UNIVERSITY OF BENIN TEACHING HOSPITAL

INSTITUTE OF HEALTH TECHNOLOGY (IHT)

DEPARTMENT OF ANAESTHESIA

SCHOOL OF ANAESTHETIC TECHNICIAN

FINAL YEAR SEMINAR
ON
PREPARATION OF ANAESTHESIA AND SURGERY,
THEATRE PROCEDURES

MAT NO- IHT/ANT/18/2638

NAME- AKUKWATA EWOMAZINO JENNIFER

SEMINAR CO-RDINATOR: DR. MRS OKOJIE

DATE- 1/06/2021

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 OUTLINE
INTRODUCTION
DEFINITIONS
PREOPERATIVE CARE
HISTORY
GENERAL ANAESTHESIA
REGIONAL ANAESTHESIA
TYPES
BASIC PRINCIPLES
STANDARD OF GENERAL ANAESTHESIA
STANDARD OF REGIONAL ANAESTHESIA
THEATRE PROCEDURES
CONCLUSION
REFERENCE

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 INTRODUCTION
PREOPERATIVE CARE
It is the care given before surgery when physical and psychological preparations
are made for the operation, according to the individual needs of the patient.

PREOPERATIVE PREPARATION FOR ANAESTHESIA AND

SURGERY
The following guidelines should be strictly adhered to

1. Documentation of the condition(s) for which surgery is needed.

2. Assessment of the patient’s overall health status.
3. Uncovering of hidden conditions that could cause problems both during and after
surgery.
4. Perioperative risk determination.
5. Optimization of the patient’s medical condition in order to reduce the patient’s
surgical and anesthetic perioperative morbidity or mortality.
6. Development of an appropriate perioperative care plan.
7. Education of the patient about surgery, anesthesia, intraoperative care and
postoperative pain treatments in the hope of reducing anxiety and facilitating
recovery.
8. Reduction of costs, shortening of hospital stay, reduction of cancellations and
increase of patient satisfaction.

GENERAL HEALTH ASSESSMENT

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The History
The history is the most important component of the preoperative evaluation. The
history should include a past and current medical history, a surgical history, a
family history, a social history (use of tobacco, alcohol and illegal drugs), a history
of allergies, current and recent drug therapy, unusual reactions or responses to
drugs and any problems or complications associated with previous anesthetics. A
family history of adverse reactions associated with anesthesia should also be
obtained. In children, the history should also include birth history, focusing on risk
factors such as prematurity at birth, perinatal complications and congenital
chromosomal or anatomic malformations and history of recent infections,
particularly upper and lower respiratory tract infections.

The history should include a complete review of systems to look for undiagnosed
disease or inadequately controlled chronic disease. Diseases of the cardiovascular
and respiratory systems are the most relevant in respect of fitness for anesthesia
and surgery.

Physical examination
The physical examination should build on the information gathered during the
history. At a minimum, a focused preanesthesia physical examination includes an
assessment of the airway, lungs and heart, with documentation of vital signs 6.
Unexpected abnormal findings on the physical examination should be
investigated before elective surgery.

Laboratory work up
It is generally accepted that the clinical history and physical examination
represent the best method of screening for the presence of disease. Routine
laboratory tests in patients who are apparently healthy on clinical examination
and history are not beneficial or cost effective. A clinician should consider the risk-
benefit ratio of any ordered lab test. When studying a healthy population, 5% of
patients will have results which fall outside the normal range. Lab tests should be
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ordered based on information obtained from the history and physical exam, the
age of the patient and the complexity of the surgical procedure .

Drug history
A history of medication use should be obtained in all patients. Especially, the
geriatric population consumes more systemic medications than any other group.
Numerous drug interactions and complications arise in this population and special
attention should be paid to them10.

Generally, administration of most drugs should be continued up to and including

the morning of operation, although some adjustment in dosage may be required
(e.g. antihypertensives, insulin).

Some drugs should be discontinued preoperatively. The monoamine oxidase

inhibitors should be withdrawn 2-3 weeks before surgery because of the risk of
interactions with drugs used during anesthesia. The oral contraceptive pill should
be discontinued at least 6 weeks before elective surgery because of the increased
risk of venous thrombosis.

