DR AYMAN Y

GMU AJ

Anesthesia
Anesthesia
Intensive care
Chronic pain management

Anesthesia
Anesthesia
CPR
Acute Pain control
Difficult Lines
Evaluating critical patints

Anesthesia
Theatre
Radiology
Interventional radiology
Cardiology
ECT
GI

Types Of Anesthesia

Types
of
Anesthesia
General Anesthesia
Local Anesthesia
Sedation

General Anesthesia
Preoperative evaluation
Intraoperative management
Postoperative management

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

Pre-Operative
Assessment
History
Indication for surgery
Surgical/anesthetic history: previous

anesthetics/complications, previous
intubations,
Medications, drug allergies

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

 Hematologic: anemia, coagulopathies, blood

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

FHx: malignant hyperthermia, atypical

cholinesterase (pseudocholinesterase), other
abnormal drug reactions

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

Bony landmarks and suitability of areas for

regional anesthesia if relevant

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

Investigations: According to( ranged from none to

most complicated)
Age
Surgery
Medical condition
As clinically indicated

Low risk no further evaluation needed

Intermediate risk non-invasive stress testing

High risk proper optimization +/delaying/canceling procedure

American Society of Anesthesiology (ASA)

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

ASA 3: a patient with severe systemic disease that

limits activity, e.g. angina, prior MI, COPD (1.84.3%), DM, obesity
ASA 4: a patient with incapacitating disease that
is a constant threat to life, e.g. CHF, renal failure,
acute respiratory failure (7.8-23%)
ASA 5: a moribund patient not expected to
survive 24 hours with/without surgery, e.g.
ruptured abdominal aortic aneurysm (AAA).
ASA 6 : Brain death patient
For emergency operations, add the letter E after
classification

Medications:
Pay particular attention to CVS and resp

meds, narcotics and drugs with many side

effects and interactions prophylaxis.
Risk of adrenal suppression steroid coverage
Risk of DVT heparin SC,LMW Heparin,

Mechanical methods.

 Optimization of co-existing disease ^

bronchodilators (COPD, asthma), nitroglycerine

and beta-blockers (CAD risk factors)
Pre-operative medications to stop:
Oral hypoglycemics stop on morning of
surgery
Antidepressants.
Pre-operative medication to adjust:
Insulin, prednisone, coumadin, bronchodilator

Decide, whether to proceed with surgery ,to

send patient for further management or to

cancel the operation.
Discus anesthetic options.
Decide which is the most useful for the
patient.
Informed consent.
Risk stratification .

Types of anesthesia

GENRAL ANESTHESIA

REGIONAL ANESTHESIA
LOCAL ANESTHESIA.

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

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

Monitoring: according to paitent medical

condition and surgery proposed

Basic: ECG, NIBP,SpO2, EtCO2, Temp,FiO2,
Anesthetic gases, Airway pressure, The
presence of anesthetist all throug
procedure.
Others: Nerve stimulator, Invasive Bp, CVP,
CO, PA Catheter.
Lab tests, ABGs, CBC, LFT , Coagulation.

Basic Principles of
Anesthesia
Anesthesia defined as the abolition of

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

Induction

Maintinance

Recovery

Hypnosis Intravenous(eg
unconsciousn) :Thiopentone,P
(ess
ropofol)
Inhalational( s
evoflurane,Hal
othane)

Inhalational
Intravenous

Discontinue

Analgesia

Systemic( opio
ds,
Fentanyl,Remif
entanil,Alfenta
nil)

Systemic:
(opiods,NSAID
S)
Regional( Epid
ural,Spinal)
LA
N2O

Analgesic
Opioids,Region
al, Local
NSAIDS
Parasetamol

Muscle
Relaxation

Depolarizing
suxamethonio)
(m
Non
Depolarizing
steroids,)
(vecuronium
Benzylisoquino
lonium Cis
( atracurium

Non
Depolarizing

Reversal by
Anticholinstras
es( Neostigmin
e,)& Atropine

Intravenous Anesthetic Agents

Thiopental
Thiobarbiturates
Uses for induction, decrease ICP, Status

epilepticus
CNS: Hypnosis within 30 seconds ,decreased
intracranial pressure.
CVS depression, hypotension, tachycardia
Respiratory depression, spasm

Intravenous Anesthetic
Agents
PROPOFOL ( Deprivan)
USES: induction, maintenance, sedation in the

ICU, sedation
Contra indicated in children.
CNS: Hypnosis within 30 seconds ,decreased
intracranial pressure.
CVS: depression more than Thiopental
Respiratory: Depression, no spasm
Caloric load in the ICU, propfol infusion
syndrome

Intravenous Anesthetic
Agents
Ketamine
Phencyclidine
Uses, shock, burn, CNS, dissociation,

hallucination, analgesia,
Increased intracranial pressure.
CVS Stimulation, hypertension, tachycardia
Respiratory, less depression.

Intravenous Anesthetic
Agents
Etomidate
Stable cardiovascular
Steroid depression

Inhalational
Anaesthesia
Halothane
Enflurane
Isoflurane
Sevoflurane
Desflurane
N2o
Xenon

Inhalational
Anesthesia induced by inhalational effect
,different in their potency
.Different in rapidity of induction and recovery
, Common pharmacological properties
CVS depression with tachy or bradycardia
.RESP Depression
CNS increased intracranial pressure

Opioid
Fentanyl
Morphine
Alfentanl
Remifentanil

All have almost the same pharmacodynamics

of ,
Morphine, Analgesia, Sedation ,
Respiratory
depression, Nausea and
vomiting, meiosis, constipation.
Different in their pharmakokinitcs.

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

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

Local anaesthetics
Lidocaine, lignocaine,xylocaine
Bupivacaine ( marcaine)
Cocaine
Procaine

Regional ( spinal , epidural)

Local
Different side effects
LA toxicity. Maximum doses,
Perioral numbness, tinnitus, convulsions, resp

depression, Cardiac arrest

Treatment, ABC, symptomatic,
intralipid( propofol)

Reversal
Neostigmine
Atropine

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

Awareness
Awarness
Definition
Types
Effect
Causes
Manegment

Thank you