Approach to

Clinical
Anesthesia

Dr. Mohammed Gaber Saad MD., EDAIC

To MY
Parents
Wife
Sons

Thanks
Dr. Ahmed Abdallah
Dr. Sameh Nada
Dr. Ahmed Abo Hamar
Dr. Mahmoud Elshamy

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 TITLE Page
PEDIATRICS ANESTHESIA
Pediatrics consideration 1
Prematurity considerations 2
Foreign body aspiration 3
Adenotonsillectomy 6
Post tonsillectomy bleeding 7
Down syndrome 8
Pyloric stenosis 9
Caudal block 11
Tracheoesophageal fistula 12
Congenital diaphragmatic hernia 14
Tetralogy of Fallot 15
Epiglottitis 16
Cleft lip & palate 17
OBSTETRIC ANESTHESIA
Physiological and pharmacological changes in pregnancy 19
Analgesia for labour 20
Antepartum Hemorrhage 24
Postpartum Hemorrhage 25
Preeclampsia 27
Amniotic fluid embolism 30
Surgery during pregnancy 30
Cervical Cerclage 31
Perimortem cardiac arrest 32
ANESTHESIA FOR CARDIAC DISEASES
Pre-operative cardiac risk evaluation and management 34
Aortic stenosis 36
Aortic regurgitation (AR) 39
Mitral stenosis 40
Mitral regurgitation 42
Fontan Physiology 44
Cardiomyopathy 46
Cardiac Tamponade 47
Hypertrophic obstructive cardiomyopathy 48
Pacemaker 49
Perioperative myocardial ischemia 51
Ventricular assist devices 54
QT Prolongation 55
Wolff-Parkinson-White (WPW) Syndrome 56
Atrial fibrillation 57
Ventricular Tachycardia 59
Adult bradycardia algorithm 59
Adult tachycardia with a pulse algorithm 60

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 Adult cardiac arrest algorithm 61
Pediatric cardiac arrest algorithm 62
Neonatal resuscitation algorithm 63
VASCULAR ANESTHESIA
Carotid endarterectomy 65
Aortic Dissection 68
Femorofemoral – femoropopliteal 71
THORACIC ANESTHESIA
Lung Isolation 73
Pneumonectomy 76
Anterior mediastinal mass 78
Bullous Lung Disease 81
Bronchopleural Fistula (BPF) 82
Chronic Obstructive Lung Disease (COPD) 83
NEUROSURGERY ANESTHESIA
General considerations 87
Craniotomy 88
Posterior Fossa Surgery 90
Pituitary surgery 92
Cerebral aneurysm coiling 93
Subarachnoid Hemorrhage 94
Awake Craniotomy 95
NEUROMUSCULAR AND SKELETAL DISEASES
Epilepsy 99
Parkinson’s disease 100
Multiple sclerosis 101
Guillain–Barré syndrome 102
Amyotrophic Lateral Sclerosis (ALS) 103
Myasthenia Gravis 104
Duchenne Muscular Dystrophy 106
Cerebral Palsy 107
Scleroderma 108
Rheumatoid Arthritis 109
Scoliosis 110
ANESTHESIA FOR ENDOCRINE DISEASES
Pheochromocytoma 116
Carcinoid 119
Hyperthyroidism 121
Hypothyroidism 124
Diabetes Mellitus 125
Cushing’s syndrome 126
Adrenocortical Insufficiency (Addisonian crisis) 127
Acromegaly 128
ANESTHESIA FOR BLOOD DISEASES
Sickle Cell Disease 130
Thalassemia 132

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 Hemophilia 133
Von Willebrand's Disease 134
Massive transfusion protocol (MTP) 135
Massive blood transfusion 136
Perioperative management of patients receiving anticoagulants 136
Perioperative management of patients receiving antiplatelet 139
Guidelines for Neuraxial Anes thesia and Anticoagulation 140
UROLOGICAL ANAESTHESIA
Transurethral resection of the prostate (TURP) 142
Chronic renal failure 144
GERIATRIC 145
OBESITY 147
Obstructive sleep apnea (OSA) 149
AIRWAY ASSESSMENT AND MANAGEMENT
Airway assessment 152
The double setup 155
Pierre Robin Syndrome 155
Awake fiberoptic intubation 156
Cases based, airway management 157
DAS algorithm for unanticipated difficult airway 160
Obstetrics DAS algorithm 161
Pediatrics DAS algorithm 162
CRITICAL CARE
Acute Respiratory Distress Syndrome 166
Management of suspected COVID-19 patients in ER 167
Sepsis management 168
Burns 169
ANESTHESIA EMERGENCIES
Anaphylaxis 172
Local Anesthetic Toxicity (LAST) 173
Bronchospasm 174
Increased Airway Pressure 175
Venous air Embolism 175
Fat Embolism 176
Hypoxemia 176
Laryngospasm 177
Hypotension 178
Hypertension 178
Intraoperative Myocardial Ischaemia 179
Delayed Emergence 180
Malignant Hyperthermia (MH) 180
Transfusion hemolytic reactions 181
ADVANCED TRAUMA LIFE SUPPORT
Advanced trauma life support algorithm 183
Advanced Trauma life support(summary) 187
Airway management in trauma patient 188

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 ATLS for pregnant female 190
Traumatic brain injury (TBI) 193
PAIN AND REGIONAL ANESTHESIA
Acute pain management 197
Perioperative opioid management 198
Perioperative pain management 199
Complex regional pain syndrome 199
Regional anesthesia 200
Upper extremity blocks 200
Interscalene brachial plexus block 201
Supraclavicular brachial plexus block 201
Infraclavicular brachial plexus block 202
Axillary brachial plexus block 202
Lower extremity blocks 203
Femoral nerve block 203
Adductor Canal block (Saphenous nerve block) 203
Popliteal Sciatic Nerve Block 204
IPACK block 204
Ankle Nerve Block 205
Transversus abdominis plane (TAP) 205
Thoracic paravertebral block 206
MISCELLANEOUS
Remote areas anesthesia 207
Lung cryoablation 207
Day Case surgery 208
Decision-making scenarios 209

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Pediatric Anesthesia

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 Pediatrics consideration

Summary
1. Uncooperative patient
2. Altered airway anatomy.
3. ↑ risk of laryngospasm & airway edema.
4. Rapid desaturation on induction
5. ↑ vagal tone & potential for bradycardia
6. Rate-dependent cardiac output
7. Perioperative hypothermia is more likely.
8. Immature liver & kidney function
9. Altered pharmacokinetics/dynamics due to:
− ↑ total body water
− Immature CNS, Renal, and hepatic systems.
Leads to:
▪ ↑ MAC
▪ ↑ Sensitive to opiate and non-depolarizing muscle relaxant.

Respiratory system
Anatomically
− Considered a difficult airway as they have:
▪ large head
▪ short neck
▪ large tongue and a small mouth.
▪ narrow, easily blocked nasal passages.
▪ The epiglottis is floppy and U-shaped.
▪ The larynx is positioned higher than in the adult (at the level of C4 in a child, C5 in an
adult). The narrowest part of the airway is at the level of the cricoid cartilage in children.
− The mucosal lining at the cricoid cartilage is loosely bound to areolar tissue. Any trauma can
easily result in edema.
− Narrow airways result in increased resistance.
− The trachea is short, and this predisposes to endobronchial intubation.

Physiologically
− They are Rapidly developing hypoxia and bradycardia during airway obstruction as they have:
▪ Oxygen consumption is two to three times higher in infants.
▪ Low FRC, they have less oxygen reserve.
− Tidal volume is about the same as an adult per kg, MV is higher, and RR is two to three times.
− More compliant chest wall with horizontal ribs.
− Ventilation is rate-dependent and essentially diaphragmatic. Abdominal distension leads to
respiratory failure.
− The closing volume is relatively larger in infants and encroaches on the tidal volume leading to
Atelectasis and shunt.
− Apnoea is a common post-operative problem.

Cardiovascular system
− The stroke volume is relatively fixed; cardiac output is heart rate dependent.
− The cardiovascular response to hypoxia in neonates is bradycardia with pulmonary and
systemic vasoconstriction as parasympathetic system is more developed than sympathetic.
− Cardiac arrest occurs commonly in form of asystole (VF is uncommon).
− Hypoxia, acidosis, hypercapnia, or hypothermia can revert the circulation to fetal circulation.
− Haemoglobin higher in the neonate: 16–20 g/dL.
− Circulating blood volume 85 mL/kg compared with 70 mL/kg in adults.
− Cardiac output 200 mL/kg/min

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 CNS
− MAC infant > neonate > adult.
− More sensitive to opiate. Induced respiratory depression and apnoea.
− Immature neuromuscular junction that is very sensitive to nondepolarizing muscle relaxants but
relatively resistant to suxamethonium (use 1.5 mg/kg).
− Spinal cord ends at L3 (L1 by age 2 years).

Renal system
− RBF and GFR are low in infants.
− Both fluid overload and dehydration are poorly tolerated in children.
− Higher total body water (80%) at birth.
− Increase extracellular fluid (ECF) resulting in higher volumes of distribution of drugs.

Temperature control
− Perioperative hypothermia is more likely as:
o Children have a large body surface area-to-weight ratio leads to High heat loss.
o The shivering mechanism is poorly developed.

Prematurity Considerations
− Pulmonary:
− Respiratory distress syndrome − Post-op apnea
− Bronchopulmonary dysplasia − Persistent pulmonary hypertension
− Rapid desaturation
− Cardiovascular:
− HR/preload-dependent cardiac − Bradycardia
output − Congenital heart disease
− Transitional circulation/PDA
− CNS:
− Intraventricular hemorrhage − Apnea
− Seizures
− Retinopathy of prematurity
− GIT:
− GERD, NEC
− Metabolic:
− Impaired temperature & glucose regulation
− Haematology:
− Anemia
− Thrombocytopenia
− Altered pharmacology:
− ↑ volume of distribution
− Opioid sensitivity
− ↓ clearance, protein binding, metabolism
− ↓ MAC
− Immature renal & hepatic function
− Difficult IV access
− Post-op apnea monitoring

Anesthesia considerations:
− Preoperative:
History: Full anesthetic history from the parents focusing on:
▪ Fasting status.
▪ Respiratory tract infection:
Postpone for:
o 2 weeks: Significant URTI (productive cough, purulent chest or nasal secretions, pyrexia)
o 4 weeks: if lower RTI.
o 6 weeks: if bronchiolitis

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 Pediatric formulae
Examination: full examination focusing on:
▪ Respiratory and airway anomalies. General
▪ Cardiac murmurs. − Estimated weight (kg) = 2 × (Age + 4)
▪ Weight measurement. Respiratory
Explanation and consent for regional anesthesia (Caudal) − ETT diameter (mm) = Age/4 + 4
Premedication: − length (cm): age/2 + 12
− LMA size
▪ Oral midazolam: (0.5mg/kg), acts within 15–30 min.
o Size 1 for < 5 kg.
▪ Ketamine orally (2–5mg/kg) as a sole drug or in o size 1.5 for 5–10 kg.
combination with midazolam. (Within 15min) o size 2 for 10–20 kg.
o size 2.5 for 20–30 kg.
− Intraoperative: o size 3 for 30–50 kg.
Circulation
▪ Room preparation:
− Systolic BP = (Age × 2) + 80
A. Equipment: − Adrenaline: 10 mcg/kg
o Cardiopulmonary resuscitation − Atropine: 20 mcg/kg
o Difficult airway trolly, different sizes of − Blood volume: 75 mL/kg
laryngoscope blades, masks, and tubes − Defibrillation: 4 J/kg
o Anesthesia circuits Fluids
− Crystalloid:
o Warming devices o Resuscitation: 20 ml/kg
o Infusion devices (0.9%Nacl)
B. Medications: o Maintenance [Link] for (D5/
o Emergency drugs. 0.45% Nacl)
− RBC units: 10 ml/kg
o Diluted anesthetic drugs.
− Platelets: 10 ml/kg
o Warmed fluids − FFP: 15 ml/kg
o Blood and blood product if required. − Cryoprecipitate: 5 ml/kg
C. Monitoring: − Glucose: 2 ml/kg of 10% dextrose
o Suitable size cuffs, pulse oximeter, Drugs
electrodes − Propofol: 4 mg/kg
− Thiopentone: 3–6 mg/kg
o Precordial stethoscope
− Suxamethonium: 2 mg/kg
D. Room temperature and humidity: − Rocuronium: 0.5–1 mg/kg
o Temperature: 22 – 24 °C − Atracurium: 0.5–1 mg/kg
o Relative humidity 50 to 60%

− Postoperative:
▪ Post-operative pain.
▪ Postoperative apnea.

Foreign body aspiration

Considerations:

− Pediatric patient with potential airway obstruction & respiratory complications:

▪ Ball-valve effect & barotrauma
▪ Bronchospasm, laryngospasm Keywords of this
▪ Edema
▪ Post obstructive pneumonia/sepsis. case:
− Shared airway
▪ Rigid or flexible bronchoscopy (needs good analgesia)
Keep the patient
▪ Trauma to the airway spontaneous, avoid
▪ Difficult ventilation PPV and MR, with the
− Type the foreign body: (Consider early removal if): availability of ENT for
▪ Batteries and chemical-secreting material (airway burn) rigid bronchoscopy,
▪ Peanuts: secrets irritant materials (severe bronchospasm)
and difficult airway
▪ Seeds: absorb water and increase in size (Difficult removal)
equipment.

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Management

1. Assessment:
▪ History:
o Size and nature of the foreign body.
o Timing of aspiration.
o Complications: LOC, chest infection, distress.

▪ Examination:
o Signs of respiratory distress and increased work of breathing (retractions: suprasternal –
intercostal - subcostal, nasal flaring, tripod posturing, tachypnea)
o Auscultation
o Vital data: Spo2, pulse rate

2. Timing of removal:
− If the patient is unstable: push directly to the OR (ENT, second anaesthesiologist)
− If stable:
▪ Completing the fasting hours
▪ Optimization:
o Position:
− If upper airway FB: comfort position.
− If lower airway FB: affected lung down
o Medications:
− Bronchodilators
− Humidified O2, heliox.
− Aspiration prophylaxis
− Dexamethasone: (0.5-1.5 mg kg) to reduce swelling
− Glycopyrrolate to dry secretions
− Antibiotic if required.
o A chest X-ray.

3. Anesthesia management:
− Maintain spontaneous ventilation by inhalational induction + topicalization.
− Avoid MR and PPV to avoid hyperinflation/barotrauma, FB dislodgement/airway
obstruction)
− Before advancing the scope assess the depth of anesthesia by staged stimulation
approach:
▪ Jaw thrust.
▪ Insert oral airway.
▪ Do direct laryngoscopy & spray with lidocaine.
▪ Rigid bronchoscopy
− Maintenance:
▪ Give assisted ventilation via a T-piece attached to the side arm of rigid
bronchoscopy.
▪ High-frequency jet ventilation.
▪ If deeper anesthesia is required for the removal of the FB:
o Propofol bolus to deepen the anesthesia.
o Small dose of rocuronium.

4. Intraoperative complications:
A. Complete airway obstruction:
▪ Call for help.
▪ Ask the surgeon to remove the foreign body
immediately.
▪ If failed, push the foreign body distally into
the right main bronchus to relieve the total
airway obstruction.
▪ If failed, place the patient into the lateral or
prone position.
▪ Finally, cardiopulmonary bypass.
Rigid bronchoscope

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 B. Sudden dropped Etco2 with increased airway pressure:
▪ DD: top:
o Tension pneumothorax
o Severe bronchospasm
o Laryngospasm
o Aspiration
▪ Management: according to the cause:
o Tension pneumothorax: Immediate needle decompression at the 2nd
intercostal space mid-clavicular line.
o Severe bronchospasm: Deep the anesthesia, bronchodilator, steroids,
anticholinergics, Heliox, ECMO
o Laryngospasm: remove the stimulus, deepen the anesthesia, steroid, and
intubate.

C. Aspiration:
▪ Call for help.
▪ Turn the child’s head to the side.
▪ Trendelenburg position and suction the oropharynx.
▪ Intubate, and suction the endotracheal tube.
▪ Ventilate with 100% oxygen.

D. Intraoperative airway edema:

▪ If severe edema, perform a Cuff leak test:
o Place cuffed ETT and measure the airway pressure at which there is an
audible sound of air leak (ideally between 25 and 30 mmHg).
o If no leak at this pressure, keep him intubated overnight.

5. Postoperative stridor

− DD:
▪ Obstruction due to:
o Soft tissue relaxation
o Mucosal edema
▪ Laryngospasm
▪ Bronchospasm from airway irritation of residual foreign body fragments.

− Management:
▪ Immediately attend to bedside.
▪ Call for help.
▪ Check monitor: exclude hypoxia – arrhythmia.
▪ Reviewing what medicines were given in the OR and the PACU
▪ Medications:
o Steroids (dexamethasone 0.5–1.5 mg/kg)
o Humidified oxygen
o Nebulized racemic epinephrine.
▪ If got improved: keep him under observation for 3 hours.
▪ Assess respiration and LOC (If respiratory disturbed or LOC):
o Reintubate with a smaller endotracheal tube and keep him ventilated
overnight.

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 Adenotonsillectomy

Considerations:

− Anesthesia management is tailored according to the indications of the operation:

A. Chronic or recurrent acute tonsillitis:
Postpone for:
o 2 weeks: Significant URTI (productive cough, purulent chest or nasal
secretions, pyrexia)
o 4 weeks: if lower RTI.
B. Obstructive sleep apnea: difficult bag-mask ventilation, pulmonary
hypertension/RVF, respiratory depressant sensitivity, post-op monitoring.
− Shared airway
− Post-op complications: bleeding, negative pressure pulmonary edema, airway
obstruction, apnea, PONV, pain.

Anesthesia management:

Preoperative:

− Routine history and examination focusing on:

▪ OSA and URTI symptoms and signs
▪ Risk factors for increased post-operative complications:
o Obesity (especially if severe) o Craniofacial abnormalities
o Severe OSA o Neuromuscular disorders
o Down syndrome o Sickle cell disease

− Investigations: according to the indications: Polysomnography - Chest x-ray.

− Premedication:
▪ For OSA: avoid sedating drugs.
▪ For tonsillitis:
o Oral midazolam: (0.5mg/kg), acts within 15–30 min.
o Ketamine orally (2–5mg/kg) as a sole drug or in combination with midazolam.

Intraoperative:

− Induction:
▪ For OSA: Inhalational induction, avoid MR, consider using of nasopharyngeal airway, two
hands technique.
▪ For tonsillitis: Inhalational OR IV induction.
− Intubation:
▪ Midline oral RAE tube
− Multimodal analgesia:
▪ Paracetamol - NSAID PR – dexamethasone.
▪ Narcotic:
o For OSA: remifentanil
o For tonsillitis: morphine or fentanyl can be used.
− Antiemetic:
▪ dexamethasone or ondansetron.
− Extubation:
▪ left lateral/head-down (post tonsillectomy position) with Guedel airway.

Postoperative:

− Close monitoring for post-operative complications.

− Discharge:
▪ For patients with risk factors for increased post-operative complications:
o To be admitted to HDU or PICU.
▪ For tonsillitis: after 4-6 hours (day case surgery)

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 Post tonsillectomy bleeding

Considerations:

− Frightened child and anxious parents

− Hypovolaemia
− Full stomach
− Residual effects of the anaesthetic
− Difficult intubation

Management:
Attend -assess- resuscitate – Push.

1. Attend the patient immediately: call for help.

2. Assess:
− Airway: exclude obstruction
− Breathing: pattern of breathing- SpO2 - Administer oxygen via a face mask
− Circulation: signs of dehydration (usually underestimated amount of blood):
▪ Heart rat ▪ Capillary refill time
▪ Respiratory rate ▪ Mental status
▪ Blood pressure ▪ Urine output.
Low blood pressure and an altered state of consciousness are signs of severe volume depletion.
− Review anesthesia record
− Send a sample for cross-matched, CBC, and bleeding tests.

3. Resuscitate:
− Venous access a large-bore cannula, If cannot: intra-osseous.
− Initial fluid management: crystalloid 10-20ml/kg and check the response.
− Further fluid management should be guided by the trends in monitoring and an improvement in
clinical signs.
− Consider blood transfusion if needed.

4. Push
− Once hemodynamic stability is achieved.
− Senior consultant anesthetist for help.
− Room preparation:
▪ Standard equipment
▪ Different laryngoscope blades
▪ ETT a half to one size smaller than used previously,
▪ Two suction devices

Induction:
− Modified RSI with cricoid pressure. In lateral position (if severe bleeding) with ENT surgeon
scrubbed and prepared to perform a tracheostomy.
− If no venous access: Inhalational induction in the supine position with the head down or in the
left lateral position

− Insert NGT to evacuate the stomach (at the end of the procedure or after intubation if
abdominal distension).

Extubation:
− Fully awake head-down left lateral position.
− Postoperatively: Close monitoring for any reoccurrence of bleeding.

