42 SEDATION, SURGERY AND ANAESTHESIA

Techniques of anaesthesia
The choice of anaesthetic
technique depends on the Anaesthesia
type of surgery, patient
risk-factors and the
General Regional
patient’s preference. anaesthesia anaesthesia
Options generally include
general anaesthesia,
regional anaesthesia and a • Inhalation • Nerve
combination of these • Intravenous • Intravenous
techniques (Fig. 1). • Balanced • Plexus
• Relaxant • Intrathecal
• Tracheal tube • Epidural
• LMA (a)
• IPPV

Fig. 1 Anaesthesia options.

General anaesthesia
General anaesthesia (GA) entails inducing a loss of consciousness
while providing adequate operating conditions and stability of the
essential physiological functions. To achieve this, the anaesthetist
devises a strategy for each patient based on information acquired in a
preoperative visit and knowledge of the complexity of the operation.
(b)
The induction of general anaesthesia is achieved with intravenous
drugs in the majority of instances, but inhalation is a suitable
alternative both for elective procedures, and in certain emergencies
where the airway is compromised (see Fig. 2). Many children prefer
inhalation as they are spared a needle insertion while awake. The
agents used to induce anaesthesia are not always the same as for
maintaining anaesthesia during surgery. The simplest general
anaesthetic consists of using a single agent throughout for inducing
and maintaining anaesthesia, and this can either be intravenous
(using propofol) or inhalational (using sevoflurane).

Balanced anaesthesia (c)

There is debate about whether anaesthetized patients experience Fig. 2 General anaesthetic sequence.
pain. Strictly speaking they cannot, as they are not conscious.
However, hypnotic agents alone do not
prevent the responses to surgical dose of narcotic analgesics (such as in anaesthetic and surgical techniques
stimuli, such as increases in blood fentanyl) and a low dose of propofol or allow many operations to be carried out
pressure and heart rate. The addition of an inhalational anaesthetic agent (such in day-surgery units.
analgesic agents, such as opiates and as isoflurane). If appropriate, a regional
non-steroidal anti-inflammatory drugs, technique should be added to reduce the
is thought by many to be an essential adrenergic response to surgery.
component of balanced anaesthesia (see
Analgesia Hypnosis
Fig. 3). The combination of general and
regional anaesthesia is also a popular
option. Some practitioners advocate
Emergence
Balanced
muscle relaxants as essential ingredients Recovery from general anaesthesia anaesthesia
in a balanced anaesthetic technique. This depends on the elimination of agents by
view is strongly opposed by those who natural routes (lungs, liver and kidneys).
are concerned that paralysed patients Drugs with long elimination half-lives
who are inadequately anaesthetized are result in prolonged postoperative
Relaxation
unable to indicate that they are awake. somnolence. Modern anaesthesia – drugs/regional
For sick patients, techniques with facilitates reliable hypnosis and
minimal depressant effects on the heart analgesia coupled with rapid awakening
are preferable. These are based on a high and ability to function. Recent advances Fig. 3 Balanced anaesthesia.
 Techniques of anaesthesia 43

Table 1 Examples of clinical decision-making

Tracheal intubation
Indication Considerations
Placement of a tracheal tube (TT) is not a Elective orthopaedic surgery Regional, general or combination anaesthesia
prerequisite for all patients undergoing general Spontaneous ventilation – LMA
anaesthesia (see Fig. 4). The main indications are risk Intra-thoracic surgery Usually painful and extensive surgery – balanced anaesthetic
Consider a combined regional/general anaesthetic technique
of lung soiling with gastric contents and requirement
Requires IPPV to inflate the lungs – tracheal intubation is necessary
for assisted ventilation of the lungs (intermittent
Adominal surgery Balanced anaesthetic technique
positive pressure ventilation – IPPV). A laryngeal Requires muscle relaxation – tracheal intubation (or LMA) and IPPV
mask airway (LMA) is less traumatic and better Liver resection GA with low-dose hypnotic and high-dose narcotic
tolerated than a tracheal tube and is used during the Consider combination with epidural anaesthesia
majority of general anaesthetics in the UK (see Requires muscle relaxation – tracheal intubation and IPPV
Table 1). Positive pressure ventilation may be
administered via a laryngeal mask airway when there
is no pulmonary pathology.

Regional anaesthesia
There is a common misconception that regional anaesthesia is safer
than general anaesthesia. In reality, when performed by an
experienced anaesthetist, both techniques are extremely safe.
Regional anaesthesia allows the provision of excellent analgesia and
decreases the need for narcotics and hypnotic drugs. There is a
choice between local blocks of specific nerves or plexuses,
intravenous blocks of the upper limb (Bier’s), subcutaneous
infiltration and neuraxial blocks. Fig. 4 Anaesthetized patient with a tracheal tube.
Peripheral nerve blocks
Intravenous blocks Fractured jaw after an accident
The most commonly applied are dental
Intravenous blocks are used for surgery The protective laryngeal reflexes may
nerve blocks, ocular nerve blocks for
of the upper limb (Bier’s block), A be lost with danger of aspiration of
cataract surgery (see Fig. 5) and ring
tourniquet is applied to the arm and a blood, teeth and other debris.
blocks of the fingers or toes. Other useful
short-acting local anaesthetic agent Protection of the airway is the first
nerve blocks are intercostal nerve block,
injected through a previously inserted priority. This may be achieved by
to alleviate pain in rib fractures or for the
intravenous cannula. passing a tracheal tube via the nose
insertion of a chest drain and femoral
with local anaesthesia (except when a
nerve block for lower limb injuries.
Neuraxial blocks fracture of the skull base is suspected)
Epidural and intrathecal blocks can be following which general anaesthesia
Plexus blocks
used as the sole anaesthetic for most may be induced.
This technique is well established for
surgery below the waistline or as an
upper limb surgery (e.g. brachial plexus
adjuvant of general anaesthesia for
block) and for relief of cancer pain (e.g. Elderly patient for internal
thoracic, abdominal, perineal and lower
coeliac plexus block). fixation of a hip fracture
limb surgery. The decision to use
neuraxial anaesthesia as the sole The elderly often suffer from medical
technique should be influenced by the problems. The usual choice is between
health and the preference of the patient. general anaesthesia and neuraxial block.
Studies have demonstrated a reduction in
blood loss and respiratory complications
with such operations when performed
Clinical scenarios under neuraxial blockade.
Dental extractions
Anaesthesia for dental extraction should
be provided by infiltration with local
anaesthetic. The oral mucosa may be
sprayed with topical lignocaine before
Techniques of anaesthesia
needle insertion. General anaesthesia ■ Anaesthetic techniques include general
should be used only in exceptional anaesthesia, regional anaesthesia and
combinations of these.
circumstances, and then only in an
operating theatre in an established ■ Balanced anaesthesia entails the provision
of analgesic agents in addition to hypnotic
hospital. In the UK general anaesthesia is
drugs.
overused for dental procedures.
■ Tracheal intubation is seldom essential.
Cataract surgery ■ Modern general and regional anaesthesia
Local anaesthesia avoids the risks of are extremely safe.

Fig. 5 Administration of an eye block. postoperative sedation, nausea and ■ Many operations are performed in day-
Note: wearing of sherile gloves is indicated for this vomiting, and the problems introduced surgery units.
procedure. by cardiac and respiratory disease.
44 SEDATION, SURGERY AND ANAESTHESIA

Sedation
An increasing number of minimally invasive procedures are too long or too painful. A preoperative assessment as for
carried out under sedation (Table 1). Such procedures are brief general anaesthesia should be carried out.
and cause minimal disturbance to the body’s physiology, thus
not justifying general anaesthesia, especially when patient History
cooperation is required. Sedation aims at alleviating the In the presence of cardiac or pulmonary disease, reduced doses
anxiety and discomfort associated with a procedure. of sedatives may be needed. Hepatic or renal impairment may
Sedation is not a discrete end-point, but lies on a continuum affect metabolism and excretion of sedatives leading to a longer
between complete wakefulness and general anaesthesia (Fig. 1). duration of action. Previous adverse reactions to sedatives
Every patient responds to sedative agents differently. Sliding should be noted and current medication, last oral intake, and
into general anaesthesia with loss of protective airway reflexes smoking or alcohol intake noted. Alcohol and smoking may
is an important complication of sedation. Sedative dose should increase the requirement for sedatives agents.
be adjusted based on route of drug administration, drug
interactions and patient’s age and physical fitness. Examination
The airway, the lungs and the heart should be examined.
Table 1 Procedures carried out under sedation Laboratory and imaging investigations are not routinely
Medical specialty Procedures needed unless specifically indicated.
Gastroenterology Colonoscopy, gastroscopy Patients must be informed about the proposed procedure
Chest medicine Bronchoscopy and sedation plan and written consent is mandatory. Patients
Dentistry Extractions, root fillings, etc should be fasted 8 hours for solid foods and 2 hours for clear
Cardiology Cardioversion, pacemaker, PTCA liquids. Inadvertent over-sedation renders patients vulnerable
Radiology CT, MRI, etc to regurgitation and inhalation of stomach contents. Very
anxious patients may benefit from an anxiolytic medication
(e.g. temazepam) given orally 2–3 hours before the procedure.

