General anesthesia

Detail description of GA for postgraduates

1. GENERAL ANESTHESIA PRESENTED BY – DR. SWATI SAHU

2. Defination Introduction History Indications Levels of sedation Goals of sedation Sequence of depression of CNS Stages of anaesthesia Mechanism of action of GA CONTENTS

3. Pre- anesthetic evaluation Pre-operative preparation Anaesthetic Equipments Pharmacology of anaesthetics Muscle relaxants Post operative care Complications of GA. Conclusion CONTENTS

4. DEFINATION

5. INTRODUCTION

6. General anesthetics (GAs) are drugs which causes :  Reversible loss of all sensations and consciousness.  Loss of memory and awareness with insensitivity to painful stimuli, during a surgical procedure. INTRODUCTION Aref l e xia

7. Providing office based sedation, anxiolysis and analgesia to the OMFS patient’s has been standard practice for decades The goal has been to establish an environment in which the patient is comfortable and cooperative and hemodynamically stable. Charles F. Cangemi , Jr , Administration of General Anesthesia for Outpatient Orthognathic Surgical Procedures American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:798-807, 2011 INTRODUCTION

8. The focus has also been on rapid patient recovery with efficient use of time Numerous advancements in pharmacology, equipments and techniques over the years provides the surgeon with various alternatives. Charles F. Cangemi , Jr , Administration of General Anesthesia for Outpatient Orthognathic Surgical Procedures American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:798-807, 2011 INTRODUCTION

9. HISTORY

10. Alcohol is the oldest known sedative. It was used in the ancient Mesopotamia thousands of years ago. 3400 B.C. - The ‘Euphoric’ effect of Opium was discovered by Summerians . Joseph Priestly(1733-1804)- discoverd various gases like- nitrous oxide, ammonia,oxygen . T. Y. Euliano,J . S. Gravenstein , Essential Anesthesia -From Science to Practice:United States of America by Cambridge University Press, New York;2004: Introduction A very short history of anesthesia;p.1-4 HISTORY

11. 1801-Humphry Davy - Anesthetic properties of nitrous oxide. -Coined the term ‘laughing gas ’. 1804- Friedrich Serturner - isolated morphine from opium. Dec 10,1844- Sir Horace Well attended lecture on ‘Chemical Phenomenon’ by Gardner.(nitrous oxide) T. Y. Euliano,J . S. Gravenstein , Essential Anesthesia -From Science to Practice:United States of America by Cambridge University Press, New York;2004: Introduction A very short history of anesthesia;p.1-4 HISTORY

12. Dec 11,1844, Nitrous oxide was administered to Dr. Horace Well, rendering him unconcious & able to have wisdom tooth extracted without awareness of pain. T. Y. Euliano,J . S. Gravenstein , Essential Anesthesia -From Science to Practice:United States of America by Cambridge University Press, New York;2004: Introduction A very short history of anesthesia;p.1-4 HISTORY

13. 16 th oct , 1846, ether was administered by Sir William Morton for the removal of mandibular tumor . Experiment was published in Boston daily journal. And led to the discovery of Surgical anesthesia . HISTORY

14. 1853- Sir John Snow- Chloroform as anesthetic agent. 1913- Sir Chavalier Jack- 1 st to use direct laryngoscopy for tracheal intubation. 1934- Sir Ernest Volwiler . Synthesized 1 st i.v anesthetic agent- Thiopental. 1956- Sir Ivan Whiteside Magill- technique for Nasotracheal intubation. 1967- Sir Peter Murphy, discovered fiberoptic endoscope. T. Y. Euliano,J . S. Gravenstein , Essential Anesthesia -From Science to Practice:United States of America by Cambridge University Press, New York;2004: Introduction A very short history of anesthesia;p.1-4 HISTORY

15. PROPERTIES OF IDEAL ANESTHETICS

16. PROPERTIES OF IDEAL ANESTHETICS For the patient –  Should be pleasant,  Non irritating,  Should not cause nausea or vomiting.  Induction and recovery should be fast with no after effects. For the surgeon –  Should provide adequate analgesia,  Immobility and muscle relaxation .  It should be noninflammable and nonexplosive so that cautery may be used.

17. For the anaesthetist –  Its administration should be easy, controllable and versatile .  Margin of safety should be wide - no fall in BP. Heart, liver and other organs should not be affected.  It should be potent so that low concentrations are needed and oxygenation of the patient does not suffer.  Rapid adjustments in depth of anaesthesia should be possible.  It should be cheap, stable and easily stored.  It should not react with rubber tubing or soda lime.

18. INDICATIONS

19. The surgical procedures of larger magnitude , which cannot be accomplished under local anesthesia or where the regional anesthesia and / or sedation are inadequate to provide satisfactory analgesia. When the patients are uncooperative. When patient compliance is not required . Apprehensive patients where muscle relaxation is required for stabilization. INDICATIONS

20. LEVELS OF SEDATION

21. MINIMAL SEDATION MODERATE SEDATION DEEP SEDATION GENERAL ANESTHESIA Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral Maxillofac Surg 70:e31-e49, 2012, Suppl 3 LEVELS OF SEDATION

22. Minimal Sedation ( Anxiolysis ) A minimally depressed level of consciousness, produced by a pharmacologic method that retains the patients ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command. Ventilatory and cardiovascular fuctions are unaffected. Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral Maxillofac Surg 70:e31-e49, 2012, Suppl 3 LEVELS OF SEDATION

23. Moderate Sedation (conscious sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands,either alone or accompanied by light tactile stimulation.No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.Cardiovascular fuction is usually maintained. Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral Maxillofac Surg 70:e31-e49, 2012, Suppl 3 LEVELS OF SEDATION

24. Deep Sedation A drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulations . T he patient’s ability to independentely maintain ventilatory function may be impaired, and the patient may require assistance in maintaining a patent airway. Cardiovascular function is usually maintained during deep sedation. Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral Maxillofac Surg 70:e31-e49, 2012, Suppl 3 LEVELS OF SEDATION

25. General Anesthesia A drug-induced loss of consciousness- during which patient is not arousable , even by painful stimulation. The ability to maintain ventilatory function is impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of a depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral Maxillofac Surg 70:e31-e49, 2012, Suppl 3 LEVELS OF SEDATION

26. LEVELS OF SEDATION Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76

27. Minimal Sedation ( anxiolysis ) Moderate Sedation/ Analgesia Deep Sedation/ Analgesia General Anesthesia Responsiveness Normal response to speech Purposeful response to speech or touch Purposeful response to repeated or painful stimulation No response, even to pain Airway Unaffected Remains open May need help to maintain airway Often needs help to maintain airway Ventilation Unaffected Adequate May not be adequate Often require ventilatory support Cardiovascular Function Unaffected Usually maintained Usually maintained May be impaired LEVELS OF SEDATION

28. GOALS OF SEDATION

29. Provide an optimal environment for completion of surgical procedure. Minimize patient anxiety and optimize patient comfort. Control patient’s behaviour and movement and optimize patient cooperation. Optimize analgesia and minimize pain. Maximize the potential for amnesia. Optimize patient safety and maintain hemodynamic stability. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 GOALS OF SEDATION

30. CEREBRAL CORTEX CEREBELLUM SPINAL CORD MEDULLARY CENTERS Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 SEQUENCE OF DEPRESSION IN CENTRAL NERVOUS SYSTEM

31. STAGES OF ANESTHESIA

32. Arthur Ernest Guedel (1937) Stage of Analgesia Stage of Delirium Surgical anaesthesia Medullary paralysis Schwartz J.Paul ; Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)   STAGES OF ANESTHESIA

33. STAGE OF ANALGESIA Starts from beginning of anaesthetic inhalation and lasts upto the loss of consciousness Pain is progressively abolished Reflexes and respiration remain normal Use is limited to short procedures STAGES OF ANESTHESIA

34. STAGE OF DELIRIUM From loss of consciousness to beginning of regular respiration Patient may shout, struggle and hold his breath; muscle tone increases, jaws are tightly closed, breathing is jerky; vomiting, involuntary micturition or defecation may occur Heart rate and BP may rise and pupils dilate due to sympathetic stimulation No operative procedure carried out Can be cut short by rapid induction, premedication STAGES OF ANESTHESIA

35. STAGE OF SURGICAL ANESTHESIA Extends from onset of regular respiration to cessation of spontaneous breathing. This has been divided into 4 planes which may be distinguished as: Plane 1 rolling eye balls. This plane ends when eyes become fixed. Plane 2 loss of corneal and laryngeal reflexes. Plane 3 pupil starts dilating and light reflex is lost. Plane 4 Intercostal paralysis, shallow abdominal respiration, dilated pupil. STAGES OF ANESTHESIA

36. MEDULLARY PARALYSIS Cessation of breathing to failure of circulation and death. Pupil is widely dilated, muscles are totally flabby, pulse is thready or imperceptible and BP is very low STAGES OF ANESTHESIA

37. STAGES OF ANESTHESIA

38. MECHANISM OF ACTION

39. Major target - Ligand gated ion channels. GABA A receptor gated Cl ¯ channel . Examples – Many inhalation anesthetics, barbiturates, benzodiazepines and propofol . Hugh C. Hemmings jr et al; emerging molecular mechanisms of General anesthetic action; TRENDS in pharmacological sciences vol.26 no.10 october 2005 MECHANISM OF ACTION Acts by depressing Synaptic transmission

