the relative who accompanied
him to the hospital, etc. without confusion. A disoriented patient should not be
sent to the postoperative ward. The cause of disorientation must be identified
and corrected by observing him in the recovery bed.
3. Must not suffer severe pain
Patient must not be suffering from severe pain. Mild bearable pain may be
accepted. If left undisturbed the patient goes into sleep. This status is ideal.
Though completely pain free postoperative period is possible in modern days by
using techniques like epidural opioids, patient controlled analgesia, etc. These
can be ventured only in setups where facilities for continuous monitoring is
possible.
4. Must have active protective reflexes
Patient must have his protective reflexes particularly cough reflex and deglutition
reflex well recovered. This patient may be able to protect his respiratory tract
from soiling by aspirating secretions, vomitus, etc.
5. Complete reversal of muscle relaxants
The residual effect of the neuro muscular blocking drugs (muscle relaxants) is
fully reversed with antagonists like neostigmine along with atropine. All the
skeletal muscles must have near normal power.
This can be ideally tested with a peripheral nerve stimulator. There are excellent
scoring systems available to ensure that. The suitable scoring system may be used.
The recovery criteria and other test for recovery is elaborately discussed in
Chapter 13 (Recovery room: Postanesthetic care unit).
“A postoperative patient is very quiet and sleeps with loud snoring”.
Is it a good sign? Be careful!
When there is a snoring sleep, we should never be happy about it, feeling that it is a
good sleep (sound sleep?). Particularly when a postoperative patient has a snoring,
be very careful. It may be a warning about an imminent danger of severe airway
obstruction, hypoxia and cerebral damage. How?
Snoring is caused simply by the vibration of structures of the upper airway
indicating that there is obstruction and that causes the noise. We have nothing to
be happy about any noise anywhere in the respiratory tract whether it is upper
airway or lower airway. All lead to inadequate ventilation.
When a postoperative patient sleeps with a loud snore, we have to remember
the two points;
First, any noisy breathing is an obstructed breathing.
Second, the patient may be in a very deep unconsciousness. This may be due
to residual effects of anesthetics, CNS depressant drugs particularly opioids.
Both these situations are potentially dangerous. A sub-acute hypoxia, either
during anesthesia or in the immediate postoperative period leads on to hypoxic
damage to the neurons. First the cellular metabolism is affected as these are the only
group of cells that cannot have anaerobic metabolism. Initially in response to the
hypoxia neurons swell, thereby increasing the brain mass. This is actually known
as “cerebral swelling” which is different from “cerebral oedema” that occurs a
little later as a consequence of the effects of cerebral swelling. In fact, cerebral
swelling is a reversible phenomenon. A modest increase on the inspired oxygen
concentration, and relieving the airway obstruction and aiding venous drainage of
head and neck by posture totally reverses this problem.
As per the Munro Kelley’s doctrine, when one of the three compartments
(cells, vasculature and CSF) tries to expand, in the cranial cavity bound by rigid
bony skull, it can do so at the expense of the other two compartments. Hence the
expanding brain mass will first encroach on the CSF compartment and then on
the vascular compartment resulting in compression of cerebral vasculature. This
further reduces the blood flow to the brain causing more cerebral ischemia creating
a vicious cycle. This is the early effect of cerebral hypoxia particularly when it is of
sub-acute or insidious in nature meaning thereby, mild degree of hypoxia occurring
over relatively long period compared to an abrupt anoxia.
If the cerebral swelling is allowed to progress further, then it leads onto
further reduction in blood flow, and this gross reduction in oxygen supply further
perpetuates the neuronal damage. Incidentally, during hypoxia the capillary
endothelial cementing substance get damaged, its integrity is lost, fluid starts leaking
into the interstitial compartment thus worsening the situation and that is cerebral
edema. This stage is relatively more difficult to treat.
A patient who apparently recovered well who is fully awake, may slowly sink
into unconsciousness, secondary to this delayed cerebral edema and develop airway
obstruction, start snoring which may progress to irreversible cerebral edema. This
is likely to occur commonly in first few hours of recovery period.
“This patient recovered well immediately sir. Even when we visited him after
one hour in the postoperative ward, he was very quiet comfortably sleeping with
loud snoring. Soon afterwards we got a call that patient developed cardiac arrest”.
Such statements are commonly heard in the postoperative wards when unwary
house man takes a serious situation as a simple one i.e, a hypoxic encephalopathy
is mistaken for deep sleep. The scientific background of the story is that described
above earlier.
If a postoperative patient is in deep sleep with snoring, never hesitate to arouse

him and talk to him to assess his level of consciousness and orientation. Check
whether his vital parameters are normal.
Now it is necessary to have the classification of anesthesia available.
Classification of Anesthesia
The following can be taken as a broad classification of “Types of Anesthesia”.
General Regional anesthesia Total Dissociative

anesthesia (RA) intravenous anesthesia
(sleep/ awake anesthesia
unconscious) (TIVA)
• Open • Spinal e.g.: Propofol • Interruption of “Intra-
• Semi open • Epidural infusion with cerebral association
• Semi closed – Lumbar IV Fentanyl pathways”
• Closed – Caudal • Reticular activating
Controlled – Thoracic system and limbic
Anesthesia • Nerve block systems are affected
(or) • Field block partially
Balanced • Infiltration block • Depression of
Anesthesia • IV Regional thalamocortical system
Anethesia • Profound analgesia
• Topical Anesthesia • Patient appears to be
(For mucous awake
membranes) – open eyes and
• EMLA (Eutectic eye movements,
mixture of local e.g. Ketamine HCI
analgesics) (Phencyclidine
derivative)
Chapter
8 The Operating Department
Chapter Outline
Operating Department, Operating Suite, Operating Theater
v
Access Zones
v
Patient Transport and other Activities
v
Design
v
Construction
v
Lighting
v
Pendent Services
v
Ventilation
v
Storage
v
Until the middle of 19th century, surgery was carried out in any convenient room,
frequently one which was used for other purposes. Although the introduction
of antisepsis resulted in the washing of the instruments and operating table, the
operating room itself was ignored as a source of infection. Operating rooms were
designed with tiers of wooden benches around the operating table for spectators;
thus the term operating theater was introduced! (Figs 8.1A and B). During the
early part of 20th century, large windows were incorporated, as artificial light was
relatively ineffective, and high ceilings were introduced to improve ventilation.
Additional facilities became necessary for preparing and anesthetizing the patient,
for sterilisation of instruments and for the surgeon and other theater staff to change
clothes and scrub up. In addition, the design of operating theaters changed, and
smaller theaters were introduced to facilitate frequent cleaning and efficient
decontamination of atmosphere and fumigation.
Modern operating theater incorporates the following design features:
Environmental control of varying degree of complexity, to reduce the risk of
air-borne infection. This includes microfiltered air-conditioning with pressure
gradient airflow systems, laminar flow system, etc.
Services for surgical and anesthetic equipments
Operating table or tables as the case may be for placing the patient and
positioning for surgery with modern facilities such as remote control for
changing of positions etc.
Artificial lighting appropriate for the surgeon and the anesthesiologist.
Measures to ensure safety of patient and staff.
Additional facilities required based on the type of surgical work and the quantity
of work may be provided.
Figs 8.1A and B: Old operation theater and the wooden operating table
“Organization is necessary in the operating department in order to integrate a

complexity of skills, expertise and technology in the interest of patient requiring
surgery. It must be planned round a central point—‘the patient undergoing surgery’.
“The patient is unaware of the implications of standards and care in theater
and has placed his trust temporarily in people, many of whom he will never see.
This imposes a great responsibility on those who plan and those who work in the
theater, not because they will be unrecognized but because the patient has given
them complete trust.”
From the introductory paragraph in the book “The Design and Utilization of
Operating Theaters” (Clarke et al., 1984).
In simple words, this is what good management of operating department is all
about.
Chapter 8  The Operating Department 89
Many hospitals still have to utilize facilities which are not ideal with regard
to this aspect. Often inadequate information of the real user requirements given to
the designers has created this problem. So the discussions in the following pages
deal with the basic requirements of a good operating department.
Operating Department, Operating Suite, Operating Theater
Definitions
Operating Department comprises of a unit of two or more operating suites and
supporting accommodation.
Operating Suite comprises the operating theater or operating room, together with
its immediate ancillary accommodation.
Operating Theater is the room in which surgical operation and some diagnostic
procedures are carried out.
The department must be easily accessible from the inpatient wards, intensive
therapy unit—ideally on the same floor level—and with the shortest possible route
to the accident and emergency departments. The facilities incorporated depend
upon the requirements based on the work load, the specialties served, etc.
Access Zones
Aseptic discipline is an important aspect of operating theater technique, and it is
common sense not to permit unrestricted access to all parts of the department. But
the use of the traditional terms ‘clean’, ‘sterile’, and ‘dirty’ zones, which have long
established architectural connotations are no longer appropriate. However, four
access zones are described.
General access zone

Through this zone any authorized person entering the department is admitted. This
includes the entrance, reception, patient transfer area, stretcher bearer’s room, staff
changing, department store, disposal hold and office (Fig. 8.2).
Limited access zone

It comprises of the general circulation areas between the department entrance and
the operating suite, includes postanesthetic recovery, staff base, staff rest room,
seminar room/teaching facilities, equipment parking, exit of the operating suite
(Fig. 8.3).
Restricted access zone

This zone is limited to those persons, appropriately attired (changed to theater
dress), whose presence is related to activities in the operating suite; comprises of
the operating room, anesthesia room (in our country this is not usually present),
scrub up and gowning, sterile supply and utility (Fig. 8.4).
Fig. 8.2: General access zone
Fig. 8.3: Limited access zone
Operating zone (Fig. 8.5)

It is defined as the zone which encompasses the operating area. A decreased
bacterial load can be achieved by reducing the number of persons in the operating
zone to the minimum, and ensuring sufficient directed ventilatory airflow to the
other access zones.
Airflow from the air-condition is delivered in such a way that there is always
higher flow and so higher pressure in the operating room and hence when the door is
opened, air flows out to the next zone, not in the reverse direction. Similarly, the air
from the restricted access zone flows out to the limited access zone and so on. This
prevents contaminated air flowing into the operating room. The air- conditioner for
the operating suite is delivered from the air derived from a microfilter.
The operating team needs to determine the policy regarding access to the
department. It may be decided to perpetuate a ‘red line’ policy and in that case suitable
change in the design may be made. Recent microbiological research suggests that it
is unnecessary that the staff change fully to enter the limited access zone.
Fig. 8.4: Restricted access zone (scrub area)
Fig. 8.5: Operating zone
Red line
A distinctive red line is drawn between the entrance of the department and inner
zones where patients will be transferred from the ward trolley to the theater trolley
and vice versa. This ensures that the trolley wheeled on the corridors of hospital does
not enter the theater. Staff entering this route is obliged to change into appropriate
clothing before crossing this line.
Patient transport
The safety and comfort of patients, the need to reduce the number of transfers,
maneuverability of the trolley through the hospital corridor, etc. should be taken
into account. In general, a trolley traveling in the unsterile hospital corridors should
not be allowed in to the limited access zone. In other words, the outside trolleys
are restricted beyond the “red line” (Fig. 8.5A). At this point, transfer of patient
from outside trolley to the theater trolley has to be done.
Fig. 8.5A: Sliding the stretcher from ‘outside trolley’ (unsterile) onto the ‘theater trolley’
There is no universal method of transferring patients from one trolley to

another. This may be achieved by shifting the canvas stretcher manually with the
help of poles, by using rollers, manually lifting the patient, keeping the stretchers
side by side and lifting with the help of poles, or moving the stretcher over a
specially designed railing on the trolleys by keeping them end to end and locking
it in position. There is increasing awareness of the risk of injury to the operating
theater personnel as a result of lifting patients, and thus increasing tendency to
install transfer systems which do not require great physical effort.
All trolleys in operating theater should be equipped with oxygen and this should
be administered routinely to patients during transfer from theater to recovery room
at the end of the procedure, if general anesthesia has been used.
Any arrangement that best suits the hospital depending upon the availability
of space may be accepted and protocol formulated accordingly.
Supplies
Policies for supply must be clearly defined. The supply may be derived from the
Central Sterilizing and Disinfecting Unit and some special equipment such as
endoscopic instruments may be sterilized in the theater itself. Decision will have
to be made whether all supplies should enter through a single main entrance, or
alternatively via a separate entrance to the main department store.
Disposal
The method adopted for the identification and disposal of used items for destruction
or recycling, and to provide a disposal hold at a convenient point is needed.
Administration and teaching

Nursing and medical administrative facilities must be considered. Provisions must
be made for the senior nurse-incharge, theater sister, and medical staff who wish
to write up patient’s notes. Discussion room must be provided.
Catering
Most commonly accepted practice is a basic service for preparation of beverages
and limited snack, which may include vending machines. This may be augmented
by provision of hot meals from the hospital main kitchen.
Cleaning
Internal construction materials must be such that it minimizes the maintenance
and cleaning costs. Cleaning policies must be decided at the planning level and
suitable store for keeping cleaning material and equipment should be provided.
Design
Operating facilities must be centralized in the operating department rather than
dispersed in the hospital, since this has been shown to be a most economic approach
in terms of engineering services, the use of equipment and deployment of personnel.
The operating department must be so constructed that it is separate from general
traffic and air movement in the rest of the hospital. Care must be taken to prevent
transmission of noise from the ventilation plant situated nearby.
Movement of patients is made easier, if there are good planning relationship
between the operating department, surgical wards and intensive therapy unit (ITU),
with easy access to the accident emergency (AED), and radiodiagnostic (X-ray)
departments. Convenient access is required to the sterilizing and disinfecting unit
(SDU) and laboratory facilities.
Ventilation should be on the principle that the direction of airflow is from the
operating suites towards the department entrance. This has been discussed in detail
earlier. There should be no interchange of air movement between one operating
suite and another.
Construction must be such that a high standard of cleanliness may be obtained
and maintained. All surfaces should be washable and all joints between walls,
ceilings and floors curved to facilitate cleaning.
No constructed storing spaces like cupboards should be there, they are dust
traps.
Types of operating departments

The policy considerations in the design have been discussed which may be applied
for new constructions, modification of existing one or upgrading an existing one.
But basically operating theaters are classified into three main categories:
1. Single theater suite containing operating theater, scrub up and gowning,
anesthesia room, trolley preparation, utility, and exit bay, plus staff change and
limited ancillary accommodation.
2. The twin theater suite with facilities similar to No. 1, but with duplicated
ancillary accommodation immediate to each operating theater, sharing ancillary
accommodation which sometimes includes a small post-anesthesia recovery
area.
3. Operating departments consisting of three or more operating suites. Ancillary

accommodation will include post-anesthesia recovery, reception, stretcher
bearers’ place, sterile store, and staff change.
Construction
Operating room is designed around its centrally situated operating table with
overhead lighting and ventilation systems. The ideal shape is circular, but it is
inconvenient, so most operating rooms are square or nearly square. In 1980, The
Royal College of Surgeons of England suggested that the floor area must be 625 sq
ft (approximately 58 sq meters) and no smaller than 484 sq ft (approximately 45 sq
meters). Theaters for specialized surgery may require larger area to accommodate
bulky equipments.
All piped gases and electrical sockets must be positioned close to the head end
operating table either through booms or by pendants. Electrical cables should not
lie across the floor.
Walls and Ceiling

All rooms in operating suite should have impervious wall and ceiling finishes
able to withstand wet cleaning. Walls should withstand damage by trolleys and
mobile equipment; additional protection buffers should be placed especially
vulnerable points. Suitable finishes include sprayed plastic paint, an epoxy resin
type of paint, and plastic sheet with welded joints for walls. Where movement of
the structural wall is anticipated, then plastic laminate, steel or glass sheets which
can be supported independently of the walls should be used. The joints between
these sheets must be sealed to prevent penetration of moisture during cleaning.
Although ceramic tiles are durable provided the structural wall remains uncracked,
they are not ideal because new building movement may cause crevices which can
eventually form at the joints.
A semi-matt wall surface reflects less light than a highly gloss finish and is less
tiring to the eyes of the theater team. With this in mind the color must be chosen.
Walls, ceiling and floor must be light in color. Pale green or blue is acceptable as
strong colors will distort the color rendering of light sources and should be avoided.
Floors
These must be able to withstand the rolling loads of heavy operating tables
and mobile X-ray machines. The surface should be slip resistant under wet
conditions and impervious to frequent cleaning with scrubbing machines. Flexible
thermoplastic sheet or tiles with welded joints are acceptable, but the joint should
not run across the theater. The adhesives used must be strong enough to prevent
waves in the floor finish when heavy objects are moved on the floor. Antistatic
floors (conducting floors) are not needed in the modern theaters as now flammable
anesthetics are not in use.
Lighting
Some amount of natural day light is always preferable. Wherever possible, high
level windows which give a visual appreciation the “outside world” should be
provided in the operating theater. Alternatively this can be achieved by means of
borrowed light from the windows across the corridor.
If external windows are fitted, solar heat gain or loss which may affect the
control of environmental conditions must taken into account. It may be necessary
to give triple glazing of windows.
Artificial light fittings for the corridors are always flushed with the surface of
the roof and should not cause areas of shadows (Fig. 8.6).
Color corrected general artificial lighting which permits true color rendition of
the patient’s skin tones is required, together with ceiling mounted operating theater
table luminaire. If the main supply fails, there must be ‘No break’ emergency
supply which provides adequate lighting and power to complete the operation
and in emergency to commence another. In an emergency unnecessary lights are
avoided and the lights switched off as soon as possible. This will help to reduce
the generator load or battery drain. This system must be fully automatic and must
be tested frequently.
Sometimes mobile emergency luminaires are used. This incorporates a trickle
charger which is connected to the socket, this keeps the batteries continually charged
and the luminaire ready for immediate use. Battery should be completely sealed and
the charger must be away from the operating zone as far as practicable for fear of fires.
General lighting
This should be provided by color corrected (which emits all the colors of spectrum
or at least red and related colors) fluorescent lamps, recessed or surface ceiling
mounted and arranged to produce even illumination of at least 500 Lux at working
height with minimal glare. There should be means for dimming or switching off at
the time of procedures like endoscopy as that requires dark environment.
Operation area (task area) illumination (Operation lights)

Choice of operating luminaire will have to take into account such factors as the
color emitted, light intensity and pattern, shadow reduction, elimination of heat
and maneuverability.
Fig. 8.6: General lighting of corridor

Color
Color corrected general light is advised. For operating light, the surgeon must be
able to differentiate between normal and diseased tissues and perform tasks with
materials having little color contrast, for example using blood soaked sutures. The
color quality of light most generally acceptable for this purpose is in the region
of 4000 kelvin (4000 K). Operating luminaires are available at color temperature
between 3600 K and 5000 K which should meet most personal preferences.
Intensity/pattern
The density of light achieved in the operating area at operating table is directly
dependent on the intensity of light directed upon it. With a luminaire approximately
100 cm (40 inches) from the task area, the light pattern should be at least 20 cm
(8 inches) in diameter, with brightness at the pattern center of between 50,000 and
100,000 Lux, and at least 15,000 Lux at periphery. This is very high compared
with the normal general intensity of 500 Lux in the working area. The main reason
for such large levels of brightness is because of the high light absorption and low
level of reflectivity of the tissues; a large proportion of light is simply absorbed
and thus contributes for poor visibility (Fig. 8.10).
Shadow reduction
Operating luminaires are designed to produce beams of light from a variety of
angles, so that when the light source is partially obscured by the surgical team’s
heads or hands, the task area is still illuminated. Total shadow reduction is
undesirable, because if all shadows are eliminated, there will be no ‘modeling’ of
contours and three dimensional perception for the surgeon is lost.
Elimination of heat
It is important that the heat from the beams of light is kept as low as possible
to prevent ‘drying out’ or burning of delicate tissues. Most modern operating
luminaires reduce this heat by means of dichroic reflectors (cold mirrors) combined
with heat absorbing reflectors or filters.
Dichroic filters reflect visible radiation as a light beam but transmit the heat
producing infrared energy backwards for dissipation by the luminaire housing.
The radiant heat emitted by a luminaire light beam providing 100,000 Lux will
produce a temperature rise in the field of surgery approximately 12o C above the
ambient temperature. British standard norms stipulate that this temperature should
not exceed 22°C.
Maneuverability
The ceiling mounted operating luminaires should be suspended and counterbalanced
in such a way that it is easy to move, allows multiplicity of positions, horizontal
and vertical and does not vibrate or drift once it has been positioned. Some form of
the removable, sterilizable handle should be provided which enables the surgical
team to make minor adjustments if required.
The terminology
Lamp: Refers to the filament lamp (Fig. 8.7).
Luminaire: Refers to the operation theater light whether suspended from the
ceiling or on a mobile stand (Fig. 8.9).
Task area: This is the area, usually circular, illuminated by a luminaire. The
principle of task area illumination is shown in (Fig. 8.10) and the actual
illumination on the operation table is shown in (Fig. 8.11).
Types of operating Luminaires

Single lamp Luminaires (Fig. 8.8)
These luminaires have a optically perfect single large reflector (Fig. 8.8) with
properly positioned single halogen lamp (Fig. 8.7).
These are available both in wall mounted models as well as ceiling
mounted models and as single unit or double unit models depending upon the
requirement.
Fig. 8.7: Halogen lamp for use in luminaires
Fig. 8.8: Single lamp luminaire

Fig. 8.9: Multi lamp multi reflector luminaire
Fig. 8.10: The principle of ‘Task area’ illumination
Fig. 8.11: Task area illumination

Pendant services
The pipeline supply in the operating theater is best provided in two ceiling pendants
to minimize the hazard of trailing leads; one for the surgical team and the other for
the anesthesiologist. These pendants may be rigid although telescopic, retractable
versions provide adjustment in height and simplify the connection of the hoses and
electric cables (Fig. 8.12).
These pendants have outlets for oxygen, nitrous oxide, compressed air, central
suction and multiple electrical outlets for running monitoring devices, infusion
pumps, etc. The retractable pendants have at least two shelves for keeping
monitoring equipments.
Ventilation
The ventilation system provided in the operation department has three main
functions:
1. To control the temperature and humidity of the operating suite.
2. To dilute contamination by airborne microorganisms and expired air anesthetic
gases.
3. To provide acceptable air movement within the operating suite such that
the transfers of airborne microorganisms from less clean to cleaner areas is
minimized. This is achieved by the supply of heated or cooled, humidified,
clean air to the operating suite.
–– Aerobic culture using a non-selective media should indicate that not more
than 35 microorganisms—carrying particles are present in 1 cubic meter
(m3) of the supply air.
Fig. 8.12: Retractable pendant service for pipeline gases and electrical outlets
–– During surgical operations and preparation of surgical trolleys, the

concentration of airborne particles contaminated by microorganisms in the
operating theater averaged over a five—minute period should not exceed
180 per m3.
–– The optimum environmental conditions for various operating department
staff and patients can be a conflict.
–– Amongst staff, the subjective response to temperature and humidity will
depend on factors such as the mode of dress, activity and proximity to direct
radiant heat from the operating luminaire.
–– Patients are susceptible to hypothermia during an operation under anesthesia;
this is due to disruption of their heat balance mechanism resulting from
lowering of metabolism, inhibition of muscular activity, and dilatation of
peripheral blood vessels. There is a loss of body heat by evaporation which
can be increased by administration of dry anesthetic gases, the exposure of
viscera and moist tissue surfaces.
–– A survey indicated that the anesthesiologists generally preferred temperatures
2.5°C warmer than their surgical colleagues. Considering the patient safety,
surgeon’s comfort and overall comfortable environment, a compromise is
needed.
–– The British standard (DHSS Design Guide Ventilation of Operating
Department,1983) recommended the following:
- The air conditioning system must be capable of maintaining internal
temperatures of 20°C in summer and 22°C in winter in all but the most
extreme outside conditions.
- In order to ensure optimum selection of conditions, the controls for
adjustments of temperature between 15°C and 25°C should be available.
All modern air conditioning machines have all these most sophisticated
provisions available.
- The relative humidity should be allowed to vary within the range of 40
to 60% under normal working conditions, but capable of being set to a
minimum of 50% saturation when flammable anesthetics are used. The air
velocity should be maintained in the range of 0.13 to 0.25 m3 per second.
- The air distribution equipment in anesthesia room, post-anesthesia
recovery and operating theater should prevent the patient from being
exposed to unnecessary, draughts.
Plenum turbulent airflow system

A medium velocity system of this type is most commonly employed, and if
maintained and balanced correctly, is reasonably efficient. Air at roof level is drawn
by means of fans through a series of filters, is humidified, cooled, or heated, and
forced through ducts into the operating suite through high level diffusers fitted on
the walls or ceiling.
The air pressure in the operating suite should always be greater than that in
the rest of the department to prevent movement of contaminated air from dirtier to
cleaner areas. The highest pressure of air must always be in the preparation room
(sterile instrument trolley preparation room) when used for preparation of sterile
trolleys (35 Pa), followed by the operating theater (25Pa), scrub up and anesthesia
room (14Pa), exit bay (3Pa), and utility/disposal (– 5 or 0 Pa).
Extraction of air from the preparation room and operating theater is not
mechanically aided. Air from the operating theater flows through the small gaps
around closed doors and also spills via balanced pressure relief flap valves set in
the walls or lower part of doors. These flaps are hinged and weighted, so that the
air is allowed to pass in one direction only—any tendency for a back-flow
of air from less clean area will cause them to close. Approximately 10% of
the air supply to the operating theater is provided by the air flowing from the
preparation room.
It is relatively easy to maintain an outward flow of air through the gaps around
closed doors. Difficulties arise when turbulence is created by a person passing
through the doorway, or the door is left open which allows the transfer of air between
the two areas separated by the door way. There is a temperature gradient between
the operating room and scrub up room and from this room to the exit bay, in the
range of 1 or 2°C. In the normal circumstances, the flow rates that occur should
protect the operating theater from the ingress of contaminated air when only one
door is open at a time. If several doors to an operating theater remain open during
operations, this may seriously interfere with the outward airflow pattern. The
total airflow supply to an average operating theater should be between 0.75 and
1.0 m3 per second, providing 20 to 30 air changes at a velocity of 0.05 to 0.2 m
per second.
At this point, it is essential to remember that when the door of the operating
room is opened, the other doors must not be opened at the same time and when
the other door is open for any reason, operating room door should be kept closed
and not be opened unless the other door is closed.
Research has identified potential hazards to staff because of pollution of the
theater atmosphere by anesthetic gases. In particular there is evidence which points
to a risk of spontaneous abortions amongst operating department staff. It is therefore
recognized that no staff member should be exposed to anesthetic gases for at least
the first three months of pregnancy. Good, well-maintained ventilation systems will
to a great extent dilute atmospheric pollution. In addition if, scavenging system is
available, that will remove the expired anesthetic gases.
Ultraclean ventilation system

This concept originated from the development of ‘clean room’ for the assembly of
electronic components and in aerospace industries.
Advances in the surgical techniques such as joint replacements, organ transplant,
and microvascular surgeries in the past few decades necessitated the development of
this system. This system incorporates a microbacterial filter which has a minimum
efficiency of 90%, which is sufficient for stopping bacteria carrying particles and
unidirectional laminar airflow system (Fig. 8.13). The principle and mechanism
of laminar airflow which maintains unidirectional sterile airflow on the operating
area and the air exit is at the bottom near the floor (Fig. 8.14).
Fig. 8.13: An operation theater with the provision of laminar airflow
Fig. 8.14: The principle and mechanism of laminar airflow
Storage
Special mention about the storage of essential items in the operating theater has to
be made, as this is, most often, one of the neglected aspects in the stage of planning.
Main supply store; this should provide storage for both sterile packs in protective
outer wraps and bulk clean supplies. For convenience of deliveries it is situated
near limited access zone.
Clean supply will include some pharmacy items.
Equipment store; A centrally positioned store is required for bulky mobile
equipments not in daily use such as operating microscope, laser, and bypass pumps,
etc. the store should be zoned to protect equipments, some of which are delicate
and costly. Mobile X-ray equipment and image intensifier should be parked in a
separate space, with easy access to a mains power socket for charging batteries.
Gas cylinder store; Storage of limited quantities of ready to use cylinders (a type
cylinders that could be fixed to an anesthetic machine) of oxygen and nitrous oxide
for anesthesia machine is required.
Further Reading
1. Aitkenhead AR, Smith G. The operating theater environment. Textbook of Anesthesia.
Churchill Livingstone, Edinburgh, 1996.
2. Arrowsmith lWM. Design aspects of ultraclean ventilation system for operating rooms.
Journal of Sterile Service Management, 1986;17–8.
3. Arrowsmith lWM. Ultraclean ventilation system for operating rooms. Health Service
Estate, 1985;55:65–8.
4. Ayliffe SA, Babb JR, Collins BJ, Lowbury EJL. Journal of Hygiene (Camb), 1969;
67:4174–25.
5. Bartlett D. Operating Theater Lighting. NAT News, 1978:24.
6. Berry EC, Khon l. Introduction to Operation Room Techniques, 4th edition, New York:
A. Bleninston Publication, McGraw-Hill Book Co, 1972.
7. British Standard Institution. 1986;BS 4533: Section103.2 London BSI.
8. Clarke P, Dixon E, Freeman D, Whitaker M. Nurse staffing and training in operating
suite. The design and use of operating theaters, edited by IDA Johnston and AR Hunter.
London: Arnold 1984.
9. Department of Health And Social Security. Operating Department. Health Building
Note, 1989,26.
10. Department of Health and Social Security. Ventilation of Operating Departments: A
Design Guide, 1983.
11. Houghton M, Hudd J. Aids to Theater Technique, 4th edition. Chap1, London, Bailliere.
12. Johnston IDA, Hunter AR, Lidwell OM. Bacteriological considerations. The design
and Use of Operating Theaters, London: Arnold, 1984.
13. Lidwell OM, Lowbury EJL, Whyte W, Blowers R ,Stanely Sj, Lowe D. Effects of ultra-
clean air in operating on deep sepsis in the joint after total hip or knee replacement: A
randomized study. British Medical Journal, 1982;I:285.
14. Lovett PA, Halstead MB, Hill AR, Palmer DA, Ryan TJ, Sonnex TS. Color rendering
of fluorescent lamps for use in hospitals Pro. CIEW, 20th Session, 1983;1:E 28/1-2.
15. Male CG. Theater Ventilation. British Journal of Anaesthesia, 1978;50:1257.
16. Medical Research council, DHSS and Regional Engineers Association, Joint Working
Party. Operating Theater Requirements, London, MRC? DHSS, 1972.
17. Rait A. Planning Operating Departments, the principles of Commissioning. NAT News,
1982;11–14.
18. Weeks J. Planning Operating Departments, the planning of operating suites, NAT News,
1982;9–12.
19. Williams M. Planning Operating Departments, commissioning theaters, NAT News,
1983;15–18.
20. Wyon DP, Lidwell OM, Williams REO. Thermal comfort during surgical operations,
Journal of Hygiene, London1 5–18.
Chapter
Theater Asepsis and
9 Equipments Sterilization
Chapter Outline
Operating Theater Environment and Asepsis
v
Definitions
v
Theater Sterilization Schedule
v
Types of Equipments
v
Cleaning and Sterilization
v
Cold Chemical Methods
v
Methods Available
v
Physical Methods
v
Chemical Methods
v
Gamma Rays
v
Ultraviolet Rays
v
Sterilization of each Group of Equipments
v
Tuberculosis Infection
v
Tests for Adequacy of Sterilization
v
Central Sterile Supply Department (Cssd)
v
“There is no substitute for perfect asepsis for safe and successful surgery and it
is maintained by the sincere efforts of dedicated scrupulously strict nurses in the
operating room.”
— William Newman
Operating theater environment and asepsis