Clinical tip
If a patient
Awake becomes restless Prerequisites for safe sedation
anxious and confused
The American Society of Anesthesiologists have issued
sedation may be
excessive recommendations as follows:
Not
anxious 1) An anaesthetist should be present. It is reported in the USA
that complications are less frequent when anaesthetists
Light administer sedation. This recommendation is unlikely to be
sedation followed because there are not enough anaesthetists for the
number of procedures carried out.
Conscious 2) Vital signs should always be monitored. Oxygenation: the
sedation
pulse oximeter is the most useful monitor. Evidence of
• Drug
unobstructed breathing movements should be sought
• Drug dose Deep
sedation throughout the period of sedation. Circulation: a non-
• Patient factors invasive blood pressure device and an ECG monitor should
• Route of administration General be used in patients with hypertension or ischaemic heart
• Drug interactions anaesthesia disease. Consciousness: verbal contact with the patient
should be maintained. In situations where it is not possible
to speak, gestures such as ‘thumbs up’ can be used.
Fig. 1 Sedation sliding scale.
Person Monitors of vital Dedicated trained
performing signs person to administer

Definition procedure Minimum = ECG,

BP, Oximeter
sedation and monitor
patient

Conscious sedation is a state where the patient:

■ Has a depressed level of consciousness.
■ Is free from anxiety. Supplementary
oxygen
■ Is able to protect the airway.
■ Is able to respond to verbal command.
Following conscious sedation, there may be amnesia despite
continuous verbal communication. Intravenous access

Patient selection and preoperative Resuscitation equipment-

assessment including defibrillator and
emergency drugs
Appropriate patient selection reduces complications. Some
patients are unsuitable for sedation and some procedures are Fig. 2 Sedation Unit set-up.
 Sedation 45

3) The operator carrying out the procedure should not be in

charge of monitoring the patient (see Fig. 2). Another Syringe driver Patient controlled sedation
member of the staff should do this. Resuscitation
equipment including a defibrillator must be available.

MORE !!

Sedative agents
Pump controller
Many agents have been used for sedation, including
barbiturates, chlormethiazole, antihistaminc, neuroleptics,
opioids, nitrous oxide, benzodiazepines and general
anaesthetics. Modern sedation is based on midazolam or
propofol and short-acting opioids.

Opioids Switch
Opioids have some sedative effects but should be used only if
analgesia or blunting of airway reflexes is required. Morphine,
pethidine, fentanyl and remifentanil are the most widely used. Fig. 3 Patient-controlled sedation.
Their relative potency, duration of action and side-effects differ
significantly. All can induce severe ventilatory depression,
nausea and vomiting, dysphoria and itching. Respiratory Complications
depression is aggravated by concurrent use of
Good patient selection and careful drug titration minimize the
benzodiazepines. Naloxone (40–200 µg iv) is an effective
following complications:
competitive receptor antagonist, capable of reversing the
effects of opioids. It also has severe side-effects, including ■ Induction of general anaesthesia may lead to airway
pulmonary oedema. obstruction.
■ Respiratory depression results in hypoxia and hypercapnia,
which cause further sedation.
Benzodiazepines
■ Obtunded airway reflexes increase the risk of aspiration of
Benzodiazepines have important properties, inducing
stomach contents, especially during gastroscopy.
anxiolysis, amnesia and drowsiness. They are effective and safe
■ Aspiration may lead to laryngeal spasm or bronchospasm.
and an overdose is rarely fatal. Midazolam has largely replaced
■ Hypotension or dysrythmias.
diazepam; it has a shorter half-life (3 hours), causes less pain
■ Agitation and disinhibition may occur paradoxically
on injection and is more effective. The most serious side-effect
following sedation, but may be related to hypoxia or
is respiratory depression, which is more pronounced in the
hypercarbia.
elderly. In an emergency, a competitive antagonist, flumazenil,
is available to reverse the effects of benzodiazepines.
Flumazenil is safe in a dose of 0.5–1 mg, but has a much
shorter half-life than any of the benzodiazepines.
Recovery and discharge
Propofol is a general anaesthetic, used for sedation in sub Monitoring, particularly pulse oximetry, should be continued
anaesthetic doses. It is as effective as midazolam but causes and vital signs recorded regularly until the patient is fully alert
less amnesia. An advantage over the benzodiazepines is rapid and orientated. If naloxone or flumazenil were given,
recovery. Its effects can be titrated making it suitable for monitoring must be continued for at least 2 hours.
patient controlled sedation. In day-case surgery, the patient should be discharged into
the care of a responsible adult written instructions with.
Patients must not drive or operate heavy machinery until the
following day.
Routes of administration
■ Oral and rectal routes – slow onset of action and
unpredictable absorption. Clinical case 19
■ Inhalation – used in dentistry. A 42-year-old man requires an investigative bronchoscopy and biopsy.
■ Oral and nasal transmucosal – fentanyl lollipops, useful in He is a smoker and has a body mass of 130 kg.
children. See comment on page 123–124.
■ Intramuscular – useful when veins are difficult and rapid
onset is needed.
■ Intravenous – rapid onset and good titration, as a bolus or Sedation
as an infusion. Continuos infusion allows good
■ The use of sedation for surgical procedures is on the increase.
intraoperative sedation and is the choice for both
midazolam and propofol. ■ Effective and safe sedation is best provided by a trained anaesthetist.
■ Suitable patient selection is important.
Patient-controlled sedation (PCS) ■ Monitoring vital signs and oxygenation are essential and resuscitation
The patient may decide how much sedation is required, within equipment must be available.
certain limits (Fig. 3). The system is similar to patient controlled ■ Short-acting agents given by infusion are preferable.
analgesia (PCA). The operator gives the first bolus and then the
■ A responsible adult should supervise patients for 24 hours.
patient uses the system to maintain sedation. Propofol, with or
without remifentanil, is a good choice for PCS.
46 SEDATION, SURGERY AND ANAESTHESIA

The stress response and nutritional therapy

The stress response evolved as an adaptation to tissue injury,
burns, fractures and severe infection. It is characterized by
The body’s response to surgery
neuroendocrine responses, activation of the sympathetic Pain, nausea, ileus, vomiting, fatigue, sleep disturbances,
nervous system and of the coagulation–fibrinolytic network hypoxia, hypothermia, pyrexia, anxiety, muscle wasting and
(see Fig. 1). There is an acute-phase response involving immunosuppression are all features of the stress response to
cytokines and other inflammatory mediators. When an animal surgery. Acute-phase proteins such as C-reactive protein are
is injured and is threatened by acute blood loss, the released from the liver and fever often results.
physiological manifestations of the stress response increase There are various immunological changes associated with
the chance of survival, however, in the context of surgery surgery. Macrophage and neutrophil activation is increased,
where we inflict injury as part of an intended therapeutic whereas T cell-dependent antibody response and interferon-γ
intervention, certain aspects of the stress response may be production is decreased. There is increased secretion of ACTH
deleterious. and leukocytosis may be present. Blood transfusion enhances
postoperative immunosuppression.
Hypoxia results in decreased oxygen delivery to injured
tissues and wound healing is impaired. The pain that follows
Sympathetic activation surgical procedures may magnify the stress response causing a
Sympathetic nervous system activation leads to increased delay in restoration of function. The magnitude of the surgical
oxygen requirements and may cause hypertension and stress response is related to the severity of surgical trauma.
myocardial ischaemia. The hormones released include
cortisol, epinephrine (adrenaline), thyroid hormone, glucagon,
and growth hormone, all of which increase blood glucose Decreasing the stress response
concentrations and induce catabolism. There is a concomitant
If the stress response indeed represents physiological
decrease in anabolic hormones such as insulin, erthyropoietin
adaptation to injury, it is debatable whether we should
and testosterone. Increased secretion of antidiuretic hormone
attempt to attenuate it. Nonetheless, there is evidence that
leads to fluid retention and may result in hyponatraemia.
blocking some of the manifestations through targeted
interventions may improve outcome. Intravenous atenolol, for
example, given at the time of surgery and continued for a
Activation of coagulation week, has been shown to decrease the incidence of coronary
events for those at risk for up to 2 years after surgery.
The hypercoagulable state predisposes patients to venous Multimodal analgesia improves pain relief and may abort
thromboses, which are important causes of hospital morbidity the development of chronic pain syndromes.
and mortality. Inflammatory mediators and cytokines cause Those who have postoperative hyperglycaemia may benefit
pain and may precipitate hyperalgesia leading to chronic pain from insulin, glucose and early feeding, thus interrupting the
states. catabolic cascade. Thrombosis prophylaxis, such as low-
molecular-weight heparin and elastic stockings, should be
considered for all having major surgery. Stress potentiating
factors (Table 1) may be avoided in an attempt to dampen the
Hypo- CNS stress response.
Outputs Inputs
thalamus Neuraxial (epidural and spinal) anaesthesia with local
Increased H Visual, anaesthetics almost completely abolishes the early
sympathetic auditory,
manifestations of the stress response to surgery below the
outflow tactile
pathways umbilicus. Neuraxial blocks decrease both intraoperative
Increased bleeding and postoperative thromboses. They are associated
glucocorticoid
secretion with less sympathetic activation and may prevent pain.
Epidural anaesthesia, initiated before surgery and
Increased maintained for 48 hours post-surgery, prevents the decrease in
metabolic Neural
rate
protein synthesis and the increase in protein degradation that
pathway
is typically seen with surgical stress.
Increased Humoral
N2 loss pathway Table 1 Factors potentiating the stress response
Decrease in Anxiety and fear
body weight Injury Pain
Handling of viscera
Tissue injury
Blood loss and absorption of haematoma
Dehydration and starvation
Hypothermia
Hypxoxia and hypercarbia
Bacteraemia and release of bacterial toxins
Anaphylactic and anaphylactoid reactions
Fig. 1 The stress response.
 The stress response 47