Recently, the American Society of Anesthesiologists (ASA) examined the use of

herbal supplements and the potentially harmful drug interactions that may occur
with continued use of these products preoperatively11–13. All patients are
requested to discontinue their herbal supplements at least 2 weeks prior to
surgery.

The use of medications that potentiate bleeding needs to be evaluated closely,

with a risk-benefit analysis for each drug and with a recommended time frame for
discontinuation based on drug clearance and half-life characteristics. Aspirin
should be discontinued 7-10 days before surgery to avoid excessive bleeding and
thienopyridines (such as clopidogrel) for 2 weeks before surgery. Selective
cyclooxygenase-2 (COX-2) inhibitors do not potentiate bleeding and may be
continued until surgery. Oral anticoagulants should be stopped 4-5 days prior to
invasive procedures, allowing INR to reach a level of 1.5 prior to surgery .

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Perioperative risk assessment
Perioperative risk is a function of the preoperative medical condition of the
patient, the invasiveness of the surgical procedure and the type of anesthetic
administered.

The ASA grading system was introduced originally as a simple description of the

physical state of a patient. Despite its apparent simplicity, it remains one of the
few prospective descriptions of the patient general health which correlates with
the risk of anesthesia and surgery. It is extremely useful and should applied to all
patients who present for surgery. Increasing physical status is associated with
increasing mortality. Emergency surgery increases risk dramatically, especially in
patients in ASA class 4 and 5.

METHODS OF PREPARATION FOR ANAESTHESIA AND

SURGERY
1. GENERAL ANAESTHESIA
General anaesthesia is a combination of medications that put one in a sleep-like
state before a surgery or other medical procedures or it is a medically induced
coma with loss of protective reflexes, resulting from the administration of one or
more general anaesthetic agents. It is carried out to allow medical procedures
that would otherwise be intolerably painful for the patient; or where the nature
of the procedure itself precludes the patient being awake.
General anaesthesia variety of drugs may be administered, with the overall aim of
ensuring unconsciousness, amnesia, analgesia, loss of reflexes of the autonomic
nervous system, and in some cases paralysis of skeletal muscles. The optimal
combination of drugs for any given patient and procedure is typically selected by
an anaesthetist, or another provider such as an operating department
practitioner, anaesthetist practitioner, physician assistant or nurse

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anaesthetist (depending on local practice), in consultation with the patient and
the surgeon, dentist, or other practitioner performing the operative procedure.

HISTORY OF GENERAL ANAESTHESIA

Attempts at producing a state of general anaesthesia can be traced
throughout recorded history in the writings of the
ancient Sumerians, Babylonians, Assyrians, Egyptians, Greeks, Romans, Indians,
and Chinese. During the Middle Ages, scientists and other scholars made
significant advances in the Eastern world, while their European counterparts also
made important advances.
The Renaissance saw significant advances in anatomy and surgical technique.
However, despite all this progress, surgery remained a treatment of last resort.
Largely because of the associated pain, many patients chose certain death rather
than undergo surgery. Although there has been a great deal of debate as to who
deserves the most credit for the discovery of general anaesthesia, several
scientific discoveries in the late 18th and early 19th centuries were critical to the
eventual introduction and development of modern anaesthetic techniques.
Two enormous leaps occurred in the late 19th century, which together allowed
the transition to modern surgery. An appreciation of the germ theory of disease
led rapidly to the development and application of antiseptic techniques in
surgery. Antisepsis, which soon gave way to asepsis, reduced the
overall morbidity and mortality of surgery to a far more acceptable rate than in
previous eras. Concurrent with these developments were the significant advances
in pharmacology and physiology which led to the development of general
anaesthesia and the control of pain. On 14 November 1804, Hanaoka Seishū, a
Japanese doctor, became the first person to successfully perform surgery using
general anaesthesia.
In the 20th century, the safety and efficacy of general anaesthesia was improved
by the routine use of tracheal intubation and other advanced airway
management techniques. Significant advances in monitoring and new anaesthetic
agents with improved pharmacokinetic and pharmacodynamiccharacteristics also

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 contributed to this trend. Finally, standardized training programs for
anaesthesiologists and nurse anaesthetists emerged during this period.