The Nurse-incharge of the operation theater takes care of the overall asepsis of the
operating environment. She takes all the care to ensure all precautions are taken to
prevent the pollution of theater atmosphere by bacterial contaminations of any type.
Though, the Nurse-incharge supervises and guides the work, all the other
paramedical staff that includes skilled workers like Nursing assistants, Anesthesia
technician, Nursing students posted in the operation theater will contribute for the
work.
General workers, stretcher-bearers, and sanitary workers will help them to do
the manual work related to it under supervision.
Maintaining an aseptic environment is the overall responsibility of everyone
working in the operating theater and thus the team spirit and work starts at this
level.
Chapter 9  Theater Asepsis and Equipments Sterilization 105
When there is any doubt regarding the sterile status of the instruments, the fact
must be informed to the surgical team very honestly and sincerely. They must be
politely requested to either postpone the surgery or wait until the instruments in
doubt are sterilized again satisfactorily. Everyone takes such an advice in the right
sense.
Asepsis in operating rooms means no pathogenic organisms that can cause
infection are passed on to the patient from any thing belonging to the operating
room including the ambient atmosphere of the operating room and the related areas.
Although reaching this excellent goal is essential and mandatory in this modern
era, it is in no way that easy to achieve. That needs the best coordination, co-
operation and understanding work by all the members of a dedicated team belonging
to the operating theaters. Anything less than that will only be inferior and everyone
in the team must be made to feel and realize it. In fact the major responsibility of
coordinating this important job is universally shouldered by the anesthesiologist
worldwide. The salient aspects related to this subject are discussed in the following
pages.
History
Until middle 19th century, surgery was carried out in any room, frequently the one
which was used for other purposes.
Although the introduction of antiseptics resulted in washing of the instruments
and operating table, the operating room itself was ignored and never recognized as
a source of infection.
“Asepsis” which means “no infection” is the term used in modern days which
evolved gradually from “Antiseptics”, “Disinfectants”, and “Germicides”.
Operating rooms were designed with tiers of wooden benches around the
operating table for spectators; thus the term ‘operating theater’ was introduced.
Early 20th century large windows were incorporated, as artificial lights were
ineffective and high ceiling was introduced to improve ventilation in the operating
room.
Later more complex facilities were incorporated to improve the quality of work
and environment, more for sterilization of equipments (instruments). The design
changed and smaller theaters were introduced for frequent cleaning.
More than anything else, the successful outcome of any surgical procedure
primarily depends upon the perfection in asepsis reached both in intraoperative
and postoperative periods.
The following discussion is about the maintenance of aseptic atmosphere in
the operating room as well as achieving perfection in the operative procedure.
This chapter essentially explains the principles and the methods of maintaining
theater asepsis. This includes the methods of preventing pollution of atmosphere as
well as perfect sterilization of instruments and equipments used for all procedures
in the theater.
Hospital infections
Cross infection from antibiotic resistant pathogens poses a serious threat to
every patient in the hospital. About 50% of the hospital patients acquire an
infection in this manner. Majority of these nosocomial infections are caused by

gram-negative bacilli and this type of gram-negative bacteremia occurs with
a frequency of 1 per 100 admissions in the hospitals and a 30% fatality rate.
Though the rate has come down in the modern era of newer antibiotics, this is
the main source of infection in surgical patient.
Within two days, one third of intravenous catheters become colonized with
bacteria. Bacteremia occurs in 1% of patients who have an intravenous catheter
in place for more than 48 hours. The hazard of sepsis increases to 5% as the
length of time the catheter remains in place increases. In spite of the advances
in antibiotic therapy for infections and the development of more aseptic patient
care methods, infection continues.
The infectiousness of a disease is equal to the virulence of the pathogenic germs
plus the total dosage of the pathogens minus the resistance of the patient. An
effective approach to fighting infections in the hospital is to decrease the number
of bacteria below the level necessary to produce infection. (this is known by
the term ‘Disinfection’).
Source of infection
1. Patients, personnel, anesthesia equipments, air-conditioning equipments,
cleaning techniques and Intravenous fluid therapy equipments.
2. Inhalation therapy equipments, nebulizers and ventilators.
The anesthesiologist and his assistant have contacts with many ill people in
the hospital, especially within the operating room, delivery room, and intensive
care units. They must share in the responsibility for decreasing and controlling
cross-infection. They cannot control the virulence of the pathogenic bacteria or
the resistance of the patient, but they can control the total amount of pathogens in
the atmosphere.
It has been clearly demonstrated both in the operating room and in the laboratory
that all parts of anesthesia breathing equipment can become contaminated and cause
cross-infection. It is well known that mechanical ventilators and humidifiers used in
inhalation therapy can be responsible for cross-infection. It has to be accepted that
in general, adequate care is not taken care in this aspect even in many sophisticated
centers (WHO report 2009).
Apart from bacterial infections most serious infections are some, such as HIV,
Hepatitis B transmitted by contact with blood and body fluids. Hepatitis B, C and
D are transmitted by blood.
The means available for eliminating this hazard may be grouped into three,
namely;
Decontamination
Disinfection
Sterilization
For maintaining asepsis in the operating room now the following systems are
almost universally followed.
Disposable sterile equipments must be used whenever possible.
Non-disposable equipments should be decontaminated with 2% glutaraldehyde,
washed with soap and water and left in glutaraldehyde for further 3 hours.
Contaminated floors and surfaces should be washed with 1% hypochlorite
solution (kills HIV virus and Hepatitis B virus). Gloves must be worn during
washing.
It has been recommended that a bacterial filter must be placed between the
endotracheal tube and the breathing system to prevent cross-infection from a
patient with undiagnosed infection.
Effective bacterial filters without causing undue resistance to breathing are
available.
Definitions
Antiseptics
These are chemical agent which kills or restricts the growth of the microorganisms.
These agents can be used on humans (living tissues), e.g. alcohol, chlorhexidine.
Disinfectants
These are chemical agent which kills or restricts the growth of the microorganisms
in general, used mainly on instruments and equipments but cannot be used on living
tissues, e.g. phenol, formalin, glutaraldehyde.
But some antiseptics which are commonly used on humans for disinfection
of skin may be used as disinfectants for instruments, e.g. ethyl alcohol, isopropyl
alcohol.
Germicide
Usually talked about phenyl compounds. These are chemical agents which
kill microorganisms whether vegetative or spores. These may be antiseptics
like chlorhexidine with alcohol or any disinfectants (an antiseptic may be used
as a germicide but not vice versa), e.g. phenol, lysol, dettol, formaldehyde,
glutaraldehyde, etc.
Detergent antiseptics
These are chemical agents that reduce the surface tension, thereby loosen and
soften the material so that an antiseptic can penetrate and act more efficiently on
the microorganisms, e.g. cetavlon cetrimide (antiseptics may be detergents but
not vice versa).
“An antiseptic can be a disinfectant, but a disinfectant need not be an
antiseptic.”
Theater Disinfection Schedule
Daily
Washing with a disinfectant or germicide.
Wiping with chlorcresol, lysol, dettol or any chemical of this nature.
This is for floor and wall up to a height of 5½ feet.
Carbolising
Wiping the walls and all the articles with a cloth dipped in anyone of the
disinfectants.
Article means all the items like trolleys, Mayo’s table, operation tabletop, etc.
Swabbing the floor with a disinfectant solution after each surgery is completed.
Weekly washing
Washing the theater thoroughly and wiping with cloth soaked in disinfectant.
This is done, after making suitable arrangements for protection of switchboards,
lights, etc.
First washed with plain water and then with 1% lysol in water and wiping out
thoroughly with a swab.
In modern operating rooms with false ceiling, and the air-conditioning ducts
passing above that, washing of roof need not be done, but effective fumigation
is enough.
Commercially available disinfectant—Bacillocid Special

Formaldehyde-free disinfectant cleaner with low use concentration
Is a surface and environmental disinfectant
Has a very good cleansing property
Has bactericidal, viricidal, sporicidal and fungicidal activity (Fig. 9.1).
Composition
Glutaraldehyde 100 mg/g.
Benzalkonium chloride (benzyl-C12-18-alkyl dimethyl ammonium chloride)
60 mg/g.
Alkyl urea derivatives (didecyl dimethyl ammonium chloride) 60 mg/g.
Fig. 9.1: Bacillocid solution for disinfecting equipments and floor

Advantages
Very cost effective
Good material compatibility
Excellent cleaning properties
Virtually no residues
Provides complete asepsis within 30 to 60 minutes.
Areas of application
Bacillocid is suitable for the disinfectant cleaning of washable surfaces using
the wet-wipe-procedure
Especially suitable for economic short-term disinfection in risk areas that are
likely sources of infection.
Weekly fumigation with Formalin

Now weekly fumigation with formalin is commonly practiced.
1. Weekly Fumigation with formalin is done by any one of the following methods:
Micronebulizers (OTI care or other similar devices)

For a room of 1000 cubic feet size 350 ml of 40% formalin in water is nebulized
The fumes are left in the room for 6 hours and then cleared by exhausting.
Boiling
For one cubic foot 0.5 to 1 ml of 40% formalin is used
Keep the calculated formalin in a basin on a stove near the center of the
operation room and allow it to boil by using a stove
The stove may be a kerosene or electric stove
Electric stove is ideal because after sometime when the formalin fumes fills the
air, the kerosene stove may be put off before completely boiling the formalin
Electric stove can be effectively used with a switch control from outside the
operating room
The efficacy of this process is uncertain at temperatures below 20oC and relative
humidity below 70%
Separate sterilization must be used for each room in the operation theater
complex.
Potassium permanganate and formalin

The required volume of formalin is calculated (0.5 to 1 ml of 40% formalin
for one cubic foot)
Potassium permanganate is added to it (50 gram to 1 liter)
50 gram of potassium permanganate is added to 1 liter of 40% formalin kept
in a basin at the center of the operation theater.
Immediately after adding this, the formalin furiously fumes to fill the atmosphere.
Therefore, after adding the potassium permanganate, one has to rush out and
close the door.
The fumes are retained in for 6 hours and then exhausted

10% ammonia is used to neutralize residual formalin after fumigation.
Ultraviolet Rays
Special lights emitting ultraviolet rays are fixed on the roof of operating theater
in appropriate angles, so that the whole operating room area and equipments
are exposed to UV Irradiation for 12–16 hours daily (Fig. 9.2)
It is commonly used for overnight sterilization of the operating room
The switch control for the light is usually kept out side the operating room for
operating the light without being exposed to the rays
Exposure to ultraviolet rays may cause damage to the skin (sunburn) and retinal
damage may also be caused
In the morning, after switching off the light, the air is exhausted to remove the
radiation and the personnel are permitted to enter only after one hour
Clean sterile water can be generated from a unit where water is passed through
ultraviolet rays to destroy the bacteria
This UV sterilized water is used for washing hands during “scrub up”.
Patients and personnel must be protected especially the skin and eyes as it may
cause sunburn and damage to retina.
Ultraviolet Rays air cleaning system

Though efficient ventilation of the operating theater atmosphere is known to reduce
the bacterial load of operating room air, it depends on multiple factors that can
badly affect the efficiency.
More number of people moving in and out of the operating room
Frequently opening the doors
Members of the team coughing, sneezing or talking very loudly, which may
cause droplet dispersed from their oral cavity contaminating the air
Keeping more than one door open simultaneously, allowing bulk movement
of air in the opposite direction.
Fig. 9.2: Ultraviolet lights

It is practically difficult to prevent some of the above factors. Hence, the
variations in the addition of bacterial load to the atmosphere are highly variable
resulting in chances of more surgical wound infection.
Ultraviolet rays in the correct intensity has remarkable bactericidal property
If the microorganisms are exposed to the UV rays for a sufficient time, they
are killed
UV rays kill the microorganisms by destroying their DNA
Doing this effectively requires direct exposure to a high intensity UV rays,
because the rays cannot “kill” what it cannot “see”
The dose is measured in microwatts per square centimeter
Pathogens like fungi can be destroyed by 10 to 50 times more energy than that
needed for bacteria
When properly designed, high levels of UV irradiation can be attained in a
chamber with no exposure to the persons in the room.
Because ultraviolet rays can cause potential damage to retina and skin, UV
lights were in use for overnight sterilization of the air in the operating room by
exposing it during night.
In the recent past, use of ultraviolet rays during working hours to reduce
the bacterial load have been introduced in the form of UV air cleaner where the
personnel are protected from UV radiation.
These are known as “UV Air cleaners” and it is very useful equipment
(Figs 9.3A and B).
These are compact units, having a source of high-density ultraviolet rays in a
well-protected chamber. It is so constructed that it does not allow the rays to
escape out
There is no harm possible to the personnel working in the theater from UV rays
A high-intensity UV rays (23,000 microwatts/cm 2) generated by suitable lights
in a well-protected chamber
a Wall mounting model b Desktop model
Figs 9.3A and B: Ultraviolet rays air cleaner

A blower drives the ambient air of the operating room through this chamber
continuously at a regulated speed, where it is exposed to the UV rays and the
microorganisms are killed
The air passes through a filter before entering the chamber and so the air coming
out of the chamber will be particle-free and sterile
As this process is continuous, the air in the operating theater is repeatedly passed
through this unit, the microorganisms are destroyed, and thereby the bacterial
load in the air will be reduced significantly
The antibacterial effect is little more than 90%
Hence, it is a very simple and effective way of reducing the bacterial load in
the theater atmosphere, while the surgery is in progress. When the presence
of many personnel is essential for the work inside the room, the bacterial
contamination of air contributed by their exhalations is more. This equipment
is especially useful in such situations
These units are available in various capacities as per the requirement of the room
(cubic feet) and in two types; wall mounting and table top type (Figs 9.3A and B).
Assessing the adequacy of asepsis

Assessment of adequacy of asepsis in the theater ambience is carried out fortnightly
or at any specific interval for ensuring that the asepsis maintained consistently. It
is as important as the adequacy of sterilization of surgical instruments and other
equipments.
Microbiological monitoring of operation theater atmosphere

Checking is done by Microbiological test using ‘Petri’ dish to assess microbial
contamination in the air. When incubated, the bacteria multiples, each bacteria will
become a colony that can be seen as a small spot on culture medium in the ‘Petri’
dish. The growth and number of colonies present are assessed after incubation.
The number must be within the specified limits (Fig. 9.4).
Fig. 9.4: Petri dish incubated showing the number of colonies

Microbiological Monitoring in other sites of Operation Theater

Swabbing and culture for bacteria in specific areas in operation theater is carried
out once a month. The culture must be negative. The sterile swabs used for that
purpose is shown in Figure 9.5.
Specific places where swabs are taken for culture are;
Operation table at the head end
Over head lamp
Four walls of operating room and ceiling
Floor
Air-conditioning duct
Microscope handles
Instrument trolley
Drugs trolley
Anesthetic machine
Wheels of bed, if any
Wash basin and sink
Cupboard.
Sterilization of Equipments
Types of equipments
All the equipments used in the operation theater are potential transmitters of
infection from one patient to the other. If not properly handled, they can be
responsible for surgical sepsis and can cause serious morbidity to the patient.
Based on the chances of transferring infection they are classified into three groups.
They are;
Low risk equipments
Intermediate risk equipments
High risk equipments.
Fig. 9.5: Sterile swabs in a sterile tube for bacteriological monitoring

Low risk equipments

Those are pieces of equipments that come in contact with intact skin and are not
introduced into the patient, e.g. O2 therapy mask, probes of non-invasive monitors
(pulse oximeter finger probe).
Intermediate equipments
These are pieces of equipments that come in contact with the skin and mucous
membranes. For example, anesthetic face mask, oropharyngeal airway, laryngeal
mask airway, etc.
Endotracheal tube though can be classified in this group, for an obvious reason
of safety is classified into high risk equipments.
High risk equipments

These are pieces of equipments that come in contact with a break in the skin,
mucous membrane or introduced into a sterile body area. For example, all surgical
instruments, equipments used for invasive procedure, endotracheal tubes, IV
catheters, CVP catheters, etc.
Mucous secretions carry organisms. Similarly any equipment that enters into
the vascular compartment must be absolutely sterile. According to the type of
equipments the method varies.
Usually Decontamination is the basic step that may be followed by either
Disinfection or Sterilization.
Cleaning and Sterilization

The equipments used on patients must be absolutely clean
Reusable equipments must be free from organic contaminants infecting them
and must not cause cross contamination and infection
The organic contaminants like pus, blood, tissue debris, dried body fluids, etc.
may harbor the organisms or may serve as medium for their growth.
Steps
Cleaning and decontamination
Disinfection
Sterilization.
Decontamination (Cleaning)
Physical removal of infected organic matter like tissue debris, pus, blood, etc.
on which the organism live. Microorganisms cannot thrive if no organic matter
is present. The organisms may be in dormant form or in active form depending
upon multiple factors. Decontamination can be done by using the following steps.
Thorough soaking
Scrubbing
Washing with detergents.
Decontamination is essential for subsequent disinfection or sterilization
whichever is following, as the presence of foreign material (organic material) will
make the process of sterilization inefficient and incomplete.
The decontamination can be done in as follows:
i. Manual
• Thorough cleaning by scrubbing with brush
• Using soap and water for cleaning infected material
• A detergent antiseptic may be a better choice for loosening organic matter
• Thorough rinsing with clean water for flushing the contaminants.
ii. Automatic Washing Machine
• This usually combines the processes of cleaning and disinfection one by
one.
• Like a dish washer, this is provided with racks for holding equipments. It
uses treated clean water with detergents and cleans articles by pumping
water as multiple jets.
• Then disinfection is done by circulating water at 80° C and holding it for
10 minutes (pasteurization).
iii. Ultrasonic Washer
• The instruments to be decontaminated are kept immersed in a water bath
and are subjected to ultrasonic vibrations which clean the debris and
contaminants that cannot be reached by a brush (Fig. 9.6).
• Decontaminates smaller pieces of instruments with intricate shapes such
as instruments meant for microsurgeries that are difficult to clean by other
means.
The process of “decontamination” is sufficient for “low risk” items that come
in contact with the skin and are not introduced into the patient. For example, face
mask.
Fig. 9.6: Ultrasonic washing machine

Disinfection
This is removal or killing of most or all infective organisms with the exception
of the most resistant ones such as spores
Those that are not destroyed are reduced to the level that is harmless to health
(not infective). This is considered adequate for “intermediate risk” items
These are equipments that come into intact skin or mucous membrane. For
example, face masks, airway, etc.
Methods of disinfection
Cold chemical methods
Pasteurisation
Boiling.
Sterilization
This is the ultimate step for asepsis
Destroying all microorganisms including bacteria, viruses, fungi and their spores
This prevents passing on infection to patients
Essential for all “High Risk” items which means, those items that come into
contact with a break in skin or mucous membranes or introduced into the body.
General classification of Methods of sterilization of equipments

Physical methods (heat)
Chemical methods
Gamma rays
Ultraviolet rays
Filtration.
Physical methods of Sterilization (Heat sterilization)

The bacteria are destroyed by this method along with viruses and spores
The time required depends upon the temperature and also the size of the particle
Heat sterilization can be either moist heat methods or dry heat methods.
1. Moist heat
Moisture increases cellular permeability
Heating coagulates the protein of bacterial cell
This is the mechanism of killing the bacteria.
i. Boiling
• Boiling the instrument in water at 100° C for 15 minutes in a sterilizer (Fig. 9.7)
• Kills all the vegetative forms of bacteria, but spores may escape.
If the pressure inside the container of water is increased, the temperature
also will rise. Besides, this will destroy the spores by better penetration
because of increased pressure and temperature. (It will be possible in
specialized equipments known as “Autoclave” which will be discussed later)
ii. Pasteurization
• Heating the article to 70°C for 20 minutes or 80°C for 10 minutes
• This can be best done in a water bath
Fig. 9.7: Boiling water sterilizer
• Efficiently disinfects material that may be damaged by boiling

• The temperature and the timing of pasteurization must be rigidly adhered
to, otherwise disinfection would be ineffective.
iii. Autoclave (steam under pressure)
• Boiling water in an open container allows the temperature of the water to
reach only to 100°C, which cannot penetrate the spores to kill them. Hence,
higher temperature is needed, that can be achieved by closing the container
airtight, which raises the pressure also inside the container.
• This higher temperature and pressure cause penetration of heat into the
spores and kill them. An equipment known as “Autoclave” has the provision
for this where the temperature and pressure can be modified as required.
The principle of working:
The chamber has a steam jacket, where the steam pressure is maintained at 32 psi
and so the temperature is maintained at 134°C (Figs 9.8 to 9.10).
When the sterilizing chamber is opened for loading the bins, the pressure drops
to zero (atmospheric), but when the bins are loaded and the airtight door is closed,
the pressure rises rapidly and the temperature also reaches 134°C in a few minutes
time, as the outer steam jacket maintains this high temperature. The pressure inside
the chamber may be modified (lowered if delicate objects like rubber goods, glove,
etc. are autoclaved) by adjusting the pressure release valve.
Steam at 134°C with 32 psi pressure for 3½ minutes is applied
Then the steam is evacuated and sterile air is filled to remove moisture
This cycle takes 10 minutes
This method kills all the organisms both vegetative and spores, provided steam
is allowed to penetrate all the parts
The instruments are packed in the ‘Bins’ povided with perforations on their
body. These perforations permit better penetration of steam into the ‘Bin’
After sterilization these perforations are closed by the device called as ‘belt’
of the bin
This method is ideal for metal instruments and fabrics like theater linen, etc.
that can stand the temperature as well as the pressure.
Fig. 9.8: Small autoclave (single bin)
Fig. 9.9: Huge autoclave with motorized door for sterilizing in CSSD
Fig. 9.10: Table top autoclave (flash sterilizer)

The common method of operating autoclave
After loading and closing the chamber, air is exhausted from the chamber and
replaced with steam at 134°C and 32 psi pressure is applied into the chamber
for 3½ minutes
After the sterilization is over, the steam is evacuated and sterile air is filled to
remove the moisture. Then the steam is evacuated and sterile air is filled to
remove moisture
This cycle takes approximately 10 minutes (only raising the temperature and
pressure and at the end evacuating the steam and drying)
The bins are kept in this temperature and pressure for the required duration
for sterilization
It needs 15 minutes for instruments and 30 minutes for linen to be sterilized
For rubber and plastic, duration of 15 minutes at 121°C may be enough, or
else it may be damaged
Sharp instruments will be dulled and become blunt by this process (so an
alternate method, low pressure autoclave may be used)
After giving adequate time for removing the moisture, the chamber can be
opened to remove the “sterilized bins” to be taken to the operating theater or
the central store of sterile instruments
At the end of the procedure, the instruments and other articles must be dry
This cycle can be repeated to continue sterilization of many sets of bins.
Bins for Autoclaving

Common method is using special container known as ‘Bins’, which have
perforations for the penetration of steam (Fig. 9.11).
After sterilization, the device called as ‘belt’ of the bin closes these
perforations.
Fig. 9.11: Bins with perforations for autoclaving

• Note the perforations for the steam to penetrate easily
• After autoclaving, the perforations are closed by moving the belt and locking it.
Ideal Packing
The articles are packed in the bin with sufficient space in between for the
passage of steam
It should not be tightly packed. A tight packing of linen will hamper penetration
of steam uniformly to reach all articles to sterilize them
Instruments need not be packed, but can be kept in a bag of linen
Sterilization of instruments needs 15 minutes and for linen it is 30 minutes
For rubber and plastic 15 minutes at 121°C may be enough
At the end of the procedure the articles must be dry
As an alternative, the instruments can be packed in thick linen, and then covered
with crepe paper that allows penetration of steam (Figs 9.12A and B)
The properly packed instrument packs or bins are loaded in special racks meant
for that and are then loaded into the autoclave (Figs 9.13A and B)
The soft spongy items like gamgee pads, bandages are packed in perforated
basket and are loaded into the sterilizing chamber of autoclave.
a b
Figs 9.12A and B: Packing the instruments for autoclaving: (A) Note that the instruments
are packed in thick linen folded in such a way to open it without touching the contents;
(B) Then this pack is packed in crepe paper folded in the similar way and “Signaloc”
indicator tapes are stuck on it
a b
Figs 9.13A and B: Loading the packed instruments into the autoclave: (A)Note that the
packed instruments are loaded in a rack mounted on a trolley for loading; (B) Cotton
bandages, gamgee pads, etc. are loaded in perforated basket containers on a rack
mounted on a trolley
Advantages of autoclaving
Most efficient, simple and the most cost effective method
Suitable for even smallest hospital as different sizes are available
Rapid method of heat sterilization in common use
Spores are destroyed
Linen and rubber are not destroyed even after repeated autoclaving.
Testing Adequacy of Sterilization in Autoclave

Test tape (Signaloc tapes) is stuck inside and outside the bins. The change
in color indicates adequacy of sterilization
The change in color indicates that bins have gone through autoclaving and the
temperature had gone up to change the color
It may not assure that the contents are sterile, because multiple factors like
packing, the exact temperature, and the pressure inside the chamber, duration
of exposures influence the adequacy of sterilization
Hence, in everyday practice, the honesty, sincerity and the involvement of the
technician who operates the autoclave only can assure that
Culture by using a test bin. Once in a month one bin is taken and sent to
bacteriological examination
Ideal method is to introduce bacillus subtilis (resistant one) in the bin and
autoclave. A sealed small plastic test tube contains the spore of bacillus subtilis.
The medium for growing the bacteria also is kept in the tube but separately in a
breakable container. After autoclaving this test tube is removed, and by crushing
the container of the medium the spores are mixed with the medium and sent for
culture. If the autoclaving is adequate there will be no growth seen. This test is
done at specific intervals to assure adequacy of sterilization.
Low Pressure Autoclave (Steam under low pressure and

temperature)
This technique is highly suited for delicate heat sensitive instruments and sharp
instruments
Delicate instruments get spoiled and sharp instruments get dulled and become
blunt by regular autoclaving at 134°C and 20 psi pressure. To prevent such
damage low pressure autoclave is used
Water boils at 73°C if the pressure is reduced to 290 mm of Hg
This pressure is sub-atmospheric (1/3 atm). So steam is formed at 73°C
This is known as low temperature steam (LTS)
This steam at low temperature and pressure penetrates the objects well, but
takes longer time, about 2 hours
This effectively destroys the vegetative forms of all microorganisms but spores
may be spared
When this temperature and pressure are reached, formaldehyde may be injected
into the chamber to destroy the spores also
This process is known as ‘low temperature steam and formalin’ (LTSF)
Once instruments are loaded and the program is set, the machine would
automatically carry out the process.
Dry Heat
Hot Air Sterilizer (Oven)
The temperature inside the sterilizer is maintained at 160°C by a thermostat
At 160°C it needs one hour for sterilizing dry objects
The temperature and time can be programmed and the door could not be opened
before program is completed (Fig. 9.14)
Most suited for powders, greases, glass syringes, etc.
Flames
Ophthalmic instruments are directly heated on flames (approximately 1000°C)
This technique is not commonly employed.
Chemical sterilization methods (Cold methods)

Many organic agents are capable of killing bacteria and viruses. Factors modifying
their effects are concentration, duration of contact, and individual potency. Most of
them are liquids but there are some gases and vapors also. Chemicals kill bacteria
by coagulation or alkylation of proteins.
The criteria to be satisfied in the chemical methods are:
It must be non-corrosive
It must be non-irritant to the skin
It should be stable for storage
It should penetrate grease and fibers
It should be nontoxic to the patients and users
It must be economical
Usually they are disinfectants but must be capable of killing the spores
Used for objects which are damaged by heat and that cannot be sterilized by
autoclaving
Non-sporing bacteria, viruses, tubercle bacilli, spores are resisting destruction
in this order. In other words, they are destroyed in this order.
Fig. 9.14: Hot air sterilizer

Advantages
Most of the methods are technically easier
Suitable for equipments that are damaged by heat sterilization
Sophisticated chemical methods like ethylene oxide achieve perfection in
sterilization.
Disadvantages
Some of the chemicals act only on exposed surfaces and so may not reach all
areas
Some react with metals so may not be suitable for some metal objects
Some impregnate with the materials such as rubber and plastics and could not
be removed and may cause tissue irritation
The residual chemicals form a source of irritation
May destroy rubber and plastics.
The chemical agent may be
1. Vapor – Formaldehyde.
2. Gas – Ethylene oxide or propylene oxide
3. Liquid – Ethyl alcohol, isopropyl alcohol, glutaraldehyde, etc.
1. Vapor (Formaldehyde)
Specially designed formalin chambers with multiple trays for storing
instruments are used (Figs 9.15A and B)
Para formaldehyde tablets contain 95% formaldehyde in polymerized form and
contain 5% residues. These tablets are kept in adequate number in each tray
These tablets release vapor by slow and sustained sublimation (solid turning
into vapor)
Hence, the action of formalin tablets depends upon the rate of sublimation
Formaldehyde vapor requires moisture for action
May take 2 hours for adequate sterilization
May be useful for endoscopic equipments
Alternatively, 40% formalin can be nebulized in the chamber.
a b
Figs 9.15A and B: Formalin chamber: (A) The chamber has many sliding trays to load the
instruments; (B) Note that the second picture shows the endoscopy instruments loaded
with adequate number of formalin tablets
2. Gases (Ethylene Oxide or Propylene Oxide)

Ethylene oxide is a universally used gas. Though propylene oxide had been
introduced, it has not come into common use
A colorless gas with high bactericidal power
Very toxic to inhale. It is a neurotoxin, may cause neural damage
It is a highly inflammable gas in any concentration in air or in oxygen. In 3%
concentration it becomes explosive
It has high penetrating power
Does not harm any objects, even delicate gadgets, prosthesis, intraocular lens,
etc.
Kills all organisms by alkylation of proteins, but action is slow—8 to 12 hours
10% of gas in carbon dioxide or freon gas with relative humidity 30–50% is
used effectively
It is ideal for complicated and delicate apparatus like pump oxygenator, Ruben
valve, plastic pump tubing, teflon prosthesis, grafts, catheters, etc.
After completing sterilization, 6 post-sterilization vacuum pulling is done
to clear the ethylene oxide from the chamber. Storing the sterile packs in an
‘aerator’ continuously flushed with microfiltered hot air for 6 days is essential
to remove the absorbed ethylene oxide
Used for sterilizing ventilators used in infected patients. But after sterilization
flushing the air passages with sterile air for 4 hours is essential to remove the
residual gases. Otherwise it may prove dangerous
This needs equipment looking like autoclave and cylinders of ethylene oxide
(Figs 9.16A and B)
These cylinders containing the mixtures (ethylene oxide and CO2) are identified
by aluminium color painted body with shoulders colored red (red indicates
explosive) below that circular band of yellow (yellow indicates poisonous)
a b
Figs 9.16A and B: Ethylene oxide sterilizer: (A) The cylinder contains10% of ethylene
oxide with 90% CO2; (B) A conventional ethylene oxide sterilizer
At room temperature this gas can be a liquid with a boiling point of 10.6°C
In modern sophisticated programmable ethylene oxide sterilizers 100% ethylene
oxide cartridges are used (Fig. 9.17).
Programmable Automatic EO Sterilizer

100% ethylene oxide cartridges are used in it (Fig. 9.19)
In this, the EO cartridge is placed in the slot meant for that (Figs 9.18A and B)
The equipments to be sterilized are loaded with enough space around for the
gas to spread and the door is closed
The program is selected on the panel; once the program is fixed, the door will
not open until the program is completed
Fig. 9.17: Modern ethylene oxide sterilizer
a b
Figs 9.18A and B: Automatic programmable EO sterilizer: (A) The sterilizer in closed
position showing the program panel and display; (B) The sterilizer in open position and
the cartridge placed
Fig. 9.19: The EO cartridge
First, the air in the chamber is evacuated and steam is pumped and sprayed into
the chamber to raise the humidity to the required level
At this point, a pin from below punctures the EO cartridge and the gas is
released into the chamber with vacuum and penetrates into all the containers
of instruments
Once the sterilization is completed, the gas is evacuated through a special exit
that opens at a high level above the building (to prevent the gas being breathed
by people working there)
When the whole program is over, the door can be opened and the sterilized
equipments can be removed aseptically and transferred to the aerator where
HEPA filtered air circulates to remove the residual gas to the required duration
(usually 6 days).
3. Liquids
1. Phenol
2. Iodine
3. Ethyl alcohol, isopropyl alcohol
4. Hexachlorophene
5. Chlorhexidine gluconate
6. Glutaraldehyde 2% (cidex)
7. Iodophores
8. Chlorine compounds
9. Detergent antiseptics
10. Hypochlorite 1%.
Phenol
1–5% used to clean the surface of equipment
It is highly corrosive. So should not be used on surfaces, which are coming in
contact with the patient
Does not kill the spores (not in common use now).
Iodine
0.5–2% in alcohol solution was used as tincture iodine—one minute for
sterilization
Tincture iodine may irritate the skin
Povidone iodine (Betadine) is non-irritant and is in aqueous solution, needs 3
minutes for sterilization.
Ethyl Alcohol
70–80% is more efficient than absolute alcohol (100%)
Isopropyl alcohol 50–70% used in catgut sterilization in the pack itself.
Hexachlorophene
50–70% solution was commonly used; now it is not in use
One of the antiseptics which work in the presence of soap.
Chlorhexidine Gluconate
0.1% aqueous solution disinfects endotracheal tube if immersed for 20 minutes
0.5% in 50% ethyl alcohol sterilizes the skin of operating area in 30 seconds
Remarkable effect in 0.5% in alcohol in sterilizing the skin without irritation
is the reason for this agent being universally used as an ideal hand scrub for
surgeons.
Glutaraldehyde (Cidex)
The only actual sterilizing fluid available, as it destroys spores also
2% solution is made alkaline by adding 0.3% sodium carbonate and activated
Activated solution maintains its potency for 15 days
Kills bacteria in 15 minutes and spores in 3 hours
Used for sterilizing endoscopes, endotracheal tubes, breathing equipments, etc.
Equipments after sterilization must be rinsed thoroughly in clean sterile water
before use, because it is a skin irritant.
Nu–Cidex
A newer agent that has come into use which is similar to Cidex
It is a solution of stabilized, buffered, peracetic acid
It acts as an oxidizing agent both on the cell wall and the nuclei of micro
organisms.
Iodophor
It is an organic iodine compound where sodium is loosely combined with surface
acting material.
Chlorine Compounds
Commonly used for floor sterilization.
Detergents
These are quaternary ammonium compounds
They lower surface tension of solution
Good against gram positive and gram negative organisms. For example,
cetavlon cetrimide.
Gamma rays
It is derived from a cobalt 60 source
Lethal dose for bacteria is 2.5 mega rads
Tubes, catheters, endotracheal tubes, plastic equipments, all can be sterilized
in a transparent plastic envelope with an indicator
Needs protected special environment. Hence cannot be installed easily as it is
highly expensive
In our country, it comes under the control of Atomic Energy Regulatory Board,
Government of India and it is highly expensive to install a unit
A National Institute can do this for consumer with an indicator on the bag
Most common method used for sterilizing disposable equipments such as
endotracheal tubes after manufacturing
In our country, this was available only in Bhabha Atomic Research Center
(BARC) in a unit named “ISO MED”
Now recently in 2004, it is made available in Dankuni, West Bengal. This has
been established under technical collaboration with Board of Radiation and
Isotope Technology
It has been monitored by Atomic Energy Regulatory Board, Government of
India. The unit is known as “VIKIRAN”. This plant employs highly effective
radiation technology to eliminate microorganisms in healthcare and food
products.
Filtration (Bacterial filters)

Microfilters are used to prevent the entry of microorganisms into the breathing
system of ventilators, anesthetic-breathing systems, etc.
The efficiency lasts for specific number of hours, e.g. 200 hours. After that they
have to be changed by a new one
They will filter any particle down to a diameter of 0.5 microns
They can be autoclaved. The efficiency is 99.99%
Millipore filters are used for repeated injection through the indwelling epidural
catheters to prevent microorganisms getting into epidural space
Modern bacterial filters are available with 0.22 micron size (Figs 9.20A and B)
Filters that offer least resistance to breathing are available. These filters can be
placed between the endotracheal tube and the anesthetic breathing system in
case of undiagnosed infections.
For open case of pulmonary tuberculosis

Endotracheal tubes and suction catheters are disposed off.
If it cannot be done,
Kept in 0.1% chlorhexidine solution for 1 hour
Then they can be cleaned and scrubbed with soap and water
After this they can be sterilized by boiling or autoclaving
Boiling for 3 minutes will kill the tubercle bacilli
Immersed in 2% glutaraldehyde (cidex) for 1 hour
a b
Figs 9.20A and B: Bacterial filters used in breathing systems
Ideally water’s canister is to be used as this enables easy sterilization by auto-

claving.
Hepatitis B
This virus is not killed by boiling but killed by autoclaving and gamma radiation
Chemical sterilization—1% hypochlorite is helpful.
Tests for adequacy of sterilization

Inclusion of Browne’s tube or temp sensitive tape will give indication about
the appropriate temperature reached. Color changes in Browne’s tube when
autoclaved
Indicator stickers are available that could be used in every pack to show the
change of color in ethylene oxide sterilization or in gamma rays sterilization
For autoclaving, Signaloc tapes are used (indicator method to check adequacy
of autoclaving)
After the sterilization all these things are kept in a sterile room, where people
who wear sterile dress enter
This room will have different set of instruments for different procedures in
different numbers
Once the soiled sets are received in one counter, fresh new sterile sets are issued
at a different counter.
For linen—the laundry is the department in charge in a similar way.
Central Sterile Supply Department (CSSD)

Maintaining asepsis in the operating theater provides an interesting challenge to
our profession in future. The surgical team must be familiar with the pathogenesis
and pathophysiology of presenting infection and with those that may occur as a
complication of anesthesia and surgery.
This knowledge of the members of surgical team especially the Anesthesiologists
and Anesthesia technicians can make a difference in terms of limiting transmission
and modifying the infectious process and its sequelae.
There is a Central Sterile Supply Department (CSSD) or Sterilizing and