High-dose opioids may blunt the stress response, but do not

prevent it. Minimally invasive surgical procedures, such as the
use of laparascopic techniques, may modify the surgical stress
response. There is a subsequent reduction in protein
catabolism, inflammatory mediators, pulmonary dysfunction
and convalescence.
Prevention of intraoperative heat loss decreases the stress
response, the wound infection rate and possibly even
cardiovascular complications. Cytokine antagonists, free
radical scavengers, glucocortcoids and other
anti-inflammatory agents have been suggested as potential
modifiers of the stress response. Neostigmine has recently
been shown to be useful for the treatment of postoperative
pseudo-obstruction and ileus.
It is extremely difficult to achieve stress-free anaesthesia and
surgery. Yet, in striving to do so, we may hope to decrease an
assortment of postoperative complications. Minimally invasive
surgery may constitute an important step in this direction.

Starvation and catabolism

Fig. 2 Patient with a nasogastric tube.
In the surgical patient, the stress response coupled with the
decreased intake of food leads to considerable weight loss. The
patient may lose up to 30 g of nitrogen per day. In simple enteral feeding despite gastric stasis. Long-term (> 6 weeks) tube
starvation (non-surgical), blood glucose concentration falls, feeding usually requires placement of a gastrostomy or
and the patient only loses about 5–10 g of nitrogen a day. jejunostomy tube. Commonly the tube is placed endoscopically
While providing nutrition may reverse simple starvation, the (percutaneous endoscopic gastrostomy, PEG). Feeding
catabolism following surgery may be refractory to attempts at schedules can be intermittent or continuous. During and for 2
maintaining energy intake. hours after bolus intermittent feeds, the patient’s upper body
Maintaining a normal food intake preoperatively and should be elevated. Complications of enteral feeding include
providing early postoperative nutrition improves wound tube misplacement, erosive tissue damage from the tube, tube
healing and reduces catabolism considerably. occlusion, pulmonary aspiration of feeds, and diarrhoea.

Oral dietary supplements Total parenteral nutrition (TPN)

Whenever possible, oral or enteral feeding should be The intestinal tract cannot be used in patients with persistent
instituted. If the patient is able to eat, then diet can be nausea and vomiting, intolerable postprandial abdominal pain
supplemented with defined liquid formulae. Milk based or diarrhoea, mechanical obstruction, severe hypomotility,
formulae are more palatable, but are not suitable for patients malabsorbtion or high output fistulae. In general, TPN should
with lactose intolerance. Milk free formulae can be elemental be considered when energy intake has been or is anticipated to
(free amino acids), semi-elemental (small peptides) and be inadequate (<50% of daily requirement) for more than 7
polymeric (whole protein). Lactose free polymeric formulae days and enteral feeding is not possible. TPN is administered
(Ensure®, Osmolite®) are commonly used and are iso-osmolar through a central venous catheter. Peripherally inserted central
drinks containing 1 kcal/ml as 16% protein, 55% carbohydrate catheters (PICC) can also be used. Macronutrient solutions
and 30% fat. containing crystalloid amino acid solutions, glucose and lipid
emulsion are infused at a rate of approximately 0.05g/Kg/hour.
Enteral feeding The complications of TPN are reduced with careful
Enteral feeding is used when the patient cannot or will not management and close supervision. Typical problems include
ingest adequate nutrients. Short term (< 6 weeks anticipated) pneumothorax and carotid artery puncture during line
tube feeding can be achieved by placement of a soft, small bore placement, fluid overload, refractory hyperglycaemia,
nasogastric or nasojejunal feeding tube (Fig. 2). Agents to electrolyte derangement, hypertriglyceridaemia, pulmonary
improve gastric motility, such as metoclopromide and embolism and thrombosis, catheter related sepsis and
erythromycin, may be administered. A postpyloric tube allows deranged liver function.

Clinical case 20
A 66-year-old man has returned to the ward following a laparatomy for The stress response
bowel cancer. He complains of pain (despite regular morphine ■ Certain aspects of the body’s response to injury or the stress
injections), feeling bloated and nausea. Tympanic temperature is response may be deleterious following surgery.
34.7°C, blood glucose is 14 mmol/l and urine output is 20 ml/hour. His ■ Epidural analgesia decreases the stress response to surgical
abdomen is distended and there are no bowel sounds. What measures procedures below the umbilicus.
might be taken to decrease morbidity and the risk of postoperative ■ Minimally invasive surgery represents an important advance.
complications?
■ Early enteral feeding is beneficial following surgery.
See comment on page 124.
48 SEDATION, SURGERY AND ANAESTHESIA

Antibiotic prophylaxis
The risk of developing a surgical site (Fig. 2). The presence of a foreign body such as in colonic or vaginal surgery, or
infection (SSI) appears to be a balance (such as sutures) reduces the inoculum where there is insertion of an artificial
between patient-related factors, required to induce SSI from 106–102 device, for example, a hip prosthesis or
microbial factors and wound-related organisms. heart valve.
factors (Fig. 1).

Wound-related factors Spectrum of antibiotics

Patient-related factors
Devitalized tissue, dead space, and
Chronic illness, extremes of age or Broadly speaking, infections associated
haematoma formation are factors
immunocompromise including diabetes with clean surgery are caused by
associated with the development of SSI.
mellitus and corticosteroid therapy are Staphylococcal species and infections of
Historically, wounds have been
associated with an increased risk of contaminated suregry are
described as clean, contaminated and
developing SSI. The American Society polymicrobial in origin and comprise
dirty according to the expected number
of Anesthesiologists (page 7) score of 3 the flora of the viscus entered (e.g.
of bacteria entering the surgical site
or more, indicative of a patient in poor Esherichia. coli and B. fragilis in colonic
(Table 1).
medical condition, when combined with surgery). The antibacterial spectrum,
the type and duration of surgery has low incidence of side-effects and
been shown to be predictive of the rate tolerability of cephalosporins have
made them the ideal choice for
of SSI. Prophylactic
prophylaxis (Table 2).
antimicrobials The increasing prevalence of both
The administration of antimicrobial methicillin-resistant Staphylococcus
Microbial factors prophylaxis for surgery has been shown aureus (MRSA), against which
Enzyme production (Staphylococcus to decrease greatly the incidence of cephalosporins are ineffective and
aureus), possession of polysaccharide postoperative infection, particularly Clostridium difficile-associated
capsule (Bacteroides fragilis) and the where the inoculum of bacteria is high, diarrhoea, a disorder associated with
ability to bind to fibronectin in blood
clots (S. aureus and Staphylococcus
epidermidis) are mechanisms by which Table 1 Classification criteria of operative wounds according to level of
microrganisms exploit weakened host bacterial contamination
defences and initiate infection. Biofilm Classification Description Typical infection
formation, exemplified by criteria rates (%)
S. epidermidis, is particularly important Clean wound Non-traumatic, not inflamed, hollow viscus 1–3
in the aetiology of prosthetic material not entered
infections e.g. prosthetic joint infection Clean–contaminated Non-traumatic, entry of hollow viscus or 8–10
wound mucous membrane surface with minimal
spillage of contents
Contaminated Fresh traumatic wound, entry of hollow viscus 15–20
wound with spillage, especially colon
Operative site contaminated by infected bile or
urine, acute inflammation present
Dirty wound Old traumatic wound with devitalized tissue, 25–40
presence of foreign body, faecal contamination
or existing infection

Patient factors Wound factors

• How susceptible? • How dirty?