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 Down Syndrome
Considerations

− The patient has facial, hand, and foot features.

− Clinically significant features related
to the airway, respiratory, cardiac,
CNS, endocrine, and immunological
systems.

1. Airway and respiratory

− Potential difficult ventilation:
▪ Large tongue
▪ Small mouth
▪ ↑ oropharyngeal soft tissue
▪ high arched palate
▪ Tonsillar & adenoid hypertrophy

− Subglottic stenosis: needs a smaller size tube.

− Atlantoaxial instability:
▪ Potential for neurologic injury with neck manipulation
▪ If there is a need for head positioning:
o Limit the movement – tilt the table not the head.
− OSA:
▪ Sensitive to sedatives/hypnotics
▪ Upper airway obstruction.
− Recurrent upper and lower respiratory tract infections.

2. Cardiac:
− Congenital cardiac defects: (Mostly involve left to right
shunt leading to pulmonary hypertension). subglottic stenosis
▪ Atrioventricular septal defects (AVSD): most common
▪ VSD
▪ PDA
▪ Tetralogy of Fallot
5. GIT
3. Central nervous system ▪ Gastro-oesophageal reflux
▪ Developmental delay 6. Immune
▪ Epilepsy ▪ Immunosuppression
4. Endocrine ▪ Increased infections: Repeated otitis
▪ Hypothyroidism media (hearing loss)
▪ DM 7. Haematology: Leukaemia

Anesthesia management:

Preoperative:

Routine history and examination with adequate evaluation of:

− Airway assessment.
− CVS:
▪ Manifestations of congenital heart disease include:
o Breathlessness and fatigue on exertion
o Central cyanosis
o Finger clubbing
o Heart murmur
▪ Signs of cardiomegaly: displaced cardiac apex
▪ ECG, Echo, and a cardiology opinion (If indicated)

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 − OSA:
▪ Snoring during sleep associated with daytime lethargy and somnolence, behavioral
changes, and documented apnea.
▪ If positive: Polysomnography should be performed before anesthesia.
▪ NOT SUITABLE DAY CASE SURGERY

− Atlanto-axial instability:
▪ Manifestations of cord compression: decreased range of motion and tenderness of
neck, abnormal gait, weakness, increased tendon deep reflexes, positive Babinski
reflex, lower limb clonus, and neurogenic bladder.
▪ Lateral cervical Xray in flexion-extension views is indicated if:
o Positive signs of cord compression.
o Suspected difficult intubation.
o surgery requires a non-neutral position of the neck.
▪ Normal atlanto-axial gap: <4.0mm. neurological symptoms if the gap is >7mm.
− Thyroid function tests.

Medications:
− Aspiration prophylaxis

Intraoperative:

− Monitor:
▪ Standard ASA monitor
▪ If invasive monitor is required, strict aseptic condition.

− Anesthesia plan:
Allow a guardian to attend induction (according to hospital policy)
▪ If cooperative patient:
o Inhalational induction with maintaining cervical spine stabilization (jaw thrust,
oropharyngeal airway, video laryngoscope, FOB, avoid extensive flection or
extension).
▪ IF uncooperative:
o Sedation: midazolam or ketamine or both (BE CAUTIOUS IN OSA)
o Topical EMLA to facilitate IV-line insertion.
o Then IV induction (maintain spontaneous ventilation) with maintaining cervical
spine stabilization (consider airway obstruction)
− Use LMA, if ETT is required use a smaller size.
− Decrease in MAC of inhaled anesthetic agents.
− Multimodal Pain management (reduce narcotics)
− Awake extubation

Postoperative

− Observed closely in the recovery room, monitored with a pulse oximeter.

− Admit overnight if OSA or cardiac defects.

Pyloric Stenosis
Considerations

− Emergency status: NOT surgical emergency (Optimise first then push to the OR)
− Pathophysiology:
Progressive, non-bilious, projectile vomiting between the 3rd and 5th week of life, Leads to:
▪ Dehydration:
o severity is assessed with clinical examination, graded as mild, moderate, and severe.
▪ Metabolic and electrolytes disturbance:
o Hyponatraemia, hypokalaemia, hypochloraemic metabolic alkalosis. (Later on,
metabolic acidosis)
o The urine is initially alkaline and then acidic (paradoxical aciduria).

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 ▪ High risk of aspiration on induction
− Infancy considerations
− DD:
▪ Achalasia of the oesophagus
▪ Duodenal atresia
▪ Jejunal/ ileal atresia
▪ Malrotation of the gut
▪ Intra-abdominal hernia
▪ Meckel’s diverticulum.

Anesthesia management:

Preoperative optimization:
− Assessment and correction of dehydration.
− Correction of metabolic and electrolyte disturbances.
− Empty the stomach to reduce aspiration risk.

1. Dehydration:
− Severity assessment

MILD Moderate Severe

Fluid loss
5% 10% 15%
(% of body wt.)
Ant. Fontanelle Normal Sunken Markedly depressed

Eye Normal Sunken Markedly sunken

Mucus
Moist Dry Markedly dry
membrane
Skin turgor Normal Decreases Markedly decreased

Pulse Normal Increased Markedly increase

Respiration Normal Tachypnea Rapid& deep

UOP (ml/kg/h) <2 <1 < 0.5

− Correction:
▪ Estimated fluid deficit: Weight x fluid loss % (e.g. a 10kg child who is 5% dehydrated has a
water deficit of 500ml.)
o Start by a fluid bolus of 10-20ml/kg (0.9% sodium chloride).
o Further fluid replacement should be continued at a rate of 6-8ml/kg/hour. (0.45%
sodium chloride in 5% dextrose).
o Nasogastric losses should be replaced with 1 ml for ml. (0.9% sodium chloride).
o Once the metabolic targets are nearly achieved, maintenance fluid is
administered at a rate of 4ml/kg/hour.
o Once urine output is established, potassium chloride 20mmol/L can be added to
the replacement fluid.

2. Electrolytes:
▪ checked every 6-12 hours until the resuscitation target is achieved, and then every 24
hours for the duration of fluid therapy.
▪ Correction Target:
o Na > 130 mEq/L
o K > 3 mmol/L
o Cl > 100 mEq/L
o PH <7.5
o HCO3 < 27 mmol/L
o Urine output > 1cc/kg/hr

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 3. Stomach evacuation:
▪ The stomach needs to be decompressed either via NG or OG to remove as much of the
gastric contents as possible.

Anesthesia plan:
− Atropine 20mcg/kg.
− Gastric suction in four positions (supine, lateral. prone)
− Induction:
▪ RSI with cricoid pressure using Propofol 3mg/kg & succinylcholine 2mg/kg.
▪ Awake intubation
− Multimodal analgesia:
▪ Rectal paracetamol rectal loading dose of 30-40mg/kg
▪ The surgical wound infiltration with 0.25% bupivacaine at a dose not exceeding 2mg/kg.
▪ Avoid narcotics.

Postoperative
− Supplemental oxygen.
− Apnoea monitor for 6-12 hours.
− Gradual feeding commenced 12 hours postoperatively.
− Maintenance intravenous fluids continued until feeding is established to prevent
hypoglycemia.

Caudal block
Technique
− Consent from the parents.
− Full preparation with resuscitation equipment and intralipid is available.
− After induction of anesthesia, place the child in the left lateral position.
− Full asepsis with a skin preparation.
− Locate the sacral hiatus by:
a) At the apex of an equilateral triangle with the posterior superior iliac spines.
b) Locate the tip of the coccyx and withdraw the finger cephalad in the midline until
a depression is felt. (The sacral cornua can be palpated just cephalad to it)
− Insert a 20 - 22G cannula at 45 degrees in cephalad direction until a ‘click’ is felt.
− Flatten the cannula or needle slightly, then advance plastic sheath forward a short distance
(the dural sack may terminate at S2 or lower).
− Careful aspiration for blood or CSF should be performed before injection of local
anaesthetic.
− If resistance is encountered or swelling occurs, injection should be terminated and the
cannula should be repositioned.

Local anesthetic administration:

Using Armitage regimen: Additives:
− Drug: L—Bupivacaine − Clonidine 1 microgram/kg (causes post-
− Concentration: 0.25% operative sedation)
− Volume: according to operation site: − Diamorphine 30 mcg/kg
▪ Infraumbilical operation: 0.5 mL/kg − Morphine 50 mcg /kg (preservative-
▪ Up to lower thoracic operation: 1 mL/kg free).
▪ Higher thoracic operation: 1.25 mL/kg − Avoid adrenaline.

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 Tracheoesophageal Fistula

Considerations
▪ Emergency status: To be within 24 hours of birth to minimize risk of complications.
▪ Diagnosis:
At birth with:
o NGT is unable to be passed beyond 9–10 cm from the mouth.
o Increased drooling
o Coughing, choking, and cyanosis with the first feeding.
▪ Types:
According to the classic Gross classification:
o Type A: esophageal atresia with no connection to the trachea (8%).
o Type B: esophageal atresia with a fistula connecting the proximal esophageal
pouch to the trachea (<1%).
o Type C: (the most common type >85%), esophageal atresia with a fistula
connecting the distal esophageal pouch to the trachea.
o Type D: fistulas connecting the proximal and distal esophageal pouches (2%).
o Type E: the “H-type” fistula – intact esophageal with a fistula connecting to
tracheal; with no esophageal atresia (4%).

▪ Pathology:
o Aspiration risk
o Dehydration/acidosis
o GI distension can compromise ventilation, may require urgent gastrostomy
decompression.
o Associated comorbidities: VACTERL.
Considered has VACTERL if three or more of the following:
V: vertebral/skeletal anomalies
A: anal canal defects including anal atresia.
C: cardiac anomalies: VSD, ASD, TOF, right-sided aortic arch, and PDA.
TE: TEF
R: renal dysplasia including malposition, hydronephrosis, and ureteral
abnormalities
L: limb defects including radial aplasia.
o Intraoperative surgical retraction can compress airways, major vessels, & heart
Anesthesia management:
▪ Preoperatively:
▪ Minimize aspiration:
o Decompress blind upper pouch with
NG (a Replogle tube) with continual
suction and irrigation Head-up 30°
position.
o kept NPO once diagnosed.
▪ Correct dehydration and acidosis.
▪ Rapid review to roll out VACTERL.
Replogle tube
12
▪ Intraoperatively:
▪ Monitoring:
Standard ASA + 3Ps
Pre-and post-ductal pulse oximeter (to detect Rt to Lt shunt).
Preductal arterial line.
Precordial stethoscope.
▪ Position: Left lateral for right thoracotomy

▪ Anesthesia plan:
Goals:
− Maintain adequate ventilation without ventilating through the fistula to
avoid abdominal distention.
− ETT TIP PLACED DISTAL TO THE FISTULA AND PROXIMAL TO THE CARINA.
− Avoiding aspiration
− Maintaining normothermia.
− Fluid management.
Induction:
− Spontaneous inhalational induction, place the ETT down the right
mainstem with bevel forward, slowly withdraw the ETT until breath sounds
become equal bilaterally.
− Avoid muscle relaxation and PPV until the ETT position confirmed.

Intraoperative complications:
Desaturation
− DD:
▪ During positioning:
• ETT-related causes:
− Slipped:
▪ Distal into the right mainstem
▪ Proximal: causes gastric distention that compromised
ventilation.
− kinked or disconnected.
− Blocked by mucus and secretions.
• Fogarty catheter: (if used) slipped into the trachea, causing partial
or total occlusion of the trachea.

▪ During the procedure:

• The same as above
• Surgical:
− Manipulation of the (soft) trachea causing kinking or
displacement of the ETT
− Compression of vital structures
− Tension pneumoperitoneum
− Lung atelectasis.
− Management:
− Call for help.
− 100% oxygen
− Notify the surgeon.
− Check other vital signs and send off an ABG.
− Confirm position of the ETT by auscultation with the precordial
stethoscope, and over the epigastric area for an air leak.
− Manually ventilate the patient to assess for compliance and
correct atelectasis (after reassuring the tube position).
Extubation:
− Keep him intubated, sedated, and relaxed for 4-5 days to avoid tension
on the anastomotic site.
▪ postoperative
▪ In NICU
▪ Pain management: fentanyl infusion of 0.5 to 2 mcg/kg/h.
▪ Secure the NGT in place.

13
 Congenital Diaphragmatic Hernia

Considerations
▪ Emergency status: NOT an emergency, to be medically managed prior to surgery.
▪ Diagnosis:
physical exam:
▪ Barrel chest, scaphoid abdomen, bowel sounds on chest auscultation heart sounds
displaced to the right.
▪ Respiratory distress, and hypoxemia.

▪ Pathology:
Respiratory distress, and hypoxemia due to:
▪ Atelectasis from the compression of the abdominal contents
▪ Pulmonary hypoplasia
▪ Persistent pulmonary hypertension causing increased R → L shunting through a PFO and
PDA.

Anesthesia management:

▪ Preoperatively:
▪ Goal of medical optimization:
o Improving oxygenation to have a preductal oxygen saturation >90%
o Correcting acidosis
o Increasing pulmonary perfusion
o Reduction of R → L shunt by maintaining pulmonary vascular resistance (PVR).
▪ To be in the NICU
▪ Immediate intubation (Avoid PPV by face mask).
▪ NGT to decompress stomach.
▪ Maintain PVR by:
A. Avoid factors increasing:
o Hypoxia – acidosis – hypercarbia – sympathetic stimulation – PPV - Hypothermia.
o Avoid 100% oxygen.
B. Measures to decrease:
o NO administration
o Lung protective ventilation strategy:
− Target SaO2 > 85% & permissive hypercapnia (PaCO2 <65 mmHg, pH >7.25)
− PCV or PSV PIP < 25-30 cmH2O
− Inspiratory time 0.35 s
− PEEP 3-5 mmHg
− RR < 65
o HFOV
o ECMO if all measures failed.
▪ ABG, chest x-ray, echocardiogram

▪ Intraoperatively: (after medical stabilization).

▪ Monitoring:
o Standard ASA + 3Ps
− Pre-and post-ductal pulse oximeter (to detect Rt to Lt shunt, If preductal >
post ductal).
− Preductal arterial line.
− Precordial stethoscope.
o Umbilical central line:
− Avoid in lower extremity: due to IVC compression after reduction of the
hernia.
− Avoid neck veins for possible ECMO therapy.
o Urine output

▪ Anesthesia plan:

14
 ▪ Goals:
− Avoid increase PVR.
− Avoid barotrauma.
− Maintaining normothermia.
− Fluid management (target MAP 45-50 mmHg)
▪ Induction:
− Usually intubated.
− Spontaneous inhalational maintenance, avoid muscle relaxation, and
100% O2 to keep Spo2 around 95%.
− Lung protective ventilation strategy (as above).

▪ Intraoperative complications:
• Hypotension with hypoxia:
During the procedure:
DD:
− Top of DD: Pneumothorax in the contralateral lung.
− Other:
o Severe pulmonary hypertension
o Compression of great vessels
o Acute blood loss, hypovolemia
o Allergic reaction to a drug administered.
Management:
− Call for help.
− Check monitor for vital signs to exclude a malignant arrhythmia.
− 100% oxygen temporarily
− inform the surgeon (to release the compression and check bleeding)
− open fluids
− Auscultate the lungs to assess if a pneumothorax, If positive:
o Immediate needle decompression (2nd intercostal space in the
midclavicular line)
o A chest tube placed by the surgeon.
o Avoid hyperventilation to prevent air leak into the pleura.

After abdomen closure:

− Mostly due to inferior vena cava compression leads to venous return.
− Reopen the abdominal cavity and covering the abdominal defect
temporarily with a Silastic patch.
▪ postoperative
▪ Transferred intubated to NICU.
▪ Pain management: fentanyl infusion of 0.5 to 2 mcg/kg/h.

Tetralogy of Fallot
Considerations
Congenital heart defect resulting, with high risk of perioperative cardiac complications.
− Characterized by:
▪ Large VSD
▪ Aorta that overrides RV & LV
▪ RVOT obstruction
▪ Right ventricular hypertrophy
− Resulting in:
▪ Both fixed & dynamic RVOT obstruction
▪ Right to left shunt.
▪ Hypoxia
− Associated conditions:
▪ Paradoxical embolus.
▪ Polycythemia
▪ Tracheoesophageal fistula & trisomy 21

15
Anesthesia management:
Goals:
1. Avoid significant RT to LT shunting:
− Avoid ↓ SVR.
− Avoid ↑ PVR:
▪ Hypoxia, acidosis, hypercarbia, sympathetic stimulation, aggressive PPV/PEEP
− Full preload
− ↓ contractility to reduce dynamic RVOT obstruction.
2. Avoid paradoxical embolism: avoid air bubbles in lines.

Monitoring:
− Standard ASA: (ECG – temperature probe – Rt and LT pulse oximeter)
− Arterial line – CVP
Plan:
− ketamine IV (2mg/kg), then paralyze, then ETT
− If no IV line: Sevoflurane induction, then place IV then paralyze then ETT.
− Avoid propofol/remifentanil to avoid reduction in SVR/contractility.
− SBE prophylaxis

Intraoperative complications:
− Sudden hypoxia:
▪ DD:
on top of DD cyanotic spells due to ↑ R → L shunt caused by:
o Infundibular spasm
o ↓ systemic vascular resistance
o Increased PVR.
▪ Management:
o Call for help:
o Check monitor: level of hypoxia, exclude hypercarbia and malignant
arrhythmia.
o 100% O2 +/- gentle PPV
o Increase preload: Fluid bolus
o ↓ sympathetic drive: morphine 0.1mg/kg
o ↑ SVR:
− Knee chest position.
− Phenylephrine 5 mcg/kg,
o ↓ infundibular spasm: propranolol 0.1-0.3mg/kg.

Repaired Tetralogy of Fallot:

Chronic problems after repair:
− Chronic pulmonary regurgitation, pulmonic stenosis
− RV enlargement & dysfunction
− Aortic root & valve dilation
− Arrhythmias

Epiglottitis

Considerations
It is an emergency condition due to:
▪ Impending airway obstruction:
− Difficult bag mask ventilation & intubation
− Risk of aspiration
− Increased secretions
− Upper airway irritation leads to obstruction: do not upset child or manipulate airway.
▪ Sepsis & need for early goal-directed therapy.
Needs post-op PICU & plan for extubation once process resolved.

16
Anesthesia management:
− Room preparation:
▪ Second anesthetist or anesthesia assistant.
▪ Difficult airway cart, rigid bronchoscopy & tracheostomy set.
▪ ENT ("double set up")

− Premedication:
▪ Aspiration prophylaxis.
▪ Glycopyrrolate 10 mcg/kg to dry secretions

A. Airway management:
− Maintain spontaneous ventilation inhalational induction using styletted, cuffed, and
smaller endotracheal tubes (1-3mm smaller) with ENT is scrubbed and ready for
tracheostomy.

B. Sepsis management
− Obtain CBC & blood cultures.
− Antibiotics: cloxacillin, cetriaxone, ampicillin, clindamycin +/- vancomycin
− Fluid bolus 20 ml/kg, repeat prn.

− Extubation plan:
▪ Ensure there is a leak & swelling has resolved.
▪ Then extubate in the OR & be prepared for re-intubation.

− Transfer to PICU

Cleft Lip & Palate

Considerations
▪ Airway:
− Potential difficult airway
▪ Bag mask ventilation
▪ Direct laryngoscope enters the cleft on insertion: requires support or pack in the cleft.
− Shared airway:
▪ Consider reinforced tube.
− Requires a pharyngeal pack (if applicable to avoid blood clots aspiration)
− Post-op airway complications:
▪ Laryngospasm
▪ Edema/obstruction (surgery makes airway management more difficult)
▪ Swallowing dysfunction:
− Recurrent chest infection
− Restrictive lung disease
− Malnutrition
▪ Associated craniofacial disorders and congenital diseases:
− Pierre-Robin syndrome
− Congenital heart disease.

Anesthesia management:

▪ Preoperatively:
▪ Optimise chest conditions.
▪ Search for other congenital anomalies.
▪ Careful airway assessment.
▪ Correct malnutrition and optimize hydration.
▪ Intraoperatively:
▪ Induction:
o Maintain spontaneous ventilation using inhalational induction, insert a reinforced
tube using a pack in the cleft deft to stabilize the direct laryngoscope, or
alternatively, use FOB through LMA.
▪ Safe post-op airway management

17
Obstetric anesthesia

18
 Physiological and pharmacological changes in pregnancy

Cardiovascular

− Increased CO by 50%. (Up to 80% immediately postpartum).

− Increased SV by 30%.
− Increased HR by 25%.
− Uteroplacental blood flow is not autoregulated, dependent on uterine BP (after the 20th week).
− Aortocaval compression by the gravid uterus results in reduced VR and CO.
− Physiological anemia of pregnancy: due to:
▪ Increased plasma volume by 50% by term
▪ Increased red cell mass only by 30%.
− Hypercoagulable:
▪ Increased concentrations of factors I, VII, VIII, IX, X, and XII
▪ Decreased antithrombin III.