Disinfecting Unit (SDU) situated near the operating department to provide a
total hospital service
Actually, this department has three sections namely, cleaning, packing and
sterilizing.
Different hospitals have different systems.
Sterile pack system

All the items required for an operation are prepared together in one or several
packs as a set
The packing may be in Bins or packed in other materials such as Linen, Crepe
paper, or Non-woven fabrics.
Theater sterile supplies

The instruments are packed in different bins and sterilized
Similarly, the various linen items are packed and sterilized in large bins
These bins are kept in the sterile store of the operating theater
Before each surgery, the nurse prepares the instrument trolley for each operation
with suitable instrument and linen.
If the sets for each procedure are supplied from central sterile supply department,
the used sets are delivered at a point and new sets are received at another point.
However, the complete department must have the following areas divided by the
type of work performed.
Soiled truck unloading area
Processing area for soiled instruments; mechanical and ultrasonic washing
machines
A tray assembly area
Supplementary pack assembly area
Prepared pack and tray holding area
Sterilizing area
Processed store area
Administrative area
Linen inspection and repair area may be incorporated in this or may be a part
of hospital laundry.
Utilization
Sterile instrument sets are kept ready for use in the operating department store
for delivery when required to each operating suite
After use, sets are returned immediately to the Central Sterile Supply
Department for processing and sterilization
New sterile sets are received from the sterile supply counter and taken to the
operation theater
The sets of instruments are primarily packed in linen in a way that can be easily
opened and this pack is covered in a second packing with a special craft paper,
sealed with stickers, and sent for autoclaving after keeping on a tray
Soiled instruments returned from operation theaters are received in a separate
counter for cleaning, disinfecting and packing for sterilization
Sterile packs are issued only in exchange for soiled sets after checking and
verification
The department houses many large autoclaves, large bins for bulk sterilization,
all types of sterilization devices like hot air oven, low-pressure autoclave, etc.
Sets of instruments in large numbers, modern mechanical automatic cleaning
devices, washing machines with steam generators and other equipments in
adequate quantities depending upon the load of work.
Further Reading
1. Ayliffe GAJ, Coates D, Hoffmann PN. Chemical Disinfectants in Hospitals. London:
Public Health Laboratory Service, 1984.
2. British Standard Institution. Specification for paper bags for steam sterilisation for
medical use. 1982;BS6254, BSI.
3. Maurer IM. Hospital Hygeine. London: Edward Arnold, 1985;79.
4. Sills GA. Sterilisation, Nursing, 1986;1(3):109–110.
5. Whyte W, Bailey PV. Reduction of microbial dispersion by clothing. Journal of
Parenteral Science and Technology, 1984;39:1.
Chapter
Operating Table and
10 Positions for Surgery
Chapter Outline
Operating Table and its components
v
Positions for Surgery and the Caution Required
v
Supine or Dorsal Recumbent Position
v
Trendelenburg Position
v
Gall Bladder and Liver Position
v
Lateral Position of Extension (Kidney Position)
v
Lithotomy Position
v
Position for Abdominoperineal Resection of Rectum
v
Pads used for Positioning
v
Who is responsible for the maintenance of the operation table? The surgeon? The
Anesthesiologist? The theater-incharge sister? or The theater technician? There is
no single word answer for this question as this responsibility is entrusted to various
people in different institutions and setups. However, it is reasonable that all the
members in the surgical team are collectively responsible for the best maintenance
of the operating table. In fact, that is true.
For reasons of safety and practicability, the anesthesiologist and his assistant
(Anesthesia technician) are directly responsible for maintaining the operation
table.
The anesthesiologist must be well versed with the operating controls of the
table, as he is the person who will be modifying the positions that is comfortable
for the surgeon. At the same time he knows the limit which may compromise
the safety of the patient.
Because of this reason, the olden day’s operation tables had the provision
of all the controls at the head end of the table that is convenient for the
anesthesiologist to operate and modify the positions.
All the modern Hydraulic operation tables have hydraulic device for adjusting
the height of the table (Fig.10.1).
General purpose four section operation tables are in common use. The sections
are for supporting Head, Back, Lumbar region, and Legs.
The leg section may be a single piece or double piece for individual leg.
Now electrically operated tables with remote control are available for easy
operability. It is powered by self-contained rechargeable battery giving backup
for several days’ operation (Fig. 10.2).
Chapter 10  Operating Table and Positions for Surgery 133
Fig. 10.1: Hydraulic operation table with manual controls
Fig. 10.2: Electronic operation table with remote controls
The modern operation table is a sophisticated piece of apparatus capable of

adjustment to give a variety of safe positions for patient undergoing surgery. Most
tables are designed as an all-purpose apparatus suitable for a wide range of general
operations, but can be adapted for specialized procedures by addition of suitable
accessories. Standard accessories are available for supporting different positions
(Fig. 10.3).
A standard operating table has the dimensions of 6 feet length and 1.5 feet (18
inches) breadth.
It provides raising, lowering, Trendelenburg, anti-Trendelenburg and lateral
tilting mechanism for the tabletop.
Adjustable head end and foot end are provided.
The tabletop is covered with antistatic firm sponge rubber mattress for each
section that can be removed for cleaning.
–– Arm board, shoulder rest, side support, lithotomy posts.
It must have provision for keeping a kidney bridge and a gall bladder bridge
either incorporated in the tabletop (Fig. 10.3) or available as an attachment.
The pillow used on the operating table must be of the right size.
It must not overflow and hang out of the table causing inconvenience for
positioning the patient, fixing the breathing system, etc.
The pillows used in the wards for the patient’s bed is usually too big and very
soft.
Such soft and larger pillows should never be used on the operating table.
Figs 10.3A and B: Operation table with accessories fixed
The standard size of the pillow is 18 inches long, 12 inches broad, and 2–3
inches thick made of soft foam or quilt which is comfortable for the patient.
It is essential that all the members of the theater staff familiarize themselves
with the operation table and its accessories which must be easily accessible
and ready for immediate use.
This will be of immense help during the time of any crisis, to urgently change
the position of the table to head down to protect the airway of the patient in
case of vomiting or regurgitation of stomach contents.
The whole apparatus must be maintained in good working order and checked
before each operation list.
Positions for Surgery

An unconscious person can easily be injured because he cannot complain of
discomfort or react to it by moving.
Careful and correct positioning of the patient is very important
It is essential to provide good access for surgery
It has to take into account patient safety, anesthesia technique, monitoring and
position of IV line, etc. (Smith and Aitkenhead, 1985)
Great care is necessary in moving unconscious patient with muscle relaxation
to prevent ligaments strain through excessive movements of joints
Relaxed muscles allow abnormal movements of the joints which may result
in serious damage
Due care is taken to prevent harm to the patient due to pressure, especially on nerves
and bony prominences. Any undue pressure can cause damage to nerves and skin
Positioning must ensure that, there is no local pressure in any particular area
If there is local pressure on the skin for a prolonged period, particularly in the
sick or old, an ulcer (pressure sore) may develop
The unconscious patient does not have the normal control of the circulation
(depressed cardiovascular reflexes) so that sudden changes of position must
be avoided
Specially, a sudden foot-down tilt will cause blood to pool in the vessels of the
leg, thus reduce the circulation to the brain
Care must be taken that nowhere the patient has direct contact with metal parts
of the table, especially if diathermy is to be used. Otherwise, serious damage
could be caused by burns deeper than skin
The position in which the patient is placed on the table depends upon the
operation to be performed.
The common positions used are;
1. Supine or dorsal recumbent position
2. Trendelenberg position
3. Gallbladder and liver position
4. Lateral position of extension (kidney position)
5. Lithotomy position
6. Position for abdominoperineal resection of rectum.
Points to note
All positions, except supine (lying on the back) affect the patient in various
ways, by limiting the respiratory excursions and vital capacity or by affecting
the circulation.
In the prone position, it must be made possible, the abdominal wall, and thus
the diaphragm, must be left free to move by supporting the patient at hip and
the chest (supported prone position).
Supine or Dorsal Recumbent Position

This position is used for many operations, including those on the eye, ear, face
chest, abdomen, legs or feet, and with modifications is suitable for operations
on the breast and arms or hands, which may be placed across the chest or
extended on an arm board.
This is the position where there are not many problems (Fig. 10.4).
Operations on the flexed knee are performed by lowering the foot end of the
table with the division between the center and the foot sections situated at the
point of knee flexion.
Alternatively the foot end of the table can be removed completely.
Fig. 10.4: Supine position
Trendelenburg Position
This position, a modification of supine, (deep head down Figs 10.5A and B)
is used for intrapelvic operations, the object being to allow the intestines to
displace away from the pelvic cavity by gravity towards the upper abdomen.
They may then be packed off readily with an abdominal pack to have easier
access to pelvic organs.
The arm must be secured either on the side of the body and tucked securely or
kept on a side arm board and secured with straps.
The flexion of the knee must be directly over the junction of the foot and the
central sections of the table.
The pressure points to watch and protect are: The heels, leg strap (folded towel
between the strap and legs must be used), behind the knees and the shoulders.
The well padded shoulder rests must be positioned to the point of the shoulders.
On any account, the shoulder rest should not be placed at the root of the neck,
because this would cause pressure upon the brachial plexus and result in
paralysis.
These rests must prevent the patient from slipping and becoming suspended
by flexed knees, which would cause pressure on the lateral popliteal nerve.
Alternatively, well-padded pelvic supports may be used to retain the patient
in position.
Gallbladder and Liver position

This is another modified supine position which is used for operations on the
gallbladder or liver
The patient is positioned over the back (Fig. 10.6)
The elevator (gallbladder bridge) which is raised to produce extension of the
back and thereby push the gallbladder towards the anterior abdominal wall
Alternatively the patient can be positioned on the hinged section of a “break
back” table when flexed produces similar effect
The arms can be positioned on the side arm boards. The abduction should not
be more than 90° to prevent stretching of brachial plexus.
a b
Figs 10.5A and B: (A) Trendelenburg position; (B) Reverse trendelenburg position
Fig. 10.6: Gallbladder position
Pressure points to watch and protect are: The heels, behind the knees and at the
point where the arm is extended from the table.
Lateral Position of Extension (Kidney Position)

This position is used for operation on the kidney and chest, but may be modified
slightly for the operations on the hip
For kidney surgeries the patient positioned over the kidney elevator (kidney
bridge) which is raised to extend this region (Fig. 10.7)
Alternatively, if operation table which incorporates a “break back” is used,
extension is achieved by positioning the patient over the division in the centre
section before adjusting the angle of the tabletop (Fig. 10.8)
For operations on the hip, the same lateral position without extension is used
The upper arm is supported by a Carter Braine’s arm support (Fig. 10.8). The
lower hand is placed at the side of the face and secured, if necessary
The underneath leg is flexed under the upper which is kept straight and secured
to the tabletop with a padded bandage (Pos Belt may be used for this purpose.)
(Fig. 10.9)
The patient is supported with pelvic and chest supports, which are well padded,
and for additional support, a bandage may be placed round the thighs and
tabletop.
Pressure points to watch and protect are: The heels, between the legs, under the
thigh retainer, upper and lower arms.
Fig. 10.7: Lateral position

Note that the “Kidney Bridge” is raised to lift the loin
Fig. 10.8: Kidney position with the arm support

Note that the “Kidney Bridge” is raised and the loin is widened
The arm is supported by a Carter Braine’s arm support
Fig. 10.9: Kidney position supported by Pos Belt

Note that the padded belt prevents the patient rolling
Fig. 10.10: Lateral tilt of the table
Lateral tilt of the table

The patient may be kept in any suitable position for the proposed surgery
Sometimes the surgeon may require having a little lateral tilt of the table for
better surgical access
The table has provision for such a tilt on either directions, but if necessary, the
patient may be well fastened to the table with a belt. (Fig. 10.10)
Lithotomy Position
This position is used for operations on the external genital organs, perineum,
and anal region (fig. 10.11)
For Vaginal hysterectomy this position is commonly used
The buttocks projects well over the edge of the table at the junction of the center
and foot section, which is either lowered or removed
The legs are flexed at the hips and knees, and raised with the feet supported in
webbing slings. These slings are suspended from the lithotomy poles (Fig. 10.12)
The arms are secured in the usual manner
The patient is first placed supine on the table and is then lifted down until his
buttocks are at the edge of the center section (foot section lowered or removed).
Both legs are then flexed at the same time, abducted and secured by the webbing
slings outside the poles
The legs may be supported with the leg support (Fig. 10.11) or by slings
(stirrups) at the feet (Fig. 10.12)
The proper position of leg support pads (Fig. 10.13) or leg and foot support
pads (Fig. 10.14) are used to prevent pressure effects.
Pressure points to watch and protect are: The forearms, buttocks, and the inner
aspect of the thighs, which must be protected from the pressure by the poles with
pads of gamgee or sponge rubber. Note that the lithotomy poles are padded with
sponge rubber to minimise still further any pressure on the patient’s legs.
Fig. 10.11: Lithotomy position with leg support
Fig. 10.12: Lithotomy position with feet supported by slings (stirrups)
Fig. 10.13: Proper positioning of leg support for abdominoperineal resection
Position for Abdominoperineal Resection of Rectum

This is a modified lithotomy position where two teams of surgeons do operation
on abdomen and perineum simultaneously
The legs are supported by a specially designed modified extended pole that
supports the legs with partial flexion of hip and knee.
Fig. 10.14: The way of using the leg and foot support pads
Fig. 10.15: Supported prone position with relton frame and pads
Prone Position
Prone position is commonly used for spine surgeries by posterior approach.
Some times used for lung surgeries
Always a supported prone position is used to prevent pressure on abdomen
that will hamper respiration by preventing movement of diaphragm
Support may be given at the upper thoracic region and on the pelvic girdle to
leave lower thorax and abdomen to move freely
The support may be achieved by using firm pads of appropriate sizes or relton
frame with pads (Fig. 10.15) may be used.
The pressure points to watch and protect are:
The head is supported at proper level with pillows and head ring
The head is turned to one side and the eyes are protected with eye cotton pads
and plaster
The side of the face is protected with a soft cotton pad
Pressure on major vessels of upper limb and lower limb must be prevented by
adequate padding
Upper limb is properly supported to prevent stretch injury to brachial plexus.
a b
Figs 10.16A and B: Positioning on ortho table with C—arm (image intensifier)
Fig. 10.17: A wedge pad made of sponge and covered with washable rexin
Fig. 10.18: Different supporting pads of molded sponge
Positioning on Orthopedic table

Orthopaedic procedures on lower limb could be done on special modification
on the operation table (orthopedic table)
These operations require the equipment known as image intensifier (C—arm)
Figure 10.16 shows the details of the table and C—arm.
Fig. 10.19: Molded gel filled pads for different uses
Supporting pads for positioning

Correct positioning of the patient for surgery is one of the most important
criteria for successful outcome. “Position is everything in life”
Suitably shaped pads of correct size must be used
The pads needed for supporting the various parts of the patient’s body to achieve
the best position for the proposed surgery can be made in the hospital by using
sponge cushion covered with washable rexin (Fig. 10.17)
Now pads made of molded sponge (Fig. 10.18) are available in different sizes
and shapes, or molded and gel filled (Fig. 10.19).
Further Reading
1. Aitkenhead AR, Smith G. Textbook of Anaesthesia, 3rd edn. Edinburgh, Churchill
Livingston, 1996.
2. Martin JT, Warner MA. Positioning in Anaesthesia and Surgery, 3rd edn. Philadelphia,
WB Saunders, 1997.
Chapter
Assessment of Blood Loss
11 and Volume Replacement
Chapter Outline
Facts about Blood Transfusion
v
Assessment of Blood Loss During Surgery
v
Recommendations from Various Authorities Regarding Transfusion
v
Role of Colloids Solutions In Blood Volume Replacement
v
Commonly Uses Iv Fluids—Their Composition and Indications
v
“Blood transfusions must be controlled by rules which control dangerous drugs.”

“Single unit transfusions are avoidable transfusions”.
“Anemia by itself may not kill a patient suddenly but a transfusion may”.
“Any blood transfusion without proper indication is contraindicated” (American
Society of Blood Banks).
“The safest transfusion that any one can receive is his own blood” (Autologous
transfusion).
Blood loss during any surgery is inevitable. But the quantity of blood lost in
relation to the total blood volume may be very insignificant in most cases. Surgeries
involving massive dissection and resection of tissues may cause considerable blood
loss which may require replacement.
The old saying “Blood for blood” carries very little or no meaning in modern
clinical practice.
Similarly the common statement “We shall improve the hemoglobin level and
then take him up for surgery” also is not very relevant.
Many of our patients live a normal healthy life with a hemoglobin level of
10g%. When they are subjected for a surgery where we don’t expect any significant
blood loss, a properly conducted anesthesia is very unlikely to do any harm to the
patient, provided he is not suffering from any other systemic illness like severe
respiratory infection or cardiac disease.
It is one of the most important responsibilities of anesthesiologist is to assess the
patient’s preoperative status with regard to the hemoglobin level and the possible
blood loss that may occur during the proposed surgery and to decide whether blood
has to be kept in reserve for transfusion if needed during surgery. It is not a very
easy thing to do, as multiple factors may influence the ultimate decision. Hence, a
careful clinical assessment is needed for coming to a logical conclusion regarding
blood reservation and replacement.
Chapter 11  Assessment of Blood Loss and Volume Replacement 145
Facts about Blood Transfusion

Man is endowed with at least 25% more Hemoglobin than what is actually
needed
Blood is a tissue
The striking difference between this and other tissues is that the matrix here is
fluid (plasma), making it to circulate within the vascular tree
Not like other tissues, it is very easy to have access to the vascular tree and
collect blood easily and store it
So the transplantation of this tissue is known as transfusion
Because of the easy accessibility of blood, transfusions are given very
commonly. Many times they are unwarranted transfusions
Like any other tissue, this tissue also may be rejected by the recipient if it is
not matched correctly
In other tissue transplants the rejection usually affects mainly the transplanted
tissue
In blood transfusion the rejection means fatal reactions with serious damage
to other organs also
Apart from this, the transfusions are the prime route of entry for many bacterial,
viral and spirochete infections into the body
The most dreaded are HIV and Hepatitis B virus. Their transmission is possible
if utmost care is not taken
Many times the transfusions cause more problems than the surgery itself.
Considering all these facts blood has to be treated as a dangerous yet necessary
commodity which has to be used only with proper indications and cautions.
Assessment of blood loss during surgery

“The surgeon always underestimates the blood loss and the anesthesiologist always
over estimates the blood loss.” This statement also is not always true but needs
reevaluation.
This statement is commonly made whenever the blood transfusion is done
without scientific reason. In fact when the surgeon will be concentrating on the
steps of surgery, it is likely that he may miss to assess the blood loss and he is likely
to imagine that the loss was not considerable. Whereas a careful anesthesiologist
who is concentrating on the overall care of the patient continuously watches the
blood loss and has the right idea as to how much of blood had been lost till that
moment. There are two common methods used for assessing the blood loss.
Gravimetric Method
The simplest and most commonly employed method
The swabs and gauzes used are weighed before and after use the gain in weight
is calculated by weighing them
One gram is approximately equal to 1 ml of blood
To this, the amount of blood collected in the suction bottle also is added
This method is said to underestimate the loss by 25%.
Colorimetric Method
Swabs and mop pads are washed thoroughly with a large known volume of
water which is then estimated colorimetrically
Errors may occur due to incomplete extraction of all the blood from the swabs
or contamination with bile
Patient’s hemoglobin must be known
Blood loss (ml) = (colorimetric reading × volume of solution ml)/200 ×
patient’s Hb%.
Practically easier most commonly employed method

Each mop pad when it is fully soaked with blood contains certain volume of
blood
Each fully soaked swab contains certain volume of blood
For this, the ‘size’ of the mop pad and ‘the number of layers of gauze’ must
be known
A standard pad with a dimension if 11 inches square and 8 layers of standard
gauze thickness will normally hold about 60 ml of blood when fully soaked
Similarly a gauze swab folded in four layers with a size of 2 inches square will
normally hold about 4 ml of blood when fully soaked
To this calculated volume the blood aspirated into the suction bottle and the
volume that is spilt on the draping has to be added to estimate the actual loss
Each institution may set their standard regarding the size of the mop pad, gauze,
etc. and calculate the volume it holds when fully soaked, etc. so that it is fixed.
There can be gross errors possible in whatever way this estimation is done.
Hence, it is necessary to have a careful clinical correlation before giving a
transfusion. There cannot be any hard and fast rule regarding blood transfusion
(blood replacement) during surgery.
Blood transfusion should not be the first consideration during the management
of patient with active hemorrhage
Volume replacement is urgent and then red cell replacement
Any healthy individual without any systemic problem can lose up to 20% of
their blood volume which will be well compensated without any untoward
effects
From 20 to 30% compensation by the system may be inadequate, and addition
of circulating volume by crystalloid solutions like ringer lactate or normal
saline may suffice.
Any loss more than 30% of blood volume need to be managed with crystalloid
solutions, colloid solutions like polygelene which is a polymer of degraded
gelatin 3.5% (Haemaccel) and if necessary with compatible blood transfusion.
It has been established that with a hematocrit value of 25–35%, there is
improved oxygen delivery to the tissues (Sanders–1972) by shifting the oxygen
dissociation curve to the right and also by reducing the viscosity of blood there
by improving the tissue perfusion.
Recommendations from various authorities regarding

transfusion
Blood transfusion should not be ordered as a “Prime reaction” arising out of
the patient’s condition
Any transfusion which is not indicated is contraindicated and single units are
rarely indicated
Single unit transfusions should be avoided
Single unit transfusions have limited value and vast majority of cases easily be
substituted by plasma volume substitute
Encourage more use of plasma volume substitutes and conserve the blood for
the really needy patients (severe anemia or blood loss more than 30%)
In elective surgery, alternate methods such as autologous blood transfusions can
be considered. This considerably reduces the transfusion induced complications.
role of colloid solutions in blood volume replacement

There are two terms very commonly used by the clinicians for referring to one
entity but have totally different meanings.
Plasma volume substitute
Plasma volume expander.
Plasma volume substitute

When there is a sudden blood loss, the cardiovascular compensatory mechanisms
reduce the capacity of vascular tree and maintain the vital organ perfusion. At this
point, crystalloid solution like normal saline or ringer lactate may replace the lost
volume with resultant hemodilution. When the loss of blood is insignificant, this
step is quite adequate to maintain the hemodynamics without any problem. But
when the blood loss is considerable, i.e. more than 20% of the total blood volume,
infusion of crystalloids solution may cause tissue edema because of two effects.
1. The plasma volume is diluted and the osmotic pressure exerted by the plasma
protein which is the main force that retains the fluids in vascular compartment
is reduced and so there will be a tendency for the fluids to diffuse into the
extravascular compartment.
2. The crystalloid solutions normally diffuse out of vascular tree faster.
So with major blood loss, plasma volume substitute will be more ideal than
crystalloids solution.
At this moment, if blood is given, both the cellular elements as well as proteins
are replaced correcting the defects. If blood is not available, at least the osmotic
pressure contributed by plasma protein may be temporarily substituted by some
other agent that can exert the same degree of osmotic pressure. Thus, the lost
volume of plasma is substituted. These substitutes are iso-oncotic to plasma.
Plasma volume expander

In a situation where there is intravascular volume depletion with severe increase
in extracellular volume presenting with edema, a hyperoncotic solution which
osmotic pressure very much higher than the normal osmotic pressure of plasma is
infused. This solution by virtue of the higher osmotic pressure draws fluid from the
extra-cellular compartment and expands the intravascular volume. The expansion
may be to the tune of four times the infused volume.
Such a situation is very rarely encountered in surgical patients. Normally in
hypovolemia plasma volume substitution is needed and not expansion. In fact,
patients presenting with moderate hypovolemia would first develop reduction in
circulating blood volumen and later reduction in extravascular (interstitial) fluid
volume of varying degrees as well. Use of plasma volume expanders in this scenario
may draw the fluid from extravascular (interstitial) compartment and dehydrate it
further, making the situation worse.
The colloid solutions available

Dextran 40
It is a polysaccharide
Dextrans are produced by the action of bacterium leuconostoc messenteroides
on sucrose
Dextran 40 has molecular weight of 40,000
10% solution is strongly hyper-oncotic
Duration of useful plasma expansion is about 1 hour
Used commonly to increase the intravascular volume, reduce the blood viscosity
and improve flow in microcirculation
It is said to prevent intravascular aggregation of red cells (sludging) and reverse
peripheral ischemia
It does not interfere with cross matching, blood grouping or coagulation
Contraindicated in dehydrated patients, because it may produce viscous urine
and can cause renal failure.
Dextran 70
Dextran 70 is the same polysaccharide with a molecular weight of 70,000
6% solution is available in saline or dextrose
It is hyper-oncotic. Infusion of 500 ml will usually increase the circulating
plasma volume by 750 ml
Has an acid pH 4.5–6 and may degrade acid labile drugs
Proved useful as a plasma volume expander and in the prevention of venous
thromboembolism
Used to reduce the incidence of thrombosis
If more than 1.5 liters are infused within 24 hours, may interfere with blood
grouping and cross-matching owing to rouleaux formation
May interfere with plasma protein estimation
Large volumes can cause bleeding by interfering with platelet stickiness,
enhancing fibrinolysis and blood flow
Remains in the circulation in decreasing amount, for up to a week. Some of its
larger molecules are stored in reticuloendothelial system
Only 25% is excreted within 3 hours and only 50% can be recovered from urine.
Gelatin
These are produced by hydrolysis of collagens. They have long shelf life, reasonable
cost, and there is no risk of transmission of viral diseases.
Haemaccel
It is 3.5% solution of polymer of degraded gelatin with all the electrolytes in
the same concentration as plasma
Urea linked gelatin, the molecular weight is 35,000
pH is 7.2–7.3
Because it contains calcium it should not be given along with citrated blood
Infusion of 500 ml will substitute a lost volume of 600 ml
It helps in promoting postoperative diuresis.
Gelofusine
It is 4% succinylated gelatin in normal saline
Molecular weight is 30,000
pH is 7.4
Duration of useful effect on plasma volume is about 2 hours
No effect on blood cross matching, but only dilutional effect on clotting factors
may be caused
Short biological half life, less than 12 hours
85% excreted by the kidney.
Hyrdoxyethyl Starch (HES)

Hetastarch is 6% solution in normal saline
Molecular weight is about 70,000. But the molecules have average molecular
weight of 100,000–150,000
pH is 5.5
Intravascular volume expansion is about 4 times the infused volume
Expanded volume effect is for 14 hours
Does not interfere with grouping or cross matching and coagulation
Anaphylactic reactions do occur
Because of the very high molecular weight, it has to be degraded into smaller
molecules in the reticuloendothelial system before it could be excreted by
kidney. Hence, it exerts a strain on reticuloendothelial system.
Each one of these agents has its own merits and demerits. Appropriate agent
that best suits the clinical situation may be chosen for the best outcome.
Commonly used IV Fluids, their Composition and Indications

Establishing an IV line before any surgical procedure has many purposes. An open
vein helps:
For inducing the anesthesia with intravenous agents in a very pleasant manner
For modulating the anesthesia by intravenous agents supplemented by careful
incremental doses
For maintaining fluid balance by infusing IV fluids, if necessary for transfusion
of blood
For administration of emergency medications during any period of crisis
For supplying calories and fluids as long as the patient is not allowed oral fluids
in the postoperative period.
In general, it is commonly used only for administering intravenous fluid for
maintaining fluid and electrolyte balance and supplying calories as well. Hence, it
is essential to have a clear idea of the commonly used intravenous fluid and their
composition.
Dextrose Injection
This is available in three concentrations.
Dextrose injection 5% w/v
Benefits
Provides ready energy for the body metabolism when oral food intake is not
possible
Higher concentration may be used in conditions where there is restriction for
water intake while need for supplying more energy.
Indications
Dehydration or excessive water loss through urine and sweating
Prevention of excessive tissue protein catabolism and liver glycogen depletion
Promotion of sodium diuresis following excessive use of electrolyte solutions
Preventing ketosis due to starvation, diarrhea, vomiting and hyperpyrexia.
Drip rate
The maximum infusion rate should not exceed 0.35 g/kg/h.
Contraindications
Concurrent administration with blood
Water intoxication
Neurosurgical procedures particularly in the presence of intracranial hemor-
rhage.
Dextrose and Sodium Chloride Injection

Dextrose 5% w/v.
Sodium chloride 0.9% w/v.
Water for injection q. s.
Electrolytes mEq/Lit
Sodium 154
Chloride 154
Energy 190 calories
Benefits
Used in conditions where calories are needed and the chloride loss is greater
than sodium loss.
Indications
Dehydration, excessive protein catabolism, liver glycogen depletion, chloride
loss, deficient calorie intake and alkalosis.
Drip rate
In normal circumstances 400 ml/h and more rapidly in shock.
Contraindications
Renal insufficiency, edema in patients with cardiac, hepatic or renal disease.
Ringer Lactate Solution

It contains Sodium chloride, potassium chloride, calcium chloride and lactate.
Sodium 131
Potassium 5
Calcium 4
Bicarbonate 29 (as lactate)
Chloride 111
Benefits
Supplies electrolytes similar to that of plasma along with lactate a precursor of
bicarbonate for correction of mild acidosis
Lactate is rapidly metabolised to bicarbonate except in patients with liver
diseases, hypoxia, shock, or congestive failure where already the blood lactate
is elevated.
Indications
Dehydration
Restoration of normal fluid balance
Moderate metabolic acidosis
Replacement of extracellular fluid not characterized by marked acid base
disturbances.
Drip rate
5–10 ml/kg body weight per hour
Can be infused rapidly at the rate of 30 ml/kg/h in the absence of cardiac and
other contraindications.
Contraindications
Severe metabolic alkalosis
Impaired lactate metabolism as in severe liver insufficiency
Addison’s disease (potassium free fluids are preferable).
Acetated Ringer’s Solution

Though ringer lactate is very widely used and is recognized in many clinical
conditions, the use of sodium lactate may not be suitable where lactate metabolism
is impaired and serum lactic acid levels are elevated. Acetated ringer’s solution
overcomes these problems. Acetate is more efficiently metabolized in conditions
associated with tissue hypoxia, such as shock, because its metabolism requires less
oxygen. In addition, it is metabolized primarily by muscle and other peripheral
tissues in contrast to lactate which is metabolized largely by the liver. Therefore,
it is the preferred solution in metabolic acidosis associated with circulatory
insufficiency.
Sodium 130
Potassium 4
Calcium 3
Chloride 109
Acetate 28
Calories 9
Indications
Restoration of intravascular volume following hemorrhage
Restoration of normal fluid and electrolyte balance, following external loss of
extracellular fluid or translocation into third space due to surgery, shock and
other cardiovascular emergencies
Burns, fractures, infection, peritonitis, and such clinical conditions
Correction of moderate metabolic acidosis as in mild renal insufficiency, infant
diarrhea, diabetic ketosis
Dehydration of any type with less fluid intake or increased water and electrolyte
excretion.
Dose and drip rate

Usual adult dose is 1–3 Lit/day. Rate is 5–10 ml/kg/h.
Contraindications
Severe metabolic acidosis that has to be corrected with 1/6 molar sodium
lactate solution
Severe metabolic alkalosis which has to be treated with ammonium chloride
solution.
Sodium Chloride injection 0.9% w/v. (Normal Saline)

Normal saline contains 154 mEq / Lit of each sodium and chloride. Plasma contains
142 mEq of sodium per liter and only 103 mEq of chloride per liter. Hence, the
terms “normal saline” and “physiologic saline” are misleading because “normal
saline” is neither normal in the chemical sense of the term nor physiologic because
of its comparatively high chloride concentration. Still it is one of the commonest
IV fluids in clinical use.
Sodium 154
Chloride 154
Benefits
Replaces sodium and chloride ions which are important constituents of extra-
cellular fluid.
Indications
Alkalosis in the presence of fluid loss
Sodium chloride solutions are still useful, nevertheless in cases where the
chloride loss has been greater than or equal to the loss of sodium.
Drip rate
400 ml per hour in adults normally
Higher rates of infusion according to necessity in shock due to sodium loss.
Contraindications
Renal insufficiency, edema in patients with cardiac, hepatic or renal disease.
Sodium Chloride injection 0.45 w/v (Half Normal Saline)

Electrolyte mEq/Lit
Sodium 77
Chloride 77
Benefits
Useful for replacing electrolyte and fluid loss in pediatric patients.
Indications
Excessive sweating, vomiting due to pyloric obstruction, gastric suction with
loss of hydrochloric acid
Dehydration.
Invert Sugar 10%

Invert Sugar 10% w/v
Energy content 180 calories.
Benefits
Invert sugar is metabolized faster than glucose, as it bypasses the steps catalyzed
by glucokinase and phosphofructokinase and, therefore, provides energy more
rapidly than glucose
Fructose is also less dependent on insulin which is required for glucose
metabolism.
Indications
Severe dehydration (along with electrolytes)
Pre and postoperative conditions
Intensive care patients
Trauma and burns patients
Hospitalized infective hepatitis patients
Hyperemesis gravidarum.
Drip rate
2.5–5 ml/kg/h.
Contraindications
Lactic acidosis.
Chapter
Vital Organ Function and
12 Anesthesia
Chapter Outline
Anesthesia and Liver
v
Anesthesia and Kidney
v
Anesthesia and Brain
v
Anesthesia and Heart
v
Anesthesia and liver