Surgical site
infection

Microbial factors
• How canny?

Fig. 1 Factors predisposing to surgical Fig. 2 Surgical site infection associated with recent implantation
site infection. of a prosthetic hip.
 Antibiotic prophylaxis 49

Table 2 Antibiotic prophylaxis regimens for common surgical procedures (NB policy Infective endocarditis
may vary according to the local situation) prophylaxis
System Surgery Antibiotic regime Certain surgical procedures (Table 3) are
Gastrointestinal Upper bowel and biliary Cefuroxime 750 mg iv associated with bacteraemia, which puts
Large bowel and appendix Cefuroxime 750 mg + metronidazole 500 mg iv patients with certain cardiac
ERCP Ciprofloxacin 750 mg po
abnormalities at risk of infective
Orthopaedics Simple open fracture Cefuroxime 750 mg iv
Joint replacement and internal fixations Cefuroxime 750 mg iv, 8-hourly for 24 hours
endocarditis (IE). Antibiotic prophylaxis
Gynaecological Hysterectomy Cefuroxime 750 mg + metronidazole 500 mg iv is indicated in such cases (see Table 4).
Caesarean section Cefuroxime 750 mg iv after the cord is clamped The main cardiac indications are
Urinary tract TURP and cystoscopy Ciprofloxacin 500 mg po rheumatic heart disease, prosthetic
heart valves, congenital heart disease,
mitral valve prolapse with regurgitation,
cephalosporin use, may result in skull fractures with or without CSF a previous episode of IE, and
the substitution of other agents in leakage. Antibiotic use may select hypertrophic obstructive
future. resistant flora. cardiomyopathy. Patients at particularly
high risk are those with a prosthetic
Timing MRSA heart valve or a history of IE.
The ‘decisive period’ is 0–2 hours before During an outbreak or when methicillin- Antibiotic prophylaxis is not indicated
surgery. Three hours after surgical resistant Staphylococcus aureus (MRSA) in patients with coronary artery disease,
incision, prophylaxis is no longer is endemic in the ward, vancomycin or previous bypass surgery or permanent
effective. teicoplanin prophylaxis should be used pacemakers.
in cardiac, vascular and orthopaedic
surgery.
Duration
For most procedures a single dose is Clinical case 21
adequate. Prolonged surgery
A patient who is aged 67 years and has mitral
(> 3 hours) may necessitate a second Table 3 Procedures for which prophylaxis
for endocarditis is recommended stenosis after rheumatic fever as a child is
dose. Prophylaxis should certainly be
undergoing a colonoscopy for chronic
discontinued within 24 hours of the Dental procedures
diarrhoea. Is antibiotic prophylaxis indicated?
procedure. Respiratory procedures
See comment on page 124.
Tonsillectomy
Surgery involving respiratory mucosa
Prosthetic devices
Rigid bronchoscopy
Prophylaxis is given for 24 hours.
Gastrointestinal procedures Antibiotic prophylaxis
Sclerotherapy of varices
■ Antibiotic prophylaxis if given
Dirty surgery Oesophageal dilatation appropriately is very effective.
Antibiotics are given therapeutically ERCP
■ In the pathogenesis of surgical site
as full courses (5–7 days), e.g. bowel Biliary tract surgery
infection (SSI) there is a balance between
perforation, complex open fracture. Surgery involving intestinal mucosa host defences, microbial virulence and
Genitourinary procedures wound factors.
Skull fractures Prostatic surgery
■ Wounds can be prognostically classified
The literature does not support the use Cystoscopy as being clean, clean–contaminated,
of prophylactic antimicrobials in closed Urethral dilatation contaminated or dirty.
■ Timing – the ‘decisive period’ is thought to
be 0–2 hours before surgery.
■ Duration – prophylaxis should be
Table 4 Suggested regimens for the prophylaxis of infective endocarditis (NB policy may
vary according to the local situation) discontinued within 24 hours of the
procedure.
Indication Dosage Timing
Standard general prophylaxis Amoxicillin 3.0 g po 1hour prior to procedure ■ Dirty surgery – antibiotics are given
Amoxicillin 1.5 g po 6 hours after therapeutically as full courses (5–7 days).
Unable to take oral medication Ampicillin 2.0 g iv or im 30 min prior to procedure ■ MRSA – requires the use of
Allergic to penicillin Clindamycin 600 mg po, or cephalexin 2.0 g po, 1h prior to procedure vancomycin/teicoplanin prophylaxis in
or azithromycin or clarithromycin 500 mg po cardiac, vascular and orthopaedic surgery.
Allergic to penicillin, unable Clindamycin, adults 600 mg iv, or cefazolin 30 min prior to procedure ■ Prevention of bacterial endocarditis
to take oral 2.0 g iv or im, or vancomycin 1 g iv should be priority. A risk-assessment
Gastrointestinal or genitourinary Gentamicin 1.5 mg/kg iv or im should be added should be made on each case.
procedures to regimen
50 SEDATION, SURGERY AND ANAESTHESIA

Fluid management
Water is the major constituent of the Table 1 Features of hypervolaemia and hypovolaemia
human body, composing 60–80% of Hypovolaemia Hypervolaemia
total body mass (Fig. 1). Body water is Suggestive Thirst, exercise, oliguria, blood loss, burns, trauma, Intravenous fluid therapy, heart failure,
distributed in three compartments. history diarrhoea and vomiting, diabetes, polyuria, diuretic therapy, kidney failure, liver failure
About 60% of the water is intracellular orthostatic syncope, infection

and 40% is extracellular, of which 75% is Suggestive Dry mucous membranes, sunken eyes, tachycardia, Peripheral oedema, ascites, elevated
clinical signs orthostatic hypotension, pulsus paradoxus, jugular venous pulsation (JVP), basal
interstitial fluid and 25% is intravascular
thready pulse, decreased skin turgor, confusion, lung crackles, confusion, sweating,
(Fig. 2). The blood volume in adults is concentrated urine, decreased body mass, cold increased body mass
usually 5–6 litres. The average person peripheries with poor capillary refill
has minimum obligatory daily fluid Suggestive High urine osmolaliy, low urine output, high plasma urea, Low urine osmolality, high urine output,
losses exceeding a litre and typically investigations no increase in JVP and wedge pressure to fluid challenge, low plasma urea, exaggerated
decreased cardiac output, swings in pressure trace of increase in JVP and wedge pressure
requires a daily fluid intake of about 2.5
pulse oximeter and arterial line, decreased end tidal CO2 to fluid challenge, evidence of
litres. cardiomegaly and pulmonary
There is significant fluid flux in the oedema on CXR, echocardiographic
perioperative period. Patients presenting evidence of increased cardiac filling
for surgery frequently have a fluid Possible Decreased venous return to the heart and hypovolaemic Cardiac failure
deficit, having been nil by mouth for at problems shock
Prerenal failure progressing to established renal failure Cerebral oedema and raised intracranial
least 8 hours. This fluid deprivation is
Vital organ hypoperfusion resulting in ischaemic cerebral, pressure, which may cause
unnecessary as it is both safe and myocardial, renal, and liver injury irreversible brain damage
desirable to have unlimited clear fluids Inadequate tissue oxygenation leading to anaerobic Pulmonary oedema causing
metabolism and lactic acidosis intrapulmonary shunting leading to
hypoxaemia and all its attendant problems
Impaired oxygen delivery at a tissue level

up to 2 hours before elective surgery. During surgery obligatory fluid losses

Some patients are at risk for profound through urine (measured losses),
= 60%
water
40%
other
dehydration, including those who have
lost excessive volume through blood,
sweating and breathing (insensible
losses) continue. Additionally there is
urine, sweat, faeces or vomitus. bleeding and third-space losses
Dehydration may be prevented in these (sequestration of fluid into tissues,
circumstances through early gastrointestinal tract and peritoneal
administration of sufficient and space). Fluid losses are ongoing in the
Fig. 1 Water composition of the human appropriate intravenous fluids. postoperative period. Throughout this
body. time, patients are unable to fulfil their
own fluid requirements and it falls to
medical and nursing staff to provide
adequate resuscitation.
Antidiuretic hormone and
25 25 26.2
mineralocorticoids are released as part of
the stress response to surgery. Urine
output cannot thus be relied upon for
12 12 12.6 evaluation of intravascular volume,
although output persistently less than
5 0.5 ml/kg/hour is worrying. Not
3 3.2
surprisingly, both hypovolaemia and
a
IC IF IV
b
IC IF IV
c
IC IF IV fluid overload are common perioperative
complications necessitating regular
25 25 clinical assessment and accurate
monitoring of fluid balance (Table 1).