Respiratory
− Increased tidal volume by 45% and a slight increase in rate.
− Increased minute ventilation by 45-50% (mainly due to Vt).
− Decreased FRC: rapid desaturation.
− Increased PaO2, decreased PaCO2, and alkalosis (hyperventilation during labour with Entonox
leads to marked alkalosis)

CNS
− Due to the progesterone effect:
▪ Reduced MAC by 20-30%
▪ Reduced the requirement s of LAs in regional and topical anesthesia.
− Reduced dose in neuraxial blocks due to:
▪ Reduced intervertebral space due to increased lumbar lordosis.
▪ Distended vertebral venous plexuses.
▪ Reduced CSF volume.

Gastrointestinal
− Gastro-oesophageal reflux (up to 48h post-delivery) due to:
▪ Effects of progesterone on the lower oesophageal sphincter
▪ Increasing intraabdominal pressure by enlarging the uterus
− Gastric emptying is normal apart from during labour.

Renal
− Increased RBF by 75% at term, GFR by 50%.
− Both urea and creatinine plasma concentrations fall.
− More glucose is filtered resulting in glycosuria.

Airway:
Increased incidence of airway-related morbidities due to:
1. Increased possibility of intubation difficulty:
▪ Oedema& swelling in upper airway tissue.
▪ Fragile mucosa
▪ Enlarged breasts.
2. Increased risk of aspiration.
3. Rapid desaturation Decreased FRC + Increased O2 consumption)
Consider:
− Preoxygenation
− Aspiration prophylaxis
− Smaller size ETT
− Decrease No of intubation attempts.
− Prepare difficult airway equipment.

19
 Analgesia for labour

Pain pathway
− Uterine pain: T10 to L1
− Perineal sensation: S2 to S4
Pain during labour progress:
− 1st stage: Uterine and visceral pain: T10 – L1
− 2nd stage: as 1st + S2-S4

Painless labour management

20
Epidural anesthesia for Obstetrics
− Contraindications
▪ Patient refusal.
▪ Allergy (true allergy to amide LAs is rare).
▪ Local infection.
▪ Raised ICP
▪ Uncorrected hypovolaemia.
▪ Coagulopathy:

To insert Epidural catheter:

− Platelet count > 75 × 109/L
− Normal clotting screen
− Tests of coagulation and the platelet count should be within 6hr.
− Consider if the trend platelet count is falling.

− Technique:
3 Ps: Preparation, position, puncture
1. Preparation:
− Consent − Equipment check:
− Explain the procedure to the ▪ Emergency resuscitation
patient. equipment
− Review lab and anesthesia ▪ Intralipid availability
evaluation − Establish IV access.
− Apply the maternal monitor. − Aseptic technique
− fatal HR

2. Position:
− full lateral or sitting position.

3. Puncture:
− Median approach:
▪ Skin − Para median approach:
▪ Subcutaneous tissue ▪ Skin
▪ Supraspinous ligament ▪ Subcutaneous tissue
▪ Interspinous ligament ▪ Ligamentum flavum
▪ Ligamentum flavum

− Introduce 4–5cm of the catheter into the epidural space.

− Test dose:
lidocaine 1.5% with epinephrine 1:200,000, in combination with aspiration.
▪ If motor block or CSF backflow on aspiration: intrathecal
▪ If tachycardia >20%: intravascular

− Epidural initiation:
For normal delivery:
A. Loading dose: 8 -15 mL of 0.125% bupivacaine with 2 micrograms/mL of fentanyl.
B. Maintenance: using one of three methods:
1. Patient Controlled Epidural Analgesia:
▪ Rate if infusion: 5–10mL boluses of 0.125% bupivacaine with 2 micrograms/mL of
fentanyl.
▪ Lock out time:10–20min.
▪ Advantage:
o More patient satisfaction.
o Less amount of LAs.
2. A continuous infusion of LA: 5–12mL/hr of 0.125% bupivacaine with 2 micrograms/mL
fentanyl)
3. Intermittent top-ups of LA: 10–15 mL of 0.1% bupivacaine with 2 micrograms/mL of
fentanyl.

For Cesarean section: (target sensory level T4):

A. If proceeded from painless labour to CS:
▪ 10 mL of 2% lidocaine then assess the level.

21
 B. If primarily for CS:
▪ 5 -8 mL of 2% lidocaine with 1:200 000 Adrenaline every 3 min (maximum
dose 7mg/kg (OR)
▪ Five mL of 0.5% bupivacaine/levobupivacaine/ropivacaine every 4–5min,
up to a maximum of 2mg/kg in any 4hr period
Opioid (fentanyl 100 mcg or diamorphine 2.5mg) to improve the block.

− Combined spinal epidural:

− Indications:
▪ Rapid analgesia in women who are unable to cope with labour pain.
▪ preservation of leg strength for women who want to walk in labour.
− Dose:
▪ Intrathecal: 0.5–1mL of 0.25% bupivacaine with 5–25 micrograms/mL of fentanyl.
▪ Epidural: as above.

− Management of poorly functioning epidural:

Problem Management
Global failure Re-insert
▪ Top-up epidural, with the painful side in a dependent position (use LA
and 50–100 micrograms of fentanyl)
Unilateral block:
▪ Withdraw the catheter 2–3 cm and give a further top-up.
▪ Re-site the epidural
▪ Top-up with opioid (50–100 micrograms of fentanyl).
Missed segment:
▪ Continue as per unilateral block
▪ Check sacral block and that the bladder is empty.
Perineal pain ▪ Top up with more LA in the sitting position.
▪ Continue as per unilateral block

− Complications of epidural analgesia

Classified as drug or procedure-related:

1. Drug-related:
− LAST, allergy to LAs, direct LA-induced nervous tissue injury.
2. Procedure-related
− Mild or transient:
▪ Back pain
▪ Pneumocephalus
▪ PDPH
− Potentially life-threatening:
▪ Subdural injection
▪ Total or high spinal
▪ Infectious or aseptic meningitis
▪ Cardiac arrest
▪ Epidural hematoma formation
▪ Permanent neurologic injuries.

− Dural puncture
Immediate management: either:
1. Advance the catheter into the subarachnoid space (Continuous spinal anesthesia)
− Label the catheter clearly as an intrathecal catheter.
− only Anaesthetists are allowed to perform top-ups.
− Dose: top-ups (1.0–2.5mg of bupivacaine + 5–25 micrograms of fentanyl)
− Advantages:
▪ Better analgesia
▪ Less incidence of PDPH (to be remove after 24 hours)
− Disadvantages:
▪ Increased risk of introducing infection
▪ The catheter may be mistaken for an epidural catheter.
2. Reinsert the epidural at a different interspace—usually one interspace higher.

22
 Late management:
It is the management of post-dural puncture headache.

Post-dural puncture headache

− DD:
▪ Migraine or other primary headaches ▪ Infective causes (encephalitis - meningitis)
▪ Preeclampsia/eclampsia ▪ Subdural hematoma
▪ Spontaneous intracranial hypotension ▪ Cerebral venous thrombosis

− Clinical picture
▪ Onset: Typically, 24–48hr post-dural puncture.
▪ Headache:
o Fronto-occipital
o Worsen on standing.
o Relieved by bed rest.
o Associated with neck stiffness.
▪ Nausea
▪ Photophobia and difficulty in accommodation
▪ Severe form: Hearing loss, tinnitus, and 6th nerve palsy with diplopia are possible.
▪ Seizures, subdural hematoma, and cerebral herniation.

− Treatment:
▪ Symptomatic treatment
o Simple analgesics: paracetamol and NSAIDs
o Adequate fluid intake.
o Caffeine/theophylline: act by reducing intracranial vasodilatation.
o Transnasal sphenopalatine block: using topical intranasal local anesthetic.
o Greater occipital nerve block.

▪ Definitive treatment: Epidural blood patch

− Timing: Around 48hr post puncture (highest success rate) decreased if earlier or at any
time if severe symptoms.
− Mechanism of action:
o Blood injected into the epidural space compresses the dural sac and raises the ICP.
o The injected blood forms a clot over the dural tear site, sealing the CSF leak.
− Spinal level: the same or lower interspace of the dural puncture, as the injected blood
spreads cephalad.
− Technique:
o Before procedure:
▪ Consent.
▪ The patient is not feverish, no leucocytosis.
▪ Bed rest before the patch to reduce the CSF volume in the epidural space.
o During procedure
▪ lateral position to minimize CSF pressure in the lumbar dural sac.
▪ Aseptic technique
▪ Two anaesthetists, the most experienced‘epiduralist’insert the epidural
needle; the other take blood from antecubital fossa.
▪ Inject 20 ml of blood slowly through the epidural needle.
▪ Stop injection if back or legs pain develops.
o After procedure:
▪ Bed rest for at least 2hr to allow the clot to form, then allow slow mobilization.
▪ Avoid straining, lifting, or excessive bending for 48hr.

23
 Massive obstetric haemorrhage

Causes of peripartum hemorrhage:

Antepartum Hemorrhage
Considerations
A. Emergency situation required multidisciplinary team coordination:
▪ Experienced anesthetist ▪ Pediatrician
▪ Obstetrician with experience in cesarean ▪ Interventional radiologist
hysterectomy ▪ Vascular surgeon.
▪ Blood bank ▪ Haematology.

B. 2 patients:
▪ Maternal with pregnancy considerations: difficult intubation, aspiration, ↓ time to desaturation,
aortocaval compression.
▪ Fetus: distress
C. Potential for massive hemorrhage, and transfusion, with risk of lethal triad (coagulopathy, acidosis,
hypothermia)

− Goals:
▪ Early intense resuscitation.
▪ Avoid, early detection and management of massive transfusion complications.
▪ Avoid LETHAL TRIADE: hypothermia, acidosis, coagulopathy.
▪ Early diagnosis and management of the bleeding cause.
▪ Considering the concerns related to the mother and the fetus.

Management:
1. Call for help. (Multidisciplinary team).
2. Contact the blood bank for activation of MTP and contact HAEMATOLOGY.
3. Prepare post-operative ICU bed.
4. Start initial management: Follow the ABC approach:
− Airway: maintain the airway.
− Breathing: maintain oxygenation.
− Circulation:
▪ Assess: Vital data, Signs of shock: (capillary refill time, moisture of mucous membranes, skin
turgor, decreased UOP)
▪ IV access - Two14G cannula
▪ Take blood samples for:
o DIC panel: PT -PTT, INR fibrinogen and D dimer
o ABG
o CBC

24
 o Match 6 units.
5. Take a brief history (If available time).
6. Control the bleeding: Shift to OR.
− Room preparation: (call the anesthesia technician and a 2nd anesthetist)
▪ Equipment:
o Cardiopulmonary resuscitative facilities.
o Infusion devices. Double setup before induction
o Blood warmers − Vaginal examination performed with
the immediate capability of
converting to cesarean section
▪ Medications:
under general anesthesia.
o Blood, blood products − The entire obstetric team needs to be
o Hemostatic drugs: Tranexamic acid- Desmopressin. present (anesthesiologist,
o Ca obstetrician, pediatrician, nurse, and
o Uterotonics/tocolytic surgical technician).
o Recombinant factor Vlla. − The patient should have large bore
intravenous access, standard
▪ Monitoring: + (Fetal monitoring). monitoring, and appropriate
anesthetic drugs available in the OR.
o Standard ASA.
o Arterial line.
o Central line for fluid monitoring and vasoactive infusion
o UOP

7. Resuscitation:
− Start with WARMED crystalloid up to 2000ml - colloid up to 1500ml.
− Blood transfusion:
▪ ABO Type: O-negative blood (if no time for testing) or group-specific blood until
crossmatched red blood cells are available.
▪ Blood product ratio protocol:
A. Empiric ratios of [Link] of red cells, FFP, and platelets
B. Point of care: (based on TEG or lab testing):
After 4U RBC give:
o FFP (1 unit for each PRBs unit) If INR >1.5
o Platelets if <50x109/l.
o Cryoprecipitate 1 unit per 5kg, if fibrinogen <1.5 gm/L
o If DIC is suspected, transfuse platelets and cryoprecipitate early.
▪ Consider recombinant factor Vlla 90mcg/kg.
▪ Consider 10 ml Calcium chloride 10% over 10 mins.
− Give tranexamic acid 1gm IV infusion over 10 min then 1 gm after 3 hours.

8. Monitor:
− Blood work should be checked every 2 to 4 hours.
− Coagulation status should be checked every 1 to 2 hours.
− Vital signs should be checked every 15 minutes. Goals of management
− Fetal monitoring.
− Type of anesthesia: GA
▪ Assess the airway.
▪ Temperature >35°C
▪ Induction:
▪ pH >7.3
▪ Base excess < –6
o Aspiration prophylaxis
▪ Lactate < 4 mmol/L
o Preoxygenation
▪ Ionised calcium >1.1 mmol/L
o Modified rapid sequence induction with
▪ Platelet count > 50 × 109/L
cricoid pressure using (ketamine 0.7-1.5 mg/kg
▪ PT <1.5 × normal
Or etomidate 0.3 mg/kg) + (Succ or ▪ INR <1.5
rocuronium if sugammadex available) + ▪ APTT <1.5 × normal
opioid. ▪ Fibrinogen level >2.0 g/L.

Postpartum Hemorrhage
Definition: Cumulative blood loss ≥1000 mL or blood loss with signs or symptoms of hypovolemia within
24 hours postpartum.

The most common cause is uterine atony.

25
Management:
A. If the bleeding intraoperative, the same resuscitation as the antepartum Hge with focusing on
management of the uterine atony.
B. If the patient in recovery area or the ward:
▪ Immediately attend the patient.
▪ Check monitor for vitals.
▪ ABC management.
▪ Review anesthesia chart, how much blood loss has occurred intraoperatively and
postoperatively.
▪ perform a focused physical examination for signs of shock and signs of DIC.
▪ Take blood samples for:
o DIC panel: PT -PTT, INR fibrinogen and D dimer
o ABG
o CBC
▪ Inform the surgeon.
▪ Manage the hemorrhage as antepartum hemorrhage.
Management of uterine atony:
1. Pharmacological:
− Oxytocin (first-line): 10 to 40 units in 500 to 1000 mL normal saline infusion.
− Ergometrine (second line): 0.5 mg IM or slow IV infusion.
− Carboprost: 0.25 mg IM every 15 to 90 minutes up to 8 doses.
− Misoprostol: 0.8 to 1mg sublingually (preferred) or rectally in a single dose
− Carbetocin: 100 micrograms IV over 1min

2. Nonsurgical interventions:
− Uterine massage
− Tamponade: intrauterine balloon or alternative device (e.g., bladder catheter bulb)

3. Surgical interventions
− Uterine compression suture (eg, B-Lynch suture)
− Uterine artery ligation
− Uterine tourniquet
− Resuscitative endovascular balloon occlusion of the aorta (REBOA)
− Internal iliac artery (hypogastric artery) ligation
− Hysterectomy

4. Interventional endovascular procedures

− Selective arterial embolization
− Common iliac artery balloon occlusion

Ecobolics
Drug Nature Dose Side effects
− 2–5IU bolus − Peripheral vasodilatation
Synthetically produced
Oxytocin − 10 -40 IU in 500mL − Drop in systolic BP up to 30%.
hormone
crystalloid, slow infusion − Tachycardia
Long-acting analogue of − Avoid in pre-eclampsia,
Carbetocin 100 mcg IV over 1min
oxytocin eclampsia, and epilepsy
− Nausea and vomiting.
An ergot alkaloid − Systemic vasoconstriction
Ergometrine 0.5mg IM or slow IV
derivative − Avoid in pre-eclampsia,
specific cardiac disease
− Nausea, vomiting.
15-methyl prostaglandin 0.25mg IM every 15min − Diarrhoea.
Carboprost
F2a (max of 2mg) − Pyrexia
− Severe bronchospasm
− Nausea, vomiting.
− Diarrhoea.
Misoprostol PGE1 analogue 0.8–1mg PR
− Pyrexia
− Severe bronchospasm

26
 Preeclampsia

Considerations

Multisystem disease increases the risk of perioperative morbidity.

1. Pathophysiology:
− DD: Severe preeclampsia:
▪ Pre-existing hypertension: pre-pregnancy or <20 weeks
▪ SBP ≥160 mmHg or DBP ≥110 mmHg.
▪ Pregnancy-induced hypertension.
▪ Proteinuria more than 5 g/24 h, sudden oliguria.
▪ Preeclampsia ▪ Preeclampsia + one of:
− Maternal:
− Diagnosis: ▪ Evidence of end organ damage.
1. > 20 weeks gestation. o CNS: headache, vision disturbance,
2. Hypertension: >140/90 mmHg. cerebral edema, ↑ ICP
o Liver dysfunction - right upper quadrant
3. Proteinuria: > 300 mg/ 24 h
pain.
o Thrombocytopenia.
With Multisystem disease: o HELLP.
▪ Airway: edema (increased difficulty) o Epigastric pain
▪ CVS: o Pulmonary edema.
o Reduced circulating volume, − Fetal compromise:
▪ IUGR, oligohydramnios, no reassuring fetal
o ↑ SVR, hypertensive crisis, LV Dysfunction
testing.
▪ Renal: oliguria, ATN
▪ Coagulopathy: thrombocytopenia, MAHA, risk of DIC
▪ ↓ uteroplacental perfusion, IUGR, placental abruption

2. Medications:
▪ Antihypertensive
▪ MgSo4:
The therapeutic range is 2–4 mmol/L.
o Effect: (VAST)
− V: vasodilation–hypotension.
− A: anticonvulsant.
− S: sedative, skeletal muscle relaxant
− T: tocolytic (decreases uterine activity) which increases uterine blood flow.

o Side effects: treated with IV calcium (10mL of 10% calcium chloride or gluconate)
− Loss of deep tendon reflexes, blurred vision > 5 mmol/L
− Respiratory depression > 6-7 mmol/L
− Cardiac conduction defects > 7.5 mmol/L
− Cardiorespiratory arrest >12 mmol/L
− If oliguria: Reduce the infusion rate.

o Contraindications:
− Myasthenia gravis
− Heart block, myocardial damage
− Renal failure
− Hypermagnesemia

Management:
Goals:
1. Control Blp:
Target to be <160/110 mmHg:
▪ Oral:
o Labetalol: 100-400 mg TID
o Nifedipine (10- 20 mg) BID.
o Alpha methyl dopa: 250 – 1000 mg TID.
o Avoid ACEI.

27
 ▪ Rapid control of severe hypertension:
o Labetalol (5–10mg IV every 10min OR infusion.
o Hydralazine (5mg IV - maximum of 20mg)
2. Optimize fluid status.
▪ Avoid overhydration.
▪ Total fluid intake is < 80mL/hr.
▪ Measure the hourly urine output.
3. Prevent seizures: Magnesium prophylaxis.

Timing of delivery:

Anesthesia plan:
− Multidisciplinary team: (Anesthetist, intensivist, neonatologist, obstetrician)
− Large Iv line
− Invasive monitoring in severe preeclampsia
− Focusing on:
▪ Airway assessment.
▪ Coagulation status.
− Avoid Ergometrine
− Consider post operative ICU or HDU

Regional anesthesia (epidural) is the preferred technique.

− It is UNSAFE if:
▪ Platelet count < 75 × 109/L
▪ Coagulopathy within 6hr
▪ Falling platelet count within 3 hours.
▪ Antiplatelet agents

28
Eclampsia
Is an emergent, life-threatening event (ABC Approach)

Management

1. Immediate:
− Call for help.
− Airway: (left lateral position with jaw thrust)
− Breathing: (bag-and-mask, ventilation, and measure O2 saturation)
− Circulation: (IV access, measure BP, and avoid aortocaval compression).
− Control fits with magnesium:
▪ Load with 4g IV over 5min, followed by 1g/hr for 24hr.
▪ Recurrent seizures should be treated with 2–4g bolus over 5min.
▪ If MgSO4 contraindicated or ineffective:
o Benzodiazepines and phenytoin.
− Antihypertensive therapy (labetolol 10-20mg IV or hydralazine 5-10mg IV)

2. Further obstetric management:

− The patient should be stabilized on magnesium, and then consideration given to vaginal or
operative delivery.
− Care should be continued on the HDU or ICU.
− Eclampsia is not an indication for an emergency Caesarean section unless:
▪ Fetal distress.
▪ Persistent fetal bradycardia.

29
 Amniotic fluid embolism

Considerations
− Pathology:
It is an anaphylactic response to fetal tissue leads to Life threatening conditions with multi-system
derangements.