40. Hugh C. Hemmings jr et al; emerging molecular mechanisms of General anesthetic action; TRENDS in pharmacological sciences vol.26 no.10 october 2005 MECHANISM OF ACTION

41. Hugh C. Hemmings jr et al; emerging molecular mechanisms of General anesthetic action; TRENDS in pharmacological sciences vol.26 no.10 october 2005 MECHANISM OF ACTION

42. Other Mechanisms : Glycine – Barbiturates, propofol and others can activate in spinal cord and medulla N – methyl D- aspartate (NMDA) type of glutamate receptors – Gates ca + selective cation channel Nitrous oxide and ketamine selectively inhibits this receptor. Hugh C. Hemmings jr et al; emerging molecular mechanisms of General anesthetic action; TRENDS in pharmacological sciences vol.26 no.10 october 2005 MECHANISM OF ACTION

43. PREANESTHETICEVALUATION

44. The fundamental process of taking detailed history and performing a systematic clinical examination remains the foundation on which preoperative assessment relies, backed up by ordering appropriate investigations where indicated. James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring, Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)   PREANESTHETIC EVALUATION

45. To Confirm that surgery proposed is realistic compared the likely benefit with the possible risks . To obtain pertinent information about the patient’s medical history and physical as well as mental condition. To determine the need for a medical consultation and the kind of investigations required. AIMS James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring, Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)   PREANESTHETIC EVALUATION Use the ASA and GOLDMAN scale for anaesthetic risk.

46. To educate the patient about anaesthesia, anaesthetic technique and post-operative care. To choose the anaesthetic plan to be followed, guided by the risk factors uncovered by the medical history. Prescribe premedication and/ or other specific prophylatic measure if required. To obtain informed consent. PREANESTHETIC EVALUATION

47. Medical history questionnaire Physical examination Lab investigations James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring, Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)   PREANESTHETIC EVALUATION

48. 1. Current problems 2. Other known problems 3. Treatment/medicines for the problems: dose, duration and effectiveness 4. Current drugs use: reason, dose, duration, effectiveness and side effect 5. History of drug allergies 6. History of use of tobacco—smoking or smokeless tobacco or alcohol consumption, frequency, quantity and duration 7. Prior anesthetic exposure: type and any adverse effects. 8. General health and review of organ systems James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring, Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)   MEDICAL HISTORY QUESTIONAIRE

49. Vital Signs Airway Heart Lungs Extremities Neurologic examination James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring, Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)   PHYSICAL EXAMINATION

50. Pulse rate and Blood pressure (BP) should be checked to find out about any irregularity of pulse or whether there is any deviation from the normal values of both. If there is rise in blood pressure from the normal values of 120-140 systolic and 60-80 of diastolic in adult, the patient might need treatment to bring it to normal value and hence should be referred for further evaluation and management to physician. VITAL SIGNS

51. AIRWAY ASSESSMENT

52. Difficult airway defined to be one in- “ Which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of upper airway, difficulty with tracheal intubation, or both.’’ Richard H. Haug , Henry H. Rowshan , Dale A. Baur ; Atlas of the Oral & Maxillofacial Surg Clinics Of North America: Management of Airway,vol 18 No.1, March 2010 AIRWAY

53. i . Patency of nares : look for masses inside nasal cavity (e.g . polyps) deviated nasal septum, etc. ii. Mouth opening of at least 2 large finger breadths between upper and lower incisors in adults is desirable. AIRWAY EVALUATION GENERAL, PHYSICAL AND REGIONAL EXAMINATION

54. iii. Teeth : Prominent upper incisors, or canines with or without overbite, can impose a limitation on alignment of oral or pharyngeal axes during laryngoscopy and especially in association with a large base of tongue, they can compound the difficulty during the direct laryngoscopy or bag-mask ventilation. An edentulous state, on the other hand, can render axis alignment easier but hypopharyngeal obstruction by the tongue can occur.

55. iv. Palate : A high arched palate or a long, narrow mouth may present difficulty. v. Assess patient’s ability to protrude the lower jaw beyond the upper incisors ( Prognathism ). vi. Temporo -mandibular joint movement : It can be restricted ankylosis /fibrosis, tumors , etc.

56. vii. Measurement of submental space ( hyomental / thyromental length should ideally be > 6 cm). viii . Observation of patient’s neck : A short, thick neck is often associated with difficult intubation. Any masses in neck, extension of neck, neck mobility and ability to assume ‘sniffing’ position should be observed. ix. Presence of hoarse voice/stridor or previous tracheostomy may suggest stenosis.

57. x. Any systemic or congenital disease requiring special attention during airway management (e.g. respiratory failure, significant coronary artery disease , acromegaly, etc.). xi. General assessment of body habitus can yield important information . xii. Infections of airway (e.g. epiglottitis, abscess, croup, bronchitis , pneumonia). xiii. Physiologic conditions : Pregnancy and obesity.

58. Mallampati Classification Upper Lip Bite Test Atlanto occipital joint (AO) extension Thyromental Distance Sternomental Distance Mandibulo -hyoid distance Maximum vertical opening (MVO ) LEMON airway assessment method Richard H. Haug , Henry H. Rowshan , Dale A. Baur ; Atlas of the Oral & Maxillofacial Surg Clinics Of North America: Management of Airway,vol 18 No.1, March 2010 AIRWAY EVALUATION

59. UPRIGHT, MAXIMUM JAW OPENING, TONGUE PROTRUSION WITHOUT PHONATION MALLAMPATI TEST

60. https://www.speareducation.com/spear-review/wp-content/uploads/2014/05/Tonsil-Grading-2.png MALLAMPATI CLASSIFICATION Class I : the entire palatal arch,including the bilateral faucial pillars, are visible down to their bases . Class II : the upper part of the faucial pillars and most of the uvula are visible. Class III : only the soft and hard palates are visible. Class IV : only the hard palate is visible.

61.  Class 1: Lower incisors can bite upper lip above vermillion line.  Class 2: Lower incisors can bite upper lip below vermillion line.  Class 3: Lower incisors cannot bite the upper lip ULBT (Upper lip bite test)

62. It assesses feasibility to make sniffing or Magill position for intubation i.e. alignment of oral, pharyngeal and laryngeal axes into an arbitrary straight line. The patient is asked to hold head erect, facing directly to the front , then he is asked to extend the head maximally and the examiner estimates the angle traversed by the occlusal surface of upper teeth. Any reduction in extension is expressed in grades: Grade I : >35° Grade II : 22°-34° Grade III : 12°-21° Grade IV : < 12° Normal angle of extension is 35° or more. Atlanto occipital joint (AO) extension

63. https://i.ytimg.com/vi/blqwvuA7NKw/maxresdefault.jpg THYROMENTAL DISTANCE Upright, neck extension, mouth closed, Distance < 6.5cm difficult intubation The distance between the mentum and the superior thyroid notch . A distance greater than 3 finger breadths is desirable .

64. Richard H. Haug , Henry H. Rowshan , Dale A. Baur ; Atlas of the Oral & Maxillofacial Surg Clinics Of North America: Management of Airway,vol 18 No.1, March 2010 THYROMENTAL DISTANCE

65. http://clinicalgate.com/wp-content/uploads/2015/04/B9780702035258000021_f02-03-9780702035258.jpg STERNOMENTAL DISTANCE Extended head and neck, mouth closed, distance <12.5cm is a difficult intubation

66. Richard H. Haug , Henry H. Rowshan , Dale A. Baur ; Atlas of the Oral & Maxillofacial Surg Clinics Of North America: Management of Airway,vol 18 No.1, March 2010 STERNOMENTAL DISTANCE

67. Measurement of mandibular length from chin (mental) to hyoid should be at least 4 cm or three finger breadths. It was found that laryngoscopy became more difficult as the vertical distance between the mandible and hyoid bone increased . MANDIBULO-HYOID DISTANCE

68. Richard H. Haug , Henry H. Rowshan , Dale A. Baur ; Atlas of the Oral & Maxillofacial Surg Clinics Of North America: Management of Airway,vol 18 No.1, March 2010 Maximum vertical opening (MVO) Generally greater than 2.5 to 3 fingerbreadths (depending on observers fingers) Less than or equal to 2.5 cm is considered a potentially difficult intubation.