13.4
12
Perioperative fluid
5
3.6 requirements
IC IF IV IC IF IV Deficit and maintenance
d e
Maintenance fluid requirements can be
estimated as 1.5 ml/kg/hour or more
Fig. 2 Body fluid distribution. (a) Average 70 kg adult male. (b) Following 2 l acute blood loss.
(c) Replacement of acute blood loss with 5% dextrose. (d) Replacement of acute blood loss with conservatively as 1 ml/kg/hour when
crystalloid. (e) Replacement of acute blood loss with colloid (IC = intracellular fluid, IF = interstitial fluid, fluid restriction is indicated.
IV = intravascular fluid). Maintenance fluids, 5% dextrose being a
 Fluid management 51

typical example, are administered to

replace insensible losses from all three
body compartments. Dextrose solutions
are not good plasma volume expanders
because the dextrose is metabolized and
water distributes freely into all
compartments. Pure water is not
administered via the intravenous route,
as it would flood into red cells and cause
haemolysis.
In addition to obligatory water loss,
there is concomitant electrolyte loss,
particularly sodium, chloride, potassium
and magnesium. For acute deficit and
replacement it is usually necessary to Fig. 4 Which fluid when?
administer fluids containing only sodium
and chloride, as these are the most
abundant extracellular ions. If sodium is Acute fluid loss occurs with Debate rages about the most
not given, life-threatening hyponatraemia haemorrhage, burns, pancreatitis, appropriate fluid in a given setting (Fig. 4).
may result. An adult needs about 9 g of peritonitis, diarrhoea, ileus and losses There is little evidence in the medical
sodium daily. 0.9% saline (normal saline) from the upper gastrointestinal tract. In literature to provide reliable guidance.
contains 0.9 g of sodium chloride per 100 sepsis, profound vasodilation coupled Currently, many doctors choose a
ml of water, or 9 g per litre, enough for with loss of fluid into the interstitium judicious mixture of crystalloids and
daily salt requirements. results in intravascular hypovolaemia. colloids. Starch and gelatine based
Excessive fluid replacement therapy Blood loss should be replaced initially colloids are popular because,
with chloride-containing compounds with a crystalloid solution (balanced salt theoretically, they remain in the plasma
may result in hyperchloraemia and solution) with a volume of three times compartment longer. Albumin has
metabolic acidosis. In order to avoid this the blood loss, as the crystalloid will become less popular owing to cost and
it is sometimes appropriate to use distribute throughout the extracellular evidence suggesting that in certain groups
solutions with lower chloride than space. 2 litres of warmed Ringer-lactate of patients, albumin administration may
sodium concentrations, such a Ringer- is frequently the initial fluid be associated with increased mortality.
Lactate (Hartmann’s solution). resuscitation following major trauma.
Subsequent replacement of blood loss
Replacement may be with a colloid solution, which is
Acute fluid losses deplete plasma temporarily confined to the plasma Clinical case 22
volume more rapidly than other body space (see Fig. 2). A previously healthy 55-year-old man with a
compartments. Replacement should be Crystalloid administration may body mass of 80 kg has undergone major
with fluids which stay in the increase the risks of fluid overload and colonic surgery for cancer. Intraoperative
extracellular space. Balanced salt intersitial oedema (see Fig. 2). Colloids, fluid therapy was appropriate and the
solutions (normal saline, Ringer’s on the other hand, will leak into the haemoglobin was 11 g/dl following surgery.
lactate), colloids and blood products interstitial space within several hours If he is expected to lose 500 ml of blood over
satisfy this requirement. There is no and may cause platelet dysfunction. All the next 24 hours and is unable to take oral
evidence that colloids improve survival patients who receive large amounts of fluids, write an appropriate fluid chart for his
compared with crystalloids following fluids may develop a dilutional needs.
acute losses (see Fig. 3). coagulopathy. See comment on page 124.

Colloids Crystalloids
Fluid management
■ Hypervolaemia and hypovolaemia are
common perioperative problems.
■ Fluid therapy should aim to replace fluid
• Rapid • No proven • Inexpensive • Inappropriate deficit, insensible losses and acute
intravascular benefit over • No hypersensi- fluids: losses.
replacement crytalloids tivity risk • hyponatraemia
■ A pure dextrose solution may be
• Decreased • Platelet • May decrease • metabolic
administered to replace some of the
thrombotic dysfunction bleeding acidosis
insensible water loss, but does not
tendency • Hypersensitivity • Drugs may • Replace
replace electrolytes and is unsuitable for
• Replace reactions be added blood 3:1
acute losses.
blood 1:1 • Expensive • Possible hyper-
coagulability ■ Dangerous hyponatraemia may result if
dextrose solutions are administered
Pros Cons Pros Cons exclusively.
■ Balanced salt solutions and colloids are
suitable for acute resuscitation.
Fig. 3 The pros and cons of colloids and crystalloids.
52 SEDATION, SURGERY AND ANAESTHESIA

Blood products
Life is unsustainable without the dropped below 30%, the ‘10/30 rule’. provide energy for the cells and render
constant flow of blood. Every minute the Blind adherence to this rule resulted in them viable for up to 35 days if stored at
total blood volume circulates countless unnecessary blood 4–6°C. Phosphate is added in an attempt
throughout the body. Nutrients, transfusions with the attendant to preserve 2,3 DPG levels in stored red
hormones and drugs are delivered in the complications and costs. cells. Depletion of 2,3 DPG reduces
blood to the various organ systems, and No single laboratory value should be offloading of oxygen from haemoglobin
waste products are collected and used as a trigger, rather several factors by shifting the oxyhaemoglobin
couriered to the lungs, kidneys and liver should be considered. These include age, dissociation curve to the left. Citrate is
for disposal. Haemoglobin is a underlying medical conditions, type and an anticoagulant, which is rapidly
specialized molecule in red blood cells, time-course of the anaemia, amount of metabolized by the liver following
whose designated task is the efficient anticipated blood loss and the presence transfusion.
carriage of oxygen. When the body is of lactic acidosis or hypoxaemia. Even Platelets are stored at 22°C only for 5
threatened by infection, white cells, for critically ill patients, evidence days because of the risk of bacterial
macrophages, cytokines, complement, suggests that transfusion may be contamination. Plasma separated from
killer cells and immunoglobulins meet withheld if the haemoglobin exceeds whole blood may be rapidly frozen and
the onslaught. Platelets and clotting 8 g/dl. Treatment with haematinics or stored at –30°C. Thawing FFP at 4°C and
factors are adapted to plug breeches and recombinant erythropoietin increases then refreezing to –30°C yields
promote coagulation, thereby preventing haemoglobin concentration and may cryoprecipitate. Blood products in the
exsanguination following injury. subvert the need for transfusion. UK are leukocyte-depleted to reduce the
Fresh frozen plasma (FFP) is occurrence of febrile non-haemolytic
frequently transfused inappropriately, reactions, as well as possibly reducing
with many doctors administering the transmission of prion disease,
Transfusion plasma whenever there is significant variant – Creutzveldt–Jacob.
Healthy volunteers donate whole blood, blood loss. In reality, only a fraction of
which is fractionated into packed (red normal clotting factor concentration is
blood) cells, plasma, cryoprecipitate and needed for adequate coagulation. FFP is
indicated only if clotting tests confirm a
Pretransfusion tests
platelets (see Table 1). These components
may be life-saving when infused into the coagulopathy. Empirical transfusion Before transfusion, a sample of the
bloodstream of recipients who have may be warranted if there has been patient’s blood must be collected and
inadequate haemoglobin levels, impaired massive blood loss (more than twice the the blood group determined. The ABO
platelet function or clotting disorders. blood volume) with inadequate and Rhesus groups are of major clinical
Immunoglobins and specific clotting haemostasis. significance, since antibodies to donor
factors are also obtained from donor Platelet transfusion is usually red cells can cause fatal transfusion
blood. indicated if the platelet count is less than reactions.
50 × 109/L at the time of major surgery The patient’s blood is tested for red
Changes in transfusion practice or if there is documented platelet cell antibodies and is mixed with the
The term ‘transfusion trigger’ is used to dysfunction. Aspirin therapy is not an donor red cells (cross-match) to ensure
denote the circumstances when indication for platelet transfusion. The compatibility. The bedside check of
transfusion would be reasonable. For effects on operative bleeding of newer patient identity against the blood units
many years it was advocated that anti-platelet drugs, like clopidogrel, is vital to prevent fatal errors (Fig. 1).
surgical patients should receive a blood ticlopidine and abciximab, are not well Two health professionals, both of whom
transfusion if the haemoglobin fell established. Thrombocytopenia and
below 10 g/dl or if the haematocrit impaired platelet function are more
common than clotting factor deficiencies
following major trauma and surgery.
Table 1 Blood components and their uses.
Component Uses
Whole blood Acute, large-volume bleed
Exchange transfusion Collection and storage
Packed red Symptomatic anaemia
cells Major acute blood loss Blood products are screened for
Platelets Thromboctyopenia with bleeding antibodies to Hepatitis B and C viruses,
Massive transfusion with dilutional human immunodeficiency virus and
coagulopathy and active bleeding
syphilis. • Name
Platelet dysfunction (congenital or
acquired) with bleeding
Red blood cells are stored in bags • Date of birth
containing additives and anticoagulant. • Hospital number
Fresh frozen Emergency correction of acquired
• Blood group
plasma and inherited coagulation defects Typical additive solutions are SAG-M
• Pack number
Massive blood transfusion with bleeding (sodium chloride, adenine, glucose and • Expiry of unit
Emergency reversal of warfarin therapy mannitol) with citrate and CPD-A • Date blood required
Liver failure with bleeding
(citrate, phosphate, dextrose, adenine). Fig. 1Crucial items to check prior to
Cryoprecipitate Low fibrinogen levels
The sugar, phosphate and adenine administering blood.
 Blood products 53