PREPARATION OF GENERAL ANAESTHESIA

In preparing for general anaesthesia , the Anesthetic technicians prepare
equipment needed for the patient to safely undergo anesthesia. This involves:
 Check age of patient
 Checking and setting up the anesthetic machine, test for leakage in the machine
or faults
 Prepare the breathing circuits- Mapleson A-F and test for leakages.
 The suctioning machine has to be readily made available, tested and trusted
 The multiparameter monitor should be made available , as well as other portable
mobile monitors
 Airway- the airway equipment should be made available as well as equipment for
difficult intubation as –
o Laryngoscope- 0-4 sizes
o endotracheal tube- 2-10.5mm sizes
o gum elastic bougie,
o Stylets
o laryngeal mass airway,
o plaster for stripping tube,
o Intubating face mask.
 Infusions- colloid and cyrstalliods should readily be made available such as-
o normal saline ,
o 5% dextrose saline,
o ringers lactate,
o gelofusine,
o Haemacel
o Blood if needed, etc.
 preparing induction drugs-
o ketamine,
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 o sodium thiopental,
o midazolam, propofol),
 preparing of muscle relaxants drugs-
o Suxamethonium- short acting,
o Atracurium
o , Pancuronium,
o Vecuronium),
 inhalationals preparations –
o halothene-red,
o sevoflurance-yellow,
o desflurance-blue,
o isoflurance-purple),
 preparing analgesia drugs for pain relieve, which includes:
o acetamorphine(paracetamol),
o non-steriodal anti-inflamatory drygs(non-opoiods)- acupan, keterolac,
diclofenac, and
 opoiods ( pethidine, Promethazine, pentazocine, Tramadol, fentanyl, morphine
etc),
 preparing resuscitation drugs- atropine, amiodarone, sodium biocarbonate,
calcium gluconate, dopamine, ephedrins, frusemide, glucose, hydrocortisone,
hysocine,isoprenaline,lidocaine, magnesium sulphate,Naloxone, potassium
chloride, ranitidine, Metoclopramide,adrenaline, non adrenaline, dubtamine etc.
 preparing intravenous therapy administration equipment as –
o syringes,
o cannulas of different sizes,
o tourniquet,
o plaster,
o cotton wool ,
o drip stand, drip given set, blood giving set etc.
 communicating with the patient when they arrive into the operating theatre
 oxygen in pipelines, nitrous oxide should readily be made available

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 Check soda lime granules if expired.
 Assist in establishing peripheral intravenous access.
 Applying anesthetic monitoring to help assess the patients' condition whilst
under anesthesia. This may include electrocardiography (ECG), pressure
and oxygen saturation devices. The monitoring of other parameters such as
anesthesia depth monitors (EEG, bispectral index etc.) may also be necessary.

2. REGIONAL ANAESTHESIA
DEFINITION
This is the use of local anaesthetics to block sensations of pain from a large area
of the body, such as arm or leg or the abdomen.

HISTORY
The first spinal analgesia was administered in 1885 by James Leonard
Corning (1855–1923), a neurologist in New York. He was experimenting
with cocaine on the spinal nerves of a dog when he accidentally pierced the dura
mater.
The first planned spinal anaesthesia for surgery in man was administered
by August Bier (1861–1949) on 16 August 1898, in Kiel, when he injected 3 ml of
0.5% cocaine solution into a 34-year-old labourer. After using it on 6 patients, he
and his assistant each injected cocaine into the other's spine. They recommended
it for surgeries of legs, but gave it up due to the toxicity of cocaine.

TYPES OF REGIONAL ANAESTHESIA

SPINAL ANAESTHESIA
Spinal anaesthesia  also called spinal block, subarachnoid block, intradural
block and intrathecal block, is a form of neuraxial regional anaesthesia involving
the injection of a local anaesthetic or opioid into the subarachnoid space,
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generally through a fine needle, usually 9 cm (3.5 in) long. It is a safe and effective
form of anesthesia performed by nurse anesthetists and anesthesiologists which
can be used as an alternative to general anesthesia commonly in surgeries
involving the lower extremities and surgeries below the umbilicus. The tip of the
spinal needle has a point or small bevel. Spinal anaesthesia is a commonly used
technique, either on its own or in combination with sedation or general
anaesthesia. It is most commonly used for surgeries below the umbilicus,
however recently its uses have extended to some surgeries above the umbilicus
as well as for postoperative analgesia
Recently, pencil point needles have been made available (Whitacre,
Sprotte, Gertie Marx and others).