− Clinical Features (often a diagnosis of exclusion)

Sudden:
▪ Restlessness, agitation, numbness, tingling.
▪ Hypotension, biphasic cardiovascular collapse:
o First phase (initial 15-30 min): RV failure & acute pulmonary hypertension
o Second phase: LV failure
▪ Bronchospasm, hypoxemia, pulmonary odema, respiratory failure
▪ Coagulopathy: DIC
▪ Seizures/coma

− Differential Diagnosis:
▪ Obstetrical: o Pulmonary embolism
o Placental abruption o Sepsis
o Eclampsia o Anaphylaxis
o Uterine rupture or laceration o Venous air embolism
o Uterine atony o Transfusion reaction
o Peripartum cardiomyopathy ▪ Anesthetic:
▪ Non-obstetrical: o High neuraxial
o Myocardial infarction o Local anesthetic toxicity

− Management:
treatment is mainly supportive: (ABC approach)
▪ Call for help.
▪ Airway, breathing: intubate, 100% O2.
▪ Circulation:
o Fluid resuscitation in increments, avoid fluid overload.
o Support:
− Initially, vasopressors: start with norepinephrine.
− Then inotropes in 2nd phase:
− Inodilators if needed: dobutamine, milrinone.
▪ Monitoring:
o Invasive monitoring: arterial line, CVP monitoring.
o TEE
▪ Treat coagulopathy:
o Initiate massive hemorrhage protocol.
o Correct INR/PTT & platelets
o Ensure normothermia & normocalcemia.
▪ Fetus management:
o Institute fetal monitoring
o Deliver fetus if fetal distress or maternal cardiopulmonary arrest.
▪ If cardiac arrest → follow ACLS guidelines with obstetrical modifications
▪ Post resuscitation care in ICU

Surgery during pregnancy

− Timing of surgery:
▪ Emergency: performed regardless of the trimester.
▪ Non-urgent but cannot wait until delivery (cholecystectomy): to be performed in the second
trimester.
▪ Completely elective: To be delayed until after delivery.

30
− Considerations:
Maternal and fetal considerations:
▪ Maternal: physiological changes of pregnancy
o Gastric acid prophylaxis.
o DVT prophylaxis from the 1st trimester.
o Aortocaval compression: > 20 weeks
o Consider regional anaesthesia.
o Airway in the 1st and early 2nd trimesters remains as nonpregnant.
o Treat haemorrhage aggressively
▪ Fetal:
o Teratogenic effect: in the 1st trimester (midazolam – N2O)
o Fetal death:
− Fetal monitoring.
− Maintain UBF
o Premature labour:
− Obstetric and Pediatrics teams consulted.
− Consider steroid (lung maturity)
− Availability of NICU
− Tocolytic medications: (It’s Not My Time):
• Indomethacin (NSAIDs): avoid after 32 weeks.
• Nifedipine (CCB).
• MgSo4
• Terbutaline (B2 agonist).

Cervical Cerclage
− Considerations
Surgery during pregnancy (see above)
− Anesthesia management:
▪ Goals:
o Produce adequate analgesia (T10 – S4)
o Prevent increase in intrauterine/intraabdominal pressure.
▪ Type of anesthesia:
Depends on degree of cervical dilation and membrane bulging:
o If there is cervical dilatation + membrane bulging: GA.
o If NO cervical dilatation OR dilatation without membrane bulging: Regional anesthesia

31
 Perimortem cardiac arrest
Modifications of ACLS in maternal cardiac arrest:
1. Chest compression is higher and deeper.
2. Early intubation (suspected difficult intubation, most experienced should perform)
3. IV line to be supradiaphragmatic.
4. Relieving aortocaval compression.
5. If No ROSC in 4 min, Perimortem CS over one min.

Other considerations:
▪ If on mgSo4, stop and start Ca chloride or gluconate.
▪ Remove fetal monitoring.

Common causes of maternal cardiac arrest:

− Anesthesia complications − Drugs

▪ High neuraxial block ▪ Oxytocin
▪ Aspiration ▪ Magnesium
▪ Local anesthetic toxicity ▪ Opioids
▪ Hypotension ▪ Anaphylaxis
▪ Respiratory depression ▪ Drug administration error
− Accidents − Embolism
▪ Trauma ▪ Pulmonary embolus
▪ Suicide ▪ Amniotic fluid embolus
− Bleeding ▪ Venous air embolism
▪ Uterine atony ▪ Cerebrovascular event
▪ Placenta accreta − Fever
▪ Placental abruption and previa ▪ Sepsis
▪ Uterine rupture ▪ Infection
▪ Coagulopathy − General
▪ Transfusion reaction ▪ Hypoxia
− Cardiovascular ▪ Hypovolemia
▪ Arrhythmia ▪ Hypokalemia/hyperkalemia
▪ Myocardial infarction ▪ Tamponade
▪ Congenital heart disease ▪ Toxins
▪ Aortic dissection − Hypertension
▪ Heart failure ▪ Pre-eclampsia and eclampsia
▪ HELLP syndrome

32
Anesthesia for cardiac diseases

33
 Pre-operative cardiac risk evaluation and management

Stepwise approach management of cardiac patient for non-cardiac surgery

Step 1: surgery emergency status

Step 2: presence of active cardiac condition

Step 3: risk of the surgical procedure

Step 4: Level of the functional capacity

Step 5: for the patient with poor functional capacity, what is the surgical procedure risk?

Step 6: presence of clinical risk factors.

Step 7: Non-invasive testing

Active cardiac conditions:

Surgical risk factors

Functional capacity assessment

34
Clinical risk factors

The stepwise approach

35
 Valvular heart diseases

Aortic stenosis

Considerations
1. Increased risk of perioperative cardiovascular complications (MI, CHF, arrhythmias).
2. Pathology:
It is a low-fixed CO lesion due to fixed left ventricular outflow obstruction (LVO).
a. Consequence:
1. LVO reduces blood flow through the aortic valve during systole.
2. Increased LV afterload leads to LVH which causes:
− Diastolic disfunction
− Myocardial ischemia as coronary perfusion pressure (CPP) = Aortic diastolic
pressure (ODP)-LVEDP (after load maintenance is mandatory)
3. Late: Systolic dysfunction and decreased CO leads to heart failure.
4. Potentially ineffective CPR.
3. Symptoms of severity:
− Syncope
− Chest pain
− Heart failure

4. Comorbidities and complications:

− Coronary artery disease (CAD): 50% of patients.
− Other valvular disease D
− Pulmonary hypertension
− Sudden cardiac death/malignant arrhythmia
5. Medications
6. Timing of non-cardiac surgery:
According to the emergency status:
A. If emergency:
− Proceed to the surgery (no time for optimization)
− Consider the planning for intra and post-operative management.
− Postoperative ICU bed.

B. If time-sensitive: e.g., Cancer or carotid endarterectomy:

− Multidisciplinary team decision.
− Consider Balloon Valvoplasty (BVP). (if severe lesion)
− In a specialized tertiary center.

C. If elective:
− Multidisciplinary team decision
− Postpone for valve replacement if severe lesion.

Anesthetic management

The primary goal is to avoid myocardial ischemia.

How:
▪ Preload: maintain adequate intravascular volume to fill non-compliant ventricular
chamber.
▪ Rate: low normal (maximize diastolic filling & coronary perfusion)
▪ Rhythm: sinus (atrial kick contributes up to 40% of total cardiac output)
▪ Contractility: maintain.
▪ Afterload: maintain (coronary perfusion pressure)

36
Preoperative:

General preoperative assessment focusing on assessment of severity:

− History:
▪ A triad of syncope – chest pain – HF (severe lesion)
▪ Functional capacity.
− Examination:
▪ Signs of heart failure
▪ Signs of end-organ damage
▪ Murmur: mid systolic ejection murmur heard best at the right upper sternal
border radiating to the neck and carotid arteries
− Investigations: Echocardiography to assess:
▪ Valve area: <1 cm2 is severe.
▪ Trans-valvular gradient of >40 mmHg is severe.

Mild Moderate Severe Critical

Aortic valve area (cm2) > 1.5 1.5 -1.0 < 1.0 > 0.7

Mean gradient (mmHg) < 20 20 - 40 > 40 > 50

Intraoperative

A. Room preparation:
− Monitors: invasive monitoring transducers (arterial line – CVP – TEE)
− Equipment:
▪ Cardiopulmonary resuscitative facilities.
▪ Defibrillator with pads attached to the patient.
▪ Warmers
▪ Cardiopulmonary bypass machine (CPB) if cardiac arrest
− Medications:
▪ Phenylephrine
▪ NA
▪ Digoxin
▪ Esmolol

B. Monitoring:
− arterial line before induction
− Central line after induction
− TEE
C. Type of anesthesia:
− GA is the ideal choice.
− Avoid neuro-axial in severe cases.
− Induction:
▪ Etomidate 0.2-0.3 mg/kg , fentanyl, lidocaine IV, and MR
▪ Avoid pressor response.
▪ Esmolol is available if sympathetic stimulation with intubation.

D. Intraoperative complications:
− Hypotension:
▪ Call for help.
▪ Check monitor:
• Recycle the non-invasive cuff and check arterial wave.
• Exclude hypoxia- hypercapnia – malignant arrhythmia.
▪ Inform the surgeon to check the field for bleeding.
▪ Manage:
• 100% O2.
• IV fluids (be cautious)
• If with bradycardia: NA
• If with tachycardia: phenylephrine

37
 − Atrial fibrillation:
▪ Call for help.
▪ Monitor:
• Confirm Blp reading.
• Check carotid pulsation.
• Exclude hypoxia – hypercarbia.
▪ Manage:
• Apply 100% O2.
• Synchronized cardioversion (120-200 J).
• Consider sedation in awake patients.
▪ Search for the cause (send STAT labs including ABG, H/H, electrolytes,
cardiac enzymes, and a basic chemistry panel)

− Hypertension:
▪ Call for help.
▪ Check monitor:
• Recycle the non-invasive cuff and check arterial wave.
• Exclude hypoxia- hypercapnia – malignant arrhythmia.
• Ensure the level of anesthesia- analgesia – relaxation.
▪ Manage:
• 100% O2.
• Esmolol IV bolus
• Avoid vasodilators or CCB in severe lesions.
• Digoxin: if pulmonary oedema.

− Extubation: smooth extubation.

Postoperative:
− In ICU or HDU
− Avoid hypothermia.
− Adequate pain management: multimodal – PCA.

Aortic stenosis in pregnancy

Considerations:
1. Implications of physiological changes of pregnancy on AS:
− Increased blood and plasma volume: → potential for volume overload.
− Decrease in hematocrit: → decreases oxygen delivery.
− Decrease diastolic and systolic blood pressure & SVR: →decreases coronary perfusion
pressure.
− Increased HR: → Decreases coronary filling time.
− Aorto-caval compression: → low cardiac output
− Avoid lithotomy position.
2. Severe symptomatic aortic stenosis is a contraindication for pregnancy.
3. Labour and assisted vaginal deliveries are preferred.
4. In patients with severe AS, general anesthesia remains the gold standard.
5. The goals of anesthetic management: the same as non-pregnant + avoiding aortocaval
compression
6. Oxytocin should be administered judiciously as infusion and bolus should be avoided.

Aortic stenosis with difficult airway

Airway management:
Drug-assisted awake tracheal intubation. The main goal is avoidance of pressor response and
sympathetic stimulation.

38
 Aortic regurgitation (AR)

Considerations
1. Increased risk of perioperative cardiovascular complications (MI, CHF, arrhythmias).
2. Pathology:
− Chronic AR:
▪ volume overload of the left ventricle (LV) with eccentric LV dilation.
▪ Dilated cardiomyopathy in advanced stages
▪ Decreased myocardial contractility and cardiac output (CO)
▪ Increased left atrial (LA) and pulmonary artery pressures (PAP)
− Acute aortic regurgitation:
D cardiogenic shock & pulmonary edema
▪ Sudden increase in LV volume,
▪ ↑ sympathetic drive

3. Comorbidities and complications:

− Aortic arch dilation: Marfan’s syndrome – ankylosing spondylolysis – Aortic dissection.
− Other valvular disease: Aortic stenosis.
− Coronary artery disease
− Pulmonary hypertension
4. Medications

Anesthetic management

The primary goal is to decrease the regurgitant volume (fast and loose)
− How:
▪ Preload: Normal to high to augment cardiac output.
▪ Rate: fast HR (80 to 100 bpm)
▪ Rhythm: Sinus
▪ Contractility: maintain or augment
▪ Afterload: Normal to low afterload to promote forward flow

Preoperative:

General preoperative assessment focusing on assessment of severity:

Severe lesion:
− History:
▪ Heart Failure
− Investigations: Echocardiography to assess:
▪ Regurgitation fraction: > 50%
▪ LV ejection fraction: < 40 %

Mild Moderate Severe

Regurgitation fraction % < 20 20 – 50 > 50

LVEF % < 40

− If elective surgery with severe symptomatic lesion: postpone for aortic valve correction
procedures.
− If not: proceed to surgery.

Intraoperative:

− Monitor: no need for invasive monitoring unless severe symptomatic patient.

− Type of anesthesia: both GA and regional are accepted.
− If regional: titrated epidural is preferable.

39
 − Intraoperative complications:
− Bradycardia:
▪ Ephedrine
▪ Glycopyrrolate if necessary
▪ Low-dose infusion of epinephrine if necessary

− Hypertension:
▪ Providing adequate anesthetic depth and effective analgesia
▪ Restrictive fluid management
▪ Intravenous nitroglycrin infusion for volume overload

− Hypotension
▪ Dobutamine is the drug of choice.
▪ Careful titration of ephedrine.
▪ Consider milrinone.

Mitral stenosis

Consideration:
1. Increased risk of perioperative cardiovascular complications.
2. Pathology:
Decreased blood flow through the valve which affects:
− LV: decreased LVEDV and CO.
− LA: Volume overload and dilatation leads to:
▪ Arrhythmia
▪ Stagnation and atrial thrombosis
▪ Lt recurrent laryngeal nerve injury.
− Pulmonary pressure: elevated pulmonary venous then arterial pressure.
− RA dilation and TR.
3. Comorbidities and complications:
− Other valvular lesions
− Rheumatic heart disease.
− Collagen diseases: Marfan’s – rheumatoid arthritis
− Pulmonary hypertension
− AF – thrombosis
4. Medications:
− Anticoagulants
− Antiarrhythmic
5. Timing of non-cardiac surgery: As for aortic stenosis

Anesthetic management
The primary goal is to avoid developing heart failure and pulmonary edema.
How:
▪ Preload: maintain adequate intravascular volume to fill the ventricular chamber.
▪ Rate: low normal (60-80/min) is more important than rhythm.
▪ Rhythm: sinus (atrial kick contributes up to 40% of total cardiac output)
▪ Contractility: Maintain
▪ Afterload: Maintain
▪ Pulmonary vasculature: Avoid factors precipitating PHT (hypoxia – hypercarbia – acidosis –
sympathetic stimulation).

Preoperative:

General preoperative assessment focusing on assessment of severity:

− History:
▪ NYHA class ΙΙΙ or ΙV (severe lesion)
▪ Functional capacity.
− Examination:
▪ Signs of heart failure and pulmonary odema.

40
 − Investigations: Echocardiography to assess:
▪ Valve area: <1 cm2 is severe.
▪ Trans-valvular gradient of >10 mmHg is severe.

Mild Moderate Severe

Aortic valve area (cm2) > 1.5 1.5 -1.0 < 1.0

Mean gradient (mmHg) <5 5 - 10 > 10

Intraoperative

A. Room preparation:
− Equipment:
▪ Cardiopulmonary resuscitative facilities.
▪ Defibrillator with pads attached to the patient.
▪ Warmers
− Medications:
▪ Phenylephrine
▪ NA
▪ Adrenaline

B. Monitoring:
− arterial line before induction (if severe)
− Central line after induction
− TEE
C. Type of anesthesia:
− GA is the ideal choice.
− Avoid neuro-axial in severe cases.
− Induction:
▪ Narcotic-based, Lidocaine IV, etomidate 0.2-0.3 mg/kg, and MR
▪ Avoid pressor response.
▪ Esmolol is available if sympathetic stimulation with intubation.

D. Intraoperative complications:
− Hypotension:
− Call for help.
− Check monitor:
• Recycle the non-invasive cuff - arterial wave.
• Exclude hypoxia- hypercapnia – malignant arrhythmia.
− Exclude increasing pulmonary vascular resistant precipitating factors.
− Inform the surgeon to check the field.
− Manage:
• 100% O2.
• IV fluids (be cautious)
• If with bradycardia: NA
• If with tachycardia: phenylephrine
• If failed, adrenaline.

− Atrial fibrillation:
− Call for help.
− Monitor:
• Confirm Blp reading.
• Check carotid pulsation.
• Exclude hypoxia – hypercarbia.
− Manage:
• Apply 100% O2.
• Synchronized cardioversion (120-200 J).
• Consider sedation in awake patients.
− Search for the cause (send STAT labs including ABG, H/H, electrolytes,
cardiac enzymes, and a basic chemistry panel)

41
 − Hypertension:
− Call for help.
− Check monitor:
• Recycle the non-invasive cuff - arterial wave.
• Exclude hypoxia- hypercapnia – malignant arrhythmia.
• Ensure level of anesthesia- analgesia – relaxation.
− Manage:
• 100% O2.
• Avoid vasodilators or CCB in severe lesions.
• Management of pulmonary edema

E. Extubation: smooth extubation.

Postoperative:
− In ICU or HDU
− Avoid hypothermia.
− Adequate pain management: multimodal – PCA.

Mitral stenosis in pregnancy

1. Risk:
− Mild to moderate MS without severe pulmonary HTN is considered low maternal or fetal
risk.
− Mitral stenosis with NYHA class II-IV symptoms is considered high maternal risk.
2. Anesthetic options:
− Vaginal delivery
▪ Symptomatic patients will require invasive monitoring.
▪ Adequate analgesia for first stage (epidural)
▪ Second stage should be assisted by low forceps/vacuum.
− Caesarean section
▪ Epidural is the preferred method (if not severe).
▪ If GA required need to keep goals.

Mitral regurgitation

Considerations
1. Increased risk of perioperative cardiovascular complications (CHF, arrhythmias).
2. Pathology:
− Chronic MR:
▪ volume overload of the left Atrium (LA) and enlargement which leads to:
• Atrial dysrhythmias (AF).
• Increased pulmonary vascular resistance (PVR) and pulmonary artery pressure.
▪ Left ventricle (LV) volume overload.
▪ LV ejection fraction typically overestimates (if LVEF is reduced, it means significant
ventricular dysfunction).
− Acute mitral regurgitation:
▪ Sudden increase in LA volume, cardiogenic shock & pulmonary edema
▪ ↑ sympathetic drive

3. Comorbidities and complications:

▪ Marfan’s syndrome –SLE.
▪ Other valvular disease: mitral stenosis.
▪ Coronary artery disease
▪ Pulmonary hypertension
▪ AF

4. Medications

42
Anesthetic management

The primary goal is to decrease the regurgitant volume (fast and loose)
How:
▪ Preload: Normal to high to augment cardiac output.
▪ Rate: fast HR (80 to 100 bpm)
▪ Rhythm: Sinus
▪ Contractility: maintain or augment
▪ Afterload: Normal to low afterload to promote forward flow
▪ Pulmonary vasculature: Avoid factors precipitating PHT (hypoxia – hypercarbia – acidosis –
sympathetic stimulation).

Preoperative:
General preoperative assessment focusing on assessment of severity: Severe lesion:
− History:
▪ Heart Failure – pulmonary odema.
− Investigations: Echocardiography to assess:
▪ Regurgitation fraction: > 50%
▪ LV ejection fraction: < 60 %

Mild Moderate Severe

Regurgitation fraction % < 20 20 – 50 > 50

LVEF % < 60

− If elective surgery with severe symptomatic lesion: postpone for aortic valve correction
procedures.
− If not: proceed to surgery.
Intraoperative:

− Monitor: no need for invasive monitoring unless severe symptomatic patient.

− Type of anesthesia: both GA and regional are accepted.
− If regional: titrated epidural is preferable.

− Intraoperative complications:
− Bradycardia:
▪ Ephedrine
▪ Glycopyrrolate if necessary
▪ Low-dose infusion of epinephrine if necessary

− Hypertension:
▪ Providing adequate anesthetic depth and effective analgesia
▪ Restrictive fluid management
▪ Intravenous nitroglycrin infusion for volume overload

− Hypotension
▪ Dobutamine is the drug of choice.
▪ Careful titration of ephedrine.
▪ Consider milrinone.

Pregnancy Considerations:
The consideration as aortic regurgitation with considering avoidance of factors those
precipitate increased pulmonary vascular resistance.

43
 Fontan Physiology

Background
It is the last step of the palliative procedures for patients with
univentricular physiology (hypoplastic left heart syndrome).

Basically: the normal cardiac blood flow from the atria to the ventricles
is replaced by:

− Single dominant ventricle pumps the blood to the systemic

circulation.
− The venous return by passive flow of the blood through a cavo-
pulmonary connection to the pulmonary circulation (NO active
pumping of blood through the lungs).
− The driving force for blood flow through the pulmonary circulation
is the difference between central venous pressure (CVP) & atrial
pressure.