Table 2 Complications of blood transfusion

Acute complications Cause Comments
Haemolytic transfusion reaction (mismatch) ABO incompatibility Usually due to clerical and administrative errors
10% mortality
Febrile non-haemolytic reaction Antileukocyte antibodies Decreased with leukocyte-depleted blood
Urticaria Antibodies to infused plasma proteins
Anaphylaxis As for urticaria
Transfusion-related acute lung injury (TRALI) Donor plasma has antibodies to patient’s leukocytes May be fatal
Occurs with massive transfusion
Dilutional coagulopathy Massive transfusion
Septic shock Bacterial contamination of blood products
Congestive cardiac failure Volume overload
Hypothermia Warm blood if large volume transfused
Hyperkalaemia Usually transient
Hypocalcaemia Usually transient
Citrate toxicity Massive transfusion Treat with iv calcium chloride
Delayed complications
Delayed haemolytic transfusion reaction Antibodies to donor red cell antigens which are not detected
in the cross- match
Graft versus host disease Donor T cell response against immunodeficient recipient Often fatal
Immunosuppression Related to white cell exposure Cancer recurrence and postoperative infection
Viral infection Failure to detect virus in donor blood Risk depends on virus:
HIV < 1 in 3 × 106; HBV/HCV < 1 in 200 000
Iron overload Multiple transfusions

sign that they have checked the blood of blood transfusion. However donation lost. Collected blood, rich in cells and
before transfusion, must perform the prior to surgery is generally not clotting factors, is transfused following
check. In emergencies when there is considered cost-effective. Acute surgery. Intraoperative blood salvage
insufficient time to wait for cross- normovolaemic haemodilution entails systems have been developed, which
matched blood, group O removal of blood at the start of surgery allow collection and re-infusion of blood
Rhesus-negative blood may be given. and simultaneous replacement with during surgery. Red cell substitutes offer
Specific compatibility is not necessary crystalloid or colloid. This lowers an alternative to blood transfusion, but
for plasma, which is pooled from haematocrit so that fewer red cells are are currently expensive and of limited
multiple donors, or platelets, which may efficacy.
be pooled or from a single donor.

Clinical case 23
Complications of
A patient receiving a blood transfusion on the
transfusions ward develops pyrexia of 38.3°C and the
The complications of red cell heart rate increases to 110 beats/min. The
transfusions are shown in Table 2. The patient complains of sweating and mild
major risk with plasma and platelets is itching. What should be done?
infection. Following a platelet See comment on page 124.
transfusion, patients develop antibodies
to platelet antigens. There is a high risk
of thrombocytopenia with a subsequent
platelet transfusion. If a high volume is Blood products
transfused there is a danger of
■ Whole blood is rarely required.
hypothermia unless the blood is
■ Packed red cell transfusion is seldom
warmed (Fig. 2).
indicated when the haemoglobin exceeds
8 g/dl.
■ There are numerous complications
associated with blood transfusion.
Alternatives to
■ Two health professionals should check
homologous transfusion blood before it is administered.
Fig. 2 Patients during and after surgery
Autologous blood transfusion involves may receive massive transfusions of ■ Empirical transfusion of platelets and FFP
the use of the patient’s own blood, blood and blood products with all their should be avoided.
thereby avoiding several of the hazards attendant complications.
54 SEDATION, SURGERY AND ANAESTHESIA

Oximetry and capnography

The pulse oximeter provides a
continuous, non-invasive, indirect in vivo
(1) 660 nm
measurement of the proportion of
oxyhaemoglobin to total haemoglobin
in arterial blood. It estimates the (2) 940 nm
oxygenation of arterial blood, thus PE1 PE2
replacing invasive measurements of
PaO2 in samples of arterial blood. The
pulse oximeter has become F (3) Ambient light
indispensable for monitoring patients 1 2 3
receiving sedation or anaesthesia and for
those in the intensive care unit.
PD
Pulse oximetry was developed To computer
following a chance observation in 1971
that arterial pulsations (observed in two Fig. 2 Diagram of the pulse oximeter. F = finger, PE = light-emitting diodes,
signals received from an ear oximeter PD = photodiode. The output of the detector responds in sequence to the two light-emitting diodes and
transmitting light at 805 and 900 nm) to ambient light.
showed a change in relative amplitude
during breath-holding. It took another Pulse oximetry pressure wave and on the proportion of
15 years to develop a device for clinical Pulse oximeters use beams at 660 and oxyhaemoglobin. A decrease in
use and for its acceptance in routine 940 nm. A finger probe (see Fig. 1) oxyhaemoglobin leads to a decrease in
clinical monitoring. contains two light-emitting diodes on amplitude of the pulsatile signal picked
Pulse oximeters display functional one side of the finger and a single up from the 940 nm diode and an
saturation in %, which represents the photodiode on the other, to pick up the increase in that from the 660 nm
proportion of oxyhaemoglobin in the radiation transmitted through the tissue. diode.
sum of oxy- and reduced haemoglobin Each diode emits short pulses of light Pulse oximeters have an integral
according to the equation and the frequency of switching between computer which first calculates the
100 × HbO2 the two wavelengths is very rapid ratios between the pulsatile and steady
Sat (%) = (> 400 Hz). Between the light pulses components of the signals at 660 and
(HbO2 + Hb-red)
there is a short interval without 940 nm, and then the ratio between
emission when the detector picks up these two ratios is calculated. The final
ambient light in order to subtract this reading in % results from a complex
Oximetry calculation following an algorithm
signal (see Fig. 2).
At 660 nm (red) and 940 nm (infra-red) The pattern of the signal in a finger derived from simultaneous
light absorption coefficients are different probe is in Fig. 3. There are two measurements made in a bench
for haemoglobin and oxyhaemoglobin components of the signal: a steady oximeter during hypoxic experiments in
allowing the measurement of the component arising from the non- volunteers. All pulse oximeters are
relative amounts of the two states. Two vascular parts of the tissue, the venous calibrated at the factory empirically.
additional beams of different blood and non-pulsatile arterial blood, Accuracy varies from instrument to
wavelengths are needed to measure and a pulsatile component, typically 2% instrument and values of less than 60%
methaemoglobin or carboxy- of the steady one, arising from the are unreliable.
haemoglobin. Standard bench oximeters alternating filling and emptying of the Several factors can cause false
measure absorption at 4 or more arterioles with each cardiac pulsation. Its readings or prevent pulse oximeters
wavelengths. amplitude depends on the arterial from functioning:

AC component (2%)
Non-pulsatile arc
Venous blood

DC
component
Tissue (98%)
absorption

Time

Fig. 3 Simplified trace of the reconstituted signal picked up

Fig. 1 Pulse oximeter finger probe in situ perioperatively. by the photodiode of a pulse oximeter at one wavelength.
 Oximetry and capnography 55

