Day 3

General anesthesia journey
“induction, maintenance, emergence”

Dr. Mohammed Aljahdali
From A - Z
• Pre anesthesia clinic.
• Operating rooms holding area.
• Operating room (Induction of anesthesia).
• Operating room (Maintenance of anesthesia and
monitoring).
• Operating room (Emergence from anesthesia)
• PACU (Post Anesthesia Care unit)
Pre anesthesia clinic
Description Example NCEPOD
CLASSIFICATION OF
Immediate Life/limb/organ saving Rapid bleeding, e.g. trauma,
• Resuscitation occurs aneurysm INTERVENTION
simultaneously with surgery
• Surgery within minutes (NATIONAL
CONFIDENTIAL
Urgent Life/limb/organ threatening Perforated bowel or less
• Surgery within hours urgent bleeding ENQUIRY INTO PATIENT
Early surgery (within a day or Large bowel obstruction,
OUTCOME AND DEATH
Expedited two) closed
long bone fracture
elective Timing to suit patient and Joint replacement,

hospital unobstructed
hernia repair, cataract
The preoperative visit
The preoperative visit of all patients by anesthetist is
an essential requirement for the safe and successful
conduct of anaesthesia
• Main aim is to assess the patient's fitness for

anaesthesia
• The Best to be performed by an anaesthetist
• Preferably the one who is going to administer the
anaesthetic
The Goal of Preoperative visit.
• To educate about anesthesia , perioperative care and pain
management to reduce anxiety.
• To obtain patient's medical history and physical examination .
• To determine which lab test or further medical consultation are
needed .
• To choose care plan guided by patient's choice and risk factors
• Three situations where special arrangements are
usually made
1-Patients with complex medical or surgical problems
• patient is often admitted several days before surgery
• anaesthetist is actively involved in optimising their condition
prior to anaesthesia and surgery
2-Surgical emergencies
only a few hours separates admission and operation in these
patients urgent investigations or treatment
3-Day-case patients
• These are patients who are planned
• Generally ‘fitter’ ASA1 or ASA 2
• Assessment in anesthesia clinic
Pre anesthesia clinic
• Assessment (history taking, physical examination).
• Any investigation required?
• Any consultation required?
• Any optimization needed?
• If the answer is NO, then patient is cleared for surgery.
• Educate your patient about available anesthetic
options for his case.
• make up your final anesthesia plan.
Anaesthetic history and examination
Anaesthetist
Examine each
should take a
patient
full history &
Hospitals
Enquire about inherited or 'family' diseases

PREVIOUS • sickle-cell disease
ANAESTHETICS • porphyria
AND Difficulties with previous anaesthetics
OPERATIONS • nausea
• vomiting
• dreams
• awareness
• postoperative jaundice
Active Cardiac Conditions
Unstable coronary Decompensated Significant Severe valvar

syndromes HF arrhythmias disease
• Unstable or
severe angina
• Recent MI
THE EXAMINATION
THE The airway
EXAMINATION  Try and predict difficult intubation

 Assessment is often made in three stages
1. Observation of the patient's anatomy
• Look for limitation of mouth
opening, receding mandible
position, number and health of
teeth, size of tongue.
• Examine the front of the neck for
soft tissue swellings, deviated
larynx or trachea.
• Check the mobility of the cervical
spine in both flexion and
extension.
WHY WOULD
THIS MAN’S
AIRWAY
BE DIFFICULT
TO MANAGE?
THE
EXAMINATION
2. Simple bedside tests
- Mallampati criteria
- Thyromental distance - < 7 cm suggests
difficult intubation
3. X-rays
- lateral X-ray of the head and neck
- reduced distance between the occiput
and the spinous process of C 1 (< 5 mm)
and an increase in the posterior depth of
the mandible (> 2.5 cm)
Airway Evaluation
• Oropharyngeal visualization
• Mallampati Score
• Sitting position, protrude tongue, don’t say “AHH”
Special Investigations
Baseline investigations
• If no concurrent disease, investigations can be limited as:
Age Sex Investigations

<40 Male Nil
<40 Female Hb
41-60 Male ECG, Blood sugar, creatinine
41-60 Female Hb, ECG, Blood sugar, creatinine
>61 All Hb, ECG, Blood sugar, creatinine
Mortality related to anaesthesia
• Approx 1:26,000 anaesthetics
• One third of deaths are preventable
• Causes in order of frequency
• inadequate patient preparation
• inadequate postoperative management
• wrong choice of anaesthetic technique
• inadequate crisis management
ASA grade Definition Example
I A patient normal healthy
II A patient with mild systemic disease Well-controlled
hypertension, asthma
III A patient with severe systemic disease Controlled CHF, stable
angina
IV A patient with severe systemic disease Unstable
angina,symptomatic COPD,
symptomatic CHF that
is a constant threat to life
ASA grading V A moribund patient who is not expected

sepsis syndrome hemodynamic
Multiorgan failure,
survive without the operation

VI A declared brain-dead patient
whose organs are being
removed for donor purposes
“E” – added to the classifications indicates emergency surgery.
29 years old lady.
Your case…
Booked for
myomectomy for
uterine fibroids.
Operating room
• Holding area:
- Review note from anesthesia clinic.
- Assess the airway by yourself.
- Make sure patient is fasting.

Airway assessment.
Predictors for difficult mask ventilation: Predictors for difficult intubation:
• Age > 55years. • History of difficult intubation.
• BMI > 26.
• Lack of teeth. • Higher Mallampati class.
• Presence of beard. • Thyromental distance < 6cm.
• History of snoring.
• Mouth opening < 3cm.
• Prominent incisors.
• High arched palate.
August 2018 97
98
Fasting
guidelines.
Anesthesia monitoring
Peripheral Nerve Stimulation
Neuromuscular blockade
Bispectral index
• BIS value 65 advocated a measure of sedation

• BIS value 40 recommended for general anesthesia
Post anesthesia care unit
“pacu”
Aldrete Score
Score Activity Respiration Circulation Consciousness Oxygen

Saturation
Breaths BP + 20 mm
Moves all deeply and of Fully awake Spo2 > 92%
2 extremities coughs preanesth.
on room air
level
freely.
Dyspneic, or BP + 20-50
Moves 2 shallow mm of Arousable on Spo2 >90%
1 extremities breathing preanesth. calling With suppl. O2
level
BP + 50
Unable to Apneic mm of Not responding Spo2 <92%
0 move
preanesth.
level
With suppl. O2

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General anesthesia journey

“induction, maintenance, emergence”

elective Timing to suit patient and Joint replacement,

• Main aim is to assess the patient's fitness for

Enquire about inherited or 'family' diseases

AND Difficulties with previous anaesthetics

Unstable coronary Decompensated Significant Severe valvar

EXAMINATION  Try and predict difficult intubation

• If no concurrent disease, investigations can be limited as:

Age Sex Investigations

ASA grading V A moribund patient who is not expected

survive without the operation

- Review note from anesthesia clinic.

- Assess the airway by yourself.

- Make sure patient is fasting.

• BIS value 65 advocated a measure of sedation

Score Activity Respiration Circulation Consciousness Oxygen

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