Therefore: Cardiac output is dependent on pulmonary blood Flow

(volumic status + pulmonary vessels diameter)

Considerations:

1. Pathology:
− Complexed congenital heart disease patient with altered cardiac anatomy & potentially
other congenital anomalies.
− High-risk cardiac patient, consider surgery at tertiary cardiac centre.
− Consultation with cardiology for assessment and anticoagulation bridging.
− Consideration of bacterial endocarditis prophylaxis.
2. Comorbidities:
− Venous congestion: protein losing enteropathy, CKD, hepatic failure, FTT.
− Arrhythmias, embolic stroke
− LV dysfunction
− Hypoxemia & hyperviscosity.
3. Medication management:
possible beta blockers, ACEI, anticoagulants, diuretics.
4. Postoperative monitoring in HAU/ICU

Anesthesia management:
Goals
A. Pulmonary vascular resistance: keep low.
B. Hemodynamic:
▪ Preload: keep full, avoid dehydration
▪ Rate & rhythm: strict normal sinus rhythm
▪ Contractility: maintain.
▪ Afterload: maintain.

Preoperative:
− To be in specialized tertiary centre.
− Review information from patient’s cardiologist; changes in patient’s exercise tolerance, level of
cardiac impairment, details of the patient’s physiology, anatomy, & any residual & sequelae of
previous surgeries
− Check the battery status and prepare for backup power source.
− Multidisciplinary team (anaesthetist – cardiologist - cardiothoracic)
− Minimize NPO interval.
− Maintain preload
− Prophylactic antibiotic for infective endocarditis
− Anticoagulant bridging.

44
 Room preparation:
− Check the availability of TEE – other monitoring equipment.
− Cardiopulmonary resuscitation facilities

Intraoperative:

Key points:
− Maintain low PVR.
− Maintain adequate preload.

− Invasive monitoring: TEE (most important) - CVP – arterial line

Type of anesthesia:
1. Titrated epidural anesthesia: the safest technique (consider adequate hydration and fluid
status monitoring)
2. IF GA:
− Goals to be ensured:
▪ Avoid increase in PVR (Avoid hypercarbia, hypoxemia, acidosis, stress, pain,
histamine release medications)
▪ Avoid high intrathoracic pressures.
▪ Maintain preload.
▪ Avoid cardiac depressants.
− Spontaneous ventilation is the best.
− If PPV:
▪ Limit peak inspiratory pressure (<20 cmH2O
▪ Low respiratory rates (<20 bpm)
▪ Short inspiratory times
▪ Avoid excessive positive end-expiratory pressure.
▪ Moderately elevated tidal volumes (10–15 mL/kg)
− Induction: Ketamine – fentanyl – Esmoron.
− Complications:
▪ Hypotension: fluids + inotropes.

If Pneumoperitoneum is asked by the surgeon:

− Better to avoid (discuss with the surgeon)
− If required:
▪ Consider gradual rising of the pressure.
▪ Maximum pressure is 8-10 cmH2O.
▪ If haemodynamic instability, shift to open technique.

If Pregnant for CS:

− The anesthesia plan of choice is titrated epidural anesthesia.
− Avoid aorto-caval compression.
− Uterogenic medications: slow infusion oxytocin.

Postoperative:
− Maintaining volume status, acid-base balance, & cardiac output are essential in the
postoperative period.
− Avoid PONV to permit adequate hydration.
− Ensure adequate hydration.
− Adequate analgesia improves pulmonary mechanics & oxygenation.

45
 Cardiomyopathy

Considerations:
− Increases the risk of perioperative compromise: CHF, dysrhythmias, emboli, MI.
− AICD/pacemaker considerations if applicable
− Comorbid disease including possible systemic implications of etiology (eg. infiltrative disease)
− Medication management: beta blockers, ACEI, anticoagulation, diuretics

Types

Restrictive Dilated Hypertrophic

− Amyloidosis − Idiopathic (50%) − HOCM
− Hemochromatosis − Ischemic (7%) − Hypertensive
− Sarcoidosis − Valvular cardiomyopathy
− Scleroderma − Viral − Valve lesion (AS)
− Radiation-induced − Alcoholic
Etiology − Idiopathic − Toxic (cocaine,
chemo, radiation)
− Familial
− Peripartum
− Duchenne's

Pathology Diastolic failure Systolic failure Diastolic - Systolic

Preload Maintain normovolemia Maintain Full

HR High normal - Sinus Normal - sinus Low normal - sinus

goals
Contractility Maintain Maintain Decrease

Afterload maintain Maintain - decrease Maintain

Anesthesia management:

− Detailed review of functional capacity, echocardiogram, cardiology consults and medications

− Prepare vasopressors, inotropes.
− Invasive monitoring: arterial before induction, central line- TEE.
− Plan of anesthesia according to the goals of each type.

Peripartum Cardiomyopathy
− Definition: new heart failure that develops in the last month of pregnancy or in the first 5 months
postpartum
− It is a dilated cardiomyopathy.
− Echocardiogram findings: global dilation & dysfunction, strict criteria for EF ≦ 45%
− Epidural, spinal & GA are acceptable if goals met.
− If decompensated: GA is the option of choice.

46
 Cardiac Tamponade

Considerations:
1. Emergency with potential for cardiovascular collapse on induction.
2. Pathophysiology
− Impaired diastolic filling
− Fixed stroke volume
− Rate-dependent cardiac output
3. Diagnosis:
− Beck’s Triad: hypotension, elevated jugular venous pressure and muffled
heart sounds
− Dyspnoea, tachycardia
− Pulsus paradoxus
− Echocardiography
▪ Pericardial fluid can be visualized.
▪ Diastolic collapse of the anterior right ventricular free wall, right
atrium, left atrium.
▪ Increased left ventricular diastolic wall thickness.
▪ Inferior vena cava dilatation, without respiratory variation in size
4. Etiology/co-existing diseases:
− Blood: post-cardiac surgery, post-MI, aortic dissection, trauma
− Other: infectious, malignant, radiation, SLE, uremia, autoimmune,
pericarditis

Management:
− An emergency condition, multidisciplinary team
− ABC approach.
− If significant hemodynamic instability, drain prior to general anesthesia (contraindicated in aortic
dissection)
− Cardiovascular goals: Full (maintain preload), Fast (maintain HR), Tight (maintain SVR and
BP)
▪ Preload: full
▪ Contractility: maintain, avoid myocardial depressants
▪ Rate: maintain, or increase.
▪ Rhythm: strict NSR
▪ Systemic vascular resistance: maintain or increase.

Anesthesia plan:
− Intubation with spontaneous ventilation without muscle relaxation is preferred.
− Avoid positive pressure ventilation as increases in mean airway pressure can decrease preload
(venous return) resulting in decreased stroke volume and cardiac output.
− If mechanical ventilation required, ventilation strategy should use low tidal volumes and minimize
PEEP.
− Ketamine is the agent of choice.

− Hypotension management:
▪ Consider inotropes (dobutamine, Isoprenaline, dopamine) then pressors.
▪ Judicious IV fluids
− Rebound hypertension after tamponade drainage:
▪ Rapidly “deepen” anesthetic.
▪ Vasodilators and beta-blockers ready

47
 Hypertrophic obstructive cardiomyopathy (HOCM)

Considerations

1. systolic and diastolic dysfunction:

− Systolic: due to:
▪ Fixed obstruction from septal hypertrophy
▪ Dynamic obstruction if SAM is present.
− Diastolic: due to hypertrophied ventricle is stiff and relaxes poorly
− End stage: dilated cardiomyopathy
2. Perioperative hemodynamic complications:
− Arrhythmia
− MR
− Heart failure
3. Medication management:
− Beta blockers & calcium channel blockers
− Antiarrhythmics
− Anticoagulants
− Diuretics
4. Pacemaker/ AICD

Anesthesia management:
Goals:
The key point: is to avoid: hypovolemia, tachycardia, and excessive vasodilatation.
− Preload: maintain preload
− Pulse:
▪ Rate: slow-normal (avoid tachycardia)
▪ Rhythm: maintain NSR (aggressive management of AF)
− Contractility: ↓ contractility
− Afterload: maintain or ↑ afterload

Pre-operative
Standard preoperative assessment, focusing on:
− Symptoms and signs of HCM and their severity:
− Syncopal episodes, palpitations, dyspnea, or angina
− Exercise tolerance
− Pacemaker and its implications.
− Medications: Beta-blocker – anti-arrhythmic.
− Investigations:
▪ Chest Xray
▪ ECG
▪ Echocardiogram:
o Diagnosis: left ventricular wall thickness >1.5cm
o Over 3cm: major risk factor
o Systolic anterior motion (SAM) of the mitral valve and associated mitral
regurgitation.
o Ejection fraction (typically >75%): falsely high.
▪ Consult cardiologist.
▪ If severe: the procedure to be in tertiary/cardiac centre.

Intraoperative:
− Room setup:
▪ Prepare defibrillator.
▪ Pacemaker backup
▪ Cardiorespiratory resuscitation facilities.
− Preload: crystalloid before induction to ensure the patient is well filled

48
 Type of anesthesia:
− Spinal RELATIVELY CONTRAINDICATED because of the rapid onset of a sympathectomy.
− Epidural for elective cesarean section well tolerated.
− GA is the best option.
▪ Remifentanil target-controlled infusion slowly titrated up to an effect site concentration
of 3ng/ml.
▪ Propofol 1-2mg kg (slowly titrated)
▪ suxamethonium100mg.
▪ Avoid:
o ketamine
o Etomidate
o Sux if pacemaker

Intraoperative complications:
− Hypotension:
▪ Phenylephrine: the best choice
▪ Avoid positive inotropic and chronotropic properties ephedrine – adrenaline.
− Atrial fibrillation:
▪ Cardioversion: 120-200 J.
▪ Beta-blockers: (e.g., esmolol infusion).
Postoperative:
− In HDU/ICU for close observation and management of hemodynamic deterioration.
− Pain control; PCA or TAB block at the end of surgery.

Pregnancy considerations:

− SVR falls by 30–70% in later pregnancy which exacerbates the gradient across the left
ventricular outflow tract.
− Blood volume increases by 40–50% which overload a poorly functioning
hypertrophic ventricle.
− CO increases by 50% which may lead to myocardial ischemia and arrhythmias in the
presence of significant hypertrophy.
− Aortocaval compression reduces VR.
− Normal delivery:
▪ They can tolerate the normal delivery as there is increased SVR with is good for HOCM.
▪ Consider assisted 2nd Stage.
− Uterotonic drugs:
▪ Oxytocin: should be administered as an accelerated infusion.
▪ Ergometrine: is best avoided.
▪ Prostaglandins including carboprost and misoprostol are contraindicated.

Pacemaker
Considerations:
1. Avoid device failure:
− Avoid electromagnetic interference:
▪ Diathermy
o Use bipolar.
o If monopolar, consider:
− Short burst < 5 sec
− Cutting rather than coagulation
− Safe distance
− Earth plate away from the pacemaker.
▪ Peripheral nerve stimulator: Avoid using it for blocks close to the pacemaker.

2. Program modifications or device interrogation:

− In pacemaker: shift to a synchronous mode.
− In AICD: Disable the anti-tachycardia function or rate modulation (R).

49
 3. Management of failure:
− Temporary pacing:
▪ Transcutaneous
▪ Transvenous
▪ External defibrillator devices
▪ Pharmacological: Isoprenaline
− Magnet: better to avoid in programmable pacemakers.

Anesthesia management:
Preoperative:
− Establish the Indications for the device:
▪ Pacemaker: SA node disease, AV block, CRTD, MI, HOCM, dilated cardiomyopathy
▪ AICD: VT, VF, cardiomyopathy with EF<35%
− Determine dependency & history of use: from pacemaker card or technician:
▪ Type, mode, battery status, last check, and dependency.
− Investigations:
▪ 12-leads ECG: If the intrinsic rate is higher than that set on the pacemaker, assess using a
Valsalva maneuver.
▪ Chest x-ray: identify the number and integrity of leads.
▪ S. K:
o Hypokalemia →loss of capture.
o Hyperkaliemia →ventricular irritability
▪ Acid-base disturbances
▪ Digoxin level
− Program modifications or device interrogation.
− Cardiologist consultation

Intraoperative:

− Room preparation:
▪ Back-up pacing.
▪ Medications: Isoprenaline- Dopamine
▪ Cardiopulmonary resuscitation facilities.
▪ Attach DC paddles: perpendicular to the direction of the pacing wire (anterior and
posterior positions) to avoid damaged lead and burns.
− Avoid:
▪ Medications:
• Etomidate
• ketamine
• Suxamethonium
▪ Hypoxemia and hypercarbia: ectopic and arrhythmias.
▪ Hypothermia
▪ Monopolar diathermy
▪ Magnet in programmable pacemakers.
Postoperative:
- Pacemaker function should be checked at the pacemaker clinic.

Optimal location of return electrode during unipolar electrocautery – ESC guidelines 2022

50
 Perioperative myocardial ischemia
Considerations
1. ↑ risk of perioperative cardiovascular complications: MI, CHF, arrhythmias, and death. (Postpone
elective surgery for at least 60 days post-MI)
2. Optimize myocardial oxygen supply & demand:
− Improve supply:
▪ Adequate ventilation
▪ Adequate oxygenation (normal Spo2 with the least FiO2).
▪ Low normal heart rate: (BB if no hypotension)
▪ Normal hemoglobin.
− Minimise demand:
▪ Maintain low normal heart rate and blood pressure.
▪ Avoid shivering and acidosis and treat sepsis.
3. Comorbidities: HTN, stroke, renal dysfunction, peripheral vascular disease, diabetes, and smoking.

4. Management of coronary stents

− Elective procedure: Postpone for:
▪ Old generation DES: 1 year
▪ New generation DES: 6 months.
▪ BMS: 4 weeks
▪ Balloon Angioplasty: 2 weeks.
− Emergent procedures:
▪ Multidisciplinary decision with the cardiologist and surgeon: if can’t stop dual
antiplatelets: consider platelets transfusion.

Antiplatelet bridging

5. Associated medications: antihypertensives, anticoagulants, diuretics

Anesthesia management
− For emergency procedures:
▪ No time for testing or optimization
▪ Proceed to the surgery.
▪ Consider intra and postoperative complications.
− For elective procedures: Postpone for at least 60 days post-MI (if no stent).

51
Preoperative:
Routine history, examination, and investigations focusing on:
− History:
▪ Functional capacity: if <4 METs indicates increased risk.
▪ Chest pain: last attack, previous admission
▪ Stents and dual antiplatelet medications.
▪ Medications: continue BB, and aspirin. Stop ACEI.
− Investigations:
▪ CBC, creatinine.
▪ 12-lead ECG.
▪ Echocardiography.
▪ Stress testing: indicted if poor functional capacity for high-risk elective surgeries
o Dobutamine stress echo
o Dipyridamole thallium scan
▪ Coronary angiography:
Indications:
o left main coronary artery stenosis.
o Three vessels coronary artery disease with left ventricular dysfunction
o Left main equivalent (high-grade block in the left anterior descending artery
and circumflex artery)
o Intractable ischemia despite maximal medical therapy.

Intraoperative
− Monitoring:
▪ Standard ASA monitors (including a five-lead ECG)
▪ Pre-induction arterial line.
− Goals
▪ Optimize myocardial oxygen supply & demand.
▪ Preload: keep the heart small to ↓ wall tension/LVEDP & ↑ coronary perfusion pressure
gradient
▪ Rate & rhythm: slow, normal sinus rhythm
▪ Contractility: maintain
▪ Afterload: maintain, coronary perfusion dependent on diastolic pressure.

− Consider risk periods:

▪ Induction can cause hypotension.
▪ Laryngoscopy and intubation can cause hypertension and tachycardia.
▪ Surgical incision
▪ Extubation
▪ Pain post-operatively

Management of intraoperative Myocardial Ischaemia:

1. Call for help.

2. Check monitor for hypoxia, hypercarbia, Blp, and malignant arrhythmia.
3. Stop surgery if appropriate or ask the surgeon to finish early as possible.
4. Consult Cardiologist
5. Confirm Diagnosis:
− 12-lead ECG.
− Baseline and 4-hour troponin levels.
− Consider TEE or transthoracic echocardiogram if hemodynamic instability.
6. Manage:
− Hemodynamic management:
− Tachycardia with normo or hypertension:
o BB: metoprolol tartrate 5 mg IV every 5 minutes for 3 doses.
o CCB
o Nitrates:
• 0.4 mg IV every 5 minutes
• 1 aerosol spray under the tongue every 5 minutes for 3 doses
o Manage AF or flutter if present.

52
 − Tachycardia with hypotension:
o Vasopressors to maintain blood pressure then β-blockers to slow heart
rate.
o Avoid CCB
o If AF or flutter: cardioversion

− Aspirin (after discussion with cardiology and surgeon)

− Morphine:5-10 mg
− Consider use of intra-aortic balloon pump, as guided by cardiologists.

Postoperative
− In ICU or HDU.
− Serial ECGs, and troponins.
− Ensure good analgesia, euvolemia.
− Maintain normal oxygen saturation.

Management of preoperative myocardial ischemia (in the clinic or preparing room)

1. Call for help.
2. Assess and manage according to the ABC approach:
o Airway: check airway patency, no obstruction
o Breathing: Inspection, auscultation
▪ Check for respiratory distress.
▪ Attach oxygen saturation monitors; provide supplemental oxygen as needed to
maintain O2 saturation >90%.
o Circulation:
▪ Check pulsation.
▪ Attach cardiac monitoring.
▪ Measure Blp and check the rhythm.
▪ Insert IV access.
▪ If cardiac arrest, start ACLS.
3. Shift the patient to the ER.
4. 12 lead ECG
5. Send blood samples for:
o Troponin
o ABG
o Hb
6. Consult a cardiologist.
7. All causes of tachycardia, hypertension, hypotension, anemia, and pain should be treated
aggressively.
8. Atorvastatin 80 mg and aspirin 81 to 325 mg
9. Morphine: 2 to 4 mg slow IV push every 5 to 15 minutes
10. Diuretics if lung congestion
11. If patient needs revascularization:
o Indications for pre-operative coronary artery revascularisation:
▪ Acceptable coronary revascularisation risk and viable myocardium with left main
coronary artery stenosis
▪ Three vessels coronary artery disease with left ventricular dysfunction
▪ Left main equivalent (high-grade block in the left anterior descending artery and
circumflex artery)
▪ Intractable coronary ischaemia despite maximal medical therapy
12. Type of stent: According to the urgency of surgery:
▪ If can be postponed:
o > I year after intervention: DES.
o > 6 months: new generation DES
o > 4 weeks: BMS
o >2 weeks: Plain balloon Angioplasty

53
 Ventricular assist devices

Indications:
Ventricular assist devices (VADs) are used for the management of patients with end-stage HF:
− A bridge to heart transplantation
− Permanent destination therapy.

Non-cardiac surgery should be performed in surgical centres that have access to VAD teams.

Management:
Pre-operative
− Multidisciplinary team identified:
o Primary surgical
o Anaesthesia teams
o Cardiac surgery
o Heart failure cardiologist
o VAD personnel
− Pre-operative medical optimization when possible or
necessary.
− Check battery state and backup power source.
− Physical examination focused on the sequelae of HF.
− Baseline ECG, echocardiogram, and laboratory values
− Manage pacemaker/ICD settings when indicated.
− CT examination to evaluate possible driveline
interference with the operative field. Left ventricular assist device.
− Hold, bridge, or reverse anticoagulation when
indicated, after VAD team consultation.

Intra-operative
− Standard ASA monitors PLUS:
o Cerebral tissue oxygenation
o Processed electroencephalogram
o Arterial line with ultrasound guidance
o Central venous catheter if fluid shifts are
expected.
o PA catheter only if severe pulmonary
hypertension
o TEE available
− Monitor VAD control console.
− External defibrillator pads in place
− Optimize pre-load, support RV function, avoid an increase
in afterload.
− Gradual peritoneal insufflations and position changes Berlin Heart

Post-operative

− Standard post-anesthesia care unit unless ICU is otherwise indicated.

− Extubation criteria are unchanged.
− Avoid hypoventilation, optimize oxygenation.
− Resume heparin infusion when post-op bleeding risk is acceptable.