When we refer to vital organs we mean only brain, heart and kidney. Somehow,
the liver, which is the most vital organ has not been given the importance which is
due to it. In fact, the liver is the biochemical laboratory of the body dealing with
the synthesis of many essential materials for anabolic activity of the body. More-
over, it is the detoxification center for almost all the toxins in the blood. If the liver
function is affected beyond a limit, it will be impossible to sustain life.
It is necessary to recall the basic anatomy and the physiology of liver to realise
how anesthesia can affect the liver.
Anatomy
It is the largest organ in the body situated below the right costal margin just under
the diaphragm. It usually weighs between 1.5 to 4 kg, and is imperfectly divided
into two lobes, a large right and a small left one. On the inferior and posterior
surface between the right and left lobes are two smaller lobes, the caudate and
quadrate. The falciform ligament consists of two layers of peritoneum which are
closely united until they reach the upper surface of the liver, where they part from
each other to cover the peritoneal surface of the right and left lobe. This ligament
joins the liver to the diaphragm and the anterior abdominal wall. In its free edge
stretching from the umbilicus to the lower border of the liver is the ligamentum
teres containing small para-umbilical veins. At its upper end the two layers of the
falciform ligament separate widely to expose a small triangular area—“the bare
area of the liver”.
The porta hepatis is found on the inferior surface of the liver lying between
the quadrate lobe in front and a process of the caudate lobe behind. This structure
is important because it consists of a deep fissure containing most of the essential
structures of the liver. Viewed from below these structures, from right to left, are
the common hepatic duct, which gives off a branch—the cystic duct—leading on to
the neck of gallbladder, the bile duct, the portal vein and finally the hepatic artery
with a plexus of hepatic nerves.
The microscopic structure of liver comprises of a whole mass of neatly arranged
lobules. Each lobule consists of numerous cells arranged in columns which radiate
from around a central vein. Irregular blood vessels or sinusoids can be seen between
the columns of cells. The blood supply to these lobules comes from the hepatic
artery and the portal vein. Both these vessels, soon after entering the porta hepatis,
divide into right and left branches. Each branch then undergoes dichotomy many
thousands of times to supply all the lobule.
The hepatic artery brings fresh oxygenated blood for the liver cells almost
directly from aorta, whereas the portal vein carries all ingested material in the
venous blood from the gastrointestinal tract and spleen. It is necessary to remember
that hepatic vein forms 80% and hepatic artery forms 20% of the blood supply to the
liver. These two vascular supplies are carried throughout the liver on the periphery
of the lobules. Small branches are given off from both the vessels which encircle
the lobule as the interlobular plexus and from these plexuses small capillary like
vessels (sometimes described as sinusoids) run between the columns of cells of the
lobules and finally drain into the vein in the center of the lobule – the central vein.
All the central veins join up to form the hepatic veins which finally drain into the
inferior vena cava (Fig. 12.1).
Hepatic Artery supply is small 20%
Portal vein supply is larger 80%
Mixing of blood in sinusoids makes it less oxygenated (hypoxic)
Cells in the periphery of lobule get better oxygen and the cells near the central
vein receive minimal oxygen.
Fig. 12.1: Anatomy of liver lobule

Chapter 12  Vital Organ Function and Anesthesia 157
During anesthesia if for any reason the patient suffers hypoxia for a pronged time
or there is an episode of severe hypotension for a prolonged period, the liver suffers
serious hypoxic damage than any other organ.
The nerve supply of the liver consists mainly of non-medullated sympathetic
fibres which ramify around the vessels and bile ducts and finally terminate in the
liver cells. It arises from celiac plexus.
Physiology
The blood flow to the liver is about 1500 ml/minute. Of this total, about 80%
(1200 ml) reaches the liver though the portal vein and the remaining 20% (300
ml) comes through the hepatic artery. However, the blood in the hepatic artery
is about 95% saturated with oxygen whereas that in the portal vein is about 85%.
It has been estimated that the liver normally requires about 60 ml of oxygen
per minute, of which 17 ml is supplied by the hepatic artery and the remainder
by the portal vein. The total amount of oxygen available to the liver cells can be
reduced by a number of reasons;
Anesthesia may cause:
–– Reduced hepatic blood flow
–– Reduced oxygen saturation in blood
Lowered cardiac output as in shock, hemorrhage or hypotension
Inhalation of low inspired concentration of oxygen
Hypermetabolic states, e.g. hyperpyrexia
Hepatotoxic substances
Obstruction to the portal vein or hepatic artery.
It is clear, therefore, that the cells surrounding the central lobular vein are
the last to receive nourishments and oxygen. The cells at the proximal end draw
the oxygen and nutrients and by the time the blood reaches near the central vein,
there is very little in the blood to deliver, then they are the first to suffer from
any deprivation. This can be compared to the house situated at the tail end of the
supply area from an electricity transformer, receiving relatively a lower voltage.
With toxic substances such as chloroform one might expect the cells surrounding
hepatic artery to suffer the worst damage, but it is the toxins that cause the hepatic
cells to swell, and it is this swelling which further interferes with the blood supply
to the central cells and cause them to suffer worst damage.
Points to be remembered during anesthesia

The liver receives 80% venous blood and 20% arterial blood. Therefore, such
a vital organ is receiving relatively hypoxic blood
The cells around the central vein suffer the worst damage
Any reduction in blood flow or any degree of hypoxia will cause more damage.
Functions of the liver

General metabolism
Carbohydrate is converted to glycogen and stored in liver until required
Fats pass from the depots throughout the body to the liver and are broken down,
almost as fast as they arrive, into glycerol and fatty acids by the lipase
Amino acid pool reaching the liver from the bowel as end product of protein
digestion or from breakdown elsewhere, are used to build body proteins
Surplus amino acids undergo oxidative deamination. In this process the amine
group (NH2) is released as ammonia (NH3). The ammonia is either excreted as
urea or used again to build amino acids
The remainder—the non-nitrogenous part is broken down to produce energy
for the general metabolism.
Storage
Fats, proteins and glycogen and likewise certain vitamins such as vitamin B
are stored.
Synthesis
Liver synthesizes plasma proteins, prothrombin, fibrinogen and heparin.
Detoxification of drugs
Liver is able to remove many foreign substances by oxidation.
Modifications in liver blood flow

The splanchnic vascular system supplies the entire blood passing to the intestines
from which it finally drains into the portal system and is carried to the liver. As we
have seen already the liver blood flow, however receives another contribution from
hepatic artery. So the variations in the splanchnic flow and that in the hepatic artery
are reflected in the final amount of blood which passes through liver.
Flow in the conscious state

Average liver blood flow is 1.25 to 1.5 liters per minute
In a person with cardiac output of 5 liters per minute, it is about 25% of cardiac
output
The liver may have to sacrifice some of this flow in certain situations to protect
the homeostatic mechanism, maintain the systolic pressure, and ensure blood
supply to most “vital” centers as in hemorrhage, congestive cardiac failure,
severe exercise, etc.
Flow in anesthetised patient

Induction of light plane of anesthesia is sufficient to produce a drop of about
25% blood flow
Deeper planes of anesthesia produce even greater fall
Halothane anesthesia produces a fall in liver blood flow without any change
in splanchnic vascular tone.
This clearly indicates that reduction in the liver blood flow is inevitable in
general anesthesia, and the need for keeping the oxygen saturation in the highest
possible level to prevent hypoxic damage to the liver.
Flow during hypotension due to Autonomic blockade

This leads to a fall in the liver blood flow and thus increases the risk of any
possible damage to the liver cells
The mechanism of this fall in blood pressure is peripheral vasodilatation which
includes splanchnic bed
The reduced hepatic blood flow is secondary to the fall in systemic pressure
and cardiac output
This includes the paralysis of autonomic system caused by spinal or epidural
anesthesia or by ganglion blockers and alpha adrenergic blockers
This clearly indicates that whatever way a hypotension is caused during
anesthesia it must be seen that it is within the permissible limits for that patient.
Flow during hypotension associated with vasoconstriction

This occurs typically during severe hypovolemia following severe blood loss
The splanchnic bed attempts to compensate for this alteration in the
hemodynamics by vasoconstriction, which in turn results in a drop in portal flow
When the systemic pressure falls the flow through the hepatic artery also drops
Thus the combination of hypovolemia and severe vasoconstriction in splanchnic
bed with hypotension as occurs after severe hemorrhage, may lead to severe
depletion of liver blood flow.
This again indicates that in case of severe hypovolemia due to any reason;
immediate attempts to correct the volume deficit must be made to prevent damage
to liver.
Flow during Hypothermia

Hypothermia causes both a fall in blood pressure and a reduction in liver blood
flow
This has a great advantage that in this case the metabolism and oxygen requirement
of the hepatic cells are reduced with fall in blood pressure and temperature
There is no evidence to suggest that the liver cells suffer any damage due to
hypothermia alone
When cardiac arrest is induced with hypothermia as in open heart surgeries,
severe congestion of liver cells is possible.
Flow with Vasoconstrictor drugs

Administration of these drugs may reduce the liver blood flow
Local effect of adrenaline in liver is intense vasoconstriction
The systemic effect of raising the blood pressure by increasing the cardiac
output predominates and the result is that hepatic flow rises
Noradrenaline causes slight fall in spite of rise in systemic pressure. May cause
hepatocellular damage in prolonged infusion.
Anesthesia and Hepatic cells

Hypoxia and hypercarbia both can cause damage to hepatic cells
Most anesthetic drugs can be classed as protoplasmic poison of lesser or
greater degree
Because of the anatomical peculiarity of blood flow, the centrilobular cells
suffer hypoxia and damage and necrosis of cells are common
Direct toxic effect, hepatitis like effect, cholestatic (obstructive) effect are
possible
Halothane may cause hepatitis if repeatedly exposed, by causing sensitization
of the cells. This has not been proved beyond doubt
The requirement of muscle relaxants is usually less due to multiple
pharmacological reasons in patient with liver damage
Prolonged hypotension during anesthesia without attempt for correction has
led onto hepatic failure
The reserves of the liver are so great that almost all agents can be used in reduced
doses unless the patient is in a stage of rapidly approaching hepatic failure.
Anesthesia and Kidney

Anesthesia can modify the renal function in many ways and it is essential to have
an orientation of the basic anatomy and physiology of kidneys in order to conduct
the anesthesia without harming the kidneys.
Anatomy
The two kidneys are retroperitoneal organs situated on either side if the vertebral
column. The upper pole is at the level of 12th thoracic vertebra. The lower poles
reach to the level of 3rd lumbar vertebra. The right kidney is always a little lower
than the left. The approximate weight of the kidney is 150g in male and 135g in
female.
Anteriorly it is related to various intra-abdominal structures. The upper pole
is closely attached to the suprarenal gland. The renal vessels and the ureter enter
through the hilum in the medial border. Kidney is ensheathed in a fibrous capsule
which can be easily removed exposing a layer of smooth muscle fibers beneath. A
cross section of kidney shows an outer cortical and an inner medullary substance.
Vascular system
The renal artery divides into four or five branches as it enters the hilum and each one
of these give off a small branch which runs to suprarenal gland. The main branches
then proceed to divide into lobar arteries which run to the renal papillae, and each
of these forms two or three interlobar arteries which pass towards the cortex of the
kidney. On reaching the point of junction between medulla and cortex at the base
of the pyramids each interlobar artery divides into two and in a “T” shaped fashion
each branch runs at right angles to the parent stem between the cortex and medulla.
These vessels do not anstomose with their opposite number in the neighbouring
lobe, but they give off important branches which pass into the cortex to supply the
glomeruli (glomerular artery). The venous drainage is similarly arranged (Fig.12.2).
Fig. 12.2: Anatomy of kidney showing the pattern of vessels and calyces
Urinary System
The glomerulus consists of a mass of capillary vessels surrounded by the blind
end of an expanded renal tubule called the glomerular capsule
This apparatus is concerned with filtering substances other than protein from
the blood stream
The glomerular tubule leads to the first convoluted tubule, down the spiral part
to the descending loop of Henle and then up again through the ascending loop
to the irregular or zigzag tubule
From here it leads on to the second or distal convoluted tubule, from where it
finally drains into the collecting tubule
The function of this tubular system is selective re-absorption so that the material
that finally reaches the ureter is urine.
Nerve supply
This is derived from “the renal plexus” which is composed of branches from the
Celiac and aortic plexuses, the lower part of celiac ganglion, and from the lesser
and lowest splanchnic nerves. All the nerves which run to the kidney arise from
the 10th to 12th thoracic segments.
Physiology
Under normal resting conditions, about 20–25% of the total cardiac output
passes through the renal circulation each minute
The two kidneys between them receive a blood flow of 1100–1200 ml/minute
Approximately half of this total consists of plasma and the remaining is cells
Despite various shunts described, it is believed that all this blood passes sooner
or later to the glomerular capsule
Here the hydrostatic pressure of systemic circulation, opposed only by the
osmotic pull of the protein content of the blood, drives the fluid across the
glomerular membrane to reach the renal tubule
Thus, of the original total of about 1000 ml of blood that enters the kidneys
every minute, about 1/10th or 100 ml passes down the tubules
At this point the selective re-absorption mechanism plays a major role and
almost all the fluid content passes back into the circulation again
Of each 100 ml of fluid entering the tubules, 99 ml is re-absorbed
This means that 1 ml of urine is formed from every 1000 ml blood that goes
to the kidneys
In other words, normally functioning kidneys are likely to secrete urine
approximately at a rate of 1ml/kg/h.
Applied physiology of Glomerular Filtration

The glomerular membrane is permeable to both fluids and electrolytes, but not to
proteins or cells. Presence of proteins and cells in urine indicate renal damage
The driving force across the membrane is the systemic pressure and opposing
it is the osmotic tension of the protein content of the blood. If the systemic
pressure is low, less force to drive so less urine is formed
The fraction that passes across the glomerular membrane is about 1/6th of renal
plasma flow or 1/10th of renal blood flow
Thus:
The renal blood flow 1200 ml/min
Renal plasma flow 750 ml/min
Total reaching the tubules. 1/6th of 750 ml/min 120 ml/min
If the mean blood pressure is 80 mm Hg and the osmotic pressure of protein
element is 25 mm Hg, the effective filtration force will be 80 – 25 = 55 mm Hg
A number of factors influence this force; the most important is the fluctuations
in the systemic blood pressure
For example, if the systemic pressure fell to 25 mm Hg, there would be no
filtration pressure at all
Clinically, it is known that in cases of severe hypotension during or immediately
after surgery renal excretion ceases altogether
The other factors affecting the filtration pressure are; changes in osmotic
pressure of proteins and back pressure reaching the glomeruli from obstruction
lower down
In fact many patients with severe renal damage may not present with any clinical
symptoms until 35% of the glomeruli are functioning
In renal disease there is a close relationship between the severity of the damage
and the number of functioning glomeruli
So any further damage likely by anesthetic agents or any other drugs must be
considered carefully and avoided
The glomerular membrane itself is particularly susceptible for damage by
Hypoxia, Ischemia and Drugs
Normally molecules with a weight of 70,000 and over cannot pass through the
membrane, but those of 68,000 and below traverse it with ease
Albumin has molecular weight of 70,000 and cannot penetrate through the
normal glomerular membrane, whereas gelatin (6% polygelene solution such as
hemacel) with a molecular weight of 35,000 passes through without difficulty
Ischemia of the glomerulus destroys this semi-permeability, hence the value
of albumin in the urine as a guide to renal disease.
Tubular Reabsorption
The contents of the glomerular filtrate are identical with that of plasma lying
across the glomerular membrane inside the tuft of capillaries. Proteins are
absent
Though the liquid starts out on its journey through the tubular system resembling
plasma, by the time it reaches the end it bears no relation to it at all
On its way down, enormous quantities of water and certain electrolytes are
reabsorbed
This process of reabsorption is selective, so that the kidney tubules play an
important part in controlling the electrolyte balance of the body
For every 100 liters of water that enters the tubules, less than 1 liter (0.9 liters,
to be precise) reaches the urine
Any glucose which passes through the glomerular membrane is completely
reabsorbed so that none enters the urine
Nearly all the sodium, chloride and calcium ions are reabsorbed
8% of potassium ions and 25% of phosphate are absorbed
Water content of the body is controlled by the antidiuretic hormone (ADH)
of posterior pituitary. Nearly all anesthetic drugs stimulate the release of this
hormone.
Renal blood flow in conscious patient

In normal circumstances, the flow through the renal vessels does not vary widely
Kidney has its own “autoregulation” mechanism which ensures that it receives
as adequate supply of blood as possible despite variations in systemic pressure
The autoregulation range is 80 to 180 mm Hg systolic pressure
Afferent glomerular artery has myogenic control
Myogenic response to stretch constricts the artery in hypertension and dilates
in hypotension
Hemorrhage, asphyxia and ganglion blockade are factors that reduce renal
blood flow
In spinal hypotension, in clinical practice, reduction in GFR is very minimal
(10%). No renal impairment in normal patients
In hypovolemia the mechanism is complex. There is a profound fall in renal
perfusion and glomerular filtration. Even when the patient is well transfused
and the blood volume and the pressure returned to normal levels, the
vasoconstriction does not wear off for several hours. This vasoconstriction is
believed to be nervous in origin
After four hours of renal ischemia produced by hypotension, the vasoconstriction
may take many days to pass off even after suitable transfusion therapy, it may
become irreversible. This persistent vasoconstriction is thought to be of humoral
origin (Renin etc.)
In hypoxia and hypercarbia, the renal vessels tend to constrict
The ganglion blocking drugs cause dilatation of renal vessels and the renal flow
closely follows any change in the systemic pressure.
Renal blood flow in anesthetized patient

By and large the blood flow is modified by anesthesia and depends upon the
depth of anesthesia
In properly maintained general anesthesia, there is a relatively less reduction
of perfusion to the kidneys. This is mainly due to the mild reduction in systemic
pressure
During a long operation with a constant level of anesthesia, the flow remains
unaltered, and as soon the anesthesia is withdrawn the blood flow starts to
return to normal
In hypotensive anesthesia, there will be vasodilatation in the renal blood vessels
with a fall in systemic pressure. This maintains a steady flow through renal
vessels. So normal kidney does not suffer any damage from short periods of
hypotensive anesthesia. Prolonged hypotensive anesthesia or already damaged
kidney may be affected by this.
Effects of hemorrhage on renal blood flow under anesthesia

Normal kidney does not apparently suffer acute ischemia from severe
hypotension under anesthesia, and any reduction in flow that may occur can
quickly be restored by transfusion therapy
It is possible for normal anesthetized patient to lose up to 25–30 percent of
his total circulating blood volume without showing any significant changes in
blood pressure and heart rate
Under anesthesia even after a relatively massive hemorrhage, the renal vessels
still dilate, but now the vessels to muscles are found to be constricted. This is
the autoregulation mechanism which maintains an even level of renal blood
flow despite alterations in the cardiac output and systemic pressure
Severe renal vasoconstriction occurs however after 4–6 hours of hypovolemia
All these indicate that it is improbable that a transient reduction in blood
volume, as may occur during surgery, can be responsible for the ischemic
damage of the kidney that occasionally follows operations if kidney function
was normal earlier.
Effects of vasopressor drugs

When hypotension develops during anesthesia, a vasopressor drug is often used
to restore the systemic pressure to a normal level
Two assumptions are usually made when considering the use of these drugs
One is the low blood pressure is necessarily associated with a reduced flow to
the vital organs. The other is raising the blood pressure by pressor drugs will
automatically improve the flow
When considering kidney, both these assumptions are unwarranted
Adrenaline and noradrenaline produce a rise in blood pressure accompanied
by a consistent fall in renal blood flow
Methyl-amphetamine causes a rise in blood pressure and an overall increase
in renal blood flow
Dopamine in smaller doses of 2 microgram/kg/min was believed to cause a
preferential renal vasodilatation. Now it has been proved that this concept is
incorrect
Dobutamine is believed to have no effect on renal vasculature.
Renal damage in relation to anesthesia and surgery

Following major surgeries it is common to find traces of albumin, red cells and
casts in the urine during the first three postoperative days.
A prolonged period of hypotension leading to renal ischemia is the principal
cause.
During the period of ischemia, renal tubular cells are damaged.
On re-establishment of the normal blood flow these cells recover either
completely or their permeability is damaged, so that they swell with edema
and partially or totally occlude the lumen of the tubule. In this stage mannitol
may reverse this situation.
As mannitol is excreted virtually unchanged it is presumed that a hypertonic
solution not only tends to keep the lumen of the tubules patent but may also
withdraw some of the water from the swollen cells of tubules, thus diminishing
the effect of edema on the flow of urine through the tubules and the secondary
ischemia caused by the pressure on the vasculature.
The first indication of renal damage in postoperative period is “oliguria”. This
term is used to denote a total urine output in 24 hours less than 750 ml. (i.e.
0.5 ml/min).
It is to be remembered that the commonest cause of oliguria in postoperative
period is dehydration. Oral fluid intake is curtailed for many hours before
anesthesia, yet the insensible loss of sweating, humidification of inspired air,
alimentary secretions continue it is not surprising that dehydration occurs
rapidly.
The insensible loss is estimated to be 1000 ml per 24 hours. To this add the
other losses like blood loss, loss of fluid into the lumen of intestines, urine
output, etc. and adequate replacement is carefully made to prevent dehydration.
If not hemoconcentration will result.
The oliguria because of dehydration and that due to renal insufficiency can be
differentiated by checking the specific gravity of urine. If the circulating blood
volume is low as in dehydration and the renal function is normal, the kidney
will pass out very concentrated urine. The specific gravity in the presence of
dehydration will be above 1,018 and probably in the region of 1,020–1,030.
On the other hand, if the renal function is failing then the kidney loses its power
to concentrate urine by the absorption of water in the tubules, so that the specific
gravity cannot rise above 1,010.
It is estimated that as much as 450 ml of water per day is added to the total
body fluids simply due to the tissue metabolism, and a further 150 ml are
obtained from carbohydrate. This means that the body itself can produce as
much as 600 ml of water per day. This volume has to be kept in mind while
calculating the total requirement of fluid/day.
Anesthesia and Brain

As anesthesia itself is a carefully controlled depression of various modalities
of brain, one has to be very clearly aware of the basic anatomy and physiology
related to brain and its application in clinical practice
The most important difference between the brain and the other vital organs
is that the brain is contained in a rigid bony cage ‘skull’ with a cushion of
cerebrospinal fluid
This gives the brain a good protection from injuries and shock. But it has some
disadvantages when surgery is contemplated on brain
Intracranial contents are:
–– Brain 80% (this consists of 75% water)
–– Cerebral blood volume 12%
–– Cerebrospinal fluid 8%
The brain weighs 1.5 kg
The total blood flow is 750 ml/min (about 15% of cardiac output)
Oxygen consumption is about 50 ml/min (20% of that for the whole body
250 ml)
These two facts make us understand that brain has maximum blood supply
and maximum oxygen utilization and cannot survive if ischemia or hypoxia is
produced even for short time
Gray matter gets more blood supply. 70 ml/100 g, while white matter gets only
20 ml/100 g/min. Over two-third of blood supply come from carotids and the
rest from the vertebral arteries
Cerebral blood flow less than 20 ml/100 g/min causes EEG changes
A value below 10 ml/kg/100 g produces irreversible histological changes.
Cerebral metabolism
Brain is unique in that it entirely relies upon carbohydrate for energy
requirements. Glucose is oxidized to CO2 and H2O
Hypoglycemia by reducing the amount of substrate produces all degrees of
functional disturbances leading to coma
Brain needs uninterrupted supply of oxygen through circulation
Total circulatory arrest causes loss of consciousness in less than 10 seconds
There is no anaerobic metabolism in brain
“During anesthesia it is essential to see that Hypoxia, Hypoglycemia are
avoided”.
Blood supply to brain

The cerebral circulation is significantly importance because;
The anatomical features of vessels ensure uninterrupted blood supply even in
odd conditions
The anesthetic agents act on various structures depending upon the blood flow
the structure receives
Anesthetic drugs have varying effects on the blood flow
The cranium is a rigid closed compartment with more chances for compromised
blood flow
During neurosurgery when the cranium is open all the regulatory mechanism
may fail.
Anatomy of circulation
Derived from internal carotids and vertebral arteries.
2/3 supply from the internal carotids. 1/3 supply from vertebral arteries.
The vertebral arteries arise from subclavian artery on each side and join at the
level of lower border of pons to form the basilar artery.
The circle of Willis is formed by the anastomosis between the transverse
branches of the basilar artery and the two internal carotid arteries.
The purpose of circle of Willis is to guarantee that whatever be the position of
the head in relation to the trunk and to gravity, the possible variations in blood
flow are always compensated within the cranial cavity by the freest anastomosis
of arteries. Normally, regional variations in cerbral blood flow does not occur
because the arteries distal to the anastomosis only reach the brain.
The blood stream in the circle of Willis does not usually cross the midline and
mix in the midline. There is a “Zero point” or “Dead point” in the midline,
referred as similar to the “Blue Niles” and “White Niles” river.
There will be mixing of blood only when there is a block in one side (Fig. 12.3).
In young person the occlusion of one carotid does not affect the cerebral blood
flow, but in elderly person it often produces evidence of cerebral ischemia.
Fig. 12.3: Blood supply to brain ‘Circle of Willis’

Venous drainage
Venous drainage has no such pattern as the arterial supply. The Jugular bulb receives
2/3 of flow from brain. About 3% flows to extracranial veins.
Factors affecting the cerebral blood flow

Regional blood flow variations are closely related to the local brain metabolism.
Arterial PCO2
There is a linear relationship between the partial pressure of CO2 and blood flow.
If the PaCO2 is reduced to 20 mm Hg, blood flow is reduced half whereas if it is
raised to 80 mm Hg, the blood flow is doubled.
The blood flow returns to normal over about 24 hours if the change in PCO2 is
maintained, as the CSF bicarbonate is adjusted.
This limits the period of hyperventilation that is beneficial in reducing the
cerebral edema.
Arterial PO2
Inhalation of 100% oxygen reduces cerebral blood flow only to 10%.
Cerebral perfusion pressure

It is defined as the mean arterial pressure (MAP) minus intracranial pressure (ICP)
or cerebral venous pressure whichever is higher. “Autoregulation” maintains a
steady cerebral blood flow though the perfusion pressure varies between 50 mm
Hg and 150 mm Hg.
This range of autoregulation rises in hypertensive patients and in sympathetic
stimulation.
Venous and intracranial pressures

A rise in venous pressure will raise the intracranial pressure (ICP), which will tend
to lower cerebral blood flow (CBF). This is because; cerebral perfusion pressure
is lowered or a high intracranial pressure (ICP) compresses the cerebral vessels.
Normal brain may compensate for this to some extent. But abrupt rise in venous
pressure during straining, coughing may cause serious fall in CBF, especially if the
arterial pressure also falls, e.g. during intubation.
Autonomic system
There is extensive sympathetic supply from superior cervical sympathetic
ganglion
Sympathetic have very little control in the CBF
Alpha 2 receptor stimulation causes vasoconstriction
Beta 1 receptor stimulation causes dilatation
Parasympathetic is vasodilator and is derived from the facial nerve.
Temperature
Hypothermia reduces cerebral blood flow (CBF). Incidentally, it reduces the
cerebral metabolism also.
Hyperthermia increases cerebral blood flow (CBF). It increases the metabolism.
“Hypothermia protects the brain, while hyperthermia damages brain cells by
inducing demand hypoxia”.
Blood viscosity
If blood viscosity falls, the blood flow (CBF) increases and vice versa. So in anemic
status there is increased blood flow to brain.
Age
After the 60 years of age or more, there is a fall of blood flow, about 0.5% per year
and this fall is confined to the gray matter.
Drugs
All the inhalational anesthetic agents are cerebral vasodilators
The resultant increase in intracranial pressure will be greater in patients with
space occupying lesions
Ketamine is a cerebral vasodilator and increases the ICT and should not be
used in patients with increased ICT
All the intravenous anesthetics—barbiturates, propofol, benzodiazepine reduce
the CBF with a fall in cerebral metabolism.
Failure of autoregulation
When the range of 50 mm Hg to150 mm Hg is crossed
Increased PaCO2
Arterial hypoxemia
Very deep anesthesia
Extensive surgery
Circulatory arrest.
Intracranial pressure
It is not the same or synonymous with cerebrospinal fluid pressure. Both are not
one and the same. In patients with increased intracranial tension (ICT), there will
be increase in CSF tension also.
“If the ICT equals the arterial pressure, then no perfusion can occur”.
Definition
It is the pressure exerted by a unit area of cortex of the brain juxtaposing the unit
area of cranial vault.
As the cranial cavity is bounded by rigid bony wall it cannot expand in case of
increase in the size of the contents. There are three compartments namely, brain
tissue, vascular compartment and CSF compartments.
Munro Kellie’s Doctrines

In the closed cranial cavity, the total volume remains the same. If there is any
increase in the volume of any one of the compartment in cranial cavity, it can do
so only at the expense of the other two.
Hence, whenever there is a space occupying lesion, it compresses first, the CSF
compartment, then the vascular compartment and once there is no further space
the brain tries to herniate through the foramen magnum.
Causes of increased intracranial pressure

Physiological: coughing, sneezing, straining, etc.
Pathological:
Pressure from outside: bony tumor, craniostenosis, etc.
Space occupying lesions: Tumor, abscess, hematoma, etc.
Hydrocephalus
Venous obstruction and PEEP
Arterial dilatation, high PaCO2
Cerebral edema
Head down position.
Causes of reduced intracranial pressure

Dehydration or blood loss.
Cerebrospinal Fluid
This is an ultrafiltrate of blood formed by the choroid plexus in the lateral ventricles
pass through the foramen of Monro on each side to join that formed from the choroid
plexus of the third ventricle. Then it passes through the aqueduct of sylvius to the
fourth ventricle. CSF leaves from this to the subarachnoid space through the central
formen of Magendie and the lateral formina of Luschka and reaches the cisterna
magna. It bathes the whole of the central nervous system and is absorbed into the
venous sinuses through the arachnoid villi.
Total amount is 120–150 ml
Secreted at the rate of 4 ml/min
Pressure: 120 cm of CSF in the lateral position, and 300 cm of CSF in sitting
position
It is different from blood in that it almost free from cells and proteins
Proteins 30 mg %
Cells 5/c.mm
Specific Gravity 1003–1005
pH 7.3–7.4
Increased production, decreased absorption or any obstruction—all these cause
hydrocephalus.
Anesthesia and Heart

In the past, any patient with a cardiac illness was considered as a grave risk for
anesthesia. It was true to some extent because of;
The limitations in investigations to assess the available functional reserve of
the heart that is essential to decide whether the heart will stand the stress of
anesthesia and surgery
Non-availability of sophisticated therapeutic agents that can support the heart
and vascular system
Non-availability of sophisticated monitors and supportive gadgets such as
temporary pace makers
Non-availability of high dependency care units for giving care for these patients
postoperatively and so on.
Now the technological and pharmacological developments along with
sophisticated environment for care of critically ill have changed the whole scenario.
Those patients considered as cardiac cripples and considered unfit for anesthesia in
the past are now coming up for cardiac and non-cardiac surgeries with reasonably
good outcome.
For deciding about the fitness and the best possible anesthetic management
of cardiac patients and also for protecting the cardiovascular system of normal
healthy patients submitted for anesthesia the basic understanding of the anatomy,
physiology and pharmacology related to cardiovascular system is essential. In
general with the exceptions such as myocarditis or cardiomyopathy, myocardial
function depends mainly on adequacy of coronary blood flow.
Anatomy of coronary arteries

The left coronary artery arises from the left posterior aortic sinus below the level
of the free edge of the aortic cusp. The main trunk runs forwards and to the left
between the base of pulmonary artery and the left auricle to enter the atrioventricular
groove. At this point it gives off a large and important branch—the interventricular
branch—which passes downwards on the anterior interventricular groove, then
curls round the apex of the heart, and finally anastomoses with the corresponding
branch of the right coronary artery. It supplies branches to both ventricles.
Meanwhile the main trunk, the left circumflex branch of the left coronary artery
passes along the left atrioventricular groove. It continues round the left border of
the heart and accompanies the coronary sinus as far as the interventricular groove
where it anastomoses with the similar branches of the right coronary artery.
The right coronary artery arises from the anterior aortic sinus just below the
level of the free edge of the anterior cusp of aortic valve. It passes forwards and to
the right between the root of pulmonary trunk and the right auricle and then runs
in the right atrioventricular groove to the right side of the heart near its inferior
margin. Here it curls round the right border on to the posterior aspect of the heart
and runs towards the left side until it reaches the interventricular groove, where it
anastomoses with the left coronary artery. It gives off two important branches;
The marginal branch, which arises near the point where it curls round the right
border of the heart and passes along the inferior border, supplying branches to both
surfaces of right ventricle.
The interventricular branch arises just before the termination of the main trunk
on the posterior aspect of the heart. This branch runs downwards and forwards in
the interventricular groove, giving off branches as it goes until finally it ends by
anastomosing with the corresponding branch of the left coronary artery (Fig.12.4).
Fig. 12.4: Anatomy of coronary arteries
The blood supply of the neuromuscular tissue of the heart is of some importance.
The Sinoatrial (SA) node receives a branch directly from either the right or
left coronary artery
The atrioventricular node (AV) is supplied by twigs from the left coronary artery
The atrioventricular (AV bundle) bundle has abundant blood supply, receiving
branches from the left coronary artery which accompanies the bundle in the
moderator band and supply the right division of the bundle
The left limb of the bundle has no specific branch and is supplied by small
arterioles in the neighborhood.
Coronary artery blood flow

The normal myocardium accounts for 11% of the total body oxygen consumption.
But the coronary circulation receives only 4% of cardiac output
Considering its metabolic demands, the myocardium is one of the more poorly
perfused tissues in the body
There is a need for a balance between the oxygen demand and oxygen supply
to the myocardium (myocardial oxygen balance)
The balance is dependent on the following:
Myocardial oxygen supply Myocardial oxygen demand

Heart rate Heart rate
Coronary perfusion pressure Ventricular preload and afterload
Arterial oxygen content Myocardial contractility
Coronary artery diameter

Any pathological disturbance that changes the myocardial oxygen balance will
result in ischemia
Coronary artery flow begins during the period of isometric relaxation, when
the ventricular muscle is relaxed and the pressure in the aorta is high
The inflow continues to rise up to the mid point of diastole and then falls off
again in the second half of diastole
During systole, the contraction of the ventricular muscles prevent the coronary
arteries from filling.
Since the circulation through these channels is of such great importance the
coronary arteries possess some intrinsic mechanisms for their protection against
changes in the environment.
Oxygen saturation in the blood

Alterations in this may influence the lumen of the coronary vessels. A fall in
saturation to 50% results in a four fold increase in coronary flow in an attempt to
compensate for the myocardial hypoxia.
Cardiac output
Changes in cardiac output have marked effect, since coronary flow varies inversely
with it. When the cardiac output falls the coronary flow increases and vice
versa.
pH of blood
A fall in pH of blood leads to an increase in flow.
Blood pressure
The mean aortic pressure influences the coronary flow. An increase in pressure leads
to an increased flow. But this does not take into consideration the other factors like
cardiac output, coronary artery diameter and peripheral resistance.
Coronary artery dilators

Coronary vessels supply the myocardium with oxygen and other nutrients necessary
for contractile activity. If the heart is called upon to do more work without a
corresponding increase in the coronary flow then the myocardial efficiency will
suffer.
Glyceryl trinitrates are generally considered as powerful coronary vasodilators
in the presence of angina pectoris. This drug acts by producing peripheral venous
dilatation in low dose and venous and arteriolar dilatation in higher dose. This
results in reduction in venous return (preload) to the heart and reduction in
peripheral resistance (afterload) and reduces the workload of heart. Ultimately the
end diastolic ventricular volume is reduced which improves the subendocardial
perfusion. Besides, there is a direct coronary vasodilatation.
It is important to remember, therefore, that a reduction in the myocardial work
is as important as an increase in coronary flow.
The heart rate