69. The score with a maximum of 10 points is calculated by assigning 1 point for each of the following LEMON criteria : L = Look externally (facial trauma, large incisors, beard or moustache, large tongue) E = Evaluate the 3-3-2 rule (incisor distance-3 finger breadths , hyoid-mental distance-3 finger breadths, thyroid-to-mouth distance-2 finger breadths) M = Mallampati (Mallampati score > 3). O = Obstruction (presence of any condition like epiglottitis , peritonsillar abscess, trauma). N = Neck mobility (limited neck mobility) Patients in the difficult intubation group have higher LEMON scores. LEMON airway assessment method LEMON airway assessment method ; 1 = Inter incisor distance in fingers, 2 = Hyoid mental distance in fingers, 3 = Thyroid to floor of mouth in fingers

70. Categories of difficult airway Known or expected difficult airway. Potentially difficult airway. Unexpected difficult airway . James Cphero et al,Adult Airway Evaluation in Oral Surgery, Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)   AIRWAY EVALUATION

71. 1. Known or expected difficult airway H/o difficult/failed intubation H/o difficult/failed mask ventilation. Conditions associated with difficult airway. - Acquired and congenital AIRWAY EVALUATION

72. 2 . Potentially difficult airway Limited neck extention . Limited mouth opening. Receding mandible. Mallampati class III or IV Short thyromental distance James Cphero et al,Adult Airway Evaluation in Oral Surgery, Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)   AIRWAY EVALUATION

73. 3. Unexpected difficult airway Supraglotic mass. Hyperplasia of lingual tonsils. Missed evidence of difficult airway James Cphero et al,Adult Airway Evaluation in Oral Surgery, Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)   AIRWAY EVALUATION

74. CARDIOVASCULAR SYSTEM

75. EXAMINATION OF CVS General Examination (CVS) Examination of the Neck Veins Examination of the Precordium

76. 1)General Examination P allor I cterus C yanosis C lub b ing E dema T emperature P ulse R espiratory Rate B lood Pressure L ymphadenopathy

77. P allor (Anemia) The pallor of anemia is best seen in the mucous membranes of the conjunctivae, lips and tongue and in the nail beds Many causes of anemia can cause sinus tachycardia, heart failure ( Hyperdynamic )

78. C yanosis This is a blue discoloration of the skin and mucous membranes caused by increased concentration of reduced hemoglobin (5g/dl) Central cyanosis may result from the reduced arterial oxygen saturation caused by cardiac or pulmonary disease. Intracardiac or extracardiac shunting. Cardiac causes include pulmonary edema and congenital heart disease. ( e.g. Fallot’s tetralogy ).

79. Peripheral cyanosis may result when cutaneous vasoconstriction slows the blood flow and reduced oxygen level in red blood cells . It is physiological during cold exposure. It also occurs in heart failure, when reduced cardiac output produces reflex cutaneous vasoconstriction.

80. Clubbing is painless soft-tissue swelling of the terminal phalanges. congenital cyanotic heart disease Infective endocarditis C lubb i ng

81. E dema Edema is tissue swelling due to an increase in interstitial fluid Pressure should be applied over a bony prominence (tibia, lateral malleoli, sacrum) Cardinal feature of congestive heart failure. Edema is most prominent around the ankles in the ambulant patient and over the sacrum in the bedridden patient

82. Arterial Pulse Rate (recorded as beats per minute) Rhythm (regular or irregular) Volume Character ( thready , weak, bounding, full) Condition of the vessel wall Equality on both sides

83. B lood P ressure Palpatory Method Auscultator y Metho d Oscillatory Method

84. JUNE 25, 2018 GUIDELINES

85. RESPIRATORY RATE Normal respiratory rate for an adult - 14 to 18 breaths per minute. Bradypnea ( abnormally slow rate) may be produced by, among other causes, opioid administration, T achypnea (abnormally rapid rate ) is seen with fever, fear (hyperventilation), and alkalosis. The most common change in ventilation noted in the dental environment will be hyperventilation, an abnormal increase in the rate and depth of respiration. The most common cause of hyperventilation in dental and surgical settings is extreme psychological stress.

86. TEMPERATURE The “normal” oral temperature of 37.0° C (98.6° F) is only an average. The true range of normal is considered to be from 36.11° C to 37.56 ° C (97° F to 99.6° F). Fever represents an increase in temperature beyond 37.5 ° C (99.6° F). Temperatures in excess of 38.33° C ( 101° F ) usually indicate the presence of an active disease process. Evaluation of the cause of the fever is necessary before treatment. If the patient’s temperature is 40.0° C (104° F) or higher , pretreatment medical consultation is indicated.

87. Body temperature should be maintained at or as near to normal as possible. Certain types of anesthetic agents are more commonly associated with excessive body temperature changes . Low body temperatures , although generally less likely to develop during dental or office-type anesthesia , may cause a delay in drug metabolism and patient recovery . High body temperatures may cause a hypermetabolic state and increase oxygen consumption.

88. Precordium is the area of the chest wall lying in front of the heart . Inspection Palpation Percussion Auscultation The subject should be examined in the recumbent and sitting position, and in good light. EXAMINATION OF THE PRECORDIUM

89. Inspection for Chest wall abnormalities Inspection for Position of trachea Inspection for Apex beat Inspection for Other pulsations Inspection for Dilated and engorged veins Inspection for Surgical or any Scars INSPECTION

90. Chest wall ( Skeletal) abnormalities Precordial Bulging Pectus excavatum (funnel chest) Pectus carinatum (pigeon chest) Kyphosis (forward bending of spine) Scoliosis (sideward bending of spine) may displace the heart and affect palpation and auscultation

91. Apex beat Lowest and the Outermost point of definite cardiac impulse can be palpated.

92. Dilated and engorged veins SVC or IVC obstruction Coarctation of aorta

93. Palpation for Apex Beat (Position and Character) Palpation for Position of trachea Palpation for Parasternal Heave Palpation for Thrills Palpation for Direction of flow in veins Palpation for Tender points PALPATION

94. Auscultation for Heart Sounds First sound (S1) This corresponds to mitral and tricuspid valve closure at the onset of systole. Second sound (S2) This corresponds to aortic and pulmonary valve closure following ventricular ejection. AUSCULTATION

95. Murmurs Heart murmurs are produced by turbulent flow across an abnormal valve, septal defect or outflow obstruction. Timing Duration Character and pitch Intensity Location Radiation

96. RESPIRATORY SYSTEM

97. General Examination (RS) Examination of the Chest EXAMINATION OF THE RESPIRATORY SYSTEM Upper Respiratory Tract Lower Respiratory Tract

98. 1)General Examination P allor I cterus C yanosis C lub b ing E dema T emperature P ulse R espiratory Rate B lood Pressure JVP L ymphadenopathy

99. 2) Examination of the Chest Inspection Palpation Percussion Auscultation The subject should be examined in the Standing or Sitting position in an erect , and in good light.

100. Inspection Inspection for Position of trachea Inspection for Symmetry of Chest Inspection for Chest wall abnormalities Inspection for Movement of the Chest Inspection for Apex beat Inspection for Dilated and engorged veins Inspection for Surgical or any Scars or Sinuses

101. Inspection for Movement of the Chest It is described in terms of rate, rhythm, equality and type . Breathing Rate The normal respiratory rate in relaxed adults is 14-18 breaths per minute The type of breathing in women is thoraco-abdominal and in men is abdomino-thoracic The ratio of pulse rate to respiratory rate is 4 : 1.

102. Palpation Palpation for Apex Beat (Position and Character) Palpation for Position of trachea Palpation for Measurement of the Chest Expansion Palpation for Assessing of Chest Expansion Palpation for Vocal fremitus (VF) Palpation for Direction of flow in veins Palpation for Tender points

103. Tenderness over the Chest Wall It may be due to: Empyema Local inflammation of parietal pleura, soft tissue and osteomyelitis Infiltration with tumor Non-respiratory cause (amoebic liver abscess).

104. Percussion Percussion for the Lung fields

105. Auscultation Auscultation for Breath Sounds Auscultation for Vocal Resonance Listen: anteriorly from above the clavicle down to the sixth rib laterally from the axilla to the eighth rib posteriorly down to the level of the 11 th rib. Assess the quality and amplitude of the breath sounds. Identify any gap between inspiration and expiration, and listen for added sounds.

106. ABNORMAL BREATH SOUNDS Normal, unobstructed airflow is relatively quiet, a smooth “whooshing” sound heard in the earpiece. The presence of this quiet whooshing sound is indicative of a patent airway. Silence in the earpiece, on the other hand, is ominous and must trigger an immediate response. Respiratory obstruction (in the presence of exaggerated ventilatory movements) or respiratory arrest (no chest movements) may have developed and must be corrected immediately, or it may merely be that the stethoscope has become disconnected from the patient. Wheezing indicates partial obstruction in the lower airways (i.e ., bronchioles) and is termed bronchospasm.

107. Snoring or the sound of fluid (a gurgling sound ) indicates the presence of partial obstruction of the upper airway. Snoring most often results when the base of the tongue falls against the posterior wall of the pharynx, whereas the bubbling, gurgling, or crackling sound of fluid indicates the presence of a liquid (i.e., blood, saliva, water, or vomitus ) in the airway.

