Anaesthesia in the presence of some surgical and medical con

• Anaesthesia in the presence of some surgical and medical conditions
• Surgical procedures and administration of anaesthesia

  • Associated with a complex stress response and risks
  • Stress response is proportional to the magnitude of injury, total operating time, amount of intraoperative blood loss and degree of postoperative pain
  • Adverse metabolic and hemodynamic effects of this stress response can present many problems in the perioperative period
  • Problems are worsened in the presence of certain surgical approaches and medical conditions
  • Decreasing the stress response to surgery and trauma is the key factor in improving outcome
• Classification of surgery based on purpose

  • Minor
  • Intermediate
  • Major
• Classification of surgery based on urgency

  • Emergency
  • Urgent
  • Scheduled
  • Elective
• Surgical conditions classified by speciality

  • Neurosurgery
  • Cardiothoracic
  • ENT
  • Orthopaedics
  • General surgery
• Examples of surgery grades

  • Minor: Excising skin lesion, Draining breast abscess
  • Intermediate: Primary repair of inguinal hernia, Excising varicose veins in the leg, Tonsillectomy or adenotonsillectomy, Knee arthroscopy
  • Major: Total abdominal hysterectomy, Radical neck dissection, Endoscopic resection of prostate, Colonic resection, Lumbar discectomy, Lung operations, Thyroidectomy, Total joint replacement
• Anaesthesia for surgical emergencies

  • Risks are accentuated
  • Anaesthetic care could be modified by the extent of the pathology and/or concurrent medical problems
  • Special concerns include: Full stomach, Limited time for patient's preparation, Hypovolaemia, Need for resuscitation, Deranged investigation results, Co-existing medical conditions, Pain
• Surgical emergencies frequently encountered

  • Acute abdomen
  • Intestinal obstruction
  • Perforated viscous
  • Appendicitis
  • Polytraumatized patients
  • Penetrating eye injury
  • Antepartum haemorrhages
• Anaesthesia for emergency surgical procedures

  1. Preoperative assessment

  2. Intraoperative management

  3. Post operative care
• Preoperative assessment for emergency surgery

  • All patients must be assessed preoperatively by the anaesthetist
  • Physical examination should determine risk of regurgitation/aspiration and ease of tracheal intubation
  • Laboratory investigation should contribute to patient management
• Intraoperative management for emergency surgery

  • Resuscitation of the patient prior to induction of anaesthesia is important
  • Anaesthetic care must be individualized
  • Antacid prophylaxis to reduce risk of regurgitation/aspiration
  • General anaesthesia is more often employed due to urgency
• Anaesthesia for intestinal obstruction


  • Dilemma between surgeon's desire to operate and anaesthetist's concerns with fluid and electrolyte balance
  • Correction of fluid and electrolyte is vital
  • Institutional problems may lead to delay in electrolyte correction
  • Fluid therapy is best conducted with balanced salt solutions
  • Haemodynamic variables should be within normal limits prior to induction of general anaesthesia
• Anaesthesia for penetrating eye injury

  • Often presents as full stomach
  • Dilemma between need for rapid sequence induction with suxamethonium and prevention of raised intraocular pressure
  • Increased intraocular pressure could lead to vitreous loss and blindness
  • Delay of surgery may facilitate gastric emptying and minimize aspiration risk
  • Rocuronium at high doses suggested as substitute for suxamethonium
• Anaesthesia for antepartum haemorrhage

  • Anaesthetic concerns include difficult airway, consideration of mother and baby, adequate intravenous access, ready availability of cross-matched blood
  • Significant blood loss associated with placenta praevia, accreta, abruptio and uterine rupture
  • Regional anaesthesia for caesarean section is associated with reduced blood loss and decreased blood transfusion
  • Use of regional anaesthesia in a bleeding patient and risk of morbidly adherent placenta is contentious
  • Presence of placenta accreta indicates extensive surgery and increased risk of blood transfusion
• Medical conditions relevant to anaesthesia and surgery