■ Methaemoglobinaemia and or sharp changes in metabolic rate available with a miniaturized sensor
carboxyhaemoglobin cause over- (e.g. malignant hyperthermia). placed directly on the breathing system
estimation errors. Fetal Hb and ■ Variations in the shape of the (mainstream), avoiding some problems
hyperbilirubinaemia do not interfere capnograph waveform indicate of the sidestream sampling. This sensor,
with readings. changes in dead space (e.g. in however, is vulnerable to physical
■ Artefact – poor peripheral perfusion pulmonary gas embolism) or damage and is very expensive.
(hypovolaemia, hypothermia, left maldistribution of ventilation (e.g. in
ventricular failure or compression of bronchospasm).
supplying arteries by BP cuff) results The most commonly used capnograph
Clinical case 24
in a poor pulsatile signal and uses the infra-red light absorption A patient admitted to the intensive care unit,
unreliable or unobtainable reading. property of CO2 to measure its with a provisional diagnosis of an overdose
■ Artefact – movement of the probe or concentration. The main components of including an opiate drug, has been urgently
of the limb where the probe is applied air (nitrogen and oxygen) do not absorb intubated and placed on a mechanical
may cause erroneous readings, infra-red light. Gases and vapours used ventilator following a period of deterioration
especially if the movement is in anaesthesia (nitrous oxide, isoflurane) of efforts to breathe spontaneously. Despite
rhythmic. absorb infra-red light with a normal ventilator settings for the patient’s
Most pulse oximeters alert the user to a characteristic spectrum, different from size and absence of physical signs and
poor signal, meaning that the pulsatile that of CO2. The gas sample passes history of lung pathology, the readings
fraction of the light received is less than through a chamber crossed by an infra- obtained from the pulse oximeter show a
0.5% of total light; the machine alerts red beam directed at an infra-red saturation of 81% with a clear, good
the user to the unreliability of the detector in the opposite side. The larger amplitude pulsation. The capnograph trace
reading. the content of CO2 in the sample, the shows a slow rise in CO2 concentration
lesser is the energy of the beam reaching during expiration, never reaching a plateau.
the detector. Available instruments, There are no leaks or obstructions in the
measuring CO2, N2O and a volatile breathing system linking the patient to the
Capnography
anaesthetic, are provided with three ventilator, inspired oxygen concentration is
Capnography is the measurement of infra-red beams, at different 60% and the chest wall moves with each
carbon dioxide (CO2) in respiratory wavelengths, chosen to coincide with the ventilation cycle.
gases (see Fig. 4). It is a very useful highest peaks of the infra-red absorption See comment on page 124.
monitor for patients under anaesthesia spectrum of each gas.
and for those in intensive care units for Most clinical capnographs
the following reasons: (sidestream) contain a suction pump Oximetry and capnography
■ It indicates if the lungs are being pulling a small amount (50–200 ml/min)
■ Pulse oximetry and capnography have
ventilated (can be linked to an alarm). of gas from the patient’s airway via a become indispensable monitoring devices
■ It excludes oesophageal placement of long sampling tube (Fig. 5), into the in the settings of anaesthesia and
a tracheal tube. analysing cell within the apparatus, thus intensive care.
■ End-tidal CO2 can be used as a guide introducing a delay in the reading ■ Both techniques are non-invasive.
to adjust mechanical ventilation. (0.1–0.3 seconds) due to the travelling ■ Pulse oximetry indicates oxygenation of
■ Short-term variations in end-tidal CO2 time between the point of sampling and arterial blood and capnography indicates
indicate variations in cardiac output the sensor. Instruments are also adequacy of ventilation.
■ Data provided by these instruments is
susceptible to artifacts.
■ Knowledge of the operating principles of
pulse oximetry and capnography is
desirable for appropriate interpretation of
the readings.

(a)

Fig. 4 (a) Monitor showing

oximeter and capnograph
traces. (b) Portable
combination pulse oximeter
(b) and capnograph. Fig. 5 Sampling tube of a ‘sidestream’ capnograph.
56 SEDATION, SURGERY AND ANAESTHESIA

Postoperative recovery
At the end of a surgical procedure,
irrespective of whether it was carried out
under regional or general anaesthesia,
patients can have an unstable
cardiovascular system. In addition, those
who have had a general anaesthetic may
still be unconscious and unable to
protect or maintain their airway. Clearly,
it would be unacceptable to return such
patients directly to a general ward.

Fig. 1 One-to-one
attention of staff is
vital in the recovery
The recovery room
room.
For the post-anaesthetic patient, the
recovery room bridges the period supervision of the sort provided in the
leading to the return of consciousness, recovery room. This may be because of
Core functions of the
full return of protective airway reflexes continuing cardiovascular instability, the recovery room
and resumption of spontaneous need for respiratory support and In many ways, comparison can be made
respiration and cardiovascular stability monitoring, increased risk of bleeding between the situation of the post-
(depending upon the type of anaesthetic or problems related to an underlying anaesthetic patient and that of an
and surgery). In addition to supervising medical condition. These patients may individual requiring resuscitation. A
the return of normal physiological be admitted directly to a high- direct analogy exists between the
function (See ‘Core functions’, below), dependency unit (HDU – sometimes principles of recovery room care and
recovery room staff ensure that the referred to as a progressive care unit, those of basic life-support. Hence, on
patient is not bleeding, nauseous or PCU) or to an intensive care unit, until arrival, the post-anaesthetic patient is
hypothermic, has adequate pain relief the required degree of physiological checked for:
and has been prescribed appropriate stability has been achieved.
analgesia and intravenous fluids prior to The recovery room provides, on a one- Airway integrity and patency
return to the ward (Table 1). Depending to-one basis (Fig. 1), staff skilled in Unless the patient arrives in the recovery
upon local guidelines, and the type and airway management and basic life- room fully conscious, the anaesthetist
nature of the anaesthesia and surgery, support. Recovery staff will closely will often have left an airway device,
patients will remain in the recovery supervise the post-anaesthetic patient such as a Guedel airway, laryngeal mask
room for between 30 minutes and 1 until consciousness has returned. or endotracheal tube, in place. The
hour. Thereafter, the patient will be regularly recovery room nurse must check that
In some situations, particularly after monitored until discharge criteria (Table the airway is patent and be ready to
major surgery, some patients may 2) have been satisfied and the patient is suction secretions or vomit.
require an extended period of close able to return to the ward.
Breathing
The patient should be breathing
spontaneously, and there should be no
evidence of airway obstruction. An
oxygen mask should be applied and the
patient attached to a pulse oximeter to
Table 1 Extended functions and observations of the recovery room.
check oxygen saturation. Extending the
Additional function Observation Comment
patient’s neck or repositioning the
Nausea Patients vomits or complains of If not already administered, anti-emetic may be needed
nausea Aspirate from nasogastric tube if present airway may be helpful in treating minor
Pain Pain score high or verbal complaint Administer prescribed analgesia/start regime after degrees of airway obstruction. If airway
of pain checking previous administration obstruction persists, an anaesthetist
If shivering, see below should be called.
Hypothermia Patient shivering, complains of cold Apply warm air blower or reflective ‘space’ blanket Many anaesthetics involve the use of
Rectal temperature decreased Shivering can occur after GA when normothermic.
muscle relaxant drugs and patients may
Shivering increases oxygen requirements
be unable to breathe adequately if these
Hyperthermia Patient may feel hot, may be Measure temperature
sweating or have a tachycardia May indicate transfusion reaction, sepsis or drugs have not been fully reversed.
malignant hyperpyrexia Simple clinical tests such as coughing,
Summon help head-raising and hand-squeezing may
Postoperative drugs Absent or unused drug chart Adequate and appropriate analgesia should have reveal whether there is residual muscle
been prescribed to avoid delays in administration
weakness. If residual weakness is
Postoperative fluids Sufficient fluids to cover the first 24 hours
suspected, it should be reported to the
postoperatively
anaesthetist and treated urgently.
 Postoperative recovery 57

Circulation Table 2 Recovery room discharge criteria

Pulse and blood pressure should now be Parameter Value Comment
checked. Tachycardia and hypotension Level of consciousness Awake or immediately Patient must have recovered from the anaesthetic and has not
may mean that the patient is awakens to command been over-sedated by the postoperative analgesia

hypovolaemic and requires transfusion. Airway No obstruction Patient must be able to maintain and protect airway from
Can cough effectively secretions and vomit
The patient should remain under one-
and swallow secretions
to-one supervision until consciousness is Breathing Respiratory rate > 10 Adequate rate and depth of respiration necessary
regained and he or she is able to Patient should have oxygen saturations > 95% in room air
maintain their airway. Circulation Mean arterial pressure Patient should have warm, well-perfused peripheries, with no
> 65 mmHg peripheral cyanosis
There should be no evidence of bleeding or hypovolaemia
Dressings and drains should be checked

Extended functions of the Temperature 36.5–37.5°C Shivering can cause wound pain
Wet or soiled linen and bedclothes should be changed
recovery room Pain Little or no discomfort Patients should be comfortable, able to sleep or rest, but not
In addition to supervising safe return to over-sedated
Nausea No nausea See section on nausea and vomiting
consciousness, recovery staff ensure that
the patient is not nauseated or in pain,
and initiate appropriate treatment where
necessary. Postoperative regimes for
infusion of analgesic drugs via the In order to fulfil their responsibilities, recovery room staff require full, modern
epidural, intravenous or subcutaneous monitoring equipment of the highest standard, piped oxygen supplies and effective
routes may be started. The extended suction units. Oxygen masks, airways and other anaesthetic equipment should be
functions of the recovery room staff are readily to hand (see Fig. 2).
summarised in Table 1.
Discharge criteria
Before post-anaesthetic patients can safely return to the ward, they should satisfy a
number of criteria (Table 2). The criteria listed are suggestions only and may vary
Basic requirements between units and in certain clinical circumstances.
Staffing and equipment
Recovery room staff should be highly
skilled in the care of post-anaesthetic
patients. They should be able to
recognize and initiate basic treatment Clinical case 25
for all the problems alluded to above, A 37-year-old female patient has returned to the recovery room
both rapidly and effectively. There following laparoscopic surgery. She has a laryngeal mask airway and
should be an effective call system to her breathing is shallow at a rate of 26 per minute. Despite
allow skilled help to be summoned supplementary oxygen, peripheral saturation is only 94%. Her hands
quickly. Staff should undergo regular and feet are warm and appear over-perfused, but her tympanic
periods of skills retraining and re- temperature is 35.5°C. She is unresponsive and fine twitching
education. movements are observed in the upper limbs, shoulders and facial
muscles.
See comment on page 124.