108. NERVOUS SYSTEM EXAMINATION

109. MENTAL STATE  Appearance and Behavior  Emotional state  Delusions and Hallucination  Orientation in Place and Time  Level Of Consciousness  Intelligence

110. EMOTIONAL STATE Mood : facial expression ( reflective of depression, mania, anxiety, schizophrenia )  Sleep and dreams : insomnia , sleep disturbing dreams

111. ORIENTATION IN PLACE & TIME DISORIENTATION : Organic Brain Disease Schizophrenics Hysterical states

112. LEVEL OF CONSCIOUSNESS  Stupor - Patient shows some response, eg . to painful stimuli  Coma - makes no psychologically meaningful response to external stimulus or to internal need

113. CRANIAL NERVE EXAMINATION

114. medical status mortality ASA I Normal healthy patient without organic, biochemical, or psychiatric disease 0.06-0.08% ASA II Mild systemic disease with no significant impact on daily activity e.g. mild diabetes, controlled hypertension, obesity . Unlikely to have an impact 0.27-0.4% ASA III Severe systemic disease that limits activity e.g. angina, COPD, prior myocardial infarction Probable impact 1.8-4.3% ASA IV An incapacitating disease that is a constant threat to life e.g. CHF, unstable angina, renal failure ,acute MI, respiratory failure requiring mechanical ventilation Major impact 7.8-23% ASA V Moribund patient not expected to survive 24 hours e.g. ruptured aneurysm 9.4-51% ASA VI – A declared brain dead patient whose organs are being removed for donor purposes. (last approved by ASA house of delegates on October 15, 2014)

115. GOLDMAN RISK ASSESMENT SCALE (1977) Factors Value History Age > 70 years (5 point) Myocardial infection with in 6 month (10 points) Cardiac Exam Signs of CHF: ventricular gallop or JVD (11 points) Significant aortic stenosis (3 points) Electrocardiogram Arrhythmia other than sinus or premature atrial contractions (7 points) 5 or more PVC's per minute (7 points) General Medical Conditions PO2 < 60; PCO2 > 50; K < 3; HCO3 < 20; BUN > 50; Creat > 3; elevated SGOT; chronic liver disease; bedridden (3 points) Operation Emergency (4 points) Intraperitoneal, intrathoracic or aortic (3 points) 0-5 Points: Class I 1% Complications 6-12 Points: Class II 7% Complications 13-25 Points: Class III 14% Complications 26-53 Points: Class IV 78% Complications

116. A chest x-ray, electrocardiogram and blood chemistry (glucose, blood urea nitrogen and electrolytes) are indicated in patient with symptoms or signs of pulmonary or cardiac disease or a history of diabetes, hepatic or renal disease. Patients with a history of a bleeding disorder should have tests for estimation of bleeding time, prothrombin time and partial thromboplastin time . LABORATORY INVESTIGATIONS

117. PREOPERATIVE PREPERATION

118. INCLUDES- Patient’s counselling or psychological preparation Premedication Preoperative instructions - Fasting instructions - current or pre-existing drug therapy. PREOPERATIVE PREPERATION

119. Patient’s counselling or psychological preparation Anticipated surgical events, risks and limitations, benefits and alternatives of anaesthetic procedure should be discussed with the patient and his relatives. PREOPERATIVE PREPERATION

120. Written, informed, valid consent for anesthesia as well as for surgery to be obtained prior to procedure. Also, special consent for medical problems due to medical diseases and for tracheostomy, if difficult intubation or airway is suspected . An adult who is mentally stable, well-oriented , not under influence of drugs or alcohol - can sign the consent form himself . Mentally subnormal individuals – Parents / guardians Minor patients – parents / guardians Orphanage patients - chief INFORMED CONSENT

121. CONSENT PREOPERATIVE PREPERATION

122. OBJECTIVES OF PREMEDICATIONS – 10 A’s A nxiolysis - Relief of apprehension or anxiety / sedation A nalgesia – smooth induction of GA A mnesia of perioperative events – Anterograde amnesia A ntiemetic effect - Prevention of nausea and vomiting A ntisialagogue effect – Reduction of salivary & bronchial secretion A ntacid usage – Reduction of stomach acidity & volume A ntiautonomic parasympathetic / sympathetic reflexes care - Vagolytic actions A naesthetic induction – Smooth facilitation Prophylaxis against A llergies A ntibiotic regimen – Prophylactic / Specific PREANESTHETIC MEDICATION

123. Provide relief from apprehension & anxiety , P eri -operative amnesia  Benzodiazepine  anxiolytics but no analgesia  MIDAZOLAM  I h v r – 0.05-0.1 mg/kg (2 to 5 mg in 0.5 mg increment) – return to normal within 4  Intra-nasal dose – 0.6 mg/kg DIAZEPAM  Gold standard  Oral doses – 0.2 - 0.5 mg / kg Intravenous – 0.04 – 0.1 mg/kg  With opioid can produce respiratory and cardiovascular depression  FLUMEZANIL  Drug antagonized the sedative and amnestic effect of midazolam  0.1 -0.5 mg  Short acting – preferably given in infusion form

124. SEDATIVES-HYPNOTICS  Barbiturates  Priorly used but now generally no use  Replaced by benzodiazepine  Doses – 50-200 mg orally  Action within 15 to 20 minute – duration last – 2 to 4 hr  Butyrophenon  Mainly antiemetic but can produce sedation  Doses – IV/IM – 2.5 to 7.5 mg  Phenothiazine  Sedation, anticholinergic and antiemetic effect  Always used with opioids  Lytic cocktail – 50 mg pethidine + 25 mg promethazine + 10 mg chlorpromazine Promethazine  Antisialogogue + antihistaminic + Antiemetic + sedative  Doses – Orally – 10 – 25 mg Trimeperezine tartrate  Doses – 3-4 mg/kg – 2 hr preoperatively

125. ANALGESIC AGENT  Ketamine – Potent IV induction agent Posses analgesic property Major disadvantages – Increased salivation Emergence delirium (More common in adults & childrens ) Very popular for premedication in children Combined with vagolytic agent to combat with the increased secreations Dose – Oral : 8 – 10 mg/kg IM : 4 – 5 mg/kg IV : 0.5 – 1 mg/kg

126. ANALGESIC AGENT  Morphine  Well absorbed after IM injection  Onset – 15 to 30 minute  Peak effect – 45 to 90 minute  Lasting for 4 hr  May cause – orthostatic hypotension, respiratory distress, addiction  Fentanyl (preferred most now a days/ given just before induction)  50 to 125 times potent than morphine  Respiratory depression is high  Dose – 1-2u gm /kg  Onset – 30 to 60 second  Route – intranasally, orally, transdermally Reversal agent - Naloxone  Pethidine  Doses – 50 to 100 mg – IM / IV – single dose lasts for 2 to 4 hour  Buprenorphine  Highly potent drug  3 to 6 umg/kg – IM/IV  Respiratory depression

127. ANTICHOLINERGIC AGENTS  Actions Vagolytic  Increase heart rate by blocking acetylcholine on muscarinic receptor in SA node  Atropine is more effective than glycopyrolate / scopolamine  Useful in preventing intraoperative bradycardia resulting from vagal stimulation or carotid sinus stimulation  Atropine (0.5mg IM) also helps in preventing vasovagal attack Antisialogogue Induce drying of salivary, gastric, tracheobronchial and sweat gland secretion Glycopyrolate (0.1-0.3 mg IM) is more potent – long acting drying effect Should be given 30 minute prior to the procedure Sedation and amnetia  Atropine and scopolamine cross blood-brain barrier  Atropine cause delirium in elderly  Scopolamine has good sedative and amnesic effect Side Effects Pupillary dilatation Tachycardia, cardiac arrhythmia Delirium, confusion, restlessness Increase body temperature

128. An t iemetic s - - Metoclopramide (10mg i.m.) used as antiemetic & as prokinetic gastric emptying agent prior to emergency surgery – 30-60 minute prior to surgery Domperidone (10mg oral) more preferred (does not produce extrapyramidal side effects) Ondansetron (4-8mg i.v.), a 5HT 3 receptor antagonist, found effective in preventing post- anaesthetic nausea & vomiting DRUGS REDUCING ACID SECRETION - Ranitidine (150-300mg oral) or Famotidine (20-40mg oral) given night before & in morning along with Metoclopramide reduces risk of gastric regurgitation & aspiration pneumonia Proton pump inhibitors like Omeprazole (20mg) with Domperidone (10mg) is preferred nowadays

129.  For OUT PATIENT DENTAL SURGERY  Atropine/ Glycopyrolate – 30 min prior to surgery  Diazepam (0.25mg/kg) – orally night before procedure  For longer procedure – Midazolam (0.05-0.1mg/kg) – IM- 30 min prior to surgery  If pt. having pain – fentanyl (100mg) may be added to midazolam  For MAJOR MAXILLOFACIAL SURGERY  Atropine / Glycopyrolate + Pethidine + Promethazine – 30 min prior to surgery  Promethazine act for drying secretion + Sedation + prevent Histamine release  For PEDIATRIC / CHILD PATIENT  Vagus activity more predominant with small air passage  Presence of secretion may cause deleterious effect  Anticholinergic mandatory IM/IV  Syrup TRIMEPERAZINE / Promethazine (0.6mg/kg) – to sedate  Ketamine can also be given

130. PREMEDICATION USED IN OUR UNIT Tab. Diazepam 0.25 mg orally Tab. Pantoprazole 40 mg orally Syp . Cremaffin orally Inj. Ondensetron 8 mg IV – 1 hour prior to surgery Night before surgery / 8 – 10 hours prior to surgery

131. CONCURRENT DRUG THERAPY To be continued To be modified To be discontinued Antiarrythmics Insulin Diuretic- on the day of surgery Antiasthmatic Oral-anticoagulant Oral hypoglycemic Antibiotics Steroid cover Aspirin – 1 wk prior Antiepileptic Mono Amine Inhibitor – 2 wk prior to surgery B-blocker Oral contraceptive – 1 mnth cycle Ca channel blocker Eye drops Sedative/anxiolytic immunosuppressant

