Administration of Anaesthesia Presenter: Dr S Spijkerman Slides: Prof EE Oosthuizen SBAH & UP

TYPES OF ANAESTHESIA General Anaesthetic Regional Anaesthetic Unconscious Regional Anaesthetic Awake / Sedated Combined General - Regional Conscious sedation New name: Procedural sedation

PHASES OF A GENERAL ANAESTHETIC Pre-op evaluation and medication Preparation of equipment and drugs Intravenous access Induction of unconsciousness Management of the airway Maintenance of Anaesthesia Wake-up and reversal of muscle relaxation (NDMR) Observation and support in PACU

Start to plan the Anaesthetic when you do the preoperative assessment of the patient!

Factors that influence the choice of Anaesthetic Physiological status of the patient (physiological reserves) Anatomical abnormalities Pathology necessitating surgery Nature of the procedure Duration of the procedure Current medication

Factors that influence the choice of Anaesthetic (contd) Availability of equipment and drugs Skills and experience of the anaesthetist Preferences of the patient

Factors that influence the choice of Anaesthetic (contd) CONCLUSION: Every Anaeshetic must be tailor-made for the individual patient and the specific surgical procedure!

Preparation for Theatre Signed (informed) consent Mass (kg) Empty bladder “Nil per os” Preoperative medication Chronic medication Dentures / artificial limbs, eyes Jewels

Preparation for Theatre(cont’d) All make-up removed Appropriate theatre attire Identity and allergy tags Vital signs recorded

CONSENT Voluntarily Not retrospectively Informed Permission only includes permissible risks

Induction of Unconsciousness Surgical team must be on hospital premises Preflight checklist of equipment and drugs Emergency drugs and equipment Meticulous identification of drugs Positioning on the table Monitors connected Patent, running intravenous line Vitals recorded before take-off Proper intravenous access Routes of induction: IV / Inhalation / IM / Rectal

AIRWAY Maintenance of the Airway Facemask & oropharyngeal airway Endotracheal intubation LMA

Indications for Intubation Protection of the airway Maintenance of the airway Controlled ventilation (relaxants) Surgery on head and neck (access) Longer procedures (>30 minutes) Babies & small children

Intubation technique Opening of the mouth Laryngoscope in left hand Tongue to the left Slide blade over the tongue Deeper & shallower to find epiglottis Lift, not hinge Tip of McIntosh  vallecula Tip of Miller posterior to epiglottis

Popular Laryngoscope Blades Macintosh Miller

Correct placement of Endotracheal Tube? See tube passing through cords Auscultate See bilateral chest movement Press on chest and listen Oximetry (late sign) Capnography High index of suspicion

Complications of Intubation Sore throat Incorrect placement Trauma Regurgitation / Aspiration Bronchospasm “Stress response”

Rapid Sequence Induction To be performed on all patients with a risk for aspiration: Not fasted Delayed stomach emptying Regurgitation (hiatus hernia)

RSI Check all equipment before take-off, then: 1. Preoxygenate for 3 minutes 2. Induction with rapid acting agent 3. Cricoid pressure (Sellick’s maneuver) 4. Suxamethonium 5. Intubate & inflate cuff 6. Confirm correct placement of tube 7. Release cricoid pressure

PREOXYGENATION 100% Oxygen Tight fitting mask 3-5 minutes OR 3-5 Vital Capacity Breaths with 100% O2

Traditional Components of a Balanced General Anaesthetic HYPNOSIS ANALGESIA MUSCLE RELAXATION (not essential)

Duty of Anaesthetist during an Anaesthetic Oxygenation status Awareness Maintain correct plane of Anaesthesia Haemodynamic / respiratory monitoring & manipulation Positioning Ensure well-being of the patient perioperatively Create optimal surgical conditions Postoperative pain management

Duty of Anaesthetist during an Anaesthetic Anaesthetist / Anaesthesiologist is the perioperative physician!

Inadequate Anaesthesia Tachycardia / Dysrhythmias Hypertension Sweating / Salivation / Tears Movement if not relaxed Dilation of pupils Increased breathing efforts if not paralysed

Signs of an Overdose of Anaesthesia Hypotension without other cause Bradycardia Respiratory depression / apnoea in spontaneously breathing patients

Intraoperative Monitoring Monitor changes in physiology Senses are the most valuable monitors! Anaesthetist must be able to integrate all the parameters and respond accordingly Meticulous record keeping

Record Keeping Good record keeping ensures an easy defence! If it wasn’t recorded, it wasn’t done!