The heart rate is controlled by a balance of the inhibitory influence of the vagus
and the excitatory influence of sympathetic
At rest the heart rate is dominated by the effect of the vagus
Sympathetic contributes very minimally for the resting heart rate
The various influences affecting the heart rate may be summarized:
–– Peripheral stimulation: Hypoxia and carbon dioxide stimulate the
chemoreceptors and increase the heart rate. These receptors are in carotid
and aortic bodies.
–– Direct stimulation: A rise in body temperature stimulates the rate of discharge
from the SA node. Catecholamines directly stimulate the heart rate.
–– Impulse from other cranial centers: these may reflexly affect the heart rate.
For example, a sudden fright in a conscious subject may lead to intense vagal
stimulation, vasodilatation and hypotension with slowing of the heart, i.e.
a vasovagal attack.
Spread of respiratory neuron activity to adjacent cardiac center neurons may
cause sinus arrhythmias.
A rise in intracranial pressure causes slowing of the rate.
Vascular reflexes
–– These are the most important
–– The pressor receptors are situated in the tunica media of the roots (origin)
of the great vessels, the common carotids and the subclavian arteries and
the arch of aorta
–– The bifurcation of common carotid is dilated and is known as carotid sinus
–– Other pressor receptors are present in the atria and great veins
–– Afferents from the pressor receptors pass to the medulla
–– An increase in blood pressure (pulse pressure) is followed by a fall in heart
rate (Marey’s law) and vice versa.
Cardiac output
It is the volume of blood that each ventricle pumps out per minute
When it is related to the body surface area, it is called as “cardiac index”.
Normal–3.5 liters/sq. m
Cardiac output is not solely dependent on heart rate, as 5 fold rise in heart rate
could raise the cardiac output to 2½ time only
The major contribution to increase the cardiac output is the force of contraction
and venous return otherwise known as preload of heart.
Venous return
The venous return must equal the cardiac output
However, instantaneous changes in cardiac output may take place without
corresponding increase in venous return
To achieve such short-term inequalities, the heart must draw the reserve
volumes contained in the heart itself (diastolic volume) or from the pulmonary
circulation
Further volumes of blood may be acquired from the reduction in the capacity
of larger central veins
There is a compensatory mechanism playing in that by the baroreceptors and
autonomic activity. This invariably causes a temporary “over swing”
The sympathetic stimulation causes three effects;
–– The force of contraction of ventricles is increased
–– three is an increased stroke volume which increases the ventricular
compliance
–– there is augmented atrial contraction to fill the ventricles
Here as per the ‘Starling law’, the better filling of ventricles and the increased
end diastolic pressure and the increased fiber length cause increased force of
contraction and cardiac output.
Effects of anesthetic agents on cardiac output

All the anesthetic agents have a depressant effect on the heart
The overall effect depends upon the ability of the agent to liberate catechola-
mines in the sympathoadrenal system
Ether increases the cardiac output
Thiopentone decreases the cardiac output
Propofol produces reduction in vascular resistance and heart rate
Ketamine is a potent cardiovascular stimulant by increasing sympathetic
discharge, but its direct effect on myocardium is negative inotropic
Halothane reduces the cardiac output by the effect of blocking the action of
catecholamines on the heart
Isoflurane is a myocardial depressant, has lesser effect than halothane. Primarily
it causes a fall in systemic vascular resistance
Sevoflurane and desflurane have almost similar effect.
Vascular system
Circulatory efficiency depends as much on the integrity of the peripheral vasculature
as it does upon the performance of the heart.
It is better to remember some of the essential factors.
Arterial system
This is the resistive element of the circulation and must be optimal
Most of the peripheral resistance results from the one in the muscular arteries
and arterioles
Blood viscosity also plays a major role in the resistance
Selective constriction and dilatation of appropriate arteries is responsible for
distributing the cardiac output according to the tissue requirements
Arteriolar constriction is one of the mechanisms available for support of arterial
blood pressure on the face of a falling cardiac output
Under resting conditions, nearly 50% of the cardiac output flows to the kidney
and viscera.
Vasopressors and other vasoactive drugs tend to constrict these vessels. On the
face of hypovolemia if adequate volume correction is not done, these drugs
may cause severe tissue ischemia
The arterial side of the circulation contains only about 15% of the total blood
volume.
The capillaries
It is at the level of these smallest vessels that the metabolic exchange occurs
between the blood and tissues
Overall capacity of capillary bed is so large that if all the capillaries open
simultaneously the blood will accumulate in the tissues and circulation will fail
Flow into the capillaries is controlled by the pre- and post-capillary sphincters.
When they are constricted the blood flow by-passes the capillary bed and flows
through short arterio-venous channels
Circulatory failure becomes “Irreversible” when the tone of pre-capillary
sphincter is lost while the post-capillary sphincter remains constricted, so that
stagnant blood accumulate in the anoxic leaking capillary bed
Unlike arteries and veins, where there is primary autonomic control, local
physical and chemical agents are predominantly responsible for the regulation
of the tone in the microvasculatur, e.g. heat and cold, adrenaline, etc.
The venous system

Under normal conditions, 65–70% of blood volume is contained within the
veins which therefore act as a capacitance or reservoir system
The compliance of this system is determined by vasomotor tone, which is
controlled by autonomic impulses from the vasomotor center in the floor of
the fourth ventricle
If the blood volume falls, venous tone increases due to sympathetic stimulation,
there will be a shift of blood into the right heart, so that filling pressure and
therefore cardiac output is maintained
This maintains normal cardiac output and normal blood flow can be maintained
in spite of diminution in volume
The ability of the normal heart to discharge its function is determined by
adequacy of cardiac filling and the force of contraction
Cardiac filling is determined by the volume of blood available in the venous
reservoir, the degree of venous tone and the compliance of ventricular muscles.
Myocardial oxygen consumption under anesthesia

There is evidence that there is reduced overall oxygen consumption during
anesthesia due to reduction in metabolism
The fact that the myocardium is pumping blood against minimal after load for
supplying tissues at reduced metabolism, under well maintained anesthesia
with good ventilation there is no ischemia to myocardium.
Tachycardia
Tachycardia, more than anything else does more damage to heart and it has
to be prevented
An increase in heart rate above normal slowly encroaches upon the diastolic
time. As we know that the coronaries get filled in the first half of (phase of
isometric relaxation) diastole, the shortening of diastole means less time for
coronary filling and aggravation of ischemia
In ischemic heart disease patients it may induce infarction
When using a vasopressor if needed the choice of drug and the dose must be
such that it does not induce undue tachycardia.
Bradycardia
“Bradycardia is a forerunner of arrhythmias”:
A heart rate less than 60/min is bradycardia
Any rate less than 60/min is not ideal for maintaining normal cardiac output
and coronary perfusion
The increase in diastolic time helps in adequate ventricular filling thereby
stretching the muscles, in turn the force of contraction and the stroke volume
This increased stroke volume is not adequate to maintain the normal cardiac
output as the rate is low
Diastolic coronary filling will be better, but the end diastolic pressure is high
and that reduces the endocardial perfusion
Considering all these factors, the inference is that for maintaining optimum
cardiac function the heart rate has to be maintained from 60 to 70/min.
With all that understood by knowing the anatomy, physiology and pharmacology
related to heart, we come to know that to protect the heart in specific and the
cardiovascular system in general during anesthesia and postoperative period, the
following factors must be avoided meticulously:
Hypoxia
Hypercarbia
Hypotension
Tachycardia
Hypoglycemia.
Autonomic imbalance
Though this appears as simple five factors, it is not very easy and simple to achieve
the perfect anesthesia which avoids all these. However, if one strives hard with
continuous monitoring, it will be possible to achieve this and even the crippled
heart will be protected from further damage.
Chapter Recovery room:
13 Postanesthesia Care Unit
(PACU)
Chapter Outline
Postanesthesia Care
v
Recovery Room
v
Transport to Recovery Room
v
The Purpose of Recovery Room
v
Systems Mainly Affected during Recovery
v
Facts about a patient recovering from anesthesia
v
Recovery Criteria
v
Clinical Assessment of Adequacy of Reversal of NMB
v
Guidelines for Postanesthetic Recovery Care
v
Postanesthesia Care
Recovery from anesthesia is defined as the period from the cessation of the
administration of anesthesia until the patient is awake with protective reflexes.
Recovery from anesthesia is not a simple and uniform process. Every individual
patient presents with gross variations in that. The physical and physiological status
of the patient has the basic implication on this. Apart from that, the pathology
associated with various systems and the drug treatment instituted for correcting it,
the technique of anesthesia and the drugs used for that purpose, the duration of the
surgery and the amount of blood loss and so many other factors may modify the
recovery process. Incidentally, it is this variation that makes the recovery period
potentially more hazardous and vulnerable for dangers.
Anesthesia is usually compared to a flight of an aircraft, the induction is
considered as “take off”, the maintenance of anesthesia is “the actual flight in air”
and the recovery or emergence is “the landing”. More than 90% of the accidents
related to an aircraft occur during landing. Similarly 90% of the accidents related
to anesthesia occur during recovery indicating that it is the most vulnerable period
for mishaps.
In a study done in United Kingdom, analyzing the cause of postoperative deaths
that occurred during the period of 7 years from 1970 to 1977 (Medical Defense
Union. MDU), it has been proved that more than 50% of the deaths occurred in the
immediate postoperative period. Two other analyses done one in 1987 and another
in1990 (Confidential Enquiry into Perioperative Deaths CEPOD) indicate that more
than 80% of the postoperative deaths occurred in the first hour of postoperative
period and among them more than 75% were due to hypoventilation resulting from
Chapter 13  Recovery room: Postanesthesia Care Unit (PACU) 179
the residual effects of anesthetics and opioids or residual neuromuscular blocking
agents, rarely due to recurarisation. The CEPOD report described inadequate
recovery facilities in many hospitals in United Kingdom.
In a wider analysis of the facts about these deaths, it has been concluded that;
These deaths were preventable
Most of them occurred due to lack of care
In many cases there were no recovery rooms available at all
Many patients died during their transport from the theater to the postoperative
ward.
All these clearly indicate the importance and necessity for adequate and proper
postanesthetic care to prevent the problems and complications of the recovery
period, the worst catastrophe being death of the patient.
“One of the most illogical situations in present day anesthesia is the immense
amount of expert skill and care that is lavished upon the patient in the operating
theater, often only to be abruptly abandoned the moment the anesthetic is stopped”.
—WD Wylie
Though Wylie made this statement sometime in early 70s, the scenario has not
changed markedly over the years, particularly in Indian context.
History
1921—Facilities for postoperative care was advocated by AL Flemming,
President of Anesthetic Section, Medical Institute of Birmingham.
1942—In Mayo Clinic, John Silas. Lundy. Introduced a postoperative
observation room under his direction.
1955—In Southend Hospital. UK, the first postoperative observation room
(recovery ward) was instituted.
Now the terminology is variably used. “Recovery Room”, “Recovery Area”,
“Postoperative Care Unit” and “Postanesthetic Care Unit” (PACU) all carry the
same meaning.
Recovery Room
It is an integral part of an operating suit.
This is a setup located in the near vicinity of operating theater, preferably
in the clean area of the theater complex where adequate facilities with regard to
infrastructure, equipments and efficient well trained nursing staff are available to
give specialized nursing care and support for the patient in the immediate post-
operative period, who mostly require this type of care for varying periods from a
few minutes to a few hours and rarely for 24 hours.
This must be in the operating suit for the anesthesiologist to have a close
observation of the patient as frequently as needed.
The responsibility of the patient’s welfare here remains with the anesthesiologist.
“Probably the safest place for the patient to recover from anesthia is the operating
theater itself, since all necessary equipments and drugs are closeby for access in
the event of any mishap.” — Michael B Dobson
The Transport to Recovery Room

This transport time is one of the dangerous times where many catastrophes
can occur.
Ideally, the travel to the recovery room must be as short as possible.
The patient must be preferably in semi-prone position (recovery position) on
the trolley (Fig. 13.3).
This position is ideal and safest for maintaining clear airway during transport.
Oxygen cylinder, O2 mask, resuscitator bag and equipments for intubation must
be provided at the base of the trolley.
Intravenous infusion line should not be closed, must always be open for
administration of any emergency medications during transfer.
The patient must be accompanied by the anesthesiologist who anesthetized that
patient or at least a recovery nurse to recovery room.
Pulse and respiration must be continuously monitored and must have a pulse
oximeter for continuous monitoring of O2 saturation during transfer.
Patient is handed over to the recovery room nurse with verbal transfer of
information about the patient’s condition and the necessary instructions
regarding further management.
In case of any eventualities, the patient must be resuscitated in the recovery
room.
If there is a necessity, the patient must be wheeled back to the theater for any
emergency procedure.
There are other two terms used regarding the postoperative care of patients that
carry a little different meaning, indicating different setups that are usually present
in bigger centers located near the recovery room. These are specially meant for
different category of patients. They are;
Intensive Therapy Unit (ITU)

These are units where patient requiring more than ordinary care are admitted. These
are patients suffering from some medical illness related to some other system such
as respiratory (COPD), cardiovascular (ischemic heart disease, CCF), renal system
(chronic renal failure), etc. apart from the surgical problem requiring special therapy
for their illness.
High Dependency Unit (HDU)

These are units meant for taking care of patient who have undergone major surgical
procedures of an unusual nature that requires high dependency nursing for a variable
length of time. It may include also patients who have problems specifically related
to their age such as geriatric patients or neonates who could not be taken care of
in ordinary recovery room or postoperative ward. For example, a geriatric patient
who has undergone open heart surgery or a neonate who has undergone surgery
for ruptured encephalocele.
These patients need high dependency nursing by specially trained nurses for
this purpose and also need special equipments like pediatric ventilators.
These units are preferably situated in the same location close to each other and
they must have easy access from the operating theater. The facilities for radiological
and biochemical investigations must also be available close by.
The purpose of Recovery Room

To eliminate preventable causes of postanesthetic morbidity or mortality.
To ensure that the effects of anesthetics on the vital functions are adequately
reversed and these vital functions are stable and can be preserved without
assistance.
Every patient operated under any anesthesia, general, regional, total
intravenous anesthesia (TIVA) or dissociative anesthesia must pass through
the Postanesthetic Care Unit. After meeting out the “Recovery Criteria”, they
are transferred to the postoperative ward. This observation may take many
minutes to a few hours. The responsibility of the patient’s welfare remains
with the anesthesiologist.
“A good anesthetic management leads on to an uneventful recovery and post-
operative period”.
A good anesthetic management comprises of the following:
A good level of anesthesia (plane of anesthesia)
Adequate vascular relaxation (suppression of sympathetics)
Adequate fluid balance
Adequate blood replacement (when needed).
Systems mainly affected during recovery

Consciousness may be inadequately recovered and may be impaired for a long
time due to various reasons
This may have secondary effect on the maintenance of adequate airway and
ventilation
Excitement, confusion and restlessness may be caused by various factors
Postoperative pain may manifest as a major problem.
Hypotension may be present
Residual effect of anesthetic drugs may cause reduction in peripheral resistance
and cardiac output particularly in the absence of surgical stimuli
Hypovolemia may be present because of inadequate fluid and blood replacement
during surgery or due to continuous bleeding
Hypertension may be manifested due to various factors. Increased sympathoad-
renal response after recovery or due to inadequate analgesia and severe pain.
Respiratory System
Hypoventilation may occur very commonly
Residual effect of volatile anesthetic agents as well as opioids may cause severe
respiratory depression
Incomplete reversal of residual neuromuscular blocking agents may present as

inadequate ventilation. Sometimes recurarization may manifest after an apparent
early and adequate recovery due to various causes
Though all these systems are likely to be affected during recovery, the
immedidate danger to life is caused usually by airway obstruction or
hypoventilation resulting in hypoxia. Commonly, two factors namely,
CNS depression or inadequate power of respiratory muscles due residual
neuromuscular blockade are responsible for that. So, these two aspects are
given priority in observing a patient during recovery.
Some facts to be remembered during the observation of

postanesthetic patients
Maintenance of airway in Unconscious Patient

The importance of supporting and maintaining the airway of an unconscious patient
could not be overemphasized. The patient becomes unconscious as soon as the
anesthesia is induced and hence, the problem of maintaining the airway starts then.
Particularly when the surgical procedure is relatively short and the anesthesiologist
wants to maintain anesthesia with the help of a mask, the maintenance of airway
becomes the important step.
In fact, many times the major catastrophe is caused by improper maintenance
of the airway. Intubation of the trachea is the sure way of maintaining the clear
airway. That is one of the reasons why a beginner in anesthesia feels always happy
when he successfully intubates the patient’s trachea.
The following points are highly significant and are to be remembered.
Identifying obstruction
A patient with a clear airway breathes very effortlessly and there will be no
noise during breathing
If the airway is partially obstructed, there is usually noise during breathing
If the airway is completely obstructed, then there is absolutely no sound
Very loud snore with apparently regular breathing also indicates respiratory
obstruction
Observation of movement of the patient’s chest and abdomen invariably give
an idea of cause of obstruction
The characteristic “paradoxical respiration” could be observed, where during
inspiration as no air enters the lungs, the chest wall is drawn inwards and the
abdomen protrudes out because the diaphragm contracts. The reverse occurs
during expiration without any air movement.
Quickly the patient becomes cyanosed. The airway has to be restored
immediately to prevent hypoxic brain damage.
Mechanism of airway obstruction

The obstruction in almost all cases is due to the relaxation of the muscles of neck
and those that support the mandible. This causes the mandible with the tongue to
sag backwards and the base of tongue sits on the posterior pharyngeal wall causing
obstruction. This is commonly referred to as “falling back of tongue” (Fig.13.1A).
Maintaining clear airway

The maneuvers
This can be very easily relieved by a simple maneuver which is a combination
of two steps. First flexing the neck and extending the head. This is tilting the
head backwards so that his nostrils point upwards. This lifts the mandible and
base of tongue away from the posterior pharyngeal wall and clears the airway
(Fig.13.1B).
If this maneuver is not effective then pushing the jaw anteriorly by lifting at
both the angles by the ring fingers of both hands and bringing the mandible
to prognathic attitude. This is keeping the lower incisors anterior to upper
incisors (Figs 13.2A and B).
With these procedures usually the airway gets cleared and patient breathes
normally.
Recovery position
The patient may be turned onto ‘recovery position’ which takes care of airway and
drainage of secretions. It is turning the patient onto his side with the head and neck
extended and one of the knees pulled up to prevent him falling onto his face. The
patient may be retained in that position till he is able to maintain his airway well.
a b
Figs 13.1A and B: The common mechanism of airway block and relieving it
• Note the relaxed mandible and tongue sitting on the posterior pharyngeal wall blocking the airway
• After removing the pillow, extension of the head and tilting the chin upwards makes the airway
patent
a b
Figs 13.2A and B: Jaw thrust and chin up postion for keeping airway patent
This recovery position is best suited for both transport as well as for nursing during
recovery unless there is objection for keeping the patient in this position for surgical
reasons (Fig. 13.3).
Artificial Airways
If muscle power and reflexes have not recovered during this time, manually
maintaining the airway like this may be difficult. Now the right size Guedel’s
airway (Fig.13.4) may be inserted properly in the oral cavity and simple lifting
of chin will maintain the airway (Fig.13.5).
Alternatively ‘Berman’s Airway’ which is very similar in shape may also be
used (Fig.13.6).
It must extend from the lips to the angle of mandible.
Sometimes the patient may not tolerate the oropharyngeal airway (Guedel’s
airway). Then forcing that in position may induce vomiting. Now a
nasopharyngeal airway well lubricated with local anesthetic jelly can be
passed through the widest nasal cavity and left near the glottis by carefully
listening to the breath sounds at the proximal end of the airway and fixed in
that position (Fig.13.7).
Carefully clearing the oropharyngeal secretions by using suction with adequate
power will keep things under control. Electrically operated suction is usually
available in all postoperative wards. Foot operated suction may be an effective
tool to be carried anywhere (Fig.13.8).
If all these efforts fail to maintain the airway patent, the next option without
causing further delay must be intubating the patient with a proper size cuffed
endotracheal tube and observe him in the recovery room till he is able to
maintain his airway (Fig.13.9).
Respiratory depression and Hypoventilation

Ventilatory drive may be badly affected by the hypocapnea as a result of
hyperventilation during anesthesia and the depression continues until PaCO2
is returned to normal.
Similarly hypothermia and primary metabolic acidosis may also depress the drive.
Fig. 13. 3: “Recovery position” or ‘Safe position”

• Lateral position with the upper thigh flexed to draw the knee up
• Head is tilted a little extension to keep the airway open
• Any secretion or vomit will drain through the angle of mouth.
a b
c d
Figs 13.4A to D: Different Guedel’s airways and assessing the right size for the patient
a b
Figs 13.5A and B: Method of inserting a Guedel’s airway and maintaining the patency
Fig. 13.6: Berman’s airway

a b c
Fig. 13.7: Nasopharyngeal airway
a b
Fig. 13.8: Electrically operated and foot operated suction pump
Fig. 13.9: Intubation of trachea

Depression of ventilatory drive is easy to diagnose, as there is reduction in
both rate and tidal volume.
All volatile anesthetic agents and IV anesthetic agents with the exception of
ketamine depress the respiratory center; significant concentrations of these
drugs remain in the brain stem during early postoperative period.
All opioid analgesics depress ventilation. With most opioids the effect is
dose dependent, although the agonist-antagonist agents are claimed to have a
ceiling effect (once the particular dose is reached, any further increase in dose
is not likely to cause proportional increase in respiratory depression). The
stimulant effect of raised PaCO2 on the respiratory center will be depressed or
abolished. This manifestation will be marked particularly when repeat doses
of opioids were administered to relieve the postoperative pain completely. One
must remember that “pain is the physiological antagonist to the respiratory
depression caused by opioids.”
Mild hypoventilation is acceptable provided the oxygenation remains adequate;
this can easily be achieved by a modest increase in fractional concentration
of oxygen (FiO2).
Spinal opioids particularly the lipid soluble agents like morphine may produce
ventilatory depression after some hours of administration. Patients who received
subarachnoid or epidural opioid should remain in the recovery room for 12
hours. After fentanyl at least for 4 hours.
Naloxone is a opioid antagonist. It reverses the respiratory depression caused by
opioids like morphine, pethidine, etc. It may also reverse the analgesia produced
by the systemic opioids administered by parenteral route but not that of opioids
administered by spinal or epidural route. Large doses of this drug used in an
attempt to reverse respiratory depression may cause severe hypertension or
rarely even cardiac arrest.
Commonest peripheral factor causing hypoventilation is residual neuro-
muscular blocking agents (NMB). Measurement of tidal volume is not a
reliable guide to adequacy of reversal of neuromuscular blockade; a normal
tidal volume may be achieved with only 20% of return of diaphragmatic power,
but the ability to cough remains severely impaired.
In reversing the residual neuromuscular blockade, neostigmine may be
administered by titration of dose. a total dose of 5 mg should not be exceeded.In
higher doses, neostigmine can worsen neuromuscular function. These drugs may
cause severe adverse effects on cardiovascular system and also may intensify
postoperative nausea and vomiting (PONV).
Difficulty in reversal may be due to over dosage of muscle relaxants, too
short interval between the administration of the last dose and the reversal,
hypokalemia, respiratory or metabolic acidosis, aminoglycoside drugs, local
anesthetic drugs, diseases affecting neuromuscular junction, etc.
Delayed elimination of muscle relaxant drugs due to renal and hepatic
insufficiency, low urine output due to dehydration may also cause difficulty
in reversal. This may sometimes present as recurarization particularly when
cumulative drug such as pancuronium is used. Patient may appear to have been
adequately reversed, but after variable length of time gets paralyzed again
leading onto either ventilatory inadequacy or respiratory arrest.
Recovery Criteria
These are criteria to certify that the patient has recovered adequately from the effects
of anesthesia and surgery and is fit to be transferred to the postoperative ward.
Different authorities have proposed different recovery criteria to be fulfilled
before sending a patient to postoperative ward. Some of them quote even twenty
criteria particularly for day care set up. But unfortunately not all of the proposed
criteria are foolproof and reliable. Moreover, many of the criteria are practically
difficult to test. However every institution must have their own recovery criteria
scientifically formulated depending upon their work load as well as the availability
of personnel and equipments. If the recovery criteria are not fulfilled before sending
the patient to the postoperative ward, then there is every chance that the patient is
exposed to an unjustified risk of the two most common life threatening recovery
problems namely, respiratory inadequacy and cardiovascular depression. So the
main concentration in the postanesthetic recovery is pointed towards these two.
Taking all of these into consideration and putting all that proposed criteria in
a nutshell, the following five recovery criteria may be considered practical, ideal
and reliable. They are:
1. The patient must be fully awake.
2. He must be well oriented.
3. He must not be suffering severe pain.
4. His protective reflexes must have recovered fully and are active. Particularly
cough reflex and deglutition reflex must be active enough to protect his airway.
5. Residual neuromuscular blockade must have been fully reversed.
1. The patient must be fully awake: Patient must be awake or in quiet sleep,
could be aroused with verbal command of conversational volume of voice. Too
drowsy or unconscious patient should never be sent to postoperative ward.
2. He must be well oriented: This is tested by various methods advocated by
various authorities but ideally if the patient is able to tell his name, his profession
and the name of his relative who accompanied him to the hospital, etc., it is
acceptable. This information could be easily gathered from the patient just
before induction or when he is in the preoperative waiting room.
3. He must not be suffering severe pain: Suffering from severe pain may increase
the restlessness and muscular activity along with moderate hypertension
and tachycardia. All these increase O2 demand in general and particularly to
myocardium that may be detrimental to patients with ischemic heart disease.
Such patients must be given adequate analgesic in recovery room by intravenous
route with small increments and titrated for desired response and relief.
–– Mild pain where the patient is comfortable and when left alone going into
sleep is acceptable.
4. His protective reflexes must have recovered and active: Particularly cough reflex
and deglutition reflex must be active enough to protect his airway.
–– Even if vomiting occurs, the patient may be able to protect the airway to a
greater extent than a patient with depressed reflexes.
5. Residual neuromuscular blockade must have been fully reversed: This could
be essentially checked with the help of a peripheral nerve stimulator to be sure
that it is more than 80%. Ideally a TOF ratio of 0.8 is considered adequate.
Even this is questioned by some authorities on the grounds that the response
of respiratory muscles for nerve stimulation is different from that of the other
skeletal muscles.
There are many places where a peripheral nerve stimulator may not be readily
available at hand. Even in these circumstances, it is essential to assess the adequacy
of reversal of residual NMB. There are clinical tests that can be used to assess the
adequacy of reversal.
Clinical assessment of adequacy of reversal of NMB

Various authors have suggested various scoring systems for assessing the adequacy
of reversal of NMB. Measurement of tidal volume is not a reliable guide to adequacy
of reversal. As the diaphragm is the last muscle to be paralyzed and the first muscle
to recover, with 20% of return of diaphragmatic power, a normal tidal volume can
be achieved, but the ability to cough remains severely impaired.
In conscious and cooperative patients the following tests are suggested.
Sustained eye opening for more than 5 seconds
Protrusion of the tongue well
Normal swallowing
Ability to cough
Ability to sustain head lift for at least 5 seconds
Sustained leg lift for 5 seconds
Sustained hand grip for 5 seconds
Arm lift to the opposite shoulder
Tongue depressor test.
Tongue depressor test is done by keeping a tongue depressor in between the

incisors and asking the patient to clench the jaw. Then the tongue depressor is
pulled to lift the head of the patient off the pillow. It is a very reliable test that
corresponds with a TOF of 85%.
This can be done in a little modified way; the patient is asked to bite one end
of a clean handkerchief and while he is biting, it may be pulled up to lift his head
off the pillow. He must be able to sustain biting for 5 seconds.
Whatever way it is done, this needs intact and strong incisors and extreme
degree of cooperation of the patient.
Sustained leg lift is many times impracticable particularly in patients subjected
for abdominal surgeries.
Some of them are cumbersome and could not be tested by a nurse. But clinically
the following tests may be considered as good indicators of adequacy of reversal
of NMB. These are simple and reliable tests among the available lot, that could be
done by any one including a nurse and have the scientific and clinical relevance
confirmed by testing with a nerve stimulator. They are six in number and should
be done in the order from 1 to 6. This is the order of importance because if the
first test could not be done, then it is imperative that the second cannot be done
and so on.
For example, if the patient is not able to open his eyes either due to depression
by opioids or due to residual neuromuscular blockade, it is meaningless to proceed
further with the other tests. It is essential to carefully observe the patient and give the
necessary support till the patient recovers to the level suitable for doing these tests.
The six tests are:
Ability to open the eyes and look up continuously for more than 7 seconds
Ability of sharp protrusion of tongue out of mouth
Ability to close the mouth and swallow
Ability to cough effectively on command
Ability to take the hand from the side of the body to reach the nose, touch with
the index finger and then go back to the original position. Some authors have
put this test as—the ability to raise the hand and touch the opposite shoulder.
Ability to raise the head off the pillow and sustain it for more than 5 seconds.
1. Ability to open the eyes and look up continuously for more than 7 seconds:
This indicates the recovery of levator palpabre superioris muscle which is the
elevator of upper eyelid. This muscle is affected very early with the lowest dose
of non-depolarizing relaxants before any other muscle gets affected. This is
correlated well as the earliest clinical sign noted in Myasthenia Gravis. If this
muscle has recovered, it is reasonably accepted that the other muscle would
have recovered adequately.
The limitation of this test is, if the patient is too drowsy and couldn’t be
commanded, he may not open the eyes even when the muscles have recovered
well.
2. Ability of protrusion of tongue out of mouth: Protrusion of the tongue out
of mouth essentially needs both the intrinsic muscles and extrinsic muscles
of tongue in full power. If the tip of the tongue looks sharp and the surface
shows longitudinal grooves on it, that indicates the full recovery of intrinsic
muscles. If almost half of the tongue comes out of mouth that indicates that the
extrinsic muscles have also recovered fully. Recovery of these muscles has the
significance that they take part in the first step of deglutition.
3. Ability to close the mouth and swallow: Closing the mouth basically needs
effective contraction of two muscles.
One is masseter—one of the very strong muscle. This has the power of crushing
a hard nut kept between the teeth. Closing the mouth by bringing the mandible
up towards the maxilla needs less than 1/10 of its power. So if the patient is
having a relaxed mandible, possibly his level of neuromuscular recovery is
very poor. But here again if the patient is too drowsy mandible may be seen
relaxed.
The second muscle is “orbicularis oris”. This is one of the muscles of facial
expressions, a subcutaneous muscle without any bony attachments and is known
as the sphincter of mouth. This slender muscle only when fully recovered can
contract to close the mouth. If a patient is able to close the mouth and swallow,
it means the muscles of deglutition have recovered well and if the delicate
muscle orbicularis oris has recovered well it is reasonably correct to say that
the other muscles of body would have recovered fully well.
4. Ability to cough effectively on command: Ability to cough indicates that the
intrinsic muscles of larynx have recovered well particularly the tensors of vocal
cord. Secondly effective cough needs the power of abdominal muscles (the
secondary muscles of respiration). This is a very good index of NM recovery.
5. Ability to take the hand from the side of the body to reach the nose, touch with
the index finger and then go back to the original position.
Some authors have put this test as—the ability to raise the hand and touch the
opposite shoulder.
Whatever way it is done, this is a very sophisticated test. This involves very
well coordinated, complicated movements of various groups of muscles starting
from trapezius, deltoid, flexors and extensors of elbow, flexors of digits and
intrinsic muscles of hand. Excellent coordination and balance of action among
all these muscles are required to do this and also a good degree of wakefulness
and orientation.
If a patient is able to do this successfully, it indicates that all groups of muscles
of upper limb have recovered fully and so also the muscles of other parts of the
body. This is a very sensitive test.
Sometimes the patient may be able to flex the elbow and try to touch the nose
but may not be able to go back to the original position by extending the elbow.
The explanation for this is; in upper limb the flexors are antigravity muscles
and are more powerful than the extensors. Even if there is 20% recovery in
flexors the patient may be able to flex the elbow and touch the nose, but as
the extensor (triceps) is a weak muscle, 20% recovery is not sufficient to do
the extension of elbow. So the recovery is inadequate, we have to observe the
patient for further recovery or give additional titrating dose of neostigmine as
the case may be.
6. Ability to raise the head off the pillow and sustain it for more than 5 seconds:
The interesting fact about this test is that almost all the scoring systems have
included it as one, because it is a very reliable indicator of adequate recovery.
It indicates TOF 0.85 or more. But this also has limitations as this maneuver
causes powerful contraction of the anterior abdominal muscles, particularly the
rectus abdominis. This should not be done in patients with abdominal incisions
more so with upper abdominal incisions as it may detrimentally affect the sutures
which may give way resulting in incisional hernia later. Incidentally, it increases
the pain and morbidity. So also it could not be done in head and neck surgeries.
It is generally accepted that if four out of six tests are positive strongly, the
recovery is excellent. These tests very well correlate with more than 80%
recovery proved by peripheral nerve stimulator.
If the cardiovascular system is stable as ascertained by a normal and stable BP
without fluctuations and normal volume, rate and rhythm of pulse, the major
problems related to anesthesia could be excluded.
Recovery Room: Postanesthetic Care Unit

Common Postoperative problems
Respiratory obstruction leading onto hypoxia
Hypoventilation due to excessive opioids or residual NMB
Retention of secretions in oropharynx or tracheobronchial tree

Hypovolemia leading onto hypotension
Nausea and vomiting
Pain
Hypothermia or hyperpyrexia
Shivering
Restlessness
Bleeding.
Except bleeding all the other problems are basically related to anesthesia and
it is the responsibility of the anesthesiologist to manage them.
The real life threatening problems are related to respiratory and cardiovascular
systems.
Guidelines for Postanesthetic Care

The purpose of proposing guidelines for postanesthetic care is primarily to eliminate
the preventable causes of morbidity and mortality.
Secondly, it is to formulate a protocol that is best suited for the institution concerned
and thereby assuring that the patients get the best care during the vulnerable period.
The guidelines are proposed and the design of recovery room is made with the
following expectations in mind irrespective of the quantum of work, availability
of personnel and equipments, as it has to be an outcome oriented design.
Expectations
No patient is left uncared in the postoperative period
To keep them in a common place for giving them the required care
To look out for the common problems and complications, identify them
To manage the problems if encountered
To tackle the complication if any successfully
To be prepared for managing any eventualities.
Formulating Guidelines
The guidelines may be broadly classified into three heads. They are:
1. Infrastructure
–– Location and set up
–– Space allocation
–– Equipments
2. Staffing—personnel
3. Procedure—protocol.
1. Infrastructure
Location
Recovery room must be located in the clean area of the theater complex or
operating suit, as close to the operating room as possible which would permit the
following. Anesthesiologist must be able to accompany the patient to recovery
room and inspect him as and when required.
Fig. 13.10: A recovery room
He may take suitable resuscitative measures if needed in the recovery area.