132. GROUP DRUGS EFFECT SIDE EFFECTS DOSES Benzodiazepines Diazepam Midazolam Sedation Amnesia anxiolysis -CNS depression when given with opoids 0.04-0.08mg/kg IV/IM Opoids Pethidine Morphine Fentanyl Sedation Analgesia -Resp. depression -PONV -50-100mg IV/IM -1-2 μ gm/Kg Barbiturates Thiopental Methohexital Sedation - Antianalgesic effect -Cardio respiratory depression -3-5mg/kg IV -1-1.5mg/kg IV Phenothiazines Chlorpromazine Promithazine Sedation Anticholinergic Antiemetic -Hypotension - Restlessness -10-25mg IV/IM Butyrophenones Haloperidol Droperidol Antiemetic - Dysphoria -Restlessness -2.5-7.5mg IV/ Im Anticholinergic Atropine Glycopyrolate Scopolamine Vagolytic Antisialogogue Sedation, Amnesia Dry mouth Restlessness -0.12mg/kg -0.04mg/kg Antiemetic Ranitidine Metoclopramide ondansetron Antiemetic - -50-100mg IV -5-20mg IV -4mg IV

133. Fasting Guidelines AGE CLEAR FLUIDS NON-CLEAR FLUIDS/SOLIDS Child< 6 months 2 hr prior 4-6 hr prior Child-6-36 months 2-3 hr prior 6 hr prior Child> 36 months 2-3 hr prior 6 hr prior Adults 2-3 hr prior 6 hr prior/ overnight PREOPERATIVE PREPERATION

134. PRE OPERATIVE ORDERS PREOPERATIVE PREPERATION

135. SMOKING – Ideally should be stopped 4 to 6 weeks prior to the surgery to decrease the incidence of postoperative pulmonary complications. Stopping 1 to 2 weeks before the surgery - benefits the patient by enhancing the ciliary activity of respiratory mucosa and by reduction in the sputum volume . Nicotine - causes tachycardia and peripheral vasoconstriction. With high levels of carbon monoxide in blood - patients are susceptible for hypoxic episodes . OTHER INSTRUCTIONS

136. 2. DENTURES – Chances of aspiration of loose dentures or slipping from the position - can cause obstruction of the airway. 3. ARTIFICIAL LIMBS – Should be removed as metal component of the artificial limb may induce electrical burns . 4. ARTIFICIAL EYES AND CONTACT LENSES – Dislodgements can cause corneal abrasions or injury to surrounding delicate structures of eye.

137. ANESTHETIC EQUIPMENTS

138. Anesthesia machine is an equipment, by which the operator can deliver a desired concentration of a mixture of anesthetic agents (gases as well as liquids) in an inhalational (gaseous) form with oxygen and/or air , which serves as a vehicle to carry this mixture to the outlet of the equipment. ANESTHETIC EQUIPMENTS ANESTHESIA MACHINE

139. PARTS OF ANESTHESIA MACHINE

140. Anesthesia machines can be of either intermittent flow or continuous flow variety. Intermittent flow machines (e.g. Walton 5 machine ) - there is a demand valve , i.e. gases flow only on demand of the patient . In continuous flow machines (e.g. Boyle machine), oxygen, nitrous oxide, air, etc. have individual flow meters for setting desired flow of each gas.

141. Vaporizers - for setting desired percentage output concentration of the liquid anesthetic agents like halothane, isoflurane , etc . Flow meters for gases and vaporizers for liquid anesthetic agents are gas/agent specific and the one meant for a particular gas or anesthetic agent cannot be used for the other . Most dangerous hazard - is the delivery of a hypoxic gas mixture This can lead to hypoxic brain damage and coma , even cardiac arrest and death can occur. To avoid this hazard - newer anesthesia machines have devices , which in the event of delivery of a hypoxic gas mixture activate an alarm either auditory or visual, which tells the operator that a hypoxic gas mixture is being delivered, so that immediate action can be taken

142. Breathing system is an assembly of equipment, that not only carries anesthetic mixture from the outlet of anesthesia machine to the patient, but also allows to monitor and control patient’s breathing. COMPONENTS – Bag mount with a reservoir bag (1.5 to 2 liter Capacity) L ong (one meter) corrugated rubber or plastic tubing/s (breathing tube/s) An expiratory valve - Ordinary spring loaded/ nonrebreathing valve, which is connected to a mask or an endotracheal tube attached to the patient. BREATHING SYSTEM (CIRCUIT)

143. Breathing system can be reusable or disposable. 3 TYPES – Single simple corrugated tubing (e.g. Magill’s system) Coaxial tubings , i.E. One tubing within the other (e.g. Bain’s system) Double tubings , inspiratory and expiratory (e.g. Closed circuit).

144. Mask is an integral part of any anesthetic breathing system/circuit during the induction phase ( beginning) of anesthesia or any resuscitation procedure. Allows administration of gases from the breathing system , without introducing any invasive apparatus (e.g . endotracheal tube) into the patient‘s airway. P laced on the patient’s face covering his/her mouth and nose (face-mask) or only on the nose (nasal-mask). ANESTHETIC MASK

145. Parts: Connector or mount – in which breathing system is attached; can be made of hard rubber, plastic / metal Body – made up of rubber, neoprene, plastic / silicon Edge or seal – Part of mask that comes in contact with the face; anatomically shaped Sizes : 1, 2, 3, 4, 5 . Body of the mask - made up of rubber, neoprine , plastic or silicone.

146. Laryngoscope is designed for doing direct laryngoscope (directly viewing the vocal cords) and to pass an endotracheal tube into the larynx under vision. • Parts: Handle, blade with light bulb. • Sizes (for the blades): Neonate (infant), pediatric (child ), adult and extra large. LARYNGOSCOPE

147. Laryngoscope blades can be - Curved (e.g. MacIntosh Laryngoscope—most popular) S traight (e.g. Miller Laryngoscope—useful for neonates and small children)

148. PARTS OF BLADE – Base Tongue plate Flange Web Tip Bulb socket

149. The base is slotted to engage the hinge pin of the handle. The tongue blade or spatula serves to manipulate the tongue and other soft tissues to visualize the larynx. The flange is parallel to the tongue plate and connected by a web. It helps to deflect the interfering soft tissues and to guide the endotracheal tube.

150. The tip of the blade is blunt and thick to prevent trauma to the soft tissues. It elevates and secures the epiglottis directly (with straight blade) or indirectly (with curved blade). The bulb socket is meant for fitting the light bulb. It has an electrical connection to the hook on the base. As the blade is locked on the handle (at 90 degrees), electrical connection is made complete and the bulb is illuminated.

151. METHOD OF INSERTION

152. ENDOTRACHEAL TUBE Endotracheal tube is a specially designed tube with one end straight and the other being obliquely cut ( bevelled end). Beveled end enters the trachea through the laryngeal inlet It is always passed with direct laryngoscopy under vision after anesthetizing the patient, except in cases, where patients are unable to open mouth, e.g. temporomandibular (TM) joint ankylosis or when a difficult intubation is expected . Sizes : 2, 2.5, 3, 3.5, 4,……10, 10.5 (internal diameter in mm ).

153. TYPES - Can be plain or cuffed . Can be made up of plastic (generally PVC), red rubber or latex . Disposable or reusable . Low volume-high pressure or high volume-low pressure types. May be introduced orally or nasally

154. TECHNIQUES OF INTUBATION OROTRACHEAL INTUBATION ENDOTRACHEAL INTUBATION FIBEROPTIC INTUBATION

155. OROTRACHEAL INTUBATION 1. The laryngoscope is held in the left hand. 2. With the patient’s mouth opened the blade is introduced into the right side of the oropharynx—with care to avoid the teeth. 3. The tongue is swept to the left and up into the floor of the pharynx by the blade’s flange. 4. The tip of a curved blade is usually inserted into the vallecula , and the straight blade tip covers the epiglottis. 5. With either blade, the handle is raised up and away from the patient in a plane perpendicular to the patient’s mandible to expose the vocal cords

156. 6. The “backward , upward, rightward, pressure” ( BURP) maneuver applied externally moves an anteriorly positioned glottis posterior to facilitate visualization of the glottis. 7. The cuff is infl ated with the least amount of air necessary to create a seal during positive-pressure ventilation

157. Sites for auscultation of breath sounds at the apices and over the stomach.

158. NASOTRACHEAL INTUBATION 1. A TT lubricated with water-soluble jelly is introduced along the floor of the nose, below the inferior turbinate, at an angle perpendicular to the face . 2. The tube’s bevel should be directed laterally away from the turbinates . 3. The tube is gradually advanced, until its tip can be visualized in the oropharynx.