Backflow of cerebrospinal fluid through a

25 gauge spinal needle after puncture of
the arachnoids mater during initiation of
spinal anaesthesia

EQUIPMENT NEEDED FOR SPINAL ANAESTHESIA

o Spinal Needle
o Two Garlic Pot
o Sponge Holding Forcept
o Sterile Drape Linen
o Two Pairs Of Gauz
o Cleaning lotions

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 DRUG USED FOR SPINAL ANAESTHESIA
o Heavy Macaine
o Lidocaine
2. EPIDURAL ANAESTHESIA

Epidural anesthesia is a technique whereby a local anesthetic drug is injected

through a catheter placed into the epidural space. This technique is similar to
spinal anesthesia as both are neuraxial, and the two techniques may be easily
confused with each other. An epidural delivers drugs outside the dura
(outside CSF), and has its main effect on nerve roots leaving the dura at the level
of the epidural, rather than on the spinal cord itself.
The injected dose for an epidural is larger, being about 10–20 mL compared to
1.5–3.5 mL in a spinal. In an epidural, an indwelling catheter may be placed that
allows for redosing injections,

PREPARATION FOR EPIDURAL REGIONAL ANAESTHESIA

o Epidural needle
o Loss of resistance syringe
o Epidural cathether
o Garlic pot
o Sponge holding forceps
o Sterile drape linen
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 o Cleaning lotions

DRUGS USED FOR EPIDURAL ANAESTHESIA

o Plain macaine
o Lidocaine

NERVE BLOCK
Local anesthetic nerve block is a short-term block, usually lasting hours or days,
involving the injection of an anesthetic, a corticosteroid, and other agents onto or
near a nerve.

PREPARATION FOR NERVE BLOCK

A combination of local anesthetic (such as lidocaine), epinephrine,
a steroid (corticosteroid), and an opioid is often used. Epinephrine
produces constriction of the blood vessels which delays the diffusion of the

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anesthetic. Steroids can help to reduce inflammation. Opioids are painkillers.
These blocks can be either single treatments, multiple injections over a period of
time, or continuous infusions. A continuous peripheral nerve block can be
introduced into a limb undergoing surgery – for example, a femoral nerve block to
prevent pain in knee replacement.

BASIC PRINCIPLE OF GENERAL ANAESTHESIA

General anesthesia (GA) is the state produced when a patient receives medications
to produce amnesia and analgesia with or without reversible muscle paralysis. An
anesthetized patient can be thought of as being in a controlled, reversible state of
unconsciousness. Anesthesia enables a patient to tolerate surgical procedures that
would otherwise inflict unbearable pain, potentiate extreme physiologic
exacerbations, and result in unpleasant memories.
The combination of anesthetic agents used for general anesthesia often leaves a
patient with the following clinical constellation:  
1. Unarousable to painful stimuli
2. Unable to remember what happened (amnesia)
3. Unable to maintain adequate airway protection and/or spontaneous ventilation
as a result of muscle paralysis
4. Cardiovascular changes secondary to stimulant/depressant effects of anesthetic
agents

BASIC PRINCIPLE OF REGIONAL ANAESTHESIA

TOPICAL APPLICATION: There is only one local anesthetic capable of readily
penetrating intact skin; this is the combination of 5% lidocaine and 5% prilocaine
known as EMLA, an acronym for eutectic mixture of local anesthetics. It is a white,
oily cream that is smeared over the target area and then covered with an
occlusive dressing (such as Tegaderm); after 20-40 minutes, profound anesthesia
of the superficial skin layers (to a depth of 5-6 mm) can be anticipated. Although
the technique is useful for procedures such as tattoo removal or laser ablation of
portwine stains, the area of skin treated should probably be modest.

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LOCAL INFILTRATION: Anesthetic solutions such as bupivacaine or lidocaine
are injected into the soft tissues surrounding a wound or surgical site; the
technique is effective, for example, for the excision of small superficial cysts or
lipomas, or for painless suturing of lacerations. It is not useful for large wounds.