54
 QT Prolongation

Definition
Prolonged corrected QT for the heart rate (QTc): >470 ms (males) & >480 ms (females)

Considerations:
− Potential for hemodynamic collapse secondary to rapid polymorphic VT & VF
− Triggers ventricular arrhythmias:
▪ Sympathetic stimulation: Bradycardia, tachycardia, hypertension, hypoxemia,
hypercapnia
▪ SNS stimulation: pain, nausea, emotional stress, loud noise
▪ Medications:
o Antiemetics, antipsychotics, amiodarone, methadone, antiarrhythmic,
antibiotics, antihistamines, antidepressants.
▪ Electrolyte disturbances: (↓K, ↓Mg, ↓Ca)
− Types:
▪ Congenital long QT:
o Due to gene mutations
o May have pacemaker/AICD, perioperative β-blockers.
▪ Acquired LQTS

Anesthesia management:
Preoperative
− 12-lead ECG.
− Electrolyte
− Cardiology consultation
− Ensure optimal AICD function.
− Continue BB
Intraoperative:
− Premedication:
▪ Consider sedation: benzodiazepines.
▪ Avoid anticholinergics and antiemetics.
− Room preparation:
▪ Defibrillator pads attached to the patient.
▪ Magnesium sulphate is available.

− Goals in Anaesthesia
▪ Maintenance of homeostasis, normothermia
▪ Avoid hypoxaemia, hypocapnia, hypercapnia and high-pressure ventilation.
▪ Correct any electrolyte disorders (especially hypokalaemia, hypomagnesemia, and
hypocalcaemia).
− Management of arrhythmias:
▪ Haemodynamically stable:
o 1st line: IV magnesium 2g IV over 2 min (30 mg/kg), every 15min for 3 times.
Pediatrics dose: 25-50mg/kg.
o If recurrent:
− Consider temporary transvenous pacing (set to 100-140/minute)
− IV isoproterenol infusion: 2 μg/min and titrate to reach HR 100/min.
▪ Haemodynamically unstable:
o Due to ventricular arrhythmia:
− Synchronised cardioversion + 2 g IV magnesium.
− Avoid amiodarone.
− Give IV lidocaine instead.
▪ Pulseless arrhythmia:
o Immediate defibrillation (ACLS) + 2 g IV magnesium should be administered.

55
 Wolff-Parkinson-White (WPW) Syndrome

Definition
Presence of a congenital accessory pathway between atria and ventricles (Bundle of Kent) and episodes
of tachyarrhythmias.

ECG features of WPW in sinus rhythm

− PR interval < 120ms
− Delta wave: slurring slow rise of initial portion of the QRS
− QRS prolongation > 110ms

Considerations
− Potential for perioperative SVT or atrial fibrillation:
− Consider crash cart, defibrillator pads attached to the patient, invasive arterial access, emergency
drugs (procainamide, amiodarone)
− Avoid triggers:
▪ Sympathetic stimulation: pain, anxiety, hypovolemia, ketamine

Tachyarrhythmias in WPW
1. Atrial fibrillation or flutter.
− Management:
▪ Unstable patients: Synchronized cardioversion
▪ Stable patients:
o First line: Procainamide 20-50mg/min IV infusion
− Stop infusion if: Arrhythmia suppressed, hypotension, QRS
prolonged by 50% of original duration or total dose17mg/kg has
been given.
o 2nd line: Ic antiarrhythmic agent or dofetilide.
o Synchronized cardioversion if other therapies are ineffective or not
available.
− Contraindications:
▪ Digoxin, beta blockers, adenosine, verapamil, and diltiazem.

2. Atrioventricular re-entry tachycardia (AVRT)

It has Two types:
A. Orthodromic AVRT: anterograde conduction is via the AV node, producing a regular
narrow complex rhythm (in the absence of pre-existing bundle branch block)
− Management:
▪ Unstable: Synchronized cardioversion
▪ Stable patients:
o First line: Vagal manoeuvres
o Second line: IV adenosine
o Third line: IV verapamil OR IV diltiazem
o Other therapies: IV procainamide OR IV beta
blocker; synchronized cardioversion if other
therapies are ineffective or not feasible.

B. Antidromic AVRT: anterograde conduction is via the

accessory pathway, producing a regular wide complex
rhythm.
− Management:
▪ Unstable: Synchronized cardioversion
▪ Stable patients:
o IV drug of choice: procainamide.
− Contraindications:
▪ AV block medications:
Digoxin, beta blockers, adenosine, verapamil, and
diltiazem.

56
 Atrial fibrillation
Consideration
1. Increases the risk for perioperative cardiac complications.
2. Pathology:
Non-coordinated atrial contractions lead to:
a. Loss of atrial kick: reduce CO by:
− 10%–20% with a normal ventricle.
− 40%–50% in those with a ‘stiff’ ventricle e.g., aortic stenosis.
b. stasis of blood and the risk of thrombus formation (mostly in the atria appendage)
3. Comorbidities:
a. Etiology:
− Cardiac
▪ Structural heart disease (ASD or mitral valve disease)
▪ Ischaemic heart disease
▪ Pericarditis.
− Non-cardiac:
▪ Thyrotoxicosis
▪ Electrolyte abnormalities.
▪ Excess caffeine or alcohol (acute or chronic)
▪ Pulmonary embolism
▪ Pneumonia
b. Complications:
− CHF, tachycardia-induced cardiomyopathy
− Embolic events & stroke risk
4. Medications:
− Rate control & rhythm control (beta-blockers, calcium channel blockers, digoxin,
amiodarone)
− Anticoagulants.

Management:

Pre-operative:
According to the emergency status:

A. If urgent: Proceed to surgery, consider:

▪ Increased risk of complications if HR > 110 or CHF
▪ cardiology consultation - monitored bed.
▪ Reversal of the anticoagulants.
B. If elective:
▪ IF HR < 110 - No CHF
• Proceed to surgery.
• Continue prophylactic medications (BB) if used.
▪ If HR > 110 OR CHF
• Postpone.
• Optimization by cardiologist.
▪ Anticoagulation management.
Intra-operative AF:
Check for signs of instability:
− Systolic BP < 90 mmHg
− Signs of heart failure
− Chest pain
− HR > 150 per min
A. If Unstable: (Emergency Condition, ABC)
− Call for help.
− Check carotid pulsation.

57
 −Monitor: Exclude hypoxia – hypercarbia.
−Apply 100% O2.
−Synchronized cardioversion (120-200 J).
−Consider sedation in awake patients.
−Search for the cause (send STAT labs including ABG, H/H, electrolytes, cardiac enzymes,
and a basic chemistry panel.)
C. If stable:
− The target is rate control (rhythm control may be considered only if symptoms persist
despite optimal rate control):
▪ Beta-blockers
▪ Non-dihydropyridine CCBs (verapamil, diltiazem).
▪ If impaired ventricular function:
• Amiodarone: 1st line
• Digoxin is usually ineffective in high adrenergic conditions such as surgery.

Anticoagulant management:

1. Estimate the bleeding risk: (if high bleeding risk STOP the anticoagulant before the procedure)
2. Estimate the thrombotic risk: (If high consider bridging)
− Patient with high thrombotic risk:
▪ CHADS2 score 5-6
▪ CHA2DS2-VASc score 7-9
▪ Recent (within 3 months) stroke or transient ischemic attack
▪ Rheumatic valvular heart disease

3. Type anticoagulant: (when to stop – when to restart)

▪ Vitamin K antagonists:
▪ No stopping: in minimal bleeding risk surgery.
▪ Stop with bridging: in high thrombotic risk patients.
▪ Stop without bridging: low and moderate thrombotic patients.

▪ New Oral Anticoagulants:

must be stopped before surgery:
▪ On operation morning: low bleeding risk surgery
▪ One day before + operation day: moderate bleeding risk surgery
▪ Two days before + operation day + one day after in high bleeding risk surgery

− Bridging:
Administration of a short-acting anticoagulant, typically a low molecular weight (LMW) heparin
or unfractionated heparin (UFH) during the interruption of a longer-acting agent,
typically warfarin.
1. Initiation:
Three days before a planned procedure (two days after stopping warfarin).
2. Dose:
▪ LMW: enoxaparin, 1 mg/kg subcutaneously twice daily.
▪ UFH: 250 international units/kg twice daily.
3. Stop:
▪ 24h if a single dose.
▪ UFH: IV: 4 Hours – SC: evening before the procedure.
4. Restart:
Heparin and warfarin 12–24 h after the invasive procedure, if the bleeding is well-
controlled.

Atrial flutter management

The same principles as AF with considering:
− Drugs that slow atrioventricular conduction (digoxin, beta-blockers, or non-
dihydropyridine CCBs) are usually less effective than in AF.
− Amiodarone: to control rate, especially in HF or critically compromised patients.
− In patients with a high ventricular rate: electrical cardioversion (50 to 100 joules).

58
 Ventricular Tachycardia
Management
Emergency Condition, ABC
− Call for help.
− 100% O2.
− Monitor:
▪ Check carotid pulsation.
▪ Exclude hypoxia – hypercarbia.
▪ Check for signs of cardiovascular instability:
o Systolic BP < 90 mmHg, signs of heart failure, chest pain, and HR > 150 per min
− Manage:
1. If pulseless:
▪ ACLS protocol (shockable rhythm).
2. If unstable with pulse:
▪ Synchronized cardioversion (100 J then 150 J If no response).
▪ Consider sedation in awake patients.
▪ Consider:
o Procainamide 50mg/min
o Lignocaine 1mg/kg
o Sotalol 1mg/kg
3. If stable:
▪ Amiodarone: 150 mg IV over 10 minutes, followed by 1 mg/minute for the next six
hours
▪ Lidocaine: 1 to 1.5 mg/kg
▪ Procainamide 20 to 50 mg/minute infusion.
4. Search for the cause (send STAT labs including ABG, H/H, electrolytes, cardiac enzymes,
and a basic chemistry panel.)

Adult bradycardia algorithm

59
 Adult tachycardia with a pulse algorithm

Cardioversion doses:

▪ AF: 120 to 200 joules

▪ VT with a pulse: 100 joules
▪ Atrial flutter: 50 to 100 joules.
▪ Regular narrow complex SVT :50-100 joules
▪ VF or pulseless VT: 200 to 360 joules

60
Adult cardiac arrest algorithm

61
Pediatric cardiac arrest algorithm

62
Neonatal resuscitation algorithm

63
Vascular anesthesia

64
 Carotid endarterectomy
c

Considerations
1. Emergency state:
− It is a time-sensitive procedure.
− Indicated early if:
▪ Symptomatic: repeated TIAs – stroke.
▪ Obstruction > 70%

2. Patient comorbidities:
− Elderly patients with CAD, DM, HTN, PVD, CKD,
CVD, and smoking.

3. Procedure considerations:
− Shared airway
− Significant hemodynamic fluctuations:
▪ On clamping: hypertension, tachycardia, increased myocardial O2 demands.
▪ Carotid sinus manipulation: bradycardia, hypotension
− Requires neuromonitoring: EEG, cerebral oximetry, TCD, stump pressure.
− Related complications:
▪ CNS: CVA (ischemic/embolic), hyperperfusion syndrome, CN dysfunction.
▪ CVS: MI, labile BP (hypertension/hypotension)
▪ Airway: hematoma, airway obstruction/loss, RLN injury
4. Medication:
− ASA, Plavix, antihypertensives, statins.

Anesthesia management
Preoperative:
Routine preoperative assessment focusing on:
1. Neurological: (Document any neurological deficits)
− TIAs or symptoms of stroke
− If weakness, avoid:
▪ In the affected limb:
o Monitoring: BP cuff - NM monitor
o Placement of IV lines.
▪ Succinylcholine: risk of hyperkalaemia.
2. Cardiac:
− Baseline exercise tolerance
− Chest pain at rest.
− Signs of congestive heart failure.
− Preoperative HTN: (To be optimized around 160/90 mmHg)
− Consult a cardiologist.
3. Airway assessment
4. Medications
− Diuretics: electrolytes disorders – hypovolemia.
− Anticoagulants: aspirin and NSAIDs should be discontinued.
5. Investigations:
− ECG, CBC, urea, and electrolyte.
− Echocardiography: if indicated.

Intraoperative:
− Goals:
1. Maintain stable hemodynamic (within 20% of baseline) to:
− Optimize cerebral perfusion.
− Avoid myocardial ischemia.

65
 2. Smooth awake emergence to:
− Decrease bleeding risk.
− Neurological examination

− Monitoring
A. Standard ASA monitor:
o ECG: ST changes indicated increased ICP.
B. Arterial Line: placed pre-induction for:
o Continuous blood pressure monitoring
C. Neuromonitoring:
o Cerebral function: EEG, processed EEG, SSEP,
transcranial Doppler ultrasound, and cerebral
oximetry.
− Premedication: Be conscious with sedative - anxiolytic.
− Anesthetic Options:
A. Regional anesthesia:
− Advantages of regional anesthesia:
▪ Better monitoring of the cerebral function.
Superficial cervical plexus anatomy
▪ Avoid hemodynamic instability
associated with induction and
maintenance of general anesthesia.
− Target: Cervical dermatomes C2–C4
− Blocks:
▪ Superficial cervical plexus block + LA
infiltration by the surgeon
▪ Deep and superficial cervical plexus
block.

Superficial cervical plexus block:

Subcutaneous infiltration of 5-10ml of LA along
the midpoint of posterior border of SCM.
Deep cervical plexus block:
Using A 25-50mm short-bevelled needle Deep cervical plexus anatomy
advanced until contact with bone
(transverse process of C3), 10ml of LA
injected after careful aspiration.

− Complications
▪ Injury to surrounding structures:
o Nerves: injury
o Vessels:
• Bleeding by accidental puncture
• Intravascular injection
o Epidural space: cause a high regional block.
▪ Blocking of other nerves:
o Horner’s syndrome
o hemiparalysis of the diaphragm.
▪ Failed block
B. General anesthesia:
− Smooth induction
− Short-acting medication
− Maintain hemodynamic goals using fluids, pressors, dilators, and good analgesia.
− Cross clamping:
− Significant changes in the EEG waveform or decreased level of consciousness in
awake patient:
1. Ask the neuromonitoring technician to check all connections.
2. Optimize the O2 delivery to the brain:
− 100% Oxygen
− Correct Hypoxia, hypercarbia, hypothermia, hypotension (MAP> 75),
and anemia (Hg> 7gm/dl)
3. Turn off volatile anesthetics, if administered and convert to TIVA.

66
 4. I failed: ask the surgeon to:
− Remove the clamp.
− Place a shunt If the clamp cannot be removed.

Postoperative:
− Careful observation in a well-staffed recovery room for 2–4hr is mandatory.
− Post-operative ICU or HDU.
− Complications:
1. Post-operative stridor:
I. DD: on top of DD:
− Surgical site hematoma
− Laryngeal edema
− May be residual from anesthesia or MR.
II. Management:
− Immediately attend to the patient
− Assessment and management simultaneously according to ABC
protocol.
− Apply 100% O2
− Upright position.
− Send blood sample for: ABG – electrolyte (Ca) – CBC – Chest Xray
− According to the cause:
▪ If hematoma:
o Inform the surgeon.
o Line its borders to monitor if it increases in size.
o If causes airway obstruction: immediate suture removal,
evacuation and intubation.
▪ If laryngeal edema:
o Nebulizers
o Steroids
o Adrenaline
o If failed: intubation.
▪ Anesthesia reversal

2. Hyper perfusion syndrome

Due to exposure of areas of the brain previously protected by tight carotid stenosis
to high blood pressure.
I. Manifestations:
− Headaches and hemorrhagic CVA.
II. Management:
− BP must be closely monitored and controlled:
▪ If systolic BP >160mmHg, give labetalol 5–10mg boluses IV or a
hydralazine infusion.
▪ If systolic BP <100mmHg, give colloid 250mL stat.

67
 Aortic Dissection

Considerations

1. Emergency status: according to its type

− Surgical emergency: Stanford type A, OR DeBakey type I - II.
− Medical emergency or stent only: Stanford type B OR DeBakey type III.

2. Pathology:
− Classification:
The DeBakey classification:
• Type I – begins in the ascending aorta and extends to the abdominal aorta.
• Type II – begins and remains in the ascending aorta.
• Type IIIA – originates beyond the left subclavian artery and extends to the
diaphragm
• Type IIIB originates beyond the left subclavian artery and extends to the aortoiliac
bifurcation.
Stanford classification:
• Type A: All dissections involving the ascending aorta.
• Type B: All dissections NOT involving the ascending aorta.

3. Comorbidity:
− Complications:
o Aortic insufficiency, tamponade, MI, CVA (Stanford A)
o Acute renal failure
o Ischemia of:
▪ Spinal cord
▪ Gut
▪ Limbs
o Bleeding:
▪ Shock.
▪ Pleural effusion.
▪ Retroperitoneal haematoma.
− Cause of aortic dissection:
o Trauma
o Hypertension, atherosclerosis
o Cocaine, amphetamine use
o Pregnancy
o Collagen vascular disease (Marfan)
4. Medication and fluids:
− Major vascular surgery with expected
massive blood transfusion and fluid shifting.
− Related to comorbid diseases.
Classifications of aortic dissection

Anesthetic management:

1. Preoperative:

− History: standard with focusing on:

o Cardiac: Recent episodes of chest pain or dyspnea at rest, murmur, any stress tests, or
Echocardiography.
o Pulmonary: smoker or has any signs or symptoms of COPD
o Renal: renal dysfunction
− Examinations: General examination with focusing on:
o Signs of shock – pulmonary edema, effusion, and abdominal collection.
− Investigations:
o CBC – ABO – bleeding profile – RFT - electrolytes.
o ECG – Echocardiography (if available time)

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2. Intraoperative:

− Room preparation:
i. Monitors: Invasive monitoring transducers availability (AL – CVP)

ii. Equipment:
▪ Cardiopulmonary resuscitation facilities
▪ Defibrillator.
▪ Difficult airway setup
▪ Blood transfusion sets and warmers.
▪ CPB machine if required.
iii. Medications:
▪ BB: labetalol – esmolol
▪ CCB
▪ Vasodilators: NGT IV
▪ Vasopressors: Phenylephrine – NA

− Monitoring: Standard ASA monitor +

1. Arterial line: Both pre-clamp (Rt redial) + Post-clamp (femoral)
2. CVP
3. Foley’s catheter.
− Goals:
1. Main goal is to ↓ cardiac contractility & BP to reduce intimal shear stress.
− Preload: maintain adequate preload; avoid aggressive fluid therapy
− Rate: Slow <60bpm + Sinus
− Contractility: reduce contractility
− Afterload: reduce SBP to a target of 100-120 mmHg.
2. Adequate pain control.
3. Avoid
− Inotropes
− Hydralazine: causes aortic wall shear stress
− Vasodilation before beta blockade, which can cause reflex sympathetic
activation.
− Pericardiocentesis in tamponade before surgical correction.

− Anesthesia plan: GA (induction agent according to hemodynamic at induction)

− Cross clamping:
1. The hemodynamic changes:
a. Proximal to the clamp:
▪ Increased afterload
▪ Increased BP to the upper half of body.
▪ The Increased CVP and pulmonary artery occlusion pressure
▪ Decreased CO and EF.
b. Distal to the clamp:
▪ Decreased RBF and mesenteric blood flow.
c. General:
▪ Increased mixed venous oxygenation.
▪ Decreased O2 consumption.
▪ Metabolic acidosis
▪ Increased catecholamine release.

− Intraoperative complications:

1. Pre-clamp site HTN:

a. Check both radial and femoral readings.
b. Check other vitals to exclude arrhythmia and hypoxia.
c. Target: maintain MAP pre-clamming of 100 mmHg – post-clamping 50
mmHg.
d. How:
▪ Adequate pain control
▪ 1st line therapy is beta blockers:
i. Labetalol (bolus 20-80mg then infusion 0.5-2mg/min)

69
 [Link] (bolus 0.5-1 mg/kg then infusion 50-200
mcg/kg/min)
▪ Consider diltiazem (2.5-5mg IV q15min) & verapamil (2.5-5mg IV
q15min) in patients intolerant of beta blockers.
▪ Consider adding sodium nitroprusside (0.25-0.5mcg/kg/min) to
reduce the afterload.

2. lower extremity hypotension:

a. Check both radial and femoral readings.
b. Check other vitals to exclude malignant arrhythmia and hypoxia.
c. Asking the surgeon to place a shunt, reimplant arteries to perfuse vital
organs such as the kidney, spinal cord, liver, and institute hypothermia.

3. Post-clamping removal hypotension:

a. Check both radial and femoral readings.
b. Check other vitals to exclude malignant arrhythmia and hypoxia.
c. Instruct the surgeon to immediately reapply the clamp. Once the BP
improves then incrementally remove the clamp.
d. Infusion of norepinephrine or phenylephrine to increase the patient’s
SVR.
e. IV fluids.

4. Hypothermia.

3. Postoperative:

− ICU or HDU as it is a major vascular operation with likely blood loss and massive fluid shifts.
− Pain management: PCA – multimodal analgesia.
− Post-operative investigations to monitor:
▪ DIC
▪ Renal function tests.
▪ Post-operative bleeding.

Aortic dissection in pregnancy

− Goals: the same as above with:

▪ Continuous fetal heart rate monitoring (a marker for end-organ perfusion)
▪ Aggressive alpha & beta-blockade to ↓ dP/dT
▪ Avoid reduction of uterine tone caused by vasodilator (nitroglycerin)
▪ Avoid fetal toxic medications (sodium nitroprusside)
▪ Avoid ergotamine.