159. FIBEROPTIC INTUBATION FOI is ideal for : • A small mouth opening • Minimizing cervical spine movement in trauma or rheumatoid arthritis • Upper airway obstruction, such as angioedema or tumor mass • Facial deformities, facial trauma

160. COMPLICATIONS OF INTUBATION

161. BOUGIE The bougie (also called  'introducer' ,  'gum-elastic bougie '  or  'GEB' ) is device which allows a  Seldinger -like technique of intubating a patient's airway. This means the device is inserted into the airway first, then an endotracheal tube is railroaded over the bougie into the airway, after which the device is removed. The device is moderately  flexible  and can be  bent into shape  from its straight form, in which it is supplied ANESTHETIC EQUIPMENTS ADJUNCTS TO INTUBATION

162. LIGHTED STYLET Lighted stylet guided intubation can be a useful technique for oral and nasal intubations in both asleep and awake patients. It can be used in anticipated and unexpected difficult airways where conventional direct laryngoscopy has failed. Manipulation of the head and neck can be kept minimal and the patient does not require a wide mouth opening (6-8 mm) which makes this technique extremely useful.

163. OROPHARYNGEAL AIRWAY An   oropharyngeal airway  (also known as an  oral airway ,  OPA  or  Guedel pattern airway ) is a medical device called an  airway adjunct  used to maintain or open a patient's airway. • Parts : Flange , bite portion, air/ suction channel (curved portion) • Sizes: 00,0 , 1 , 2, 3, 4,5,6 It does this by preventing the  tongue  from covering the  epiglottis , which could prevent the person from breathing. When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway

164. INSERTING OROPHARYNGEAL AIRWAY

165. NASOPHARYNGEAL AIRWAY The NPA provides a passage of airflow between the nares and pharynx and can be used in patients who are conscious or semiconscious with intact gag reflex. • Parts: Flange or a movable disc attached to a tube • Sizes (diameter) – 7.0/7.5 for adult males – 6.5/7.0 for adult females – Same/one size smaller than an appropriate endotracheal tube for children.

166. LARYNGEAL MASK AIRWAY (LMA) Laryngeal mask airway (LMA) is a device which is midway between mask and endotracheal tube. Just as mask makes an airtight seal around the face, LMA makes an airtight low-pressure seal around laryngeal inlet after inflation of the cuff. • Parts: Mask, tube at an angle of 30 degrees, black line on tube to face upper incisors and pilot balloon. • Versions: Plain, reinforced, and intubating, pre-sale LMA . • Sizes: 1, 1.5, 2, 2.5, 3, 4, 5.

167. MAGILLS FORCEPS A n instrument, which is most often used for guiding an endotracheal tube, from the pharynx into the larynx during nasal intubation. It is also used to pack the throat with a roller gauze during oral and pharyngeal surgery, to pick up a broken or dislodged tooth lying in the oral cavity or to pass a Ryles (nasogastric ) tube. It is L-shaped and it has no catch. It is available in three sizes—infant, child & adult.

168. RESUSCITATION BAG Resuscitation bag is an assembly of equipment consisting of a self-inflating bag, a non-rebreathing valve and a facemask • Sizes: Three sizes are available; for infant, child and adult .

169. METHOD OF USING After proper positioning of the patient, the mask has to be placed on the patient’s face and the bag can be intermittently compressed and released while watching the inflation and deflation of the patient’s chest. The exhalation blast can be heard or felt from the expiratory port of the nonrebreathing valve.

170. MONITORING EQUIPMENTS

171. BLOOD PRESSURE MONITOR Blood pressure monitor is available in various forms: • Simple sphygmomanometer/aneroid dial • Noninvasive automatic blood pressure monitor (NIBP) • Invasive direct arterial blood pressure monitor (IABP ) Blood pressure is generally monitored on the right or left upper arm. It is necessary to monitor patient’s blood pressure as most of the anesthetic agents are vasodilators and/or myocardial depressants, giving rise to hypotension. MONITORING EQUIPMENTS

172. CARDIOSCOPE Cardioscope not only allows to monitor the electrocardiogram (ECG ) of the patient, but it also allows to monitor patient’s heart rate, rhythm, the type of arrhythmias and ST-segment changes (important to diagnose myocardial ischemia ). It has minimum three leads and maximum 12 leads. Generally, a three lead ECG is monitored under anesthesia . These leads are attached on the anterior chest wall, one near the right shoulder, one near the left shoulder and one near the lower end of sternum on the right side. MONITORING EQUIPMENTS

173. PULSE OXIMETER N oninvasive equipment that allows to monitor continuously the oxygen saturation of the patient and also the heart rate. It has a small probe which can be attached on any of the fingers or toes or on the ear lobule. MONITORING EQUIPMENTS

174. CAPNOGRAPH A n equipment that continuously records the carbon dioxide tension (in mm Hg or %) of the expired gas mixture. It is popularly known as an End Tidal CO2 monitor (ETCO2). It is a noninvasive monitor having a probe or an adapter that can be attached to an endotracheal tube, a face-mask or a nasal catheter. MONITORING EQUIPMENTS

175. OXYGEN THERAPY EQUIPMENT

176. OXYGEN CYLINDER Oxygen cylinders are available in various sizes. They are black in color with a shoulder painted white. Those meant to be used on anesthesia machines have a flushed valve whereas those used in the wards have a bull-nose valve. It is not possible to use a flushed valve cylinder in the wards. On the ward cylinder, oxygen flowmeter can be attached and there is also a facility to attach a humidifier to the flowmeter .

177. OXYGEN FLOWMETER Oxygen flowmeter allows the operator to deliver a desired flow of oxygen to the patient. Generally , 3 to 4 liters per minute of flow is given, but it varies from patient to patient, depending upon the type of oxygen delivery system , type of surgery done, age of the patient and general condition of the patient.

178. OXYGEN MASK Polymask is a semioval -shaped mask, available in two sizes, for children and for adults. It is a loosely fitting mask around the mouth and nose through which moderate flow of oxygen (3 to 6 liters ) can be delivered . Recommended flow rate is 10 to 15 liters /min of oxygen

179. NASAL PRONGS Nasal prongs are the most simplest, most commonly used and easily available devices. But, not more than 1 to 3 liters of oxygen per minute can be delivered, as high flow makes the patient uncomfortable due to wheezing sound and a feeling of dry mouth . Generally with oxygen flow rate of 1 to 2 liters / min , these devices provide 24 to 28 percent oxygen.

180. THANK YOU

181. PHARMACOLOGY OF GENERAL ANESTHETICS

182. INTRAVENOUS BARBITURATES - Thiopental 2 .BENZODIAZEPINES - Diazepam - Midazolam 3. . OPIOIDS - Fentanyl 4 . DISSOCIATIVE - Ketamine 5. MISCELLANEOUS - Etomidate - Propofol ANESTHETICS INHALATIONAL GASES - Nitrous oxide 2 . VOLATILE LIQUIDS - Ether - Halothane - Isoflurane - Desflurane - Sevoflurane Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 PHARMACOLOGY OF GENERAL ANESTHETICS

183. IDEAL PROPERTIES Pleasant odour,non irritant to respiratory tract ,pleasant and rapid induction of anaesthesia . Posses low blood/ gas solubility. Chemically stable Neither inflammable nor explosive. Capable of producing unconciousness with analgesia and some degree of muscle relaxation. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS

184. It should not be metabolized in the body, non toxic and not provoke allergic reactions. Minimal depression of CVS and RS . Easy to administer. Should be completely inert and eliminated completely and rapidly via lungs. INHALATIONAL ANESTHETICS

185. The important characteristics of Inhalational anesthetics which govern the anesthesia are Solubility in the blood (blood : gas partition co-efficient) Solubility in the fat (oil : gas partition co-efficient) Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS

186. SOLUBILITY IN THE BLOOD (blood : gas partition co-efficient) It determines the rate of induction and recovery of Inhalational anesthetics. Lower the blood : gas co-efficient – faster the induction and recovery – Nitrous oxide. Higher the blood : gas co-efficient – slower induction and recovery – Halothane. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia concept and techniques;p.67-76 INHALATIONAL ANESTHETICS

187. INHALATIONAL ANESTHETICS

188. SOLUBILITY IN THE FAT (oil : gas partition co-efficient) It is a measure of lipid solubility. Lipid solubility - correlates strongly with the potency of the anesthetic. Higher the lipid solubility – potent anesthetic. e.g., halothane Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS

189. MAC value Measure of inhalational anesthetic potency. It is defined as the minimum alveolar anesthetic concentration ( % of the inspired air) at which 50% of patients do not respond to a surgical stimulus. Greater the MAC lower the anesthetic potency. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS

190. OIL GAS PARTITION CO-EFFICIENT INHALATIONAL ANESTHETICS

191. Inhalation Anesthetic MAC value % Oil: Gas partition Nitrous oxide >100 1.4 Desflurane 7.2 23 Sevoflurane 2.5 53 Isoflurane 1.3 91 Halothane 0.8 220 Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS

192. Prepared by Priestley in 1772 Anesthetic properties described by Sir Davy in 1799 Colorless , odorless, tasteless, and is nonflammable Weak anesthetic, powerful analgesic No muscle relaxation Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS NITROUS OXIDE

193. MAC value is 105%(needs other agents for surgical anesthesia) Minimal effects on heart rate and blood pressure. Respiration- Decreases tidal volume. Post operative nausea and vomiting Avoided in 1 st trimester INHALATIONAL ANESTHETICS NITROUS OXIDE