In case of necessities the patient may be shifted back to the operating theater
for any emergency procedure.
Space allocation:
Three beds with adequate facilities are sufficient for a busy theater (Fig.13.10)
For each bed a floor area of 100 to 120 sq ft is essential
In between the beds a clear space of 7 ft is left
For privacy curtains may be provided
A clear space of 3 feet between the bed and curtain is available
The bed must be at least 4 feet away from the walls
More space is left at the head end for any emergency procedures such as
intubation or bronchoscopy, etc.
Other essential provisions:
Wall outlets for O2 compressed air and central suction for each bed at head end
Multiple electrical outlets at head end for operating monitors, infusion pumps,
ventilators, etc.
Electrically operated motorized ICU Cot provided with “Alpha bed” or ripple
bed is ideal
Good additional lighting for working in emergency
Provision of additional space is made for keeping equipments such as ventilator,
infusion pump, etc. when not in use
Proximity for radiology and biochemical laboratory facilities if necessity arises.
Equipments:
The equipments required for a recovery unit may include monitors, resuscitation
equipments, supportive equipments such as warming devices, infusion pumps,
ventilators, etc.
Monitors for every bed
Pulse oximeter
Noninvasive BP
ECG Monitor
Capnography—particularly when the patient is received in PACU in intubated
state.
For surgeries done for many hours in air conditioned theater particularly with
the abdominal viscera exposed and also in pediatric patients, hypothermia is a major
problem during recovery. These patients need to be actively warmed artificially by
using warming devices to prevent secondary complications due to hypothermia.
Similarly, there are occasions where a bigger pediatric patient with an infective
focus in a hot climate may develop hyperpyrexia that needs active cooling.
For hypothermic patients:
Temperature probe/thermometer
Forced air warming devices
Heating lamps
Thermo blankets warming/cooling.
In the recovery room every patient is likely to develop varying problems

that may require resuscitative measures starting from supplementation of O2 to
intubation and ventilation. In case the patient develops the worst catastrophe –
cardiac arrest, then means for reviving the patient including a defibrillator must
be available.
Resuscitation equipments:
O2 cannulae and masks of various sizes in adequate number
Oral airways and nasal airways of various sizes
Laryngoscopes—at least two sets
Endotracheal tubes and connectors of all sizes
Laryngeal mask airways of all sizes
Self-inflating resuscitator bag with mask (Ambu or any other make)
CVP Monitor
Sterile tracheostomy instruments in bin and tubes for emergency
ICD sets and tubes
One defibrillator
One ventilator.
2. Staffing (Personnel)
The effective functioning of a good recovery room service mainly depends on the
availability of adequate number of well trained, efficient, devoted nursing staff
to observe the patients closely, identify the problems immediately and institute
appropriate measures in time to prevent a catastrophic outcome.
Round-the-clock staffing is essential unless it is a day care unit
Nurses specially trained in special monitoring techniques and techniques like
intubation and ventilation are essential
A proper handing over and taking over protocol must be strictly followed by
the nurses in recovery room
The patient-nurse ratio varies according to the status of the patients
One for one patient: In “high dependency patient”
One for three patients: In “medium dependency patients”
One for four patients: In “low dependency patients”.
3. Procedure Protocol
All patients must be handed over to the recovery nurse properly by the
anesthesiologist or the nurse who accompanies the patient with verbal transfer
of information about the patient’s status.
The level of consciousness, BP, pulse rate, respiration and the oxygen saturation
must be informed.
Any other special instruction regarding any support needed must be informed.
Wherever possible patient is nursed in “Recovery Position” unless contra-
indicated for surgical reasons. If needed a slight head down tilt with extension
of head and neck and one of the knees drawn up to prevent the patient rolling
onto the face are added.
Continuous monitoring is done to assess that the recovery is complete.
Assessment of recovery related to the central nervous system, respiratory system
and cardiovascular system must be done in order by the protocol to certify that
the patient may be transferred to the postoperative ward.
It must be ensured that the patient does not suffer severe pain. If he does, it
must be adequately relieved and patient observed for sufficient time before
sending to the ward.
If spinal opioids are used for postoperative analgesia, special care must be
given to them as it may produce ventilatory depression. Care in using parenteral
opioids is advised.
Special protocol for observing the surgical wound must be used. Without
observing the surgical wound patient should not be sent to the ward.
Central Nervous System recovery

“An unconscious patient should never be transferred to postoperative ward for
any reason.”
Ensure
The patient is fully awake—not too drowsy
Well oriented. He must be able to tell his name, profession, the relative who
accompanied him to the hospital, etc.
Comfortable and quiet—not restless (if restless , find out the cause and treat it)
Does not suffer from severe pain.
If the patient suffers severe pain, suitable analgesic is given by IV route in
small increments till the desired pain relief is achieved. Usually, when the pain is
relieved almost completely, the patient may manifest respiratory depression caused
by opioids. (Pain is the physiological antagonist for the respiratory depression
caused by opioids.) There is a potential danger of the patient developing severe
respiratory depression or even apnea. So such patients are observed in the recovery
room for sufficient time to ensure that the respiration is not depressed.
Respiratory System: Ensure

The patient is able to maintain his airway without support
No obstruction of any cause is suspected
Respiratory rate and tidal exchange are normal

Tongue is pink and moist
Periphery is pink
On breathing room air, he is able to maintain a SpO2 of more than 95%
continuously for more than 10 minutes.
Cardiovascular Stability: Ensure

Normal BP that is stable without fluctuations
Pulse rate, volume and rhythm are normal
Color of nail bed is normal indicating good capillary perfusion
Capillary refilling in the finger pulp space is rapid
Peripheral veins are well filled indicating that there is no gross hypovolemia
Urine output/urine flow is normal (0.5 to 1 ml/min).
Surgical Wound: Observe for

Excessive soiling or bleeding
Abnormal collection in the drains
These observations are well correlated with the clinical features like
–– Progressively raising pulse rate
–– Progressive fall in BP
–– Increasing pallor.
In case of doubt, the surgeon may be summoned to inspect the wound to make
sure that nothing is wrong.
When one is satisfied with the recovery profiles of these three systems and the
surgical wound appears normal, then the patient is deemed, both in anesthetic point
of view as well as surgical aspects to be fit to be transferred to the ward.
In short, if the patient has fulfilled the five recovery criteria described earlier,
with adequate respiration and stable cardiovascular system, he is fit to be
transferred to postoperative ward.
Conclusion
All patients must pass through the “Recovery Room” irrespective of the type
of anesthesia or surgery
No unconscious patient should be sent to the postoperative ward
Proper protocol and care in PACU will prevent mortality and minimize
morbidity.
Further Reading
1. Andrade J, et al. Consciousness and Cognition,1994;3:148.
2. Association of Anaesthetists of Great Britain and Ireland. Immediate Postanaesthetic
Recovery. AAGBI. London, 1993.
3. Buck N, et al. Report of the Confidential Enquiry into Perioperative Deaths. London:
Nuffield Provicial HospitalsTrust and the Kings Fund for Hospitals, 1987.
4. Cedric Prys-Roberts, Burnell R. Brown Jr. International Practice of Anaesthesia.
Volume-I Butterworth. Meinman, 1996;53:1–11.
5. Cooper GM. Monitoring the recovery from Anesthesia: Monitoring in Anaesthesia and
Intensive Care. In: Hutton P and Prys Roberts C (Eds). Saunders, London, 1994;350 –64.
6. Crosby DL, Rees GAD Ann, Crosby DL, et al. Royal College of Surgeons. England.
1983;65:391; Ann. Royal College of Surgeons. England. 1990;72:309.
7. Department of Health and Social Security, Operating department. Health Building Note
26. HMSO, London, 1975.
8. Frost EAM, Thomson DA. Post-Anaesthetic Care. Bailliere’s Clinical Anaesthesiology,
London, 1994,
9. Hatfield A, Tronson M. The Complete Recovery Room Book. Oxford University Press.
Oxford, 1996.
10. Moller JT, et al. Anaesthesiology, 1990;73:890.
11. Pharmacology of Muscle Relaxants and Their Antagonists. Miller 5th Ed. and 7th Ed.
12. Smith G, Power I. Anaesthesia, 1998;53:521–2.
13. Standards for Post Anaesthesia Care. American Society of Anaesthesiologists, 1988.
14. The High Dependency Unit. London: Association of Anaesthetists, 1991.
Chapter
Local Anesthetic Drugs and
14 Regional anesthesia
Chapter Outline
Definition of Regional Anesthesia
v
Pharmacology of Local Anesthetics
v
Structure Pharmacological Relationship
v
Mechanism of Action
v
Xylocaine
v
Bupivacaine
v
Toxicity Reactions of Local Anesthetics
v
Techniques or Regional Anesthesia
v
Definition of Regional Anesthesia

It is the technique of temporarily and reversibly blocking the various modalities of
peripheral nerve conduction, by applying certain pharmacological agents (local
anesthetics agents) in specific concentration and volume, on the appropriate place
to act on the desired nerves to be blocked, so that the region of the body innervated
by these nerves will have analgesia as well as reflex blockade. In this the central
nervous system is totally spared.
This is achieved by application of local analgesics or local anesthetics—like
xylocaine or bupivacaine, at the appropriate location on the concerned nerves,
plexuses or nerve roots, etc.
Now there are other drugs like narcotics or opiates, e.g. morphine, pethidine,
etc., which are found to act on specific opioid receptors in the nervous system and
block the main modality—pain perception—without very much affecting, the other
modalities like motor or autonomic function.
Advantages of Regional Anesthesia

Relatively simple and safe
Airway, airway reflexes, respiratory function are well maintained
Needs very minimal equipments
It is a reversible blockade of peripheral nerves
There are very little chances of metabolic effects, so patients with metabolic
derangements may be anesthetized without any ill effects in the already
compromised metabolism
Chapter 14  Local Anesthetic Drugs and Regional anesthesia 199
Even in very sick patients, it can be employed safely after making suitable dose
reduction. The delay in metabolizing the drug may allow blood level to raise
quickly. But, as the total dose is less, toxic blood level will not be reached to
cause toxicity
Vital functions may have to be supported till the block exists
The problems related to the use of multiple drugs (poly pharmacy) in general
anesthesia with resultant problems of drug interaction both among the anesthetic
drugs as well as the drugs that the patient is already receiving can be avoided.
Disadvantages of Regional Anesthesia

Less reliable
Not suitable for anxious patients
In obese patients it is difficult as the land marks are not clear
Anatomical precision is needed. Nerves have to be blocked correctly
When infiltration anesthesia is attempted for surgeries involving large area,
the permissible safe dose may not be sufficient to cover the area. It the dose is
exceeded inadvertently, it is sure to cause toxicity.
Pharmacology of local Anesthetics

1855 Cocaine was isolated from the plant Erythroxylon Coca.
1884 Carl Koller demonstrated cocaine anesthesia on cornea.
1947 Xylocaine was first used in anesthesia.
1963 Bupivacaine was introduced. A long acting drug.
Structure of pharmacological relationship

Basic Structure of any local anesthetic has three components:
1. Aromatic lipophilic group
2. Hydrophilic group—either a secondary or tertiary amide
3. A link or chain which links these two groups—an ester (COO) or amide (NH
Co).
This group contributes for the local analgesic This group is usually available as water
action. As it has high affinity for lipoproteins. soluble salt such as hydrochloride. This
The cell membrane of the neurons or axons makes the local analgesics available as a
of the nerves which is made mainly of water soluble crystal.
lipoproteins, take up the drugs by absorption
on the membrane. The membrane becomes
stabilised—depolarisation is prevented and
conduction of impulse beyond this point is
not possible.
Mechanism of action
These drugs cause “membrane stabilization” —by preventing ionic exchange
between inside and outside of the membrane of the axons. This means depolarization
and repolarization of that area of the membrane is not possible. So no conduction
occurs beyond that point.
Based on the structure, mainly the link or the chain, the drugs are classified as
‘ester linked’ or ‘amide linked’.
1. Ester linked local Analgesics: (No longer in use now)
For example: Cocaine, procaine .
Disadvantages
Toxic drugs—Narrow safety margin
More prone to cause anaphylaxis
very unstable as solution
Degraded by hydrolysis.
Amide linked local Analgesics

For example: Lignocaine 1947. Bupivacaine 1963.
Advantages
Less toxic—wide margin of safety
less chances for anaphylaxis—very rare
Detoxified by oxidative de-alkylation in the liver
Can be autoclaved many times without loss of potency
Addition of adrenaline causes local vasoconstriction and prolong the duration
of action.
because of the delay in absorption blood level rises slowly. So, the dose also
can be increased.
Xylocaine
(1947 lidocaine or lignocaine—an amide linked drug)
Colorless crystalline salt available as hydrochloride dissolved in water.
Dose : 3 mg/kg body wt
7 mg/kg body wt—if adrenaline is used for local vasoconstric
tion and prolongation of action
Duration of action : 1 hour—1 hour 30 minutes
With adrenaline : Up to 2 hours
Availability
5% Xylocaine with dextrose 2 ml ampoule. (Xylocaine heavy) Sp. Gr. is around
1024–1035. The Sp. Gr. is higher than that of CSF—for spinal analgesia.
2% Xylocaine plain—for nerve blocks, local infiltration, etc.
can be diluted to 1.5%, 1%, 0.5% or 0.25%.
2% Xylocaine with adrenaline 1 in 200,000 concentration
can be diluted as 1%, 0.5% or 0.25%, for local infiltration.
2% Xylocaine without preservative for iv use.
To prevent or to treat cardiac arrhythmia.
4% Xylocaine solution (pink color added to differentiate).
For spraying or packing the mucous membranes.
10% Xylocaine solution in sealed container with calibrated dose delivery device
and sprout. Each time spray delivers 10 mg.
4% Xylocaine viscous with hydroxymethyl cellulose.
For use on mucous membrane of mouth, esophagus and stomach.
For esophagogastroduodenoscopy.
5% Xylocaine ointment with paraffin base.
For use in mucocutaneous junction, as in anal orifice.
2% Xylocaine jelly in carboxymethyl cellulose as the base. It is water miscible,
for use in mucous membranes of nose, trachea.
Can be used on endotracheal tube or on urethra—for dilatation.
Usual concentrations needed for various applications

Spinal—5% with dextrose to raise Sp.Gr. (heavy) (hyperbaric)
Epidural—1.5%
Nerve block—1–1.5%
Infiltration block—0.25%–0.5%
Field block—0.5–1%
Topical analgesia—4%.
Bupivacaine
Amide linked drug introduced in 1963
Longer duration of action due to very high lipophillic nature.
Duration of action 3 to 6 hours
Dose 2 mg/kg body weight
Availability 0.25% and 0.5% for nerve blocks and infiltration block
0.5% solution with dextrose (heavy) for spinal
More toxic than Xylocaine
Addition of adrenaline does not increase the duration of action.
Toxic Reactions of Local Anesthetics

Toxic manifestations are due to suddenly raised blood level of the drug above the
safe level.
The blood level of Xylocaine in micrograms and their effects:
Up to 5 µg/ml of blood – Safe—no manifestations
5 to 7 µg/ml of blood – Early manifestations of toxicity
7 to 10 µg/ml of blood – Severe manifestations of toxicity
More than 10 µg/ml of blood – Convulsions without warning
The safe blood level of bupivacaine is—2 µg/ml of blood.

Normally from the site of injection, these drugs are absorbed slowly and blood level rises
gradually. In safe doses, the blood level may not reach anywhere near the toxic
levels.
When we use adrenaline, the absorption is further delayed by local
vasoconstriction. That is why higher dose/kg is permissible with adrenaline.
Raised blood levels may be caused by two reasons:
1. Obvious and deliberate over dosage. Even with normal absorption rate, blood
level rises rapidly.
2. Accidental rise in blood level even when normal dose is used.
Accidental intravascular injection of a calculated safe dose.
Injection into a highly vascular area such as inflamed tissues or hemangiomatous
lesions.
Manifestations of toxicity
Mainly affects two systems, central nervous system and cardiovascular system.

These manifestations are more common and if not treated may be fatal.
The drug reaching the CNS through the blood stream first affects the delicate
neurons of all the inhibitory centers—like those related to higher functions (e.g.
memory, civic sense, etc.). So initially, when the inhibitory neurons are suppressed,
the excitatory neurons particularly motor neurons discharge uninhibited impulses
causing the symptoms and convulsions.
If the blood level rises further again, the more resistant excitatory neurons such
as motor neurons are also depressed and paralyzed.
Manifestations
Slight disorientation
Drowsiness
Incoherent talk
Circum oral numbness
Twitching of facial muscles.
muscles of facial expression, mainly orbicularis oris and orbicularis oculi are
involved.
At this moment the following steps may be helpful:
Increasing the flow rate of iv fluids that dilutes the concentration of the drug
and reduce the blood level
Administration of 100% O2 with a mask may reduce the irritability of neurons
and protect the brain and thereby abort the toxic manifestation
Without warning, the patient may throw convulsions suddenly
Now the management is to paralyse the patient with 50 mg of suxamethonium
and continue 100% O2 by IPPV usually the patient recovers well and by the
time the blood level also falls
If the convulsions recur even after this, the dose of suxamethonium may be
repeated to continue the paralysis at the same time IPPV is continued with
100% O2.
It will be only over all depression of CVS. conduction system is depressed.
Bradycardia and hypotension are the manifestation. Usually it is not very significant,
but with bupivacaine CVS toxicity may be significant, with cardiovascular collapse.
Techniques of Regional Anesthesia

1. Spinal – Subarachnoid block (intra-thecal block)
2. Epidural – Extradural (peridural)
• Caudal epidural (sacral)
• Lumbar epidural
• Thoracic epidural
Spinal and epidural anesthesia are commonly known
as “Central Neural Block”
3. Nerve block – Digital nerve block
4. Plexus block – Brachial plexus block
5. Filed block – A few nerves are blocked superficially. For example,
field block for inguinal herniorraphy
(Ilio-Inguinal nerve, Ilio-Hypogastric nerve and
Inguinal branch of Genitofemoral nerve)
6. Infiltration block – Infiltrating the subcutaneous tissue with 0.25 or 0.5%
xylocaine block the cutaneous branches crossing there.
7. Topical anesthesia – Intact mucous membrane of nose, mouth, larynx, etc.
with 4% xylocaine spray or pack.
8. IV Regional analgesia – ( For limbs) after exsanguination of the limb,
tourniquet applied to the limb. Then through an
indwelling cannula, required quantity of (30–40 ml)
0.25–0.5% of xylocaine is injected into the vein
(peripheral nerve endings are blocked and through
the vasa nervorum nerves are also blocked).
9. EMLA – Eutectic Mixture of Local Anesthetic
Fixed proportions of xylocaine 2.5% and prilocaine
2.5% can penetrate intact skin and cause local
anesthesia when applied as a cream and an occlusive
dressing is given for 1 hour—useful for taking skin
grafts and for doing venepuncture in children.
Central Neural block

From each spinal segment, nerve fibers leave the spinal cord as anterior and
posterior spinal roots which join together to form spinal nerve within the
subarachnoid space bathed by cerebrospinal fluid. Then the nerve drags a cuff of
dura which ensheaths it in epidural space and enters into the intervertebral foramen.
With suitable technique these nerves can be blocked either in the subarachnoid
space or in the epidural space. These two blocks—‘Subarachnoid’ and ‘Epidural’
are known as Central Neural block.
The nerves may be blocked as soon as they leave the spinal cord as anterior
and posterior spinal roots and lie within the subarachnoid space, bathed by CSF.
This is called as Spinal anesthesia or Subarachnoid block.
These nerve roots join together to form the mixed spinal nerves, before entering
the intervertebral foramen. In that process these nerves cross the two layers of dura
for a very short distance. These nerves could be blocked at this point by depositing
local anesthetics there in between the two layers of dura. This is called as Epidural
block.
Spinal anesthesia and Epidural anesthesia are together known as Central Neural
Block.
Spinal anesthesia (Spinal analgesia, Subarachnoid block)

Some facts to be remembered
Spinal anesthesia is the most commonly practiced among the regional
techniques and is easier
Because the technique is easy and is commonly used, “a false sense of safety”
develops in the minds of clinicians that it is free from complications. This leads
to inadequate monitoring resulting in complications
Mortalities are commonly and most frequently encountered, when compared
to all other regional techniques
Though it is a commonly practiced technique, this is the most commonly
mismanaged one also.
This is the most widely practiced regional anesthetic technique all over the world
because it is technically very simple to perform and is very economical. Though
the developed countries have slowly switched over to other more sophisticated,
technically complex procedures like epidural, continuous epidural, selective
epidural, etc. with their added advantages, spinal anesthesia is still the very common
technique.
First planned spinal anesthesia for surgery in man performed by August Bier
on 16th of August 1898, in Kiel in Germany, when he injected 3 ml of 0.5% of
cocaine solution into the subarachnoid space of a 34-year-old laborer. After using
it in 6 patients, he and his assistant each injected cocaine into the others theca. He
advised it for operations on legs, but gave it up owing to the toxicity of cocaine.
Until Gaston Labat’s work on spinal anesthesia published in 1921, spinal
analgesia was not popular. Labat was the great pioneer who popularized local and
regional anesthesia and described local techniques for all known surgeries. He used
procaine crystals dissolved in CSF.
Chen and Schmidt introduced Ephedrine in 1923.
Ocherblad and Dillon and Rudolf and Graham used Ephedrine to maintain
the blood pressure in spinal anesthesia in 1927. Initially, it was thought that the
hypotension was due to the paralysis of anterior abdominal wall muscles causing
decreased intrathoracic negative pressure during respiration, but later, it was
suggested that it was due to the paralysis of vasoconstrictor nerves supplying the
splanchnic and other vessels. Gaston Labat suggested that the hypotension itself
was not so important but the cerebral ischemia it might cause. This has a high
clinical relevance.
Nupercaine was introduced in 1929 and was clinically used in New York in
1930.
Bupivacaine was first used in intradural block in 1966.
The famous case of “Woolley and Roe”

In the history of spinal anesthesia in UK there was a famous case of “Woolley
and Roe”. Albert Woolley and Cecil Roe were healthy middle aged men. Woolley
aged 56 years, underwent meniscectomy of the knee and Roe, aged 45 years, had
a radical repair of hydrocele under spinal anesthesia at Chesterfield Royal Hospital
on Monday, October 13, 1947. Both of them developed paraplegia after spinal
anesthesia. The spinal anesthetics were given by the same anesthetist, Dr Malcolm
Graham, (1916-1997) on the same day, at the same hospital using the same local
anesthetic and the same technique. The outcome for the patients and their families
was devastating. It was also devastating for the use of spinal anesthesia in the UK
for the next 25 years.
In the court of law, during the trial 6 years later, Professor Sir Robert Macintosh
was called as an expert for giving opinion. Against the opinion of leading
neurologists, the judge accepted Professor Macintosh’s suggestion that phenol, in
which the ampoules of local anesthetic had been immersed, had contaminated the
local anesthetic through invisible cracks in the glass ampoules. In an interview
30 years after the verdict, Dr Graham believed that the tragedy was caused by
contamination of the spinal needles or syringes during the sterilization process.
The subsequent explanation that, on the day in question, descaling liquid (acid
solution) in the sterilizing pan had not been replaced by water, supported his belief
and finally offered a credible explanation. Still things are not very clear how it
happened. Paralysis below the waist is too large a price for a patient to pay in order
that the surgeon should have a fine relaxed field of operation.
Graham did not believe in this ‘invisible crack theory’ or the role of phenol.
In 1983, he recalled that when the ampoules were produced in the court for his
inspection he could eventually find the cracks but commented, ‘These are thermal
cracks, are they not?’ he knew that the cracks had been made in Oxford by touching
ampoules with hot wire. He and his colleague in Chesterfield had done ‘all sorts
of experiments banging them about and we could not crack one. We could smash
them, but we could not crack them… they either broke altogether or nothing
happened – unless you put a hot wire on them.’
Because of this adverse publicity and uncertainty over the true cause of these
tragedies, the use of spinal anesthesia was retarded in the UK by 20–25 years.
In UK, spinal anesthesia was under a cloud for long time, till Robert Dripps and
Vandam wrote their famous article; “The long-term follow-up of patients who
received 10098 spinal anlgesics: Failure to discover major neurological sequelae”.
In the present days there has been increased popularity for spinal anesthesia.
Bupivacaine is the drug of choice and is universally available in 0.5% solution
with 8 to 10% dextrose to make it heavy (hyperbaric). Experience shows that the
technique is safe in expert hands. In addition, there is better understanding about
the effects of the injected solutions in terms of both physiological and potential
toxic effects. For example, review of the Woolley and Roe case in the light of
modern understanding shows that it is unlikely that the phenol was the cause for
the paralysis. Therapeutic injection of phenol for chronic pain, does not give rise
to the same clinical picture. A much more likely explanation is that the apparatus
used was sterilized by boiling in a sterilizer that had been contaminated with acid
substances used to prevent scale formation.
(Anesthesia et al; February 2001, series 8.1, from Eureka Alert: www.eureka alert.org.)
Anatomy
The vertebral column consists of 7 cervical, 12 thoracic, 5 lumbar, 5 sacral and 4
or 5 coccygeal vertebrae. The sacral and coccygeal vertebrae are fused in adult life.
The spinal column has four curves of which the thoracic curve and sacral curves are
primary and are concave anteriorly. The cervical and lumbar curves have convexity
forward, and so when the spine is fully flexed, the cervical and lumbar curves are
obliterated. In supine position the 3rd lumbar vertebra marks the highest point of
lumbar curve whereas the 5th thoracic vertebra is the lowest point of the curve.
These curves have practical significance, particularly when the highest level
of spinal block is concerned. Immediately after spinal block the lumbar curve will
become almost flat and straight whereas the thoracic curve will be straightened only
Fig. 14.1: Sagittal section of spinal column showing the various structures
passed by the needle
minimally because of the limitation caused by the bony thoracic cage. Altogether
considering these changes that occur after changing the position of the patient to
supine, the probable level of blockade could be assessed.
Any anatomical deformity such as Kyphosis, Scoliosis, etc. will make the
lumbar puncture difficult. The direction of the spinous process determines the
direction in which the spinal needle must be inserted. The spinous process of the
cervical, the first two thoracic and the last four lumbar vertebrae are all practically
horizontal and therefore opposite the bodies of their respective vertebra. Other
spines are inclined downwards and their tip opposite to the bodies of the vertebrae
next below. The first lumbar spine is opposite to intervertebral disc. The fifth
lumbar spine over hangs the lumbosacral interspace. The interesting fact is, that
the interlaminar space in this level in the widest (lumbosacral interspace). So in a
difficult spinal tap a trial in this level may be successful.
The various anatomical structures of spinal column as seen in a sagittal section
are shown in Figure 14.1. The structures encountered by the needle to reach the
epidural space or sub-arachnoid space could also be seen in the figure.
Palpable bony land marks used for spinal and epidural block:
The spinous process of 7th cervical vertebra is prominent and easily palpable
The tip of the spine of T3 is opposite to the roots of the spines of scapulae with
arms at the sides of the body
The T7 Spine is opposite to the inferior angle of scapula
A line joining the highest point of both iliac crests is at the level of L4 or
L4–L5 interspace.
Clinically significant Anatomical points:
The spinal cord ends at the level of lower border of L1
The dural sac ends at the level of lower border of S 2
The dural sac below the level of L1 is filled with CSF that contains cauda equina
and filum terminale interna.
Lumbar Puncture
It is the procedure of passing a long fine needle through an interspinous space in
lumbar region below the level of L2 to reach the subarachnoid space of the dural
sac so that CSF can be drained or drugs may be deposited inside the sac.
Lumbar puncture can be performed in any interspinous space between L2 and
L4, when the patient is kept in right lateral position with well flexed spinal column
on a horizontal surface.
Local analgesic deposited by passing a long fine needle through an interspinous
space below L2 (so that the spinal cord is not damaged by the needle) into the dural
sac.
The local analgesic solution, which is heavy, (meaning thereby has specific
gravity higher than that of CSF) settles where it is injected. The CSF containing the
local anesthetic bathes the spinal nerves passing through the point. High lipophilic
nature of the drug causes immediate and rapid absorption of the drug into the
nerve fibers and cause conduction block, effectively causing anesthesia of the area
supplied by these nerves and below that level.
This regional anesthesia technique involves—blocking all the modalities of

nerve conduction (motor, sensory and autonomic) below one particular spinal
segment level.
This is achieved by injecting a known quantity and concentration of local
analgesic (xylocaine 5% or bupivacaine 0.5%) into the spinal subarachnoid space
below the level of L2 by using a spinal needle.
The Drugs
Xylocaine 5% with 7.5% dextrose for making it heavy 2 ml ampoules
Bupivacaine 0.5% with 8.5% dextrose 4 ml ampoules
Addition of dextrose makes the solution ‘Heavy’ or ‘Hyperbaric’. (Sp Gr 1035
to 45).
When the patient is turned supine, the solution being “Heavy” settles in the
site of injection backwards (posterior) and acts more on the posterior nerve roots
and prevents the higher spread by rapid diffusion.
Physiology of Spinal anesthesia and related problems

When a local analgesic solution is injected into the subarachnoid space, the drug
settles down in the site where it is injected. When the patient is turned supine the
drug moves towards the posterior aspect of the subarachnoid space by gravitational
force, as the hyperbaric solution (heavy) has higher specific gravity than CSF. The
specific gravity of CSF is 1004 and that of heavy spinal solution is 1035–45. Hence,
higher concentration of the drug is taken up by posterior spinal root (sensory) of
that site, the remaining is taken up by the anterior (motor) roots. Usually the sensory
blockade will be intense and longer lasting, and muscle relaxation is excellent
because of two reasons:
One is the drug taken up by the motor nerve root causing motor paralysis
The second is that because the sensory block is almost complete, the spinal
reflex arc is disrupted and so the muscles are totally relaxed. This is the desirable
effect as far as anesthesia is concerned.
Apart from this, the autonomic fibers which pass through the spinal nerves are
also paralyzed causing mostly undesirable effects. These side effects when not
properly understood and managed may lead on to problems. So, it is important to
realize the physiological modifications (trespass) that spinal anesthesia could cause.
Positioning the patient

Before positioning the patient, the anesthesiologist has to spend a few minutes
talking to the patient with a tone of deep concern and explain what he is going
to do and assure him that it will not be hurting him. This is a very essential step
and does immense help in making the procedure very easy.
Proper positioning of the patient on the table for performing a spinal anesthesia
is equally or even more important as the skill of the anesthesiologist. An
improper positioning may make a very skillful anesthesiologist to face difficulty
in making a lumbar puncture or at times he may fail.
Patient may lie on his side preferably on right lateral position, as it is convenient
for a right handed anesthesiologist.
Fig. 14.2: Positron of the patient for lumbar puncture

• Note that the tabletop is horizontal—should not be head-up or head-down
• A pillow of comfortable size supports the head
• Back is bent forward in a smooth curve
• The lumbar spines are marked
• Highest point of the iliac crest is marked corresponds to L4
• The marked point is the space between L3 and L4.
An anesthetic technician (theater assistant) may stand in front of the patient

and hold him without making him strain, keeping the patient well relaxed.
He must gently hold the patient by keeping right hand on the middle of lateral
aspect of thigh and the left hand gently on the back of neck.
He should not hold him by the head and feet. This will cause the patient to
strain and make things difficult.
As the patient is kept in an unusual position and is anxious, the anesthesiologist
may talk to the patient while doing the steps.
Proper positioning of the patient for spinal anesthesia is shown in Figure 14.2.
Care during the technique

One has to remember that nature has protected brain by enclosing it in a rigid
bony skull and the spinal cord in a bony canal made by articulated bones to
provide protection as well as movements.
Ordinary impacts or injuries do not affect either the brain or spinal cord in
normal circumstances.
Even chemicals and bacterial invasions are not easily permitted because of the
barriers naturally present.
Spinal anesthesia is an invasion and a trespass into the protected territory. In
other words, a needle is passed from the exterior through the skin and other
layers of structures into the meninges of spinal column (subarachnoid space)
and a foreign matter (local anesthetic) is injected into it.
When compared to the physiological trespass caused by spinal anesthesia,
the anatomical trespass is greater and potentially dangerous and is commonly
forgotten.
Because of the potential risk of introducing infection which is likely to be fatal,
one has to be very careful and strict in following the aseptic precautions while
performing lumbar puncture and spinal anesthesia.
Preparation of the back of the patient has to be done meticulously. Patient must
be asked to take bath with soap and water, if it is an elective surgery and a
bath before surgery is permitted. Afterwards, the back of the patient should be
cleaned, from the lower thorax to the lower end of sacrum and on the sides up
to the mid axillary line, first with soap and water and then with an antiseptic
like isopropyl alcohol or povidone iodine. The prepared area must be covered
with a sterile three tail towel and tied over the abdominal wall to prevent further
contamination. Lesser area than this is not acceptable on technical reasons.
The anesthesiologist must scrub up and wash the hands scrupulously without
any flaw. No compromise shall be accepted in this step. Wearing a sterile gown
and gloves must be followed as for any surgery.
Absolute aseptic care is taken in laying a table for spinal anesthesia. Usually
for every case a separate table with all the required equipments is advisable.
However, in bigger institutions, where many spinal anesthesia are to be given in
one operating session, a suitably planned table with multiple sets of equipments
arranged properly to prevent cross contamination of the table from the patients
may be accepted provided proper protocol is followed very meticulously.
These smaller details are commonly ignored and leads onto complications and
sometimes fatal outcome.
Order of blockade
Local anesthetics are taken up by absorption onto the spinal roots only and very
little is absorbed on the spinal cord
Membrane stabilization inhibits action potential at the nodes of Ranvier
At least 3 nodes must be blocked for complete interruption of impulses
50% less concentration of the drug is needed to block A δ fibers (pain and
temperature) than A γ (motor and proprioception)
Sympathetic block is 2–3 segments higher than the sensory block
Muscle tone is abolished even if the A γ fibers are not affected, because the
reflex arc is broken by blockade of afferents.
It is interesting to note that the order of blockade is related to the diameter and
myelination of the nerve fiber. The finer nerve gets blocked first. Hence, the order
is as follows;
Autonomic
Temperature (cold before warmth)
Pin prick pain (sharp pain)
Pain greater than pin prick
Touch
Deep pressure
Motor fibers
Vibration
Proprioception.
Recovery
The recovery is in the reverse order. However, the sympathetic returns before
sensation. This is clinically significant. Though autonomic fibers are blocked by
the lowest concentration of drug, the blockade is short lived. Otherwise there is a
possibility of a longer duration of hypotension.
When can a patient walk after spinal?
This is a question based on the understanding of the physiology of spinal anesthesia.
It is not advisable to allow a patient to walk for at least for 24 hours for various
reasons of safety. However, the answer for this question is; when the patient has
all his spinal reflexes recovered fully, he may be permitted to walk. This can be
assessed by the following parameters;
Presence of sensation around anus
Patient has no hypotension (no postural variation also)
Strong plantar extensor
Presence of proprioception of great toe.
Circulatory effects of Spinal anesthesia