INTRAVENOUS ANESTHESIA: The anesthetic solution is injected into a major

vain draining an extremity. Commonly used for short surgical procedures on the
arm; the limb is first squeezed free of blood (elastic bandage, then isolated
(tourniquet) and the anesthetic (almost always lidocaine 0.5%) is injected into a
distal vein. Excellent technique for surgeries such as contracture release or joint
mobilizations.

PERIPHERAL NERVE BLOCK: A major nerve supplying a limb or specific area of

the body is identified (anatomy, paresthesias, nerve stimulator) and a solution of
local anesthetic is injected very close to, but not inside, the nerve yielding a
sensory (and often motor) block dense enough for painless surgery. The block
may last up to 24 hours depending on the amount and type of anesthetic agent
used; or may be prolonged indefinitely by use of a continuous infusion of agent
directed through a fine plastic catheter.

NEURAXIAL BLOCK: A term used to describe epidural and spinal analgesia in

which small amounts of local anesthetic are injected or infused into the epidural
space (yielding a segmental blockade of the nerves supplying a large territory) or
into the subarachnoid space (yielding a spinal blockade of the lower half of the
body).

Although it is completely acceptable for local, intravenous and peripheral blocks

to be administered by non-anesthesiologists, neuraxial blocks must only be placed
by specialists who have undergone intensive training both in the techniques of
block placement and also in resuscitation and airway management.

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STANDARD OF GENERAL AND REGIONAL
ANAESTHESIA(ASA)
These standards apply to all anesthesia care although, in emergency
circumstances, appropriate life support measures take precedence. These
standards may be exceeded at any time based on the judgment of the responsible
anesthesiologist. They are intended to encourage quality patient care, but
observing them cannot guarantee any specific patient outcome. They are subject
to revision from time to time, as warranted by the evolution of technology and
practice. They apply to all general anesthetics, regional anesthetics and
monitored anesthesia care.
1. STANDARD I
Qualified anesthesia personnel shall be present in the room throughout the
conduct of all general anesthetics, regional anesthetics and monitored anesthesia
care.
1.1 Objective –
Because of the rapid changes in patient status during anesthesia, qualified
anesthesia personnel shall be continuously present to monitor the patient and
provide anesthesia care. In the event there is a direct known hazard, e.g.,
radiation, to the anesthesiapersonnel which might require intermittent remote
observation of the patient, some provision for monitoring the patient must be
made. In the event that an emergency requires the temporary absence of the
person primarily responsible for the anesthetic, the best judgment of the
anesthesiologist will be exercised in comparing the emergency with the
anesthetized patient’s condition and in the selection of the person left
responsible for the anesthetic during the temporary absence.
2. STANDARD II
During all anesthetics, the patient’s oxygenation, ventilation, circulation and
temperature shall be continually evaluated.

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2.1 Oxygenation –To ensure adequate oxygen concentration in the inspired gas
and the blood during all anesthetics.
2.2 Methods –Inspired gas: During every administration of general anesthesia
using an anesthesia machine, the concentration of oxygen in the patient
breathing system shall be measured by an oxygen analyzer with a low oxygen
concentration limit alarm in use.
Blood oxygenation: During all anesthetics, a quantitative method of assessing
oxygenation such as pulse oximetry shall be employed. When the pulse oximeter
is utilized, the variable pitch pulse tone and the low threshold alarm shall be
audible to the anesthesiologist or the anesthesia care team personnel. Adequate
illumination and exposure of the patient are necessary to assess color.
3. VENTILATION
3.1 Objective –To ensure adequate ventilation of the patient during all
anesthetics.
3.2 Methods – Every patient receiving general anesthesia shall have the adequacy
of ventilation continually evaluated. Qualitative clinical signs such as chest
excursion, observation of the reservoir breathing bag and auscultation of breath
sounds are useful. Continual monitoring for the presence of expired carbon
dioxide shall be performed unless invalidated by the nature of the patient,
procedure or equipment. Quantitative monitoring of the volume of expired gas is
strongly encouraged.
3.2.2 When an endotracheal tube or laryngeal mask is inserted, its correct
positioning must be verified by clinical assessment and by identification of carbon
dioxide in the expired gas. Continual end-tidal carbon dioxide analysis, in use from
the time of endotracheal tube/laryngeal mask placement, until
extubation/removal or initiating transfer to a postoperative care location, shall be
performed using a quantitative method such as capnography, capnometry or
mass spectroscopy.When capnography or capnometry is utilized, the end tidal
CO2 alarm shall be audible to the anesthesiologist or the anesthesia care team
personnel.