Postoperative recovery
■ The recovery room is a transition point between the operating theatre
and the general ward.
■ There is a dedicated nurse for every patient in the recovery room.
■ Vital signs and levels of consciousness are closely monitored.
■ Supplementary oxygen is provided to all patients.
■ Resuscitation equipment is available and staff trained in emergency
management are present.
■ Patients must meet certain criteria, including adequate analgesia,
Fig. 2 Essential equipment includes oxygen masks, airways and before being discharged to the ward.
other anaesthetic equipment.
58 SEDATION, SURGERY AND ANAESTHESIA

Practical procedures

Many practical procedures other than the surgery itself are

required during the perioperative period, ranging from
straightforward to more complex procedures. Adequate training
and supervision are essential when learning a new procedure.

Peripheral venous access

Securing intravenous access for administration of fluids, drugs
and blood products is essential. Likelihood of maintaining a
clean site (see Fig. 1), ease of access, patient comfort, and
avoidance of veins crossing joints are important
considerations in choosing a site. Topical local anaesthetic
preparations such as Amethocaine or EMLA® are useful in
needle-phobic patients.
Fig. 1 One consequence of not maintaining a clean injection site:
phlebitis.
Technique
Choose suitable vein and apply tourniquet proximally. Clean
skin with alcohol swab. Infiltrate skin overlying vein with local
anaesthetic. Hold skin taut, and insert cannula with needle
through skin. (Fig. 2) Advance cannula and needle into vein
until flashback obtained. Smoothly advance cannula over
needle into vein. Withdraw needle and secure cannula with
clean and transparent dressing. Always check patency/position
with saline flush before giving drugs or starting infusion.

Central venous access

If it proves impossible to gain peripheral access, central venous
cannulation may be necessary (Fig. 3). Central lines are also
needed for administration of certain drugs. Central venous
pressure monitoring provides a useful guide to intravenous Fig. 2 Insertion of cannula. Note proximal tourniquet.
fluid therapy. Attempted insertion of central venous lines
carries the risk of significant complications, including
pneumothorax, arrhythmias, air embolism, arterial puncture, guidewire. Check venous blood can be aspirated from each
infection and failure to cannulate the vein. Experienced help lumen. Secure and flush with heparinized saline. CXR – rule out
and supervision should be sought. pneumothorax and check cannula position.
The internal jugular vein can usually be felt or balloted, and
Care of central venous cannulae
pressure may be applied if bleeding occurs. A high approach
Minimal handling of the line and observance of asepsis when
carries a low risk of pneumothorax. Subclavian vein
administering drugs and fluids reduce the likelihood of
cannulation carries a greater risk of pneumothorax, and
infection. Evidence of local or systemic sepsis for which there
accidental arterial puncture may be difficult to recognize and
is no other identifiable source necessitates line removal (see
manage. The femoral vein may be useful, especially if upper
page 73). Parenteral nutrition and blood products should
body injuries are present, although it is difficult to maintain
ideally have a dedicated line. If a vasoactive drug such as
sterility. The basilic vein may be cannulated with a long line.
dopamine has been infused via the cannula, care must be
This procedure requires a cooperative patient and a full
taken when administering other drugs or fluids as a bolus.
explanation should be given. A trained assistant must be
available to help (Table 1). See also page 72.
Table 1 Equipment needed for central line insertion
Insertion of internal jugular line cannula using ■ Tilting bed.

Seldinger technique ■ ECG monitor.

Position patient with neck extended, head-down tilt. Clean skin ■ Sterile dressing pack.

with alcohol-based antiseptic. Drape area identified. Infiltrate ■ Sterile gown, gloves and drapes.

skin and subcutaneously with lignocaine 1%. Flush cannula with ■ Alcohol based skin preparation.
■ Lignocaine 1%.
saline. Insert needle at midpoint of line adjoining sternal notch
■ Suitable cannula (single or multi lumen).
and mastoid process, lateral to carotid artery. Advance needle in
■ Non-absorbable suture.
horizontal plane, towards ipsilateral nipple, aspirating
■ Sterile transparent dressing.
continuously. Once venous blood easily aspirated, remove
■ Heparinized saline flush.
syringe. Gently feed guide wire through needle, watching ECG.
■ Pressure monitoring system.
Stop if any resistance. Remove needle and insert dilator over
■ CXR facility
wire. Remove dilator and insert cannula over wire. Remove
 Practical procedures 59

(a) (b)
Fig. 3 Central venous cannulation. (a) Insertion of cannula. (b) Cannula in situ.

To prevent a bolus of a potent drug, a volume of 10 ml should be necessary to retract the foreskin. Aim to keep one hand
be aspirated from the line and discarded. clean throughout the procedure to use for catheter insertion.
Removal of a central venous line carries the risk of air Insert lignocaine gel into the urethral opening and wait for it
embolus. Head-down positioning while withdrawing the to take effect. Remove the tip of the catheter wrapping, and
catheter reduces this risk, and a sterile occlusive dressing should gradually insert the catheter into the urethra directly from the
be applied to the puncture site. Bleeding may be a problem on wrapper in order to minimize handling.
removal, so efforts to correct any coagulopathy are worthwhile. In females the urethra is short and the procedure should be
straightforward. In males insertion may be tricky, but elevation
of the shaft of the penis may help to straighten out the urethra
Arterial blood sampling (see Fig. 4). Stop if resistance is felt or the procedure is painful.
Arterial samples may be required to check adequacy of Once the catheter is inserted fully inflate the balloon with 10 ml
ventilation and severity of metabolic derangement. Possible sterile water. Stop if this causes pain as the balloon may still be
sites include the radial (ideally non-dominant hand), brachial, in the urethra. Replace the foreskin if it is retracted.
dorsalis pedis and femoral arteries. When using the radial site Urine should flow as soon as the catheter is in the bladder, but
check for collateral flow in the ulnar artery. sometimes the outlet becomes blocked with gel. Gentle
suprapubic pressure, aspiration or flushing should solve the
Technique problem.
Clean the skin overlying the artery with an alcohol swab, and
infiltrate with local anaesthetic. Advance the needle through
Bladder
the skin into the artery proximally at a 30° angle. Aspirate the
Urinary
arterial sample into a heparinized syringe and analyse
infection
immediately or store on ice and transfer to the laboratory.
Prostatic
Apply firm pressure to the puncture site for 5 minutes to trauma
prevent haematoma formation. Prostate
Symphysis
pubis
Nasogastric tube insertion
Urethra
Decompression of the stomach is commonly required after
abdominal surgery and trauma. Nasogastric tubes may be Urethral
used for feeding purposes. Orogastric tubes should be used if stricture
basal skull fracture is suspected. Urethral
trauma
Technique Blocked
Ensure the patient is in a comfortable sitting position. catheter
(e.g. by
Estimate the length of tubing required to reach the stomach
blood clot)
(usually 35–40 cm). Take a tube and lubricate with lignocaine
gel before inserting it gently into the nostril. Advance the tube Fig. 4 Male bladder catheterization route and potential pitfalls.
along the floor of the nose. Once in the nasopharynx, ask the
patient to swallow and continue advancing. Check that gastric Practical procedures
contents can be aspirated and auscultate over the stomach for
■ Always explain procedures to awake patients.
a gurgle on injection of air. Secure firmly in place and check
the position of the tip of the tube on X-ray. ■ Maintain aseptic technique.
■ Use local anaesthetic/analgesia as required.
■ Only carry out procedure for which you have received adequate
Bladder catheterization training
Open a sterile catheterization pack. Don sterile gloves and ■ Seek help if the procedure proves difficult.
clean exposed genital area thoroughly. In male patients it may