− Management:
According to dissection classification:
▪ Stanford type B or DeBakey type III:
o Medical management & expedite delivery.
o Use short-acting agents (esmolol, labetalol, phentolamine)

▪ Stanford type A, OR DeBakey type I - II:

o If diagnosed <28 weeks = surgical repair, then allow pregnancy to continue
o 28-32 weeks = surgical repair, caesarean section if obstetrical indications
o >32 weeks = simultaneous repair & caesarean section

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 Peripheral revascularization operations
(Femorofemoral – femoropopliteal)

Considerations

− Emergency status: it could be either urgent or

elective procedure.
− The patient is with vascular disease: needs
assessment of cardiovascular, renal, and CNS
systems.
− Consider anticoagulation status.
− Blood loss: consider activation of massive transfusion
protocol.

Anesthetic management:

Preoperative:
− History: standard with focusing on:
o Cardiac: Recent episodes of chest pain or dyspnea at rest, murmur, any stress tests, or
Echocardiography.
o Pulmonary: smoker or has any signs or symptoms of COPD
o Renal: renal dysfunction
− Examinations: General examination with focusing on:
Signs of shock – pulmonary edema.
− Investigations:
o CBC – ABO – bleeding profile – RFT - electrolytes.
o ECG – Echocardiography (if available time)

Intraoperative:
− Room preparation:

i. Equipment:
▪Cardiopulmonary resuscitation facilities
▪Defibrillator.
▪Difficult airway setup
▪Blood transfusion sets and warmers.
ii. Medications:
▪ BB: labetalol – esmolol
▪ CCB
▪ Vasodilators: NGT IV
▪ Vasopressors: Phenylephrine – NA

− Monitoring:
▪ Standard ASA Monitor.
▪ Invasive monitoring: arterial line – CVP
▪ UOP

− Anesthesia plan: (ensure two large (14 or 16G) IV cannula).

▪ Regional anesthesia: Spinal or epidural or combined. (if no contraindications)
▪ GA + multimodal anesthesia including femoral block.
− Heparin (3000–5000U) should be given before clamping—reverse with protamine 0.5–
1mg/100U of heparin slowly after unclamping.

Postoperative
− In ICU or HDU
− O2 overnight.

71
Thoracic Anesthesia

72
 Lung Isolation

Indications:
− Absolute indications:
− Prevention of contamination from one side to the other:
▪ Infection
▪ Massive pulmonary hemorrhage
▪ bronchopulmonary lavage.
− Control of distribution of ventilation:
▪ Massive air leaks
▪ Severe unilateral lung disease (Large bullae and lung cysts).
− Relative indications: Improve surgical exposure.
How to Isolate:
1. Double-lumen endobronchial DLT (the standard method)
2. Bronchial blockers if:
▪ Difficult intubation
▪ Distorted tracheobronchial anatomy.
▪ Tracheostomy.
▪ To avoid the post-operative exchange from DLT to SLT in patients cannot tolerate hypoxia.
3. Single-lumen tubes (SLT) advanced to non-operated side.

Double-lumen tubes

− Types: (regarding tube orientation)

▪ Right side.
▪ Left side: (mostly used as the Lt main bronchus length is 4-5 cm, Rt side 2 cm)
1. Make it more stable in its place and decrease malposition possibility.
2. To avoid inflation of RT upper lobe if Rt side tube used. (take-off of the Rt upper lobe at 2 cm)

− Sizes:
▪ Males: 37-41Fr (the most convenient for
average height males is 37 Fr)
▪ Females: 32-37 Fr (the most convenient for
average height females is 35 Fr)
▪ Narrow inner diameter: used
bronchoscope diameter to be <4mm.

− Placement (Lt side DLT)

1. Check for correct tube size and patient
selection.
2. Start intubation with the tip of endobronchial
tube anteriorly.
3. once the tip is past the glottis, partially
withdraw the stylet, and rotate the tube 90°
anticlockwise.
4. Turn the patient’s head to the opposite side.
5. Gently slide the tube down the trachea until
resistance is felt. Its depth is usually between
28 and 30 cm.
6. The tracheal cuff is inflated, and ventilation
is provided through both lumens. Chest rise,
breath sounds, and end-tidal CO2 on the
capnogram indicates that tube is in the
airway.

− Position Verification
▪ When to do:
1. After placement
2. After patient repositioning
3. Periodically throughout the surgery

73
 ▪ How:
1. Using fiberoptic bronchoscope (More reliable)
a. Start through tracheal lumen to confirm that:
− The tracheal lumen is terminated above the level of the carina.
− Bronchial lumen entering the left bronchus.
− Blue bronchial cuff just visible below the carina
b. Then through the bronchial lumen to confirm its patency and correct location of tip.

2. Auscultation:
Following next sequence:
1. the tracheal cuff is inflated and ventilation through both lumens is attempted. (Bilateral
breath sounds indicates tracheal intubation).
2. Both cuffs are inflated, the bronchial lumen is ventilated, and the tracheal lumen is
clamped. (Breath sounds will be on the Lt side).
3. Both cuffs still inflated, bronchial lumen clamped, and the tracheal lumen is ventilated.
(Breath sounds will be on the Rt side)

Bronchial blocker types:

Arndt blocker Univent tube with blocker EZ blocker Cohen blocker

Management of one-lung ventilation

− Initiating one-lung ventilation:
1. Start with typical ventilator settings during two-lung ventilation (FiO2 0.3, VT 6–8 mL/kg, and peak
airway pressure (PAW) ≤25cmH2O).
2. Increase FiO2 to 0.5 before initiating OLV.
3. Clamp the Y connection to the operative (non-dependent) lung and open the sealing cap on that
lumen of the DLT to allow the gas to escape.
4. Start lung-protective ventilation strategies:
▪ Tidal volume 4-6 cc/kg
▪ Peak pressure < 40 cmH2O
▪ Plateau pressure < 30 cmH2O
▪ Adjust PEEP/FiO2 for oxygen saturation > 90%.

− Management of hypoxia:
− Call for help.
− Check monitors: make sure the patient is not hypercarbic, hypotensive, or in a malignant arrhythmia.
− Manage:
1. Ensure FiO2 = 1.0 9. Ask surgeon for mechanical restriction of
2. Check DLT/BB placement with pulmonary blood flow to non-ventilated
fiberoptic bronchoscopy. lung.
3. Suction the airway as needed. 10. Partial ventilation of operative lung:
4. Optimize cardiac output. ▪ Selective lobar collapse
5. Recruit ventilated lung. ▪ O2 insufflation to non-operative lobes
6. Apply PEEP 5 cm to ventilated lung 11. If hypoxemia persistent (O2 saturation <90
(except COPD) percent), return to two lung ventilation.
7. Apply CPAP 5 to 10 cmH2o to non- 12. Consider ECMO if failed.
ventilated lung.
8. Intermittently ventilate both lungs.

74
Lung isolation in patient with difficult airway

75
 Pneumonectomy

Considerations:
− Major surgery with increased risk of perioperative complications.
− Multidisciplinary approach is essential: anesthetist, surgeon, respiratory physician, and radiologist.
− Indications:
▪ Cancer (the commonest cause):
o 4 M effects: Mass effect, metabolic effect (Eaton–Lambert myasthenic syndrome( ,
metastatic effect, medications effect.
▪ Bronchiectasis – TB
− Requires meticulous preoperative optimization.
− Requires lung isolation.
− Severe intra and postoperative pain.
− Position consideration
− Comorbidities:
▪ Coronary artery disease & arrhythmias (atrial fibrillation)
▪ Smoking, chronic obstructive lung disease
▪ Pulmonary hypertension

Anesthesia management

Preoperative:
Goals of preoperative management:
A. Determine suitability for resection:
Using “3-legged stool” approach: considering respiratory mechanics, gas exchange, cardio-
respiratory interaction.
1. Respiratory mechanics.
− Minimum FEV1: to determine the extent of resection:
▪ If >55% of the patient’s predicted value: pneumonectomy can be done.
▪ If >40% of the patient’s predicted value: only lobectomy.
▪ If >35% of the patient’s predicted value: only wedge resection.
− Predicted post-operative value of FEV1 (ppoFEV1) = FEV1 × (5 − number of lobes
resected)/5. (The most important test):
▪ Determine physiological suitability for procedure:
o >40% is suitable for the procedure.
▪ Determine possibility of post operative ventilation:
o >40%: extubation could be in the operating room.
o <40%: requires postoperative ventilation.

2. Gas exchange:
− The most useful test of gas exchange capacity is DLco.
− Predicted post-operative DLco is calculated using the same calculation as for FEV1.
− If ppoDLco is less than 40%, indicates predicted increased respiratory and cardiac
complications.

3. Cardio-respiratory interaction:
− Preoperative VO2 max <15 mL/kg/min (< 4 METS) indicates high risk of morbidity and
mortality.

B. Preoperative optimization:
− Smoking cessation, pulmonary rehabilitation.
− Treatment of lung infections & bronchospasm.

76
 3-legged stool approach
Intraoperative:
− Monitoring:
▪ Standard ASA.
▪ Arterial line (in the dependant radial) – Central line.
▪ UOP

− Insert wide pores cannulae.

− Position: Lateral decubitus with table broken.
− Type of anesthesia:
▪ One lung ventilation during the resection phase.
▪ Lung protective ventilation
▪ Epidural or paravertebral regional anaesthesia with catheter for post-operative
analgesia.
− fluid restriction specially in pneumonectomy.

− Intraoperative complications:
▪ Hypoxia
− Extubation:
▪ Awake in a sitting position.
▪ Timing: Depending on preoperative PPO FEV1
Postoperative:
− Continuous supplementary O2
− Ensure good analgesia is achieved.
− CXR in the recovery room.
− Postoperative complications:
▪ Acute lung injury (post ▪ Myocardial ischemia
pneumonectomy pulmonary ▪ Bronchopleural fistula
edema) ▪ Hemorrhage
▪ Cardiac herniation ▪ Pulmonary embolism
▪ Arrhythmias (AF) ▪ Myocardial infarction

77
 Anterior mediastinal mass
Considerations
− It is a high-risk procedure with an increased risk of perioperative complications.
− Pathology:
▪ Common causes:
o Lymphoma o Metastatic lesions
o Thymoma o Bronchogenic masses
o Germ cell tumors o Thyroid mass

▪ Clinical presentation:
A. Related to underlying etiology:
− Cancer 4 M’s: (mass effects, metastases, medications, metabolic abnormalities)
− Myasthenia gravis, Eaton-Lambert, thyroid, lymphoma
− Pericardial/pleural effusions.

B. Compression effect related to the mass: (worsens in the supine position)

− Airway: (dyspnea, cough, hoarseness, new-onset wheezing), (tachypnea, stridor,
rhonchi, or decreased breath sounds).
− Heart: syncope, chest pain
− Oesophagus: dysphagia
− SVC: Face edema – Congested neck veins -decreased VR - ↑ICP
− Recurrent laryngeal nerve: Stridor

C. On induction of anesthesia:
− Tracheobronchial obstruction, dynamic hyperinflation
− RVOT obstruction, cardiac chamber compression
− Possible SVC syndrome:
▪ IV line to be placed in lower extremities.
▪ Epistaxis with nasal FOI
▪ ↑ intracranial pressure

Superior vena cava syndrome symptoms

Anesthetic management

The main goals:

− knowledge of anatomy and pathophysiology of the mass.
− Careful preoperative assessment.
− Perioperative planning with surgeon.
− Preparation to manage cardiorespiratory complications.
Preoperative:

− General preoperative assessment focusing on:

A. Risk stratification: based on symptoms & CT findings:

78
 B. Optimize medically prior to procedure (steroids, radiation, chemotherapy).
C. Document the “position of comfort” for patient in terms of respiration and circulation.

Intraoperative

E. Room preparation:
− Equipment:
▪ Cardiopulmonary resuscitative facilities.
▪ cardiopulmonary bypass
▪ Rigid bronchoscopy & thoracic surgeon immediately available for
sternotomy.
▪ Stretcher immediately available for repositioning: prone, decubitus
▪ Difficult airway trolly and fibreoptic.

− Monitoring:
▪ Standard ASA
▪ Arterial line in the right radial artery
▪ Two pulse oximeters:
o In right upper extremity to diagnose right innominate artery
compression.
o In lower extremity in case of loss pulse oximeter tracing in the upper
extremity during the procedure.

F. Anesthesia management:
The golden role is to Maintain spontaneous ventilation, avoid positive pressure ventilation & muscle
paralysis until placing the ETT distal to the obstruction while ENT is ready with a rigid bronchoscope
and cardiothoracic surgeon is ready for urgent sternotomy, and stretcher ready for positioning.

79
 G. Intraoperative complications:

Sudden loss of EtCO2 tracing

− DD:
▪ Top DD: airway obstruction by mass compression (elevated peak inspiratory pressure)
▪ Ventilator disconnection - Capnography obstruction
▪ Airway misplaced – extubation, oesophageal intubation.
▪ Respiratory/Cardiac arrest
▪ Apnoea

− Management:
▪ Call for help.
▪ Check monitor for hypoxia, and malignant arrhythmia.
▪ 100% oxygen.
▪ Manually ventilate the patient to assess compliance.
▪ Double-lumen tube or long endotracheal tube are advanced beyond obstruction or
compression.
▪ Reposition patient to position of comfort (if known), lateral or prone (to decrease the
weight of tumor on airway)
▪ Resumption of previous tolerated state (e.g., upright position, spontaneous
ventilation, awaken from anesthetic)
▪ Pass a rigid bronchoscope beyond the obstruction.
▪ If failed ask the surgeon to open the chest and begin cardiopulmonary bypass.

Superior vena cava syndrome

− Presentation:
▪ facial and upper extremity edema
▪ decreased CO and hypotension.

− Management
▪ Adequate preload prior to induction
▪ Large bore iv access in the lower extremities, and arterial line placement in the
▪ Right radial artery to diagnose innominate artery compression.
▪ Reposition patient to position of comfort (if known), lateral or prone (to decrease the
weight of tumor on airway) Because of the
▪ Avoid positive pressure ventilation.

Hypotension

− Top DD:
▪ Compression mass effects
▪ Surgical manipulation of the heart or major blood vessels
▪ Increased intrathoracic pressure.
▪ Hemorrhage due to inadvertent injury to cardiovascular structures.

− Management:
▪ Optimizing volume status.
▪ Ask the surgeon to relief the pressure.
▪ Administering inotropes and/or vasopressors.
▪ Use of short-acting anesthetic agents that can be rapidly titrated to minimize
hemodynamic effects during maintenance of anesthesia.
▪ Delay of epidural activation until the mass has been resected.

Hypoxia

The same as loss of ETCO2 tracing + exclude and mange pneumothorax.

Postoperative:
− In ICU OR HDU.
− Pain management.

80
 − Post-operative stridor:
▪ DD: on top of DD:
− Laryngeal edema
− RLN injury
− Tracheomalacia
− Residual from anesthesia or MR.

▪ Management:
− Immediately attend to the patient
− Assessment and management simultaneously according to ABC protocol.
− Apply 100% O2
− Upright position.
− Send blood sample for: ABG – CBC – Chest Xray
− According to the cause:
▪ If tracheomalacia: intubate, then tracheostomy.
▪ If RLI: intubate.
▪ If laryngeal edema:
o Nebulizers o Adrenaline
o Steroids o If failed: intubation.

Bullous Lung Disease

Considerations
− Pathology:
▪ Etiology: Chronic obstructive lung disease, congenital, carcinoma, infection/abscess.
▪ pathophysiological sequelae:
o obstructive lung physiology: causing airspace expansion during PPV with risk of
pneumothorax, restrictive lung physiology & mass effect.
o Bronchopleural fistula, infection/sepsis.
o Limited physiological reserve.

Anesthesia management
Management will be according to the planned procedure:

D. If the planned is bullae resection: the management will be as pneumonectomy (SEE

ABOVE).
E. For non-thoracic surgery with lung cysts, blebs, bullae:
▪ Use local & regional techniques if feasible.
▪ If GA is required:
o Maintain spontaneous ventilation if feasible with supraglottic device.
o If PPV is required:
▪ It is an absolute indication of lung isolation.
▪ Maintain spontaneous ventilation, avoid positive pressure ventilation &
muscle paralysis till lung isolation with a thoracic surgeon ready for urgent
chest tube insertion if rupture bullae.
o Induction of anesthesia:
▪ Awake fiberoptic intubation
▪ Inhalational induction
o Lung isolation techniques:
▪ DLT
▪ Bronchial blocker
▪ Endobronchial tube
o In a patient with marginal lung function, consider lobar/segmental isolation with
a bronchial blocker.
▪ Have a surgeon skilled in chest tube placement immediately available if the need
arises, but do not place prophylactic chest tube.

81
 Bronchopleural Fistula (BPF)

Considerations
− Related to the etiology:
A. Trauma
B. Complications of a certain pathology:
▪ Empyema/abscess, bullous disease, post-lung resection, and carcinoma
− Related to comorbid disease:
▪ Chronic obstructive lung disease, malignancy, coronary artery disease, and arrhythmias.

− Related to Repeat thoracotomy considerations:

▪ Hemorrhage
▪ Sepsis, septic shock
▪ Postoperative analgesia
▪ Postoperative ICU disposition for PPV

− Why it is an absolute indication for lung separation:

A. To avoid positive pressure ventilation to the affected side:
▪ Ineffective ventilation (with chest tube in place)
▪ Tension pneumothorax (without chest tube in place)
▪ Systemic air embolus
B. To protect the healthy lung from soiling

Anesthesia management
For non-thoracic surgery with BPF:

▪ Use local & regional techniques if feasible.

▪ If GA is required, consider:
o It is an absolute indication for lung separation:
o Maintain spontaneous ventilation, avoid positive pressure ventilation & muscle
paralysis lung isolation. Have a surgeon skilled in chest tube placement
immediately available if the need arises, but do not place prophylactic chest
tube.

o Induction of anesthesia:
▪ Awake fiberoptic intubation
▪ Inhalational induction
o Lung isolation techniques:
▪ DLT (preferred to bronchial blocker to support suctioning, optimal
ventilation & isolation)
▪ Bronchial blocker
▪ Endobronchial tube
o Lung protective ventilation
o Restrictive fluid strategy
o Maintenance of normothermia & normal metabolic state.

▪ Optimization to facilitate postoperative extubation:

o Resuscitation
o Bronchial suctioning
o Bronchodilators

82
 Chronic Obstructive Lung Disease (COPD)

Considerations

1. High risk of perioperative pulmonary complications including respiratory failure.

2. Pathology:
− Physiological changes:
▪ Chronic bronchitis: bronchospasm, mucous plugging, obstructive physiology.
▪ Emphysema: pneumothorax, pulmonary tamponade
▪ Chronic hypoxemia/hypercarbia: ↑ sensitivity to respiratory depressant effects of
anesthetic agents
− Complications: Cardiovascular: pulmonary hypertension, cor pulmonale

3. Etiology & co-morbid disease:

− Smoking, coronary artery disease, hypertension, cystic fibrosis, bronchiectasis.

4. Medication management:
− Continue usual inhalers pre-operatively.
− Stress dose steroids if recent high dose steroid use.

Anesthesia management
Goals:

A. Risk stratification to predict post-operative pulmonary complications:

− Degree of airflow obstruction

FEV1 (% predicted) > 80 50-80 50-30 <30

Severity Mild Moderate Severe Very severe

− Cigarette smoking
− Presence of core pulmonale.
− Malnutrition.

B. Optimization prior to elective procedures:

− Stop smoking at least 8 weeks preoperatively.
− All patients with symptomatic COPD should receive:
▪ Daily inhaled ipratropium or tiotropium.
▪ Inhaled β-agonists
▪ Pulmonary rehabilitation and chest physiotherapy to treat atelectasis.
▪ Treat chest infections.

Preoperative:
General assessment focusing on:

− History:
▪ Dyspnoea, cough, and sputum production.
▪ Frequency of exacerbations, timings of the most recent course of antibiotics or
steroids, hospital admissions, and previous, requirements for invasive and non-
invasive ventilation.
▪ Exercise tolerance
▪ Medications: specially (steroids)

− Examination:
▪ Breathing pattern, use of accessory muscles.
▪ Auscultate for wheezing, rhonchi, or rales.
▪ Cardiac: RVF – core palmonale.

83
 − Investigations:
▪ Spirometry:
o Assessment of severity of COPD.
o Response to bronchodilator: post-bronchodilator (FEV1)/ (FVC) ratio of
less than 0.7, confirming airflow limitation that is not fully reversible.
▪ ABGs in patients with moderate to severe COPD.
▪ ECG (RV hypertrophy or strain) or IHD. Consider echocardiography.
▪ CXR is not mandatory.

Intraoperative:
− Monitoring:
▪ Standard ASA.
▪ Arterial line in severe cases.