Hypotension during central neural block is mainly a result of decrease in systemic
vascular resistance which occurs by block of preganglionic sympathetic fibers. This
allows vasodilatation and an increase in venous capacitance vessels with venous
pooling, unless gravity is used to maintain venous return. Hypotension is more
likely to occur in dehydrated and hypovolemic patients.
“Simply a reversible disparity between the blood volume and the vascular
capacity has been created.” The sensible solution for this may be adding a little
volume to make up the deficit and allow the compensations to work. In the course
carefully monitor and support the patient till the disparity is reversed.
The major factor in the development of hypotension is the level of block.
The sympathetic outflow is between T1 and L2
A block below the level of L2 has no effect on arterial pressure
A level up to T8 “sympathectomises” the lower half of the body
The sympathetic supply to the adrenal medulla is from T8 to L1, so block of
this causes inhibition of release of catecholamine and alters the arterial pressure
Fibers from T1 to T4 provide sympathetic supply to the heart and blockade of
these results in decreased contractility and bradycardia (unopposed vagal activity)
Although vagal over activity may cause severe hypotension in individual
patients, changes in arterial pressure relates more usually to the level of block
than to vagal efferent activity
A block as high as T1 totally removes the ability of the body to compensate
for other circulatory changes in addition to producing extensive vasodilatation
The level of sympathetic block is in general higher than the sensory block, but
the situation is complex. It is believed to be about 2 segments above sensory
block. But some studies show it is still higher
Sympathetic block is short lived. Sensory and motor block outlast it
The presence of bradycardia does not always indicate that cardioaccelerator
fibers are blocked. Bradycardia can be manifested when right atrial pressure
is decreased because of reduced venous return (bainbridge reflex). On the
other hand tachycardia during spinal may be explained by Mareys law which
states that heart rate is inversely proportional to the pulse pressure. However,
bradycardia is the frequent clinical manifestation.
Spinal Hypotension
The management of hypotension occurring during central neural block is a subject
of debate for over many decades. Unfortunately, in olden days this hypotension
was named as “Spinal shock” which is a misnomer and is no longer in use today.
Proponents for the use of either volume loading or vasopressors are expressing
dogmatic views. Neither of the two is the real answer for the problem. Hypotension
is a manifestation where in the background there are numerous factors. Hence, it
is essential to understand them to have a scientific approach to it.
It is important not to be too specific in the approach to this problem and to
treat each patient on individual merit, recognizing that many factors may influence
arterial pressure during anesthesia and surgery.
Control of arterial pressure

Arterial pressure is the product of cardiac output and systemic vascular resistance;
both of these variables are influenced by many factors.
Cardiac output is determined by venous return according to Frank Starling

law. Venous return is influenced by gravity, the calf muscle pump, intrathoracic
pressure and the degree of venomotor tone, which is matched to circulating blood
volume. Systemic vascular resistance is determined by sympathetic vasomotor
tone and by the influence of hormones such as rennin, angiotensin, aldosterone
and antidiuretic hormone. Endogenous vasopressin (antidiuretic hormone) also
contributes to the maintenance of arterial pressure during extradural anesthesia.
The vasomotor center in the brain stem controls the degree of sympathetic tone
in a feed back loop involving the baroreceptors. Other factors affecting arterial
pressures such as pain, exercise and emotion act directly through the vasomotor
center, which also receives input from the chemoreceptors.
Changes within the microcirculation may also influence arterial pressure,
although, it is more usual to think of those factors as being responsible for
autoregulation of flow. There are two main mechanisms: myogenic and chemical.
Myogenic autoregulation acts via stretch receptors in the vessel walls which
cause them to constrict when pressure is decreased. Chemical autoregulation is
mediated by the local concentration of vasoactive metabolites. In the presence of
vasodilatation, as produced by sympathetic block, an increase in the flow washes
the metabolites and produce reflex vasoconstriction.
Organ perfusion
It is usual to find every one worrying too much about a fall of BP. A normal BP does
not guarantee that everything is fine. Similarly a fall in BP is many times benign and
is not always an indication of a disaster. We have to remember that hypotension by
itself does not kill any one. In fact, during a very deep sleep, a healthy individual
continues to have a systolic BP of 80 mm of Hg for many hours.
We are measuring the arterial pressure and trying to adjust it to the desired level
(the level which we desire that the patient should have and not what is desirable for
the patient’s systems to function), but it is important to remember that the perfusion
of vital organs with adequate flow of blood is the vital factor. If the vital organs
are well perfused and oxygenated, the arterial pressure even if it is lower may not
harm the organs. Compensatory mechanisms ensure that the flow to the vital organs
is maintained over a wide range of pressures. This range of pressure in which the
perfusion of the vital organ is not affected and adequately maintained is known
as “autoregulation range” meaning thereby, beyond this range, this protection is
lost and the perfusion is either reduced or increased depending upon the pressure.
This is the “Autoregulation” which may be under the influence of “Myogenic or
Chemical” control.
Cerebral circulation
Cerebral blood vessels are devoid of sympathetic nerve supply. Autoregulation
flow occurs between 50 mm and 180 mm Hg by reflex arteriolar constriction in
hypertension or vasodilatation in hypotension. Thus normal cerebral perfusion
is maintained until mean arterial pressure is less than 50 mm Hg. As we know
that the mean arterial pressure is the product of diastolic pressure + 1/3 of pulse
pressure, the systolic pressure when MAP is 50 mm Hg is very much lower
indicating that perfusion will not be significantly affected unless there are other
factors like severe hypovolemia coexisting. At such a pressure, ischemia occurs,
leading to local hypercapnia and hypoxia, both of which stimulate the vasomotor
center chemically to increase sympathetic tone and systemic vascular resistance
in an attempt to restore arterial pressure.
It is emphasized here only to make it clear that arterial pressure alone is not
the factor that maintains the cerebral well being and worrying unduly about BP
and ignoring the other vital aspects like blood volume and oxygen saturation will
not do good to the patient.
Coronary circulation
Coronary blood flow is autoregulated between 60 mm and 150 mm Hg. If coronary
perfusion pressure decreases, the myocardium becomes relatively hypoxic and ADP
accumulates. This is converted onto adenosine, a potent coronary vasodilator,
which restores local blood flow. A decrease in arterial pressure results in decreased
left ventricular work and oxygen demand. Therefore hypotension may have a
benign effect unless there is concomitant tachycardia or a significant pressure
gradient across the aortic valve, both of which impair coronary filling during
diastole.
Hence, if a normal healthy individual has hypotension after spinal anesthesia
without respiratory depression and hypoxia and has a normal heart rate,
indicates that the cardiovascular system is absolutely stable without the need for
compensation.
Renal perfusion
Renal autoregulation occurs between 80 mm and 180 mm Hg. The afferent
glomerular arteriole has a myogenic response to stretch and constricts with
hypertension and dilates with hypotension to maintain a constant renal perfusion
pressure. This can be overridden by the sympathetic innervation of kidney. A
small decrease in arterial pressure produces sympathetic stimulation and causes
vasoconstriction of the efferent arteriole to maintain filtration pressure in the
glomerulus in the presence of decreased renal blood flow.
A marked decrease in arterial pressure and more intense sympathetic stimulation
results in constriction of the afferent arteriole and a decrease in both renal blood
flow and glomerular filtration. In clinical practice, glomerular filtration rate is
reduced only to a smaller extent (10%) during central neural block and this is not
enough to cause significant impairment of normal renal function.
All these indicate that the orientation of hypotension should be based on its
effects on central neural or circulatory system.
The type of block and the degree of hypotension

There are definite differences between spinal and epidural block. The degree of
sympathetic block tends to be greater, and the onset of hypotension tends to be
faster after spinal than after epidural injection, because the onset of block is faster
than the development of physiological compensation.
The obstetric patient and spinal hypotension

The obstetrics patient presents additional problems. In supine position the IVC
may be completely occluded by the gravid uterus. Unless adequate venous return is
achieved through the collateral system of extradural and azygous veins, decreased
arterial pressure and uterine blood flow results.
Aorta may also be compressed and, although this may not produce symptoms
in the mother, uterine blood flow decreases, resulting in fetal distress and neonatal
depression. This syndrome of supine hypotension by aortocaval compression may
occur from 20 weeks of pregnancy onwards and is relieved by the mother adopting
left lateral position.
Management of Spinal Hypotension

Purposefully the word “Treatment of Spinal Hypotension” is not used here because
hypotension is a problem which we anticipate whenever, we give a spinal anesthesia
and if it occurs, we manage it.
Here we may recollect the definition of a problem and that of a complication.
A problem is an anticipated difficulty while doing a procedure that may or may
not occur. If it is encountered we manage it appropriately, e.g. hypotension during
spinal anesthesia.
A complication is usually an outcome of a mismanaged procedure, which is not
normally encountered at all in properly performed procedure. When encountered, it
has to be tackled and it needs a person with better skill to do that, e.g. encountering
a “total spinal” in an attempted epidural block. It needs special skill to tackle the
complication.
A wide variety of options are available for the prevention and management
of hypotension caused by central neural block. Extensive research had been
carried out over the past few decades and still things are inconclusive for
obvious reasons.
Variability in “resting” arterial pressure is widely recognized, but in the situations
that occur after spinal anesthesia, the control figure is not clearly defined.
There is always confusion in defining “Hypotension” in a clinical situation like
this. The arbitrary definitions carry very little meaning in the clinical scenario.
Obviously these definitions relate to a normal healthy patient only.
The following are some of the definitions:
Systolic pressure < 100 mm Hg
Systolic pressure < 90 mm Hg
Decrease of systolic pressure 20 or 30% from base line
Decrease of systolic pressure by 30 mm Hg.
It is quite obvious none of these definitions could help us to decide whether
a patient needs active intervention to deal with the fall of BP at that point. So the
management has to be decided a little differently.
Because a high level of block is a major determinant of the development of
hypotension, choosing a block limited to suit the planned procedure prevents
unnecessary fall in arterial pressure. Hemorrhoidectomy does not require a block
higher than S1. But in practice for the patient to tolerate the positioning a higher
level may be needed. An abdominal hysterectomy needs a block of T10 at least.
The use of mechanical methods such as Esmarch bandage from ankle to mid
thigh, inflatable full length leg splints, keeping a wedge under the loin on the right
side for a pregnant patient on the table, etc. have been suggested, and are in use in
some centers but still they are all found to be cumbersome methods.
Volume preloading; has been suggested by many and extensive work has
been done on this during the past two decades. Some suggest crystalloid solutions
like Ringer’s lactate whereas some suggest colloid solutions like polygelene
(hemaccel). Not very conclusive evidence is there for supporting the theory that
the preloaded volume increases the stroke volume and cardiac output. In normal
physiological status any additional volume of fluid infused into the vascular
compartment will initiate reflexes to rapidly eliminate it by increasing diuresis.
Moreover there is always the chance inducing pulmonary edema in an at–risk
patient. Colloids may stay in the intravascular compartment longer and may cause
strain in the reticuloendothelial system to break down that.
This may be frankly dangerous in elderly patients with poor cardiac function.
Obstetrics patients are also at increased risk of pulmonary edema, because
interstitial lung water is increased in puerperium. A possible further complication
is urinary retention. Sympathetic vascular tone returns before bladder sensation as
the block regresses, so that overdistension occurs while the patient is unaware.
Infusion of large volume of fluid has been shown to overload the right side of
the heart.
Perhaps a more physiological approach to the treatment of hypotension induced
by sympathetic block is to counteract it as it occurs, by using sympathomimetic
drugs in small increment as and when required.
Vasopressors
Prophylactic use of vasopressors has no scientific basis. In addition, IM injections
produce unpredictable absorption and peak levels. Large bolus doses may cause unac-
ceptable hypertension. When to use the vasopressors? This question is to be answered
based on the clinical situations. There are many vasopressors in use, but in our country
only a few drugs are in common use. They are ephedrine and mephentermine.
Ephedrine
Ephedrine was used first in 1927 to counteract hypotension caused by spinal
anesthesia
Most commonly used vasopressor. It has direct and indirect mechanisms of
action and stimulates both alpha and beta receptors to increase cardiac output,
heart rate, systolic and diastolic arterial pressure
Coronary, cerebral and muscle blood flow are increased, while renal and
splanchnic blood flows are decreased
It can be used in small increments of 3–6 mg and depending upon the response
titration may be done
In larger doses it may be causing side effects like tachycardia, anxiety, central
stimulation, tremors, etc.
Mephentermine
It has direct and indirect sympathomimetic actions which increase cardiac
contraction and venous tone and hence increase the arterial pressure.
This drug may be used in increments of 3–6 mg and titrated till desired level
is achieved.
Just for completion drugs such as dopamine, dobutamine and adrenaline have
to be mentioned though they are very rarely indicated in the management of spinal
hypotension.
In the management of spinal hypotension, the following important points have
to be remembered.
Spinal hypotension as such very rarely kills anyone, but the associated factors
and complication only cause major damage.
Preoperative dehydration should be corrected before attempting spinal
anesthesia wherever possible.
Preloading with fluids may not have many benefits.
The disparity between the vascular volume and the vascular capacity can be very
easily combated by giving the fluid infusion a little fast during initial period.
It is essential to administer 100% oxygen and rapid infusion of fluids along
with other measures when a patient develops hypotension.
When a patient under the effects of premedication with a CNS depressant drug
develops hypotension, reduction of blood flow to the vital centers like respiratory
center and vasomotor center occurs. This will depress these vital centers further
resulting in aggravation of hypoxia and vasodilatation. This perpetuates a vicious
cycle to cause serious hypotension. Administration of 100% oxygen through a
mask to corrects hypoxia of vasomotor and respiratory centers and breaks the
cycle easily. Rapid infusion of fluids corrects the volume disparity.
The degree of fall is less important but the rate of fall is more significant.
A healthy patient who has developed a fall from a systolic BP of 120 mm Hg
to 80 mm Hg. over a period of 30 minutes has good compensation and does
not require aggressive management.
Whereas a similar patient develops fall from 120 mm Hg to 80 mm Hg within
the first 10 minutes indicates that his compensations are inadequate and are
likely to fail soon. He requires aggressive management.
When the BP drops below the permissible limit, give small increments of a
vasopressor, repeat if needed to titrate to the desired effect.
The decision on what degree of hypotension requires treatment can be made
only for individual patients, but there are few who cannot tolerate a decrease
of 25–30% quite safely.
An example
Think about the following clinical situation and analyze that.
An educated healthy young man of 28 years, weighing 60 kg, and belonging to
ASA Gr I, is posted for undergoing inguinal hernia repair. Preoperative counseling
by the anesthesiologist was done with clarification of his doubts and answers for his
questions about anesthesia. He was given a premedication of injection pentazocine
30 mg along with injection atropine sulphate 0.6 mg IM 45 minutes before the
proposed anesthesia.
On the operation table, he was found to be cheerful and cooperative. The BP
recorded was 120/70 mm Hg and the pulse rate was 84/min. The spinal anesthesia
was performed on the horizontal table with the patient on right lateral position.
Using a 27 G disposable spinal needle 3 ml of 0.5% bupivacaine heavy solution
was injected slowly into the subarachnoid space through the L3 – L4 interface
and the patient turned to supine position without causing undue turbulence. An
IV line was secured and dextrose with normal saline infused relatively at a faster
speed so that 250 ml of solution is infused in first 10 minutes and then the rate is
slowed down. Pulse oximeter and sphygmomanometer were connected. Sp O2 was
continuously 96–97%. The level of block was T10 as assessed after 5 minutes.
After 5 minutes the surgeon started painting the area of surgery after informing
the patient that he will feel the touch but will not have pain. Now the anesthesiologist
is communicating with the patient and patient says he is comfortable. The BP was
checked and was recorded as 110/70 mm Hg. The pulse rate was 80/min with a
very good volume. The dorsal veins on the hand appeared reasonably well filled
indicating that the volume status was good.
By the end of 10 minutes the BP was checked and was 100/70 mm Hg. Pulse
rate was 82/min with the same good volume. Respiratory rate was 14–16/min all
along. Patient was asked to put out his tongue and it was moist and pink. At this
time injection midazolam 2 mg IV was given slowly which made the patient sleep
in two minutes. With the patient in good sleep, by now it was 15 minutes, the
parameters were checked; BP 90/60 mm Hg, pulse 84/min with the same volume,
respiratory rate 14/min. The head was turned a little to the side and chin-up. No
airway obstruction could be noticed.
Patient continued to sleep quietly and the parameters continued to be the same
with the oxygen saturation of 97 and a systolic BP of 90 mm Hg. The patient was
not disturbed but was closely monitored. After 30 minutes the BP started rising
94 mm Hg and by 45 minutes it was 100 mm Hg. When the surgery was over by
about an hour the patient was aroused and he woke up with a pleasant smile. By
this time the second pint of fluid was on flow half way.
With a BP of 110/70 mm Hg, pulse rate of 98/min and oxygen saturation of
97%, the patient was shifted to recovery room, retained there for one hour for
observation and then transferred to postoperative ward.
Obviously this patient has not been given any support for cardiovascular
system as the hypotension was slow in onset over 30 minutes and the compensation
appeared adequate as proved by no changes in other parameters and no further fall.
Clinically the patient was comfortable with pink moist tongue.
If we carefully analyse this status, the cardiovascular system is in an
unphysiological state with no vascular reflexs in the lower part of the body and so
with partially deprived reflex protection. But, if offers certain advantages to the
heart to enjoy, which does not happen in normal life.
The patient is lying quietly under good sedation with reduced metabolism and
lesser oxygen demand
The lower part of body has the vascular tree totally relaxed, offering almost
no resistance to flow
Upper part of the body the vascular tree is moderately relaxed due to a good
sedation
Altogether there is a gross reduction in the afterload of the heart leading onto
modest hypotension that is not likely to affect vital organ perfusion. Workload
and oxygen demand are considerably reduced and myocardium gets good
oxygen supply
As the patient is lying horizontally, the heart has no need for pumping blood
against gravity, reducing workload to heart
In horizontal position both the onward flow of blood into the arteries as well as
the venous return to the heart are not hampered, so no reduction in cardiac output
The heart rate was within normal range allowing adequate diastolic time for
coronary filling.
Considering these benefits due for the heart no effort was taken to counteract
the hypotension in this case. Incidentally this hypotension kept the field of surgery
relatively bloodless and so the surgeon had an advantage of operating more
comfortably.
Epidural Anesthesia
This is the technique of depositing the local anesthetic solution in appropriate
concentration and volume with or without adrenaline (1 in 200,000) in between
the two layers of dura, i.e. the investing layer and the periosteal layer so that the
mixed spinal nerve that crosses the epidural space before entering the intervertebral
foramen is acted upon by the local anesthetic to cause a conduction block.
The epidural space can be identified by various methods using various types
of indicators. But universally either loss of resistance technique or hanging drop
technique is used. If the patient is unconscious, the rapid injection of the cold
solution into the extradural space is accompanied by an increase in rate and depth
of respiration (Durrans sign).
Sufficient volume of the solution has to be used to block the required number
of spinal nerves.
The mixed spinal nerve takes along with it a cuff of investing layer of dura
before entering the intervertebral foramen. So the local anesthetic has to penetrate
this dural cuff before acting on the nerve. This is the reason for the delay in the
onset of action of epidural anesthesia.
This causes slow onset of sympathetic blockade, so that the compensatory
mechanisms have adequate time to work, to prevent rapid fall of BP. Hence, in
epidural anesthesia the rate of fall is relatively slow and the degree of fall also is
less because of adequate compensation occurring during the delay.
The differences of this technique from spinal anesthesia are:
Low percentage of local anesthetic is needed. Usually 1.5% of xylocaine with
1 in 200,000 dilution is used
Large volume of solution is necessary to cover the required number of spinal
segments
This may cause accidental overdose unless one is not careful
Adrenaline can be added to the solution to increase the duration of anesthesia
by delaying the absorption. Incidentally with adrenaline the safe dose is
relatively higher.
Depending upon the region where the epidural injection is given, it is classified as:
Lumbar epidural
Caudal epidural (sacral epidural)
Thoracic epidural
Segmental epidural (only required segments are blocked selectively).
Drugs
Xylocaine 1.5% with adrenaline (1 in 200,000)
Bupivacaine 0.5 % (without adrenaline).
Advantages
Onset of hypotension is slow and relatively minimal
No chance of postspinal head ache
Continuous epidural can be used.
By passing fine graduated polyvinyl catheter into the epidural space and
after securing it repeated injections can be made to continue the anesthesia. This
technique is called as “Continuous Epidural”. This technique may be used for
prolonged surgeries and postoperative analgesia.
Disadvantages and Complications

Accidental total spinal
Likelihood of over dosage and toxicity because of the larger volume used.
Total Spinal
A totally reversible dreaded complication of epidural anesthesia
Injection of large volume of local anesthetic accidentally into the subarachnoid
space causing complete blockade of all the spinal and sometimes the cranial
nerves.
Further Reading
1. Bannister J, McClure JH, Wildsmith JAW. Effect of glucose concentration on the
intrathecal spread of 0.5% Bupivacaine. British Journal of Anaesthesia, 1990;64:232–4.
2. Bilsback P, et al. Br J Anaesthesia, 1985;57:943.
3. Bromage PR. Epidural Analgesia. Philadelphia: Saunders, 1978.
4. Coe AJ, Revanas B. Is crystalloid preloading useful in spinal anesthesia in the elderly?
Anaesthesia, 1990;45:241–3.
5. Collins C, Gurug A. Anaesthesia for Caesarean section. Update in Anesthesia, 1998;
9:7–17.
6. Cook PR, Malmqvist LA, Bengtsson M, Tryggvason B, Lofstrom JB. Vagal and
sympathetic activity during spinal anesthesia. Acta Anaesthesiologica Scandinavica,
1990;34:271–5.
7. Covino BG. Cardiovasacular effect of spinal and epidural anesthesia. Regional
Anaesthesia, 1978;1:23–6.
8. Donadoni R, et al. Anesthesia, 1985;40:748.
9. Hemmingsen C, Poulson JA, Risbo A. Prophylactic ephedrine during spinal anesthesia:
Double blind study in patients in ASA groups I–III. British Journal of Anesthesia,
1989;63:340–2.
10. Hutter CDD. The Woolley and Roe Case: A reassessment. Anaesthesia, 1990;45:859 –64.
11. Labat G. Regional Anaesthesia. Philadelphia: WB Saunders, 1923:436–55.
12. Lee JA. A Synopsis of Anaesthesia, 11th Edn. London: Butterworth-Heinemann Ltd.,
1993;25:691–736.
13. Lee JA. A Synopsis of Anesthesia, (2nd Edn). Bristol: John Wright and Sons, 1950;
165.
14. Morgan M. The Woolley and Roe Case. Anaesthesia, 1995;50:162.
15. Morgan P. Spinal Anaesthesia in obstetrics (a review). Canadian Journal of Anaesthesia,
1995;42:1145–63.
16. Ngan Kee WD. Intrathecal pethidine: pharmacology and clinical applications.
Anaesthesia and Intensive Care, 1998;26:137–46.
17. Wildsmith JAW. Spinal anaesthesia—the second fifty years. History Anaesth Soc Pro,
1998;23:40–2.
18. Wright AD. Spinal analgesia with special reference to operations above the diaphragm.
Pro R Soc Med, 1931;24:613–20.
Chapter
Guidelines for Emergency
15 Abdominal Surgeries
“Primum non nocere” this means “First of all do no harm”

The general surgeries are usually done as elective procedures after thorough
investigations, anesthetic assessment sufficiently early and the date for surgery is
fixed according to the convenience of the patient. Here the patient and the operating
team have many options regarding various aspects all that can be explained to them
for taking decision.
When emergency surgeries are concerned, the scenario is totally different.
Most of the time the patients land up almost suddenly into the hospital in a
relatively serious condition. All the people concerned will be in moderate to severe
anxiety and that has to be taken into consideration and appropriate counseling
and explanations to the relatives has to be done without fail. Being an emergency
surgery, almost every step has to be done with relative hurry and chances of lapses
or errors are more.
Many times the patient’s close kin may not be available for giving details about
the patient in general and about the present problem. Very important information
are likely to be missed.
If the situation and condition of the patient permits the team may wait for the
closest and responsible relative of the patient to come to have discussion with the
surgical team and to know about the modalities of the treatment, the degree of
risk involved and the likely outcome. The anesthesiologist must be in the scene to
explain the anesthetic risk factors and convince the relative about the necessity
for the emergency surgery.
Here the surgical team has to be very careful in examining the patient thoroughly
to assess the patient’s condition in general and regarding the emergency problem.
To prevent catastrophe, certain guidelines are followed by the anesthesiologist
to plan the anesthetic particularly in abdominal emergencies which are very often
encountered.
Carefully examine the patient system by system to detect any undetected
systemic problem.
Look at the patient; see whether he is looking very ill.
A patient presenting with sunken eyes, furred dry tongue, inelastic skin, all the
peripheral veins closed down, not secreting any urine for the past 24 hours is
certainly in a severe degree of dehydration and electrolyte imbalance.
Dehydration of severe degree may result in de-compensation during induction
leading onto cardiovascular collapse. This is the most common cause for cardiac
arrest in many of the cases of abdominal emergencies. Similarly electrolyte
imbalance causes a situation known as neostigmine resistant curarization at
the conclusion of anesthesia.
See whether he is running temperature and how long he has pyrexia.

According to the duration of pyrexia he would have been losing quite a good
volume of water through skin and through the respiratory tract (insensible loss
which is usually calculated as 1000 ml/day might go up to 1500 ml or more).
Most of the time they are presented with dehydration and electrolyte imbalance
of varying degrees. Try to assess the degree of volume depletion very carefully
noting down the hours or days of abstinence from oral fluid intake.
In severely dehydrated patients the depletion may be many liters (say to the
tune of 7–8 liters or even more).
Even in the most urgent cases except cases like ruptured spleen, injury to aorta
or heart, usually from the time of admission to the time of taking him up for
surgery, there will be some time available for fluid resuscitation of the patient.
If condition permits the delay, ideally half the calculated deficit has to be infused
in moderate speed before taking up for surgery allowing time for the vascular
tree to relax and accommodate the fluid.
In severe dehydration as the patient has a contracted vascular tree, very fast
rates of infusion even in severely dehydrated patient will induce rapid diuresis
through volume sensor—ADH mechanism and may cause negative balance
in spite of fluid therapy.
At this state without adequate fluid therapy, instituting “Dopamine” therapy
for maintaining the systemic pressure will worsen the tissue ischemia and
aggravate the metabolic acidosis.
–– A very small volume is trickling in the vascular tree within the core
circulation.
–– Blood pressure is not the only parameter to say everything is fine.
–– Status of cardiovascular system must improve, not the blood pressure.
–– Hypotension alone will never kill the patient.
A simple formula of 4–2–1 may be used for calculating the deficit. First 10 kg
weight 4 ml/kg, next 10 kg 2 ml/kg and remaining weight 1 ml/kg for every
hour of preoperative period of total abstinence of oral fluid.
For a 50 kg patient it is 40 + 20 + 30 = 90 ml/h of nil oral.
To this we have to add the insensible loss of 1000 to 1400 ml/day and the other
loses like urine output, aspirations, etc.
The third space loss also has significance in peritonitis with peritoneal
collections. In intestinal obstructions of fairly long duration with gross
distension of abdomen enormous amount of fluid will be sequestrated in the
lumen. In severe cases it may amount to a few liters.
The signs of improvement are increase in BP, decrease in pulse rate,
improvement in pulse volume, improvement in venous filling on the dorsum
of hand and secretion of urine.
Wherever possible the patient must be resuscitated with fluid, colloids, blood,
etc. as the case may be before taking him up for surgery. Even partially
resuscitated patients do reasonably well compared to patient taken up without
an attempt for resuscitation. In the name of emergency taking up patients for
surgery without volume resuscitation is highly dangerous.
See whether the patient suffers severe pain. If so attempt to relieve the pain by
using intravenous analgesic in small incremental doses titrating according to
Chapter 15  Guidelines for Emergency Abdominal Surgeries 223
the effect. Simultaneously take care to maintain adequate circulating volume
by infusing adequate fluids.
Severe pain may maintain a constant raised sympathetic tone that may maintain
the circulation. So extreme care is taken to monitor the infusion rate, BP, pulse
rate, pulse volume, and rhythm and peripheral venous filling while titrating
the dose of analgesic.
Grade the risk of the patient very carefully: If the patient falls in a risk above
Gr. IV, very careful and elaborate discussion with the surgical colleagues about
the management is necessary to analyze the possibility of modifying the proposed
procedure to an alternate step with the idea of improving the outcome. After all our
primary aim is to do good for the patient and improving his condition.
Assess whether the patient is presenting with “Multi Organ Dysfunction”. If
suspected, get the relevant specialists’ opinion for management.
At this stage the anesthetic techniques, drugs and surgical procedure may have
to be modified so that it does not produce further worsening of the condition.
Assess the status of Central Nervous System. Look whether the patient is quiet
or looking anxious. An anxious looking patient may be in severe hypovolemia
with resultant cerebral hypoxia. Identify this by verifying the other parameters.
If it is due to hypovolemic cerebral hypoxia, induction of anesthesia at this
stage will result in de-compensation and cardiac arrest. Oxygenate with 100%
oxygen with mask along with other measures of resuscitation.
Restlessness if observed: distinguish the cause – Hypoxemia, pain, distension
of bladder.
If the patient is unduly drowsy but arousable and no obvious reason could be
identified, then it could be a patient with “Diabetic Ketoacidosis” or “Ureamic
encephalopathy”. Rule out these possibilities.
Respiratory system
–– Respiratory rate and the pattern of respiration give important information.
–– Hyperventilation (hypermetabolic—commonly hyperpyrexia)
–– Tachypnea
–– Dyspnea
–– Hyperpnea.
If the patient is hyperventilating, it is preferable to take up under general
anesthesia.
If the respiratory rate is > 40/min—wait to improve the hydration, and correct
metabolic acidosis till the rate settles below 30/min.
Invariably acidotic breathing is a metabolic problem. Even sub-acute
dehydration with depleted intravascular volume causes reduced perfusion
resulting in depriving the available nutrients and oxygen to reach the cells.
This initiates anaerobic metabolism leading on to acidosis.
In acidotic breathing with increased respiratory rate, the features will be;
–– Not related to CO2 production
–– Blood will be acidotic—acidemia
–– Altered pH stimulates the chemoreceptors in the carotid body to raise the
respiratory rate.
A rise of temperature by 1°C increases the rate approximately by 5 respiration/

min.
If pyrexia is a contributing factor, reduce the temperature by tepid sponging
and injection paracetamol.
It has to be remembered that raised rate of respiration will encroach upon the
alveolar ventilation because the dead space is constant and make the patient
hypoxic (in fact in extreme rates, the ventilation of alveoli will not happen, but
the patient will breathe in and out of the dead space air only).
When the rate is more than 30/min, it is the duty of the anesthesiologist to
explain the surgeon what is the likely danger and convince him the need for
waiting.
A Clinical Approach
First of all the duration of the problem has to be known at least approximately.
It has a very high clinical relevance.
The anesthesiologist must examine a patient before taking up and anesthetizing
him.
For example, the presence of ‘board like rigidity’ of anterior abdominal wall in
an acute perforative peritonitis gives an idea that it is a recent problem whereas
after some hours the rigidity disappears and will be absent in established cases
of days old peritonitis.
Look for signs of septicemia.
Recognize hyperventilation. It is not the same and is different from tachypnea.
In mild acidosis sodium bicarbonate may not be needed. Adequate infusion of
fluids will improve the perfusion and correct it.
After starting the IV fluids periodically feel the pulse for its quality. A pulse oximeter
with a signal bar will be useful in the assessment of the improvement.
Carefully watch for urine output, if fresh urine drains it is a good sign.
Always think of giving an appropriate premedication for an emergency case
also.
Atropine should not be given to these patients intravenously. We must remember
that the perfusion to the salivary glands is almost totally cut off in severe
dehydration and these patient present with absolutely dry mouth.
Intravenous atropine even in normal patients immediately acts on the sinus to
cause tachycardia and it takes more than 20 minutes to have the effect on the
secretions of glands.
IV atropine creates a paradox. That is the drying effect is not immediate,
but the tachycardia is almost instantaneous. In a patient with cardiovascular
compromise and compensatory tachycardia already present, atropine causing
further tachycardia, which is hazardous. It increases the work load of heart as
well as reduces coronary filling by shortening the diastole.
IV premedication is only for relieving the pain. That has to be given by small
incremental titrated doses just to have adequate pain relief and not anything
more than that. Any further dose is likely to cause central depression and
respiratory inadequacy. The increments are given with minimum of 5 minutes
interval for the drug to have full effect on receptors (latent period).
Chapter
Postoperative
16 Nausea and Vomiting
Chapter Outline
Common Recovery Room Problems
v
Nausea, Vomiting, Retching and Regurgitation
v
Factors affecting PONV
v
Vomiting center, CTZ and the receptors
v
Comprehensive orientation of physiology and pathology
v
Pharmacology of antiemetics
v
Prevention and treatment
v
Guiding principles
v
Steroids in PONV
v
Is it a small problem or a big problem? No one has the answer for this question.
So it is often called as a “Little big problem”.
In the modern era of high degree of sophistications, both in the techniques
of anesthesia and drugs, and also in the developments in electronic devices in
monitoring the vital functions of the patients, we are able to provide a very safe
environment to the patients who are submitted for anesthesia and surgery. In spite
of all these developments, there are certain problems related to the postoperative
period such as postoperative pain, nausea and vomiting, shivering, hypoventilation,
airway management, etc. are causing serious concern among the anesthesiologists.
The safety and comforts for the patients are further assured by the presence of
PACU (Postanesthetic Care Units) in every operating suit of all modern hospitals.
These were originally called as “Recovery Room” later renamed as “Recovery
Area”, sometimes known as “High Dependency Area” of the postoperative ward.
The high dependency is because the patients transferred from the operating room
invariably have depressed reflexes due to the residual effect of anesthetics.
In the modern days the term “Recovery” from anesthesia has lost its significance
and is being replaced by the term “Emergence”. Still the word “Recovery Area”
is extensively used carrying the meaning of postanesthesia care unit (PACU).
Common recovery room problems