194. The second-gas effect The ability of the large volume uptake of one gas (first gas) to accelerate the rate of rise of the alveolar partial pressure of a concurrently administered companion gas (second gas) is known as the second gas effect. Ex- Halothane (1%) & N 2 0:O 2 ( 75%: 25%) Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS NITROUS OXIDE

195. Diffusion Hypoxia N 2 O has low blood solubility, rapidly diffuses into alveoli and dilutes alveolar air- PP of oxygen in alveoli is reduced, resulting in hypoxia called as diffusion hypoxia. Prevented by giving 100% oxygen for few mins , after discontinuing N 2 O. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS NITROUS OXIDE

196. 2-bromo-2-chloro-1,1,1-trifloroethane Non flammable,non explosive. Pleasant smell, non irritating. BP falls in proportion to the vapour inhaled. Depression of respiratory centre. Respiratory rate increases, depth of respiration decreases. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS HALOTHANE (FLUTHANE)

197. Mild relaxation of skeletal muscle. Pharyngeal and Laryngeal reflexes are abolished,coughing is suppressed. Urine formation is decreased due to low GFR Less post operative nausea and vomiting. About 20% is metabolized in liver, rest is exhaled out. Malignant Hyperthermia can occur in susceptible individuals. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS HALOTHANE (FLUTHANE )

198. Synthesized in 1965 by terrell , introduced into practice in 1984 Cheap and widely used Highest oil gas partition cofficient (90.8) Non carcinogenic,nonflammable,pungent Less soluble than halothane. It can cause coronary artery vasodilatation Depresses respiratory drive and ventilatory responses Myocardial depressant-less than halothane Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS ISOFLURANE (SOFANE)

199. Excellent muscle relaxant-- potentiates effects of neuromuscular blockers. Induction by 3 to 4 % isoflurane in air or in oxygen, or by 1.5 to 3 % isoflurane in 65 % nitrous oxide. Maintenance by 1 to 2.5 % isoflurane . Bronchoirritating , laryngospasm Pungent smell – not good induction agent Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS ISOFLURANE (SOFANE)

200. Volatile anesthetic is a nonflammable fluorinated varient of Isoflurane Lowest oil-gas coefficient (18.7) Very fast action (on and off) makes it a great choice for outpatient anesthesia . Induction by using 6 to 10 % desflurane in air or in oxygen, or by using 5 to 8 % desflurane in 65 % nitrous oxide Maintenance with 5 to 7 % desflurane Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS DESFLURANE

201. As higher conc. are used, may irritate air passage, and induce coughing. Pungent smell-not suitable for induction. Degree of respiratory depression and fall in B.P, similar to isoflurane . Exhaled unchanged and more rapidly. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS DESFLURANE

202. SEVOFLURANE Nonflammable fluorinated isopropyl ether. Properties intermediate between isoflurane and desflurane . Induction and emergence from anesthesia are fast. Absence of pungency makes it pleasant and administrable through face mask. It does not sensitize the heart to arrhythmias or cause coronary artery steal syndrome. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS SEVOFLURANE

203. Does not irritate the airway. Has low solubility in blood ,so used for rapid induction without intravenous anesthetics Induction by using 1.5 to 3 % sevoflurane in air or in oxygen, or by using 0.7 to 2 % sevoflurane in 65 % nitrous oxide. Maintenance with 0.4 to 2 % sevoflurane . Expensive Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INHALATIONAL ANESTHETICS SEVOFLURANE

204. CLINICAL SIDE EFFECTS OF INHALED ANESTHETICS

205. Used as inducing agent. Poor analgesic and muscle relaxant properties. Suppresses excitatory neurotransmitter ( acetylcholine) and enhance inhibitory neurotransmitter (GABA). pH>10, water soluble. Unstable, freshly prepared. Rapid onset 30-60sec. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS THIOPENTAL

206. Elimination half life-3-12 hours. Dose- 3-5mg/kg. IV Decreases blood pressure due to vasodialation . Respiratory depression, can lead to bronchospasm . Occasionally used for rapid control of convulsions. Dose-dependent suppression of CNS activity Contraindications : porphyria , status asthematicus . Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS THIOPENTAL

207. Produce sedation and amnesia Potentiate GABA receptors. Onset of action is 30-60 secs . Duration of action 50-80mins. Dose- Premedication-0.04-0.08mg/kg Induction- 0.1-0.3mg/kg IV. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS BENZODIAZAPENES

208. Minimal depression of cardiac and respiratory system. Decreases intra cranial pressure, causes anterograde amnesia. Dependence- onset of physical or psychological symptoms after reduction of dose. Overdose- treared by giving Flumazenil – 0.01mg/kg upto 0.2mg . IV Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS BENZODIAZAPENES

209. Short acting Opioid.(30-50mins) Potent anlgesic . Minimal cardiac effects-- no myocardial depression Marked respiratory depression. Tone of chest muscles may increase after rapid fentanyl injection,muscle relaxant is required. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS FENTANYL

210. Dose-2-4 μ g/kg Repeated dose may be required every 30 mins . Side effects nausea, chest wall rigidity, seizures, constipation, urinary retention Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS FENTANYL

211. Dissociative amnesia Profound amnesia/ analgesia despite maintaining counsciousness and protective reflexes. Exitation of inhibitory neurotransmitters Dose- Analgesia-0.1-0.5mg/kg IV - Induction- 4-8mg/kg Mixed with propofol infusion - 1mg ketamine per 10mg propofol Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS KETAMINE

212. Increases heart rate, cardiac output, BP. Potent bronchodialator Increases salivation. Decreases cerebral blood flow and intracranial pressure Hallucinations and nightmares. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS KETAMINE

213. Excitation of inhibitory neurotransmitters Oily liquid employed as a 1% emulsion for IV induction Available in 20 ml vials Rapid onset and short duration of action Induction dose: 1-2.5mg/kg Sedation dose: 0.2mg/kg Decreases systemic vascular resistance. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS PROPOFOL

214. Profound depression of upper airway reflexes. Anti emetic. Anti epileptic. Adverse effect- burning on injection - hypersensitivity reaction. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS PROPOFOL

215. Direct CNS depressant (thiopental) and GABA agonist Lipid soluble. Pain on injection. Dose- 0.2-0.3mg/kg Minimal cardiac and respiratory effect. Anti epileptic Post op nausea and vomiting. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INTRAVENOUS ANESTHETICS ETOMIDATE

216. Muscle Relaxant NONDEPOLARIZING Long acting - pancuronium - tubocurarine 2.Intermediate acting - vecuronium 3.Short acting - mivacurium DEPOLARIZING - Succinylcholine - Decamethonium Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 MUSCLE RELAXANTS

217. Initially nitrous oxide 70% in oxygen is used Anaesthesia is deepened by the gradual introduction of increments of a volatile agent e.g sevoflurane . Maintenance concentrations of isoflurane (1-2 %)or sevoflurane (2-3%). If spontaneous ventilation is to be maintained throught the procedure,the mask is applied more firmly as conciousness is lost and airway is supported manually Pre- oxygenation may be started with 100% oxygen using face mask. At the rate of 8L-10L/min Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INDUCTION

218. AGENT INDUCTION DOSE thiopental 3-5 mg/kg etomidate 0.3mg/kg propofol 1.5mg/kg ketamine 2mg/kg Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 INDUCTION

219. Inhalational agents Propofol infusion Oxygen + N2O Relaxants – VECURONIUM, ATRACURIUM, PANCURONIUM etc. Analgesia – opioids Sedation – midazolam etc. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 MAINTAINENCE

220. Check equipment Check drugs Turn off agents Give 100% oxygen Suction Reverse relaxant Usually a combination of neostigmine glycopyrolate in the ratio of 5:1, or neostigmine and atropine in the ratio of 5:2 is given. Wait for adequate breathing Wait until patient wakes up Extubate and give 100% O 2 by mask Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 REVERSAL

221. POSTOPERATIVE CARE

222. Shifted to recovery for Post operative care N . P. O FOR 4-6 hrs. Vitals monitoring should be done. IV fluids and blood products if required Analgesia- IV or IM NSAIDs or opioids Antiemetics Antibiotics Continue medications for medical disorders Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 POSTOPERATIVE CARE

223. ACTIVITY 2=Move all extremities voluntarily or on command 1= Move two extremities. 0= Unable to move extremities . RESPIRATION 2 = Breathes deeply and coughs freely, shallow /limited breathing 1 = Requires assistance 0 = Apnnoe CIRCULATION 2 = BP+20mm Hg of preanesthetic level 1 = BP+20-50 mm Hg of preanesthetic level 0 = BP+50 mm Hg of preanesthetic leve Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 POST - ANESTHESIA RECOVERY SCORE

224. CONCIOUSNESS 2= Fully awake 1= Arousable on calling 0= Not responding OXYGEN SATURATION 2 = > 92% on room air 1 = supplemental oxygen req. To maintain SpO 2 >90% 0 = SpO 2 < 92% with oxygen supplementation. Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2 nd edition;saunders,an imprint of elsevier inc.St . Louis, Missouri. 2009;Chapter 5: anesthesia consept and techniques;p.67-76 POST - ANESTHESIA RECOVERY SCORE

225. COMPLICATIONS

226. PULMONARY COMPLICATIONS

227. Patient experiencing hypoventilation can develop hypoxemia, oxygen deficiency in arterial blood, or hypoxia, impaired tissue oxygenation . CAUSES – Fluid overload or pulmonary embolism Cardiac arrest, Atelectasis, Underlying respiratory illness such as asthma or COPD, Breathing machine error or a diffusion deficit MANAGEMENT - Oxygenation of the patient is extremely important to raise the oxygenation levels to the desired range. HYPOVENTILATION

228. The collapse or impaired functioning of a lung or a part of a lung. First symptoms can be coughing, chest pain and difficulty in breathing with breathlessness. Atelectasis results in the reduction of functional residual capacity, which decreases inhaled oxygen volumes. Atelectasis occurs in a complication called pneumothorax . Triggered by the changes in the absorption of gases and pressures occurring during general anesthesia or by a bronchial obstruction. This results in the deflation of the alveoli, also called blebs, in the lungs . Air is then leaked into the pleural cavity from the ruptured blebs in the lung, which balances the pressure within the pleural cavity to air pressure, leading to lung collapse followed by insufficient respiratory function. PULMONARY ATELECTASIS

229. MANAGEMENT – Mild cases of atelectasis are treated post-surgically through physiotherapy and breathing exercises. M ore major cases surgical removals of obstructions or suctioning may be necessary.