  • Respiratory: Acute upper respiratory tract infection, asthma, COPD
  • Cardiovascular: HTN, arrythmias, HF & cardiomyopathies, MI, valvular heart dx, congenital heart dx
  • CNS: TBI, stroke, coma
  • Endocrine/nutritional: DM, hyper/hypothyroidism, phaechromocytoma, obesity, malnutrition
  • GIT: Peptic ulcer dx, peritonitis, oesophageal varices, pancreatitis, liver failure
  • Haematology: Anaemia, sickle cell dx, bleading diasthesis
  • Renal: Acute/chronic kidney injury
  • Pregnancy-related: PIH, preeclampsia / eclampsia, antepartum haemorrhages
  • Infectious: Hepatitis B, C, HIV
  • Immune system dysfunction: Allergic reaction, anaphylaxis, drug allergy
  • Skin and musculoskeletal: Myaesthenia gravis, kyphoscoliosis, dwarfism
  • Cancer: Lung, colorectal, prostatic, breast
  • Psychiatry, substance abuse, and drug overdose: Delerium, depression, mania, schizophrenia, substance abuse, organophosphate poisoning
• Anaesthesia and upper respiratory tract infections (URTI)

  • Patients with clear systemic signs of infection are at considerable risk of perioperative adverse events
  • Patients with URTI for days/weeks in stable/improving condition can be safely managed without postponing surgery
  • Airway hyperreactivity may require 6 weeks or more to abate
  • Economic and practical aspects of cancelling surgery should be considered before postponing
  • Intraoperative management includes adequate hydration, reducing secretions, limiting airway manipulation
  • Use of laryngeal mask airway may be a good alternative to endotracheal intubation
  • Role of prophylactic bronchodilators is not clearly established
  • Reported adverse respiratory events include bronchospasm, laryngospasm, airway obstruction, postintubation croup, desaturation, and atelectasis
  • Intraoperative and immediately postoperative hypoxemia is common and amenable to supplemental oxygen
• Anaesthesia and asthma


  • Requires assessment of disease severity, effectiveness of current management, and potential need for additional therapy
  • Goal is to formulate an anaesthetic plan that prevents or blunts expiratory airflow obstruction
  • Auscultation of chest and pulmonary function tests are important
  • Anti-inflammatory and bronchodilator therapy should be continued until induction
  • Booster dose of corticosteroids may be indicated before major surgery
  • Patients should be free of wheezing and have adequate peak expiratory flow before surgery
  • Regional anaesthesia preferred if surgery amenable
  • During GA, airway reflexes must be suppressed to avoid bronchoconstriction
• Auscultation of the chest


  • To detect wheezing or crepitations is important
• Pulmonary function tests (especially FEV1)


  Performed before and after bronchodilator therapy may be indicated in patients scheduled for major surgery
• FEV1 or forced vital capacity (FVC) reduction


  Less than 70%, as well as an FEV1/FVC ratio that is less than 65% of predicted values, is usually considered a risk factor for perioperative complications
• Anti inflammatory and bronchodilator therapy


  Should be continued until the time of induction of anaesthesia
• Booster dose of corticosteroids


  May be indicated before major surgery if hypothalamic-pituitary-adrenal suppression by drugs used to treat asthma is a possibility
• Patients should be free of wheezing

  Have a peak expiratory flow of more than 80% of predicted or at the level of the patient's personal best value before surgery
• Intraoperative regional anaesthesia


  If surgery amendable to it
• 2 puffs of patient inhaler

  Before anaesthesia
• During induction and maintenance of anaesthesia

  Airway reflexes must be suppressed to avoid broncho- constriction in response to mechanical stimulation of the hyper-reactive airways
• For induction, IV drugs

  Better than IAs, propofol supress airway reflexes better than thiopentone
• Ketamine


  Produces smooth muscle relaxation and contribute to decreased airway resistance, but increases airway secretions
• Halothane and sevoflurane


  Lesser pungency (compared with isoflurane and desflurane) may decrease the likelihood of coughing, which can trigger bronchospasm
• Opioids


  Should be administered to suppress the cough reflex and to achieve deep anaesthesia
• Opioids


  All have some histamine-releasing effects, but fentanyl and analogous agents can be used safely in asthmatic patients
• Insertion of a laryngeal mask airway

  Less likely to result in bronchospasm than insertion of an endotracheal tube
• LMA and other supraglottic airway devices

  May be a better method of airway management in asthmatic patients who are not at risk of aspiration
• Muscle relaxation


  Should be with non depolarizing blocking agent devoid of histamine release
• At the end of surgery, it is prudent to extubate the patient deep


  When anaesthesia is still sufficient to suppress hyperactive airway reflexes
• When it is deemed wise to extubate the trachea fully awake


  Consider suppressing airway reflexes and/or the risk of bronchospasm by administration of intravenous lidocaine or pre-treatment with inhaled bronchodilators
• Postoperative


  Observe for extended period in the PACU
• Avoid morphine and NSAIDS


  For postop pain management
• Supplemental oxygen


  In PACU
• Monitor closely


  For bronchospasm or larngospasm