The term “common recovery room problems” has to be viewed in the light of the
above said understanding.
Even in the best of PACU though the safety of the patients are well assured,
there are certain anticipated problems that are frequently encountered during their
stay in PACU and are known as “Common recovery room problems” namely,
1. Postoperative pain
2. Postoperative nausea and vomiting
3. Postoperative hypoventilation
4. Postoperative hypotension
5. Postoperative bleeding.
Except the postoperative bleeding all the rest need to be managed by the
anesthesiologist in the PACU, particularly in the first 24 hours and more so in the
initial postoperative hours.
Invariably the most common concerns for the postoperative patients are pain,
nausea and vomiting. Among the five problems the foremost in the order of
importance is nausea and vomiting.
In modern times relief of pain in postoperative patient is complete, with various
techniques and drugs, but nausea and vomiting may be present even after excellent
anesthetic management and excellent pain relief, because nausea and vomiting are
of multifactorial origin.
“Many times postoperative pain is suffered in silence, whereas postoperative
nausea and vomiting cannot be suffered that way”.
But when encountered in the PACU, it causes embarrassment to all concerned,
namely, the patient, the by-standers and the doctor. The patient is embarrassed that
he vomits in the presence of the dear ones. The by-stander who is usually a close
kin feels bad to see his or her dear one suffering with vomiting. The doctor when
present when the patient vomits, feels bad to watch it. Besides, he may be blamed
for not anticipating the problem and taking adequate measures to prevent it.
There are some deep concerns about this for the anesthesiologists and the
surgeon and more so for the patients.
1. If the patient vomits in the postoperative period in supine position with a little
depressed reflex, there are more chances for aspiration and lung complications,
if not immediate chocking and death.
2. The usual problem in these circumstances is ‘Acid aspiration syndrome’
otherwise known as ‘Acute exudative pneumonitis’ (Mendelson’s syndrome).
3. Forceful retching and vomiting can cause severe strain on the abdominal
incisions and lead to wound dehiscence. This may later result in incisional
hernia.
4. The strain increases the morbidity by increasing postoperative pain, particularly
with upper abdominal incisions. This may in turn lead to hypoventilation.
Earlier, vomiting and regurgitation were dealt with under the same heading,
because then it was a frequent inevitable event with anesthesia in Ether era.
The patients’ CNS was badly depressed during anesthesia and vomiting or
regurgitation in an unconscious patient contributed for many mortalities and severe
morbidity. The incidence of nausea and vomiting was about 75 to 80%. This rate
has come down to 9 to 45% in the past years. The reasons are quite obvious such
as, the technique of balanced anesthesia, less emetogenic agents and popularization
of regional techniques, etc.
Chapter 16  Postoperative Nausea and Vomiting 227
At present the rate of incidence is 25 to 30%. Here again, though we hardly use
any volatile anesthetics, we depend upon opioids in various applications and also
that there are other numerous factors contributing for vomiting in postoperative
period.
Nausea
It is defined as “an unpleasant subjective feeling prior to the onset of vomiting which
is associated with increased salivation and causes severe distress and discomfort”.
Vomiting
A physiological act related to the rejection of food from the upper gastrointestinal
tract. It may be pathological. There will be increased salivation and nausea prior
to the actual process. Apart from salivation, rapid breathing, pallor, sweating,
tachycardia and discomfort may be associated.
Vomiting center is situated close to respiratory and vasomotor centers. Similarly
salivary and vestibular nuclei are closer to it. This explains that the associated
manifestations are related to the simultaneous stimulation of these neighboring
areas in the brain.
The actual vomiting is a complex and complicated process. The glottis closes to
prevent aspiration of vomitus. The respiration is stopped in the middle of inspiration.
There is reverse peristalsis in the upper intestines to transfer the contents to the
stomach. Then lower esophageal sphincter and esophagus relax. Now there is a
powerful contraction of abdominal muscles. Because the respiration is held and
the thorax is fixed, the muscle contraction increases intra-abdominal pressure and
results in ejection of stomach contents out through the esophagus and mouth. There
are other associated muscular activities for bending forward.
Retching
This is an aborted vomiting which will be in a relatively milder form.
Regurgitation
It is a passive process. It is usually associated with:
Depressed CNS and reflexes, due to residual effects of anesthetic agents
Relaxed lower esophageal sphincter
Presence of ryles tube
Head down position
Stomach full of fluids
Increased abdominal pressure, distension with ascitis
Obstructed bowels.
All these contribute for regurgitation. The stomach contents passively move
into the mouth through esophagus and is aspirated into lungs.
Hydrodynamics of vomiting
In the upright position the pressure of 40 cm of H2O is needed to lift the stomach
contents to the mouth. During the expulsive phase the glottis goes into spasm but
soon it relaxes. So aspiration of stomach contents into the bronchial tree is bound
to happen in an unconscious patient in supine position.
Harmful effects of nausea and vomiting

Effect on Patients
Discomfort and distress – May be perceived by the patient as worse
than pain.
Shame and embarrassment – Unlike pain it is hard to suffer in silence.
Exhaustion – Persistent vomiting can be physically
draining.
Psychological – Fear of future surgery.
Medical Effects
Disruption of wounds – Caused by strong abdominal contractions.
Vitreous extrusion. Bleeding behind the
flaps.
Electrolyte disturbances – Persistent loss of gastric fluid.
Fluid and nutrition – Inability to maintain adequate intake may
slow recovery.
Interference with drug therapy – Oral medication is not possible, parenteral
route may be needed.
Aspiration of gastric contents – In patients with depressed level of con-
sciousness or patients with jaw wired.
Esophageal injury – Forceful vomiting can cause rupture.
Economic effects
Nursing time – Costs of nursing time, costs of consumables
and laundry.
Delay in discharge – Particularly a problem after day care surgery.
Factors that affect the incidence of PONV
Patient factors
Age – Risk is lower in extremes of ages.
Sex – Females, three times more risk than males.
Weight – Risk increased in obesity.
Starvation – Increased risk with prolonged starvation
(hypoglycemia).
History of “motion sickness” – May be related to early mobilization.
History of PONV previously – Has very strong correlation.
Physiological – Pregnancy.
Gastrointestinal tract disorders – Obstruction, billiary colic, delayed gastric
emptying.
Surgical factors
Gastrointestinal – Due to mechanical stimulation of autonomic
afferents.
Gynecological – Related to hormonal effect.
Otolaryngological – High incidences with ear surgery and
tonsillectomy.
Ophthalmic – High incidences with strabismus surgery.
Anesthetic factors
Premedication – Opioid premedication increases risk.
IV induction agents – Etomidate and methohexitone increase risk.
Inhalational agents – Ether and other agents are emetogenic. N2O
may increase the risk with bowel distension.
Opioids – All opioids are emetogenic.
Reversal agents – Neostigmine is emetogenic.
Other anesthetic factors – Hypotension, duration of anesthesia,
oropharyngeal stimulation, hypoxia. High
spinal blockade cause nausea, possibly
related to hypotension, hypoxia, unopposed
parasympathetic tone.
Prevention and management

For effective control of nausea and vomiting, a very simple understanding of basic
physiological aspects of vomiting may be needed.
There is no specific anatomical center. There is a central mechanism in
coordinating this process. Five neuroreceptors are clearly involved. They are;
Dopamine 2, 5HT3 (Serotonin), Histamine 1, Cholinergic (Muscarinic) and Opioid

They are sensors—stimulated by electrolytes, metabolic chemicals and drugs.
Dopamine 2, and 5HT3 (Serotonin) receptors

These are predominantly present in CTZ
They are physiologically very sensitive and are responsible for nearly 80%
of PONV.
Histamine 1 and Cholinergic (Muscarinc) receptors

These receptors are predominantly present in vomiting center
These are not very sensitive as the other two receptors and so contribute for
a very less incidence of vomiting except that originates from labrynthine
stimulation or due to very severe histamine release.
Opioid receptors
These are present both in vomiting center as well as CTZ
These are specifically stimulated by opioids only.
Vomiting Center
Though it is called vomiting center it is not basically responsible for the initiation
of vomiting. This is relatively a less sensitive center.
It is situated in the dorsolateral border of lateral reticular formation. This center
has close proximity to nucleus of solitary tract and area of postrema at the level of
dorsal motor nucleus of vagus.
Chemoreceptor Trigger Zone of Borison and Wang (CTZ)

Though this was identified as early as 1960 by Borison and Wang, better
understanding about its major contribution to the initiation of vomiting is well
understood only during the past few decades. The receptors situated in CTZ play
the major role in initiating vomiting than that in the vomiting center.
It is situated in the area of postrema near vomiting center at the bottom of the
fourth ventricle.
It is stimulated by various chemical changes in the CSF and blood due to
physiological, pathological and therapeutic causes.
This is the most sensitive center for initiation of vomiting. This center dominates
over the vomiting center. The receptors—D2 and 5HT3 present in this center are
very sensitive.
Stimuli from periphery

Esophagus, mediastinum, GI Tract, renal pelvis, peritoneum, genitalia and
glossopharyngeal and vagus nerves.
This may be stimulated by afferents literally from any part of the body except
the limbs (this statement has an objection, as one of the factors, which initiate
vomiting reflex, is severe pain and so severe pain from the limbs also may
initiate vomiting).
Chemicals in CSF and blood can directly stimulate CTZ.
Stimuli from center

Cerebral cortex, labyrinth
Optic nerve
Vestibular apparatus.
Various receptors and their locations

CTZ : Encephalins, opioid and D2 receptors.
Area postrema : Opioid, D2 and 5HT3
Nucleus solitary tract : Encephalins, histamine 1 and muscarinic
Preponderance of receptors
Vomiting center
Opioid receptors
H1 receptors
Cholinergic muscarinic.
CTZ
Opioid receptors
Dopamine 2 receptors
5HT3 receptors
Emetic neuroreceptors are sensors stimulated by drugs, electrolytes, metabolic

chemicals. Though there are more than 7 receptors present, at least 5 receptors are
directly related to this process.
Receptors and Antagonists

1. Opioid receptors – No specific antagonist
2. H1 receptors – Diphenhydramine
3. Cholinergic muscarinic – Scopalamine
4. D2 receptors – Metoclopramide
5. 5HT3 receptors – Ondansetron
The Afferent Inputs Affecting the Relevant Receptors involved

in the Vomiting Reflex
(A comprehensive orientation of the physiology and pathological processes)
With this degree of understanding of basic physiology, it is very clear that the
requirement for the scientific, management of nausea and vomiting must be only
the following two steps:
Suppression of numerous emetogenic peripheral stimuli
Suppression of central neuroemetic receptors.
A good approach includes the following points (6 Point Approach):

1. Adequate pain relief—because pain is a strong stimulus for the centers
2. Adequate intravenous hydration—because hypotension is a stimulus
3. Maintenance of normoglycemia—because hypoglycemia is a stimulus
4. Less emetogenic anesthetic techniques and drugs
5. Identifying the risk factors and avoiding them
6. Using multiple different antiemetic medications acting on various neuroreceptor
sites.
232
Pharmacology of antiemetics based on their action on the receptors
Cholinergic GABA
5 HT3 5HT3 / D2 D2 H1
Muscarinic Agoinst
Ondansetron Substituted Phenothiazines Diphenhydramine Scopolamine Benzo
Granisetron Benzemide Chlropromazine Meclizine Benzotropin diazepines
Tropisetron Metoclopramide Perphenazine Lorazepam
Dolasetron Cisapride Prochlorperazine Alprozolam
Ramosetron Corticosteriods Promethazine Midazolam
Dexamethasone Triethylperazine
Methyl Prednisolone Triflupromazine
5 HT4 antagonist Benzimidazole derivatives
Mosapride (2.5 mgs) Domperidone
Butyrophenone derivatives
Droperidol
Haloperidol
Surgeons and Anesthesia
Apfel, et al devised a scoring system using four predictors.
The four predictors are:
Female gender
History of motion sickness/PONV
Non-smoking
Use of postoperative opioids.
When 0, 1, 2, 3, 4 of these factors are present; PONV incidence will be 10; 21; 61;
79 percentages respectively.
Prevention
Now consider all the factors that are likely to cause PONV and eliminate them as
far as possible.
Avoid
Physiological factors like pain, hypotension, hypoxia and hypoglycemia
Psychological factors related to visual, auditory, olfactory stimuli, particularly
from the factors present in the recovery room or from the other patients in the
recovery room.
Psychological factors
Olfactory
If the patient smells something and suspects that someone has vomited, immediately
starts vomiting. Sometimes it may be an unpleasant smell that initiates vomiting.
Visual
Seeing some other patient in the next bed vomiting, the patient starts vomiting.
Auditory
Hearing the sound of someone vomiting in the next room, the patient starts
vomiting.
In fact, it need not be any input related to vomiting at all, any unpleasant inputs
in olfactory, auditory and visual pathways can stimulate vomiting in susceptible
individuals. For example, seeing some unpleasant scene or an unpleasant smell,
etc. may stimulate vomiting in these individuals. This is known as central stimulus
and is a awake response coming from limbic system. So the ideal management is to
adequately sedating the patient so that he is cut off from the effects of environmental
influences. Here only the GABA agonists like diazepam and midazolam help in
controlling psychogenic vomiting.
Choice of drugs for induction of anesthesia and maintenance with prophylaxis:
Propofol 1–2 mg/kg IV bolus for induction followed by 50–100 mg/kg/
min infusion for maintenance
Droperidol 0.625 mg IV 30 minutes prior to conclusion of surgery
Metoclopramide 10 mg IV 30 minutes prior to conclusion of surgery
If still causes concern;

Dolasetron 12.5 mg or
Ondansetron 4 mg may be administered IV 30 minutes prior to conclusion of
anesthesia.
Treatment
Two steps:
Suppression of peripheral emetogenic stimuli
Suppression of central neuroreceptors.
As a matter of fact, suppression of peripheral stimuli must be aimed at first by
meticulously avoiding the provocative factors in all respects and suppressing them
by good analgesia, maintaining normoglycemia, and adequate hydration, etc., so
that the input reaching the center to stimulate the receptors are maximally reduced.
Now it is advised to use minimum effective dose of a single drug or a combination
of suitable drugs in significantly reduced dose to have better response by action on
many receptors and enhanced action by synergism. Apart from the better response,
the combination therapy has the advantage of reducing the side effects of the drugs.
In the earlier discussion about ‘A good approach—6 points approach’ for the
management, it is clear that the first 5 points are related to prevention and the 6th
points is treatment ‘Using multiple different antiemetic medications acting on
various neuroreceptor site’. In other words, it is about the drugs and their choice
for treatment when vomiting occurs.
If prophylactic antiemetic has not been given, consider their use in the recovery
room. Any one of the following drugs may be used depending on the situation.
Metoclopramide – 10 mg IV
Droperidol – 0.625 mg IV
Promethazine – 12.5 mg IV
Ondansetron – 4 mg IV
Combination of two drugs in appropriate smaller doses is ideal. In very high
risk patient even three drugs may be combined in smaller doses.
In short surgical procedure it may be given IM along with premedication. In
long procedure it may be given IV 30 minutes prior to the conclusion of anesthesia.
So that it has a good postoperative cover.
Smaller doses of combinations of different drugs may be used depending upon
the necessity.
Facts
Prophylactic antiemetics may delay the recovery, particularly phenothiazines.
Hypotension during perioperative period causes a decrease in blood flow to
the midbrain emetic centers, releasing emetogenic chemicals, increasing the
possibility of PONV.
Postoperative pain may be an initiating cause of PONV—it should be treated
with analgesics as needed rather than withholding pain treatment for fear of
opioid induced PONV.
Availability of D2 receptor antagonist and 5HT3 antagonists have broadened
the options available for the treatment of nausea and vomiting.
Benefits of using combination therapy are reduction in side effects, improved
efficacy and providing various mechanisms of actions.
5HT3 antagonists such as ondansetron may have effect by blocking serotonin
(5HT) receptors both periphery and centrally. centrally on receptors in the
CTZ; in the periphery, receptors in vagal nerve terminals and the receptors
described in the intestinal walls.
Guiding principles
Nausea and vomiting can be prevented by gentle movement of the patient from
supine to walking or delaying that
Identifying the source of stimuli that activate vomiting center before choosing
an agent
Effective treatment depends upon correction of underlying causes
Most patients respond well usually to the use of right agent
Small to moderate doses should be used in combination regimens for better
efficacy and lesser side effects
5HT3 antagonist are significantly more effective than metoclopramide alone
Combination of 5HT3 antagonist and steroids are more effective than 5HT3
antagonists alone.
Steroids
Steroids have a very good antiemetic effect. Addition of steroids to other anti-
emetic therapy enhances the potency.
Steroids reduce the severity and incidences of some adverse effects such as
diarrhea induced by metoclopramide, but may aggravate hyperglycemia in
diabetics.
Because of their side effects, steroids are not used as first line of drugs in the
management of simple nausea and vomiting, but reserved for the cases when
the other agents have failed.
The exact mechanism of action of antiemetic effects of steroids is not clearly
known. They are believed to have effect on D2 or 5HT3 receptors.
Conclusion
Routine use of antiemetics is not needed
Identify the ‘high risk’ patient
Eliminate and minimize the “avoidable risk factors”
Use prophylactic antiemetics in ‘high risk’ patients
Use combination therapy in smaller optimum doses for better efficacy
In intractable cases addition of steroids to 5 HT3 and D2 receptor antagonists
would be very effective.
Index
Page numbers followed by f and t refer to figure and table respectively
a Automatic
programmable EO sterilizer 125f
Abdomen 135 washing machine 115
Abdominoperineal resection of rectum 140 Autonomic
Acetated ringer’s solution 152 imbalance 177
Acid aspiration syndrome 226 system 168
Acute exudative pneumonitis 226 AV bundle See Atrioventricular bundle 172
Airway in unconscious patient, maintenance
of 182
Airway obstruction, mechanism of 182 b
Alcohol 107
Alkyl urea derivatives 108 Bacillocid 108
Allergy, history of 51 solution for disinfecting equipments 108f
Alpha bed 193 special 108
Analgesic 67 Back 132
Anaphylaxis 38 Bacterial filters 128
Anesthesia 1, 2, 155 in breathing systems 129f
accidents during 37 Balanced anesthesia 73, 77
chart 41f, 42f definition of 78
classification of 86 Bare area of liver 155
definition of 76 Basal analgesia 71, 71f
purpose of 73 Berman’s airway 184, 185f
record and machine 34 Betadine See Iodophor 15
technician 26, 132 Bhabha Atomic Research Center 128
types of 86 Bins 117
Anesthesiologist’s register 43 for autoclaving 119
Anesthetic technician 22 with perforations for autoclaving 119f
job descriptions of 23 Blood flow
Anticholinergic 66 during hypothermia 159
Antiseptics 107 during hypotension
detergent antiseptics 107 due to autonomic blockade 159
disinfectants 107 with vasoconstriction 159
germicide 107 to liver 157
Antisialagogue 66 with vasoconstrictor drugs 159
Aortic body 174 Blood
Arterial for blood 144
oxygen saturation 47 loss 144
PCO2 168 assessment of 144
PO2 168 during surgery, assessment of 145
pressure, control of 212 pressure 39, 40, 52, 173
system 175 coronary artery dilators 173
Artificial airways 184 stream 161
Asepsis, adequacy of 112 sugar 53
Assisting nurse 22 supply to brain 167, 167f
Atrioventricular bundle 172 tissue 145
Atrioventricular node 172 transfusions 144, 145
Auscultation of heart sounds 52 urea 53
Autoclave 117 viscosity 169
Autoclaving, advantages of 121 volume 144
Boiling 116 Concentration of oxygen 187

water sterilizer 117f Continuous epidural 219
Boosting of basal analgesia 80f Coronary
Brachial plexus 141 arteries, anatomy of 171, 172f
Bradycardia 177 artery blood flow 172
Brain circulation 213
juxtaposing 169 Cotton bandages 120f
anesthesia and 166 Crepe paper 130
Break back 136, 137 Cross infection from antibiotic resistant pathogens
Bupivacaine 199, 201 105
CSSD See Central Sterile Supply Department 129
c
d
Cadaveric relaxation never 12
Capnography 39 Degree of hypotension 214
Cardiac Detergents 127
arrest 38 Dettol 107
output 173, 174 Dextran 40 148
Cardiovascular Dextran 70 148
stability 196 Dextrose 150
system 45, 52, 181, 203 injection 150
Carotid body 174 benefits 150
Catecholamines 174 drip rate 150
Catering 93 indications 150
Catheters 124 Diabetic ketoacidosis 223
CBF See Cerebral blood flow 168, 169 Didecyl dimethyl ammonium chloride 108
Ceiling 94 Different guedel’s airways 185f
Central nervous system 52, 181, 202 Diphenylheptane derivatives 69
recovery 195 Dolasetron 232
Central neural block 203 Dopamine 229
Central Sterile Supply Department 129 Dorsal recumbent position See Supine 132
Cerebral Drugs 39, 163, 208
blood flow 168 Dry heat 122
circulation 213 methods See also Moist heat methods 116
metabolism 166 Durrans sign 219
perfusion pressure 168 Dyspnea 223
Cerebrospinal fluid 166, 170
Chemical sterilization methods 122 e
Chemoreceptor trigger zone 230
Chlorhexidine 16, 107 Ear 135
gluconate 127 ECG 39
Chlorine compounds 127 Effect of
Choice of anesthesia 62 anesthetic agents on cardiac output 175
Chronic diseases 51 hemorrhage on renal blood flow under
Cidex See Glutaraldehyde 126 anesthesia 164
Circle of willis 167f intravenous atropine 69
Circulating nurse 24 opioid premedication 72f
Circulation, anatomy of 167 Electronic operation table with remote controls
CNS depressant 66 133f
drugs 68 Elimination of heat 96
Cocaine 199 Emergency
Cold methods See Chemical sterilization abdominal surgeries 221
methods 122 accident 93
Colloid solutions 148 Ephedrine 216
in blood volume replacement, role of 147 Epidural anesthesia 218
Colorimetric method 146 advantages 219
Common recovery room problems 225, 226 complications 219
Index 239
disadvantages 219 h
drugs 219
Equipment store 102 Haemaccel 146, 149
Equipments, types of 113 Half normal saline 153
Erythroxylon coca 199 Halogen lamp in luminaires 97f
Ester linked local analgesics 200 Halothane 160, 175
Ether 175 Harmful effects of
Ethyl alcohol 107, 127 nausea 228
Ethylene oxide 124 vomiting 228
sterilizer 124f Head 132
Eye 135 Heart
anesthesia and 170
rate 77, 174
f Heat sterilization 116
Hemoglobin 53
Face chest 135 Hepatic cells, anesthesia and 160
Failure of autoregulation 169 Hepatitis
Fear of B 106, 129
death 2 C 106
pain 2 Hexachlorophene 127
unknown 3 Hibiscrub See Chlorhexidine 15
Feet 135 Hibitane 16
supported by slings, lithotomy position with High dependency unit 180
140f Hospital infections 105
FIO2 See Concentration of oxygen 187 Hot air sterilizer 122, 122f
Hydraulic operation table with manual controls
Flash sterilizer 118f
133
Floors 94
Hydrodynamics of vomiting 227
Foot operated suction pump 186f
Hypercarbia 177
Formaldehyde 107
Hyperpnea 223
Formalin 109 Hypertension 21
chamber 123f Hyperventilation 223
Hypnotic 67
g Hypoglycemia 177
Hypotension 177
Gallbladder 136 Hypoxia 163
bridge 133, 136 Hypoxia 177
position 137f Hyrdoxyethyl starch 149
Gamgee pads 120f
Gamma rays 128 i
Gas cylinder store 102
Gases 124 Indian Society of Anesthesiologists 34
Gelatin 149 Infection, source of 106
Gelofusine 149 Infiltration block 203
Glass syringes 122 Inspired oxygen concentration 39
Instruments for autoclaving 120f
Glomerular artery See Glomeruli 160
Intensive
Glomerular capsule 161
respiratory therapy units 10
Glomeruli 160
therapy unit 93, 180
Glutaraldehyde 107, 127
Intermittent determinations of blood pressure 45
Good surgical anesthesia 75 Interventricular branch 171
Granisetron 232 Intracranial pressure 168, 169
Gravimetric method 145 causes of
Greases 122 increased 170
Guedel’s airway 184, 185f reduced 170
Guedel’s classification of anesthesia 73 Intravenous premedicant drugs 70
Intubation of trachea 186f position 136

Invert sugar 154 storage, functions of 158
Iodine 126 synthesis, functions of 158
Iodophor 15, 16 Living tissues 107
IRCU See Intensive respiratory therapy units 10 Local anesthetic drugs 198
Ischemia 163 Low pressure autoclave 121
Isoflurane 175 Lumbar
Isopropyl alcohol 107 puncture 207
region 132
j Lying on back 135
Lysol 107
Jaundice 51
Jehovah’s witnesses 60 m
k Maintaining clear airway 183

Malignant hyperpyrexia 38, 39
Kidney Marginal branch 171
anatomy 160, 161f Mean arterial pressure 168
anesthesia and 160 Medico-legal reasons 40
bridge 133, 137, 138f Mephentermine 216
elevator 137 Metabolic status 45
physiology 161 Methods equipments, classification of 116
position See Lateral position of extension Methods of sterilization 116
132 Microbiological monitoring 113
position with arm support 138f Micronebulizers 109
vascular system 160 Mild derangement of multiple systems 6
Mild systemic disease 6
Modern
l
anesthesia 78
Laminar airflow ethylene oxide sterilizer 125f
mechanism of 102f Moist heat 116
provision of 102f methods 116
Lateral Molded gel filled pads 143f
position of extension 137 Monitoring
tilt of table 139, 139f anesthetic machine 45
Left coronary artery 171 during anesthesia 43
Leg Morphine sulphate 68
and foot support pads 141f Multi lamp multi reflector luminaire 98f
support, lithotomy position with 140f Munro kellie’s doctrines 169
Legs 132, 135 Muscarinic 229
Lighting 94 Myocardial oxygen 176
of corridor 95f Myogenic autoregulation acts 212
Limited access zone 90f
Linen 130 n
Liquids 126
Lithotomy position 139 Nail brush with wooden handle 15f
Liver Narcotic 68
anatomy 155 analgesics, classification of 69
anesthesia and 155 Nasopharyngeal airway 184, 186f
blood flow in Natural alkaloids of opium 69
anesthetised patient 158 Nausea 226, 227
conscious state 158 Nerve
modifications 158 block 203
functions of 158 supply 161
lobule, anatomy of 156f Neuromuscular
metabolism, functions of 158 blocking agents 187
physiology 157 transmission 39, 45
Index 241
Non-woven fabrics 130 Postanesthesia care 178
Nu–cidex 127 guidelines for 192
Nurse 26 units 178, 179, 191, 225
scrub nurse 24 Postoperative
Nursing care unit 179
assistant 24, 26 nausea 187, 225
supervisor 25 vomiting 187, 225
Potassium permanganate 109
o Powders 122
Preanesthetic
Obstetric assessment 48
analgesia 11 medication 65
patient 214 drugs 66
Odophor 127 Premedication drugs See Preanesthetic
Ondansetron 232 medication drugs 66
Operating Premedication, effects of 71
departments, types of 93 Preoperative disease 63
luminaires, types of 97 Primum non nocere 32
room with members of surgical team 20f Privation of senses 2
table and positions for surgery 132 Programmable automatic EO sterilizer 125
theater environment 104 Prokinetic drugs 61
Operation table 142 Propylene oxide 124
with accessories fixed 134f Pulmonary tuberculosis 128
Opioid premedication 71f Pulse 39, 40, 52
Orbicularis oris 190 oximetry 39, 47
Organ perfusion 212 plethysmography 47
Orthopedic table See Operation table 142 Pump oxygenator 124
Outside trolley 92f
Oven See Hot air sterilizer 122
Oxygen
r
failure alarm 39
Ramosetron 232
saturation 40
Recovery
in blood 173
criteria 188
from anesthesia 83
p room 178, 193f
purpose of 181
Pads of molded sponge 142f Regional anesthesia 198
Pain 226 advantages of 198
Perioperative deaths 62 definition of 198
Peripheral pulse 47 disadvantages of 199
Pethidine techniques of 203
hydrochloride 68 Regular palpation of peripheral pulse 47
premedication 71f Relton frame and pads, prone position with 141f
pH of blood 173 Removal of rib 2
Pharmacology of local anesthetics 199 Renal
Phenol 107, 126 blood flow in
Piperidine derivatives 69 anesthetized patient 164
Planes of surgical anesthesia 73 conscious patient 163
Planning operation list 28 damage in relation to anesthesia and surgery
Planning postoperative care 30 165
Plasma volume perfusion 214
expander 148 plexus 161
substitute 147 Respiration 39
Plastic pump tubing 124 Respiratory
Plenum turbulent airflow system 100 problems 21
Plexus block 203 system 52, 181, 195
Positron of patient for lumbar puncture 209f Restricted access zone 91f
Retching 227 Sterile pack system 130

Reverse trendelenburg position 137f Sterile swabs in a sterile tube for bacteriological
Rib resection See Removal of rib 2 monitoring 113f
Right coronary artery 171 Sterilization of equipments, classification of 116
Rigid bony cage 166 Stimuli from periphery 230
Ringer’s lactate 215 Stretcher bearer 25, 27
solution 151 Subarachnoid block 204
Ripple bed See also Alpha bed 193 Subarachnoid block See Spinal anesthesia 204
Risk of death 4 Supine 135
Ruben valve 124 position 136f
Surgeon-anesthesiologist relations 11
Surgery
s type of 63
without anesthesia 1f
Safe anesthesia 32
Surgical hand disinfection 14
Safe practice of anesthesia 32
Surgical team 19
Safe surgery saves lives 32
Systemic blood pressure 162
Safety in anesthesia 36
Systems mainly affected recovery 181
Safety margin 4
Systolic and diastolic arterial pressure 216
Sagittal section of spinal column 206f
Sanctum sanctorum 13
Sanitary worker 27 t
Scrub area See Restricted access zone 91
Scrub nurse See Assisting nurse 22 Table top autoclave 118
Scrub up See Surgical hand disinfection 14 Tachycardia 177
Semisynthetic alkaloids 69 Tachypnea 223
Serotonin 229 Task area illumination 98f
Serum creatinine 53 principle of 98f
Severe Teflon prosthesis 124
hypovolemia 213 Ten golden rules of anesthesia 33
impairment of vital functions 63 Test tape 121
systemic disease 6 Theater
Shadow reduction 96 asepsis, maintenance of 30
Signaloc tapes See Test tape 121 disinfection schedule 107
Signs Guedel’s classification of anesthesia 75t nurse 28
Single runners 24
bin 118f sterile supplies 130
lamp luminaire 97f trolley 92f
theater suite 93 Thiopentone 175
Skull 166 Topical anesthesia 203
Small autoclave 118 Toxic reactions of local anesthetics 201
Small incremental dose of analgesic 80f Toxicity, manifestations of 202
Sodium chloride injection 150, 153 Tranquilizer 66
Soft nylon bristles 15f Transport to recovery room 180
Specific gravity of urine 165 Trendelenburg position 136, 137
Spinal 203 Triad of anesthesia 74, 75, 77f
analgesia 204 Tropisetron 232
and epidural block 207 Tubercle bacilli 122
anesthesia 204, 211 Tubular reabsorption 163
physiology of 208, 210 Twin theater suite 93
hypotension 211, 214 Type of block 214
management of 214
Sponge and covered with washable rexin 142f u
Stages of surgical anesthesia 73
Steam under Ultraclean ventilation system 101
low pressure 121 Ultrasonic
pressure See Autoclave 117 washer 115
Steps of surgical hand scrub 17f washing machine 115f
Index 243
Ultraviolet return 174
lights 110f system 176
rays 110 Ventilator disconnect alarm 39
air cleaner 111f Victims of poisoning, management of 10
air cleaning system 110 Vigilant anesthesia 40
Ureamic encephalopathy 223 Vital
Urinary system 161 organ function 155
Urine signs 40
albumin 53 Vomiting 226, 227
sugar 53 center 230
v w
Vagolytic 66 Walls 94
Vapor 123 Weekly fumigation with formalin 109
Vascular Weekly washing 108
reflexes 174
system 175 x
Vasomotor tone 77
Vasopressor 216 X-ray chest 54
drugs, effects of 164 Xylocaine 199, 200, 208
Venous availability 200
drainage 168

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Surgeons and

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Jaypee Brothers Medical Publishers (P) Ltd

Jaypee Medical Inc Jaypee Brothers Medical Publishers (P) Ltd

Jaypee Brothers Medical Publishers (P) Ltd

Professor Dr T Subramaniam FRCS

I had the great fortune of working with this legendary personality

Sam C Bose MS MCh

Spinal anesthesia is being practiced extensively and is associated with

I am extremely grateful to all my teachers, who always made me realize and

Clinical assessment of adequacy of reversal of NMB 189

‘Eternal vigilance is the price of safety’

‘The proper dose of any drug is enough.’

‘All anesthesiologists, however experienced and however accident-free,

Hospitalization is a dehumanizing process. Even in the best of circumstances,

Anesthesiology is a science, that is practiced as an art, which provides relief of

The situation can be explained in very simple words;

Fig. 1.2: Schematic representation of ‘Safety margins’ available for various

The anesthesiologist is a person who is basically a clinician with deep knowledge

Functions of the Anesthesiologist

 Giving the best possible pain relief for the patient.

Well informed (Knowledgeable)

In addition to anesthetics, the drugs employed by the anesthesiologist include

Operating theater suite and theater discipline

Surgical hand disinfection (Scrub Up)

Operating department Manager

7. Furuhashi M. Bulletin Tokyo Medical Dental University, 1978;25:7.

Safe surgical teams

Members of Surgical Team

Various countries propose different number of essential Technical Members

Fig. 3.1: Operating room with the members of surgical team

Assisting Nurse (Scrub Nurse)

Anesthetic Technician (Theater Assistant or Theater Technician)

Job descriptions of Anesthetic Technician

He has to do the following;

Unskilled personnel working inside the operating room

A small set up in Indian scenario

Coordinator of the Team

Responsibilities of the Coordinator

Planning the operation list

Planning the team for different procedures

Planning the postoperative care

Maintenance of Theater Asepsis

Points for theater asepsis

Universally the primary consideration in anesthesia is “Safety”.

Ten Golden Rules of Anesthesia

Indian Society of Anesthesiologists

Operation theaters: minimum requirements

Anesthesia care: principle

Anesthesia record and machine

The recovery area

Accidents during Anesthesia

Fig. 4.1A: The first page of an anesthesia chart

Fig. 4.1B: The second page of anesthesia chart

Monitoring during Anesthesia

Facts about Monitors

Monitoring the anesthetic machine

Monitoring of the patient

Of these universally accepted basic minimum mandatory monitoring are;

The cardiovascular System

Fig. 4.2: The CM5 ECG lead configuration

Monitoring the circulation

Arterial oxygen saturation: Pulse oximetry

Good patient care starts at this level as far as anesthesia is concerned.

Giving the best possible pain relief for the patient.

To suppress the undesirable reflexes from anesthetic or surgical procedures

Premedication of pethidine 50 mg was given IM and waited for 45 minutes

In spite of good analgesia, if muscle retraction causes reflexes, intravenous