230. The contents of the patient’s stomach rise up from the esophagus and end up in the trachea as the patient is under heavy sedation and cannot control swallowing and coughing him or herself. ( Niemi-Murola 2014.) The consequences can be acute lung damage or pneumonia that can ultimately lead to death of the patient. RISK FACTORS – E mergency surgery G eneral anesthesia I nexperienced anesthetist and Patient dependent reasons such as lack of fasting, delayed gastric emptying or gastric hyper secretion PULMONARY ASPIRATION

231. A bronchospasm is a reflex bronchiolar constriction that can be centrally mediated or a local response to airway irritation. This constriction can be elicited by stimuli, such as secretions, blood, or foreign bodies . CLINICAL MANIFESTATIONS – Expiratory wheezing Increased airway resistance. Tachypnea and dyspnea (consciously sedated patients) BRONCHOSPASM

232. MANAGEMENT – Nonsedated or minimally sedated patients - to inhale a B agonist inhaler, such as albuterol (4–8 puffs). In moderately to deeply sedated patients , 100 % oxygen with a full face mask should be immediately initiated. If patients can be ventilated , nebulized albuterol (6–10 puffs) can be administered. After the use of a B agonist, if the bronchospasm is still present, subcutaneous epinephrine in doses of 0.3 to 0.5 mg of 1:1000 is used. If after all the prior medications are administered and there is still difficulty ventilating patients , intubation should be considered.

233. A laryngospasm is a spasm of the intrinsic muscles of the larynx causing closure of the airway at the level of the vocal cords. It is a protective reflex mechanism that prevents irritants, such as blood, saliva , or irrigation, as well as solid materials from entering the lower airway. The classic sign - high-pitched stridor or crowing for a partial laryngospasm and silence for a complete obstruction . CAUSES - local irritants and the depth of anesthesia LARYNGOSPASM

234. PREVENTION – Proper airway maintenance. Use of throat pack or partition to keep foreign material out of the airway. Proper suctioning techniques aid in airway control. Head positioning (sniffers position) will position the airway in a straight-line physiologic position.

235. MANAGEMENT – Ventilation of patients with a full face mask and 100% oxygen. If patients cannot be ventilated, a small dose of succinylcholine 0.15 to 0.30 mg/kg intravenously (IV) in adults is used to break the spasm and initiate ventilation – smaller individuals In larger individuals or a complete spasm, 0.3 to 0.6 mg/kg IV should be considered. If the spasm continues, an intubating dose of succinylcholine 1 mg/kg should be administered along with endotracheal intubation.

236. The obstruction of the airway is usually located in the upper airway ( supraglottic region) and is caused by the loss of pharyngeal muscle tone. With the loss of muscle tone , the tongue is displaced posteriorly and occludes the airway . CAUSES – Deep anesthesia Foreign bodies, such as teeth, aspirate, prosthetic devices, or surgical Instruments. CLINICAL MANIFESTATIONS – Paradoxic breathing with sterna retraction and abdominal muscle activity. AIRWAY OBSTRUCTION

237. Emesis of gastric contents in anesthetized patients can lead to aspiration. Aspiration can exhibit as hypoxemia, tachycardia, tachypnea , bronchospasm , hypotension, and atelectasis . M edical conditions that can increase the likelihood of aspiration - obesity , hiatal hernia, pregnancy , gastroesophageal reflux disease, and obstruction of the gastrointestinal tract . CLINICAL MANIFESTATIONS – Rales , dyspnea , tachycardia, bronchospasm, and partial airway obstruction, will occur with a liquid aspirate A solid aspirate can cause partial or complete airway obstruction. EMESIS & ASPIRATION

238. MANAGEMENT – Patients should be placed in the Trendelenburg position with the head down. Patients should also be rolled to the right side using gravity and natural anatomy to minimize aspiration damage to the left lung. The oropharynx should be suctioned free of debris, and 100% oxygen via a full face mask should be started. The oropharynx should be cleaned of any solid particulate matter with the finger-sweep technique, forceps, or large-bore suction. Liquid materials are removed with aggressive suctioning techniques If patients show signs of respiratory compromise, the airway should be intubated.

239. CIRCULATORY COMPLICATIONS

240. Hypotension develops as a result of peripheral venous pooling of blood. This condition causes a decrease in the preload, so BP decreases and cerebral blood flow is decreased to the point of a loss of consciousness . Patients arriving in the office for anesthesia usually do not have preoperative hypotension and tachycardia. Their anxiety is more likely to present as minor elevations in BP as compared with their consultation BP along with tachycardia . However, the combination of volume status from being NPO and anesthetic induction medications can cause a hypotensive episode. Propofol and/or volatile anesthetic gases are known to decrease BP . Allergic reactions during anesthesia are another source of hypotension hypoxia and hypercarbia ; HYPOTENSION

241. MANAGEMENT - Before vasopressors are given, the depth of anesthesia should be reduced and a bolus of IV fluid should be tried - up to 10 mL/kg If an allergic reaction is suspected –epinephrine (IM adult dose is 0.3 mg of 1:1000) Patients that present with hypotension and bradycardia (heart rate <60 beats per minute) - anticholinergic agent like atropine ( 0.5 mg IV every 3 to 5 minutes up to a maximum dose of 3.0 mg) Ephedrine ( 5 mg IV bolus every 5 to 10 minutes as needed). Phenylephrine 1% ( 100 mg in adults every 5-minute intervals)

242. CAUSES OF INTRAOPERATIVE HTN – Intubation and airway manipulation Light anesthesia and pain Exogenous epinephrine Hypoxia and hypercarbia Hypovolemia Hypothermia Volume overload and/or bladder distention Holding perioperative antihypertensive medications HYPERTENSION

243. CAUSES - Female gender Obesity Pregnancy Abdominal distention Premedications - opiods , NSAID’s Anesthetics - ether, nitrous oxide. Presence of pain,hypoxia,hypotention,hypogycimia in post op period POSTOPERATIVE NAUSEA & VOMITING

244. MANAGEMENT - Underlying cause Supine position Antiemetics - Promethazine 12.5-25mg IM/IV(antihistaminic) Metoclopramide 10-20 mg orally. Ranitidiine 50 mg IV Sodium citrate 30-60ml orally

245. Hypermetabolic syndrome occurs in genetically susceptible patients when exposed to anesthetic triggering agents. Triggering agents - Halothane, Isoflurane , Desflurane , Sevoflurane , Succinylcholine. The syndrome is thought to be due to reduction of reuptake of calcium ions by sarcoplasmic reticulum leading to sustained muscle contraction. This results in signs of hypermetabolism like tachycardia, acidosis, hypercarbia , hypoxemia and hyperthermia. MALIGNANT HYPERTHERMIA

246. Management - Discontinue all anesthetic agents. Administer Dantrolene 2.5mg/kg IV. And repeat to a total of 10 mg/kg. Hyperkalemia to be corrected by Insulin and glucose Cold sponging Monitor urinary output

247. Even a slight descend in core temperature of the body, has great effects on some patients of certain risk groups. EFFECTS – Two- to three times more unwanted cardiac events, Doubling the amount of blood loss, Three times more likely to get a wound infection Lengthens the time of recovery from anesthesia and the operation General anesthesia itself can lower the core temperature of the patient even over one Celsius. This is due to general anesthesia’s deactivation of the thermoregulation center of the pituitary gland, which then results in core-to-peripheral redistribution of body heat. HYPOTHERMIA

248. The usage of muscle relaxants during the operation greatly affects the patient’s muscles ability to shiver and produce heat, thus resulting in the temperature drop. ( Sessler 2008.) If the temperature is not controlled and managed during the operation it can result in post-operative hypothermia .

249. MANAGEMENT -

250. CAUSES Occurs during light plane of anesthesia Causes - Irritation due to artificial airways,blood , regurgitated gastric material. MANAGEMENT Deepening of anesthesia Giving muscle relaxant COUGHING