− Type of anesthesia:
▪ Avoid GA where possible.
o Increases the risk of intraoperative complications.
o Increases the risk of post-operative ventilation.

▪ If GA cannot be avoided:
o preoxygenation
o Avoid intubation where possible.
o Indications for ETT: obesity, breathless, long operations, patients with heavy
sputum production for endotracheal toilet.
o Ventilation settings: the main goal is to avoid dynamic hyperinflation &
barotrauma.
− Prolonged expiratory time, low peak pressure, low tidal volume, slow
rate, permissive hypercapnia
− Consider using PEEP.
o Avoid airway instrumentation.
o Blunt airway reflexes: deep anesthesia, topical local anesthetics, opioids.
o Bronchodilation:
− Avoid histamine releasing medications (e.g., morphine),
− use ketamine, volatiles, MgSO4, salbutamol, ipratropium,
epinephrine.
o Extubation:
Prior to extubation:
− Ensure the neuromuscular agent is fully reversed, the patient is
warm, well oxygenated, and has a PaCO2 close preoperative
values.
− Bronchodilator
Criteria for extubation:
• Fully awake.
• Haemodynamic stable.
• Fully reversed from MR
• Vt > 5 ml/kg.
• VC > 10 ml/kg.
• MIP> -20 cm H2o
• RSI<100
• Spo2 > 90 on 40% fio2 (or close to preoperative
value)
• PEEP< 5 cm H2o
Extubate in the sitting position.
Extubation directly onto non-invasive ventilation in the high-risk patient

84
 − Intraoperative complications:

Bronchospasm

− Call for help.

− Check monitor: for hypoxia, hypercarpia and arrhythmia.
− Manage:
▪ 100% O2
▪ deepen anesthesia, remove irritants.
▪ Disconnect & hand-ventilate to assess compliance, rule out other
possibilities.
▪ Medications:
o Beta 2 agonists (are first line treatment): Salbutamol 4-8 puffs via ETT
OR 2.5-5mg via nebulizer q20min.
o Anticholinergics: ipratropium 4-8 puffs via ETT OR 0.5 mg via nebulizer
q20min PRN
o Steroids: methylprednisolone 125mg IV OR dexamethasone 8mg IV
o Bronchodilating anesthetics: volatiles > ketamine > propofol
o Magnesium sulfate 2g IV over 20min
o Epinephrine infusion 0.5-2mcg/min in severe, refractory cases.

▪ Adjuncts:
o Heliox (does not reverse bronchospasm, but can be used as a
temporizing measure)
o Neuromuscular blocking drugs (may improve mechanics of ventilation
& lower peak inspiratory pressures)
o Extracorporeal membrane oxygenation (ECMO) if severe & refractory
to all other treatments

Postoperative:

− In HDU or ICU
− Effective analgesia is a significant determinant of post-operative pulmonary function.
(Avoid excessive sedation).
− Encourage early mobilization.
− Use of saline nebulization, suctioning, and physiotherapy to prevent atelectasis and to
encourage sputum production.
− Continue with nebulized salbutamol (2.5mg qds) and ipratropium 24hr before
discharge.

85
Neurosurgery Anesthesia

86
General considerations
CPP = MAP – ICP
− To maintain adequate CPP, both (MAP – ICP) are to be strictly optimized.
▪ Normal CPP: 60 - 80 mmHg
▪ Normal ICP: 5 - 10 mmHg
▪ Normal CBF: 50ml/100gm brain tissue.

Intracranial pressure
− Clinical features of raised ICP:
▪ Headache (worse in the morning), nausea and vomiting, confusion, personality or
behavioral changes, and visual disturbances due to papilledema.
▪ Acute severe increase in ICP:
o Cushing’s triad: (Hypertension – bradycardia - bradypnea)
o Decreased GCS.
o Fixed and dilated pupils,
o Hypotension and death.

− Management of increased ICP

Regarding Monroe- Kellie doctrine: the total volume of the intracranial contents (brain,
blood, and CSF) must remain constant.

The ICP can be controlled by controlling these 3

components:
1. Blood:
▪ Elevate head of the bed 30O
▪ Loosen collars, ETT ties to promote venous
drainage.
▪ Head in midline
▪ Decrease intrathoracic pressures (change
ventilator settings, decrease PEEP).
▪ Avoid internal jugular venous cannulation.
▪ Hyperventilation: Pco2 35-40 mmHg. Mnemonic decrease ICP
▪ Discontinue inhalational (Shift to TIVA)
▪ Sedation 5Hs:
▪ Analgesia ▪ Head of bed elevated.
▪ Hypertension: keep MAP >7o mmHg
2. Brain tissue: ▪ Hyperventilation: Pco2 35-40mmhg
▪ Mannitol (0.5-1 g/kg) ▪ Hypertonic saline
▪ Furosemide (0.25-0.5 mg/kg) ▪ Hypothermia
▪ Hypertonic saline 6-8 ml/kg of 3% saline
5Ds
▪ Correct sodium and osmolality
▪ Drugs: Sedation, relaxants, diuretics,
anti-seizures.
3. CSF drainage
▪ Drain: EVD
If failed: ICP >20 mmHg. ▪ Discontinue inhalational.
▪ Paralysis ▪ Decompress
▪ Increase analgesia and sedation. ▪ Deliberate hypotension
▪ Hyperventilation: Pco2 30-35 mmHg
▪ Barbiturate coma (1-5 mg/kg sodium thiopental
then 1-3 mg/kg/hr)
▪ Hypothermia (or at least normothermia)
▪ Surgical decompression (head, abdomen)

− Consider:
▪ Seizure prophylaxis and management
▪ Shivering treatment
▪ Glycaemic control

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 Craniotomy

Indications: Excision or debulking of tumor, brain biopsy, drainage of cerebral abscess

Preoperative management:
Routine preoperative assessment focusing on:

1. Neurological: (Document any neurological deficits)

− Size, site, and vascularity of lesions
− Symptoms and signs of raised ICP.
− Assess the gag reflex.
− History of seizures
2. Cardiac:
− Preoperative HTN: (could be secondary to the elevated ICP)
▪ firstly, check signs of increased ICP, if elevated, consider reducing the ICP to maintain
CPP.
− Exclude intracardiac shunts before procedures with a risk of VAE.

3. Medications
− Antiseizures:
▪ Full drug history, including timing should be noted.
▪ Continued peri-operatively up to the time of surgery.
▪ Change from oral to parenteral to ensure the patient does not miss a dose.
− Diuretics: electrolytes disorders – hypovolemia.
− Steroids:
▪ Hyperglycaemic
▪ Consider replacement.
− Anticoagulants: aspirin and NSAIDs should be discontinued.
4. Investigations:
− ECG, CBC, urea, and electrolyte.
− Echocardiography: before procedures with a risk of VAE.
− Blood group, Cross-matching in highly vascular tumors or those near the venous sinuses.
5. Consider 4M effects of tumors (mass, metabolic, metastatic, and medications)

Intraoperative management:
− Intraoperative goals
▪ Avoid increases in intracranial pressure.
▪ Maintain brain relaxation to facilitate surgical access to the lesion.
▪ Maintain stable hemodynamic for adequate CPP.
▪ Minimize using of long-acting sedatives to facilitate post-operative neurological
evaluation.

− Monitoring
A. Standard ASA monitor:
o ECG: ST changes indicated increased ICP.
B. Arterial Line: placed pre-induction for:
o Continuous blood pressure monitoring
o Sampling for blood gases and electrolytes.
C. Central venous catheter: for possible air aspiration
during VAE. (Avoid internal jugular vein)
D. Neuromonitoring:
o Cerebral function: EEG, processed EEG,
SSEP, transcranial Doppler ultrasound, and
cerebral oximetry.
o ICP monitoring.
E. Monitoring for venous air embolism: (if sitting position)
o TEE: is the most sensitive modality
o Precordial Doppler ultrasound
ICP monitoring.
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 o Precordial or oesophageal stethoscope to
detect a ‘millwheel’ murmur.
o End-tidal Nitrogen concentrations.
F. Foley catheter

− Position:
▪ According to the procedure: supine, prone, lateral, or semi-lateral (Park Bench), and
sitting or semi-sitting

− Premedication
▪ Titrated to effect using small doses of medication.
▪ Withhold sedation for patients with increased ICP.

Ensure graduated compression stockings are fitted to prevent DVT.

− Anesthesia technique:
▪ Anaesthetics effect on ICP:
A. Volatile agents:
o Increases CBF and ICP.
o Abolishes autoregulation.
o Unaffected by concentrations of <1 MAC of isoflurane, sevoflurane, and
desflurane.
o Enflurane may cause seizures.
B. Intravenous:
o All decrease cerebral metabolism, CBF, and ICP, except for ketamine.
C. Suxamethonium:
o causes a rise in ICP through muscle fasciculation, increasing VP but of little
clinical relevance.
D. Opioid: little effect on CBF and ICP if hypercapnia is avoided

▪ Avoid hypertensive response to intubation:

o Remifentanil infusion
o lidocaine 1.5mg/kg or a β-blocker (labetalol 5mg increments).

▪ Armoured ETT to prevent kinking, and secure in place with tapes, as ties may cause
venous obstruction.

▪ Maintenance: either
o Inhalational: sevoflurane/isoflurane <1 MAC
o TIVA: propofol TCI (3–6 micrograms/mL).

▪ Ventilation:
o Mild hypocapnia, PaCO2 30–35 mmHg.

▪ Application of the Mayfield causes a marked hypertensive response:

o Pin sites can be infiltrated with LA.
o Remifentanil (0.5–1 microgram/ kg) or propofol (0.5–1mg/kg).

▪ Fluid management
o Avoid hypotonic solutions for fluid maintenance. Replace blood loss with
colloid or blood.
▪ Maintain normothermia.

− Intraoperative complications:
▪ Cerebral edema (Tight brain):
• The fastest and most effective method is CSF drainage (10-20 ml)
• Reduce blood volume:
o Elevate head of the bed 30O
o Loosen collars, ETT ties to promote venous drainage.
o Head midline

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 o Decrease intrathoracic pressures (change ventilator settings, decrease PEEP).
o Avoid internal jugular venous cannulation.
o Hyperventilation: Pco2 35-40 mmHg.
o Discontinue inhalational (Shift to TIVA)
o Ensure adequate anesthesia: paralysis, barbiturate, propofol, and analgesics.
• Brain tissue:
o Mannitol (0.5-1 g/kg)
o Furosemide (0.25-0.5 mg/kg)
o Hypertonic saline 6-8 ml/kg of 3% saline
o Correct sodium and osmolality
• If failed:
o Hyperventilation: Pco2 30-35 mmHg, down to 25-30 mmHg
o Hypothermia (or at least normothermia)

− Emergence:
▪ Avoid increasing ICP:
o Avoid coughing, straining, retching, and vomiting (prophylactic antiemetics)
o Avoid hypoventilation.
▪ Avoid long-acting analgesia for early post-operative neurological assessment.

Postoperative care
− Pain management:
▪ Regular paracetamol and weak opioids to provide sufficient analgesia.
▪ Avoid NSAIDs.
− Indication of Intensive care unit (ICU):
▪ Reduced GCS
▪ Significant intraoperative haemorrhage.
▪ Ongoing vasopressor.

Posterior Fossa Surgery

Posterior fossa contains: brainstem, cerebellum & cranial nerves IV to XII

Preoperative management:
(As for craniotomy)

Intraoperative management:
− Monitoring
A. Standard ASA monitor
o ECG: ST changes indicated increased
ICP.
B. Arterial Line: placed pre-induction for:
o Continuous blood pressure monitoring
o Sampling for blood gases and
electrolytes.
o The transducer zeroed at the
external auditory meatus.
C. Central venous catheter: for possible air
aspiration during VAE.
D. Neuromonitoring:
o Cerebral function: EEG, processed
EEG, SSEP, transcranial Doppler
ultrasound, and cerebral oximetry.
o ICP monitoring.

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 E. Monitoring for venous air embolism: (if sitting position)
o TEE: is the most sensitive modality
o Precordial Doppler ultrasound
o Precordial or oesophageal stethoscope to detect a
‘millwheel’ murmur.
o End-tidal Nitrogen concentrations.
F. Foley catheter

− Position:
1. Sitting position:
− Contraindications:
▪ cerebral ischemia when upright.
▪ Intracardiac shunt
▪ uncontrolled hypertension
▪ extremes of age
▪ COPD
− Benefits
▪ Better surgical exposure.
▪ Less tissue retraction and damage.
▪ Less bleeding.
▪ Less cranial nerve damage.
▪ More complete resection of the
lesion.
▪ Early warning of venous air embolism
and brain stem compromise.
▪ Less facial swelling.
▪ Ability to observe facial nerve
function.
− Hazards
▪ Venous air embolism.
▪ Hypotension.
▪ Nerve injury and pressure injuries.
▪ Neck hyperflexion and cervical dislocation.
▪ External pressure on the eyes from the headrest.
▪ Poor visualization, access, and confirmation of the ETT and breathing circuit.
▪ Airway and/or jugular venous compression.
▪ Cerebral ischemia.
2. Prone position:
− Allows good surgical access without the risks associated with the sitting position.
− Abdominal compression should be avoided,

3. Lateral position:
− Suitable for lateral lesions such as acoustic neuroma and operations on a cerebellar
hemisphere.
− The neck is flexed, and the head rotated towards the floor.
− Ensuring that the jugular veins are not obstructed.
− Protect pressure points over the shoulder, greater trochanter, and peroneal nerves.
− Anesthesia technique:
− Consider neuromonitoring (TIVA, avoid MR)

− Intraoperative complications:
▪ Cerebral edema (Tight brain).

▪ Hypotension with ↓ EtCO2:

− DD
▪ Top DD is VAE
▪ Other causes:
− Aspiration − Heart failure
− Massive hemorrhage − Anaphylaxis
− Tension pneumothorax − Anesthetic
− effect

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 − Management:
▪ Call for help.
▪ Check the monitor to exclude hypoxia, hypercarpia, and malignant arrhythmia.
▪ 100% Oxygen
▪ According to cause:

− VEA:
▪ Ask the surgeon to:
▪ Flood the operative field with fluid.
▪ Occlude bone edges with wax to prevent further entrance of air.
▪ IV fluids to increase Venous pressure.
▪ Vasopressors.
▪ Gentle compression of the jugular veins.
▪ Aspirate air from the CVP line.
▪ If a large volume of air: turn the patient into the left lateral position to
attempt to keep the air in the right atrium.
▪ Commence CPR, if necessary.

Post-operative
− Indication of Intensive care unit (ICU):
▪ Reduced GCS
▪ Significant intraoperative haemorrhage.
▪ Ongoing vasopressor.
▪ Respiratory depression
▪ Preoperative state was poor.
▪ Airway obstruction: due to
o Macroglossia
o Partial damage to the vagus.
o Excessive flexion of the cervical spine.

Pituitary surgery

Considerations
Presented by:
− Hypersecretion of hormones:
▪ Acromegaly
o Difficult airway due to macroglossia, prognathism, and hypertrophy of the
epiglottis/vocal cords.
o Hypertension and LV hypertrophy
o Sleep apnoea, diabetes mellitus.
▪ Cushing’s syndrome
o Hypertension, truncal obesity
o Electrolyte abnormalities (hypokalaemia, hyperglycaemia)
o Steroid cover necessary pre- and post-operatively
− Mass effects (headaches, visual field defects, hydrocephalus.
− Hypopituitarism.

Anesthesia management (As for craniotomy)

− Preoperative: endocrinology consultation

− Position:
▪ Slightly head-up, head is secured in a Mayfield head holder and the bed is turned 90
degrees with the right side away from the anesthesia team.
▪ Surgical access is via the sphenoidal air sinuses.
− Major hemorrhage: disruption of the cavernous sinus/carotid arteries.
− Bleeding into pharynx: needs oral pack.

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− On Emergence:
▪ Avoid positive pressure ventilation.
▪ Avoid of coughing.
▪ Enhanced nausea and vomiting prophylaxis
▪ Strict nasal precautions.
− Postoperative complications:
▪ Endocrinal:
o Diabetes insipidus
o SIADH
o Adrenal insufficiency & CV collapse (steroid coverage)
▪ Bleeding
▪ CSF leak (risk of meningitis)
▪ Hypothalamic injury
▪ Cerebral ischemia, stroke

Cerebral aneurysm coiling

Considerations
1. Remote radiological environment:
− Unfamiliar, limited help & specialized tools.
− Radiation, contrast complications.
2. Procedure considerations:
− Limited access to patient
− Need for absolute immobility (muscle relaxant or remifentanil infusion)
− Need to control hemodynamic:
▪ Hypotension or sinus pause for coil placement.
▪ Place external pacing/defibrillator pads
− Heparinization (to ACT 2-3X normal)
− Complications:
▪ Aneurysmal perforation/rupture
▪ Cerebral ischemia due to misplaced coils, clots, vasospasm,
dissection
▪ Seizures

Anesthetic Technique
− Pre-induction arterial line.
− Temperature monitoring and warming devices.
− Adequate venous access with large-bore cannulae.
− Hemodynamic goals:
▪ Maintain cerebral perfusion pressure (CPP) to prevent ischemia.
▪ Avoid ↑ MAP to prevent aneurysm rupture.
− Maintenance: Sevoflurane & remifentanil OR propofol & remifentanil
− If the rupture occurs:
▪ Call for help.
▪ Plan for shifting to OR.
▪ Reverse the heparin.
▪ Reduce MAP to the level before the bleed: (Deliberate hypotension could be used if a
plan for clipping)
o Isoflurane (up to 1.5 MAC).
o Further hypotension: labetalol (5–10mg increments).
o Hypotension must not be induced in the presence of vasospasm.
▪ Increase IV infusions and start blood transfusion (Hematocrit> 30).
▪ Ipsilateral carotid compression.
▪ Brain protection measures:
o ↓ ICP
o Maintain normocapnia.
o ↓ CMRO2:
• Thiopental (3–5mg/kg bolus, followed by 3–5mg/kg/hr). EEG monitoring for
dose titration to burst suppression.
• Inducing hypothermia, rewarmed once the cerebral circulation is restored.

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 o Euglycemia: glucose < 11 mmol/L
o Prevent vasospasm (nimodipine, pravastatin)

− Recovery: smooth and rapid.

− Incompletely secured aneurysm may require control of the MAP post-operatively.
− Patients with neurological complications need to be transferred to a neurological ICU for post-
operative ventilation.

Subarachnoid Hemorrhage

− Grading of SAH:
▪ World Federation of Neurosurgeons grading score:

Grade GCS Motor deficit

1 15 -
2 13-14 -
3 13-14 -/+
4 7-12 -/+
>5 3-6 -/+
− Decides the timing of intervention.
▪ Grades 1–3: early operate or coil.
▪ Grades 4–5: delay intervention.

− Complications:
▪ Neurologic
o Rebleed o Obstructive hydrocephalus
o Cerebral vasospasm o Seizure

▪ Medical:
o Neurogenic pulmonary edema
o Myocardial dysfunction, arrhythmias
o Electrolyte imbalances (hyponatremia due to cerebral salt wasting, SIADH)

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Pregnancy Management of Acute Intracranial Hemorrhage:
− Management is according to gestational age:
▪ If in 3rd trimester (>32 weeks)
o Consider simultaneous procedure or cesarean section first followed by intracranial
procedure.
▪ If pre-term viable (24-32weeks):
o Do intracranial surgery, then wait for fetal maturity.
o Deliver if fetal distress.
▪ If pre-term non-viable (<24weeks):
o Do intracranial surgery, then wait for fetal maturity.

− Mannitol:
▪ Risk of fetal dehydration
▪ If tight head → give cautiously.
▪ If non urgent indication → discuss with neurosurgery, avoid if possible.
− Maintain PaCO2 around 30 mmHg.

Awake Craniotomy

Considerations
− Indications
▪ Resection of brain tumors near or within the eloquent areas
▪ Deep brain stimulation
▪ Epilepsy surgery
▪ Resection of intracranial vascular lesions supplying functionally important areas of the
brain
− Contraindications
▪ Absolute
o Communication problems.
o Patients cannot stay still.
o Prone positioning
▪ Relative
o Morbidly obesity
o poorly controlled seizures
o Chronic cough
o Obstructive sleep apnoea
o Anticipated difficult intubation.

Anesthesia management
Preoperative
− As for craniotomy
− Full explanation of the procedures to the patient.
− Premedication:
▪ Avoid sedatives.
▪ Anticonvulsant prophylaxis
▪ Dexamethasone for tumour surgery.

Intraoperative
− Patient Positioning:
▪ Keep the patient in position suitable for:
o Surgical access
o Vocalization for language testing and swallow secretions comfortably.
o Airway management by intubation or LMA is accessible (avoid extreme neck
rotation or flexion)

− Theatre Preparation:
▪ General anaesthesia equipment.
▪ Forced-air warming device.
▪ The operating table turned 90 