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3.2.3 When ventilation is controlled by a mechanical ventilator, there shall be in
continuous use a device that is capable of detecting disconnection of components
of the breathing system. The device must give an audible signal when its alarm
threshold is exceeded.
3.2.4 During regional anesthesia (with no sedation) or local anesthesia (with no
sedation), the adequacy of ventilation shall be evaluated by continual observation
of qualitative clinical signs. During moderate or deep sedation the adequacy of
ventilation shall be evaluated by continual observation of qualitative clinical signs
and monitoring for the presence of exhaled carbon dioxide unless precluded or
invalidated by the nature of the patient, procedure, or equipment.
4. CIRCULATION
4.1 Objective –To ensure the adequacy of the patient’s circulatory function during
all anesthetics.
4.2 Methods –Every patient receiving anesthesia shall have the electrocardiogram
continuously displayed from the beginning of anesthesia until preparing to leave
the anesthetizing location. Every patient receiving anesthesia shall have arterial
blood pressure and heart rate determined and evaluated at least every five
minutes.Every patient receiving general anesthesia shall have, in addition to the
above, circulatory function continually evaluated by at least one of the following:
palpation of a pulse, auscultation of heart sounds, monitoring of a tracing of intra-
arterial pressure, ultrasound peripheral pulse monitoring, or pulse
plethysmography or oximetry.
5. BODY TEMPERATURE
5.1 Objective –To aid in the maintenance of appropriate body temperature during
all anesthetics.
5.2 Methods –Every patient receiving anesthesia shall have temperature
monitored when clinically significant changes in body temperature are intended,
anticipated or suspected.

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 THEATRE PROCEDURE
1. PREPARATION OF ANAESTHETIC ROOM/THEATRE
 Check the anaesthetic machine
 Ensure theres adequate supply of oxygen
 Prepare and check basic anaesthetic equipment as monitiors, airway
equipments, resuscitation equipment
 Prepare drugs to be used for induction, muscle relaxants, opoiods, saline flush,
antibitotics, volatile gases, emergency and for anaesthesia

2. RECHECK PATIENT CHECKLIST

 Ensure patient signed consent,
 check for allergies and risk of aspiration,
 Swabs and instrument check counts are correct

3. PREPARE ALL ITEMS FOR GENERAL ANAESTHESIA

 Induction, maintance and emergency drugs should be put in place
 Prepare all equipments needed
 Scrub patient- wearpatient gowning, remove jewelries, glasses, wigs
 Wash hands and wear glooves- universal precautions
 Scrub properly- wear hospital gowning

4. RECEIVE PATIENT TO OPERATING ROOM

 Position patient depend on type of anaesthesia to be used
 Attach basic monitor to patient- SPO2, ECG, NIBP
 Check patient vital signs
 Preoxygenate patient
 Induce patient- intravenous (propofol ) or any other
 Perform anaesthetic method either regional, general, local anaesthesia
 Keep constant record of vital signs
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 Begin surgical procedure

CONCLUSION
Anesthesia enables the painless performance of medical procedure that would
otherwise cause severe or intolerable pain to an unanesthetized patient, or would
otherwise be technically unfeasible. Three broad categories of anesthesia exist:

General anesthesia suppresses central nervous system activity and results in

unconsciousness and total lack of sensation

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 Regional and local anesthesia, blocks transmission of nerve impulses from a
specific part of the body. Drugs can be targeted at peripheral nerves to
anesthetize an isolated part of the body only, Alternatively, epidural, spinal
anesthesia, or a combined technique can be performed in the region of the
central nervous system itself, suppressing all incoming sensation from nerves
outside the area of the block.

In preparing for a medical procedure, the clinician chooses one or more drugs to
achieve the types and degree of anesthesia characteristics appropriate for the
type of procedure and the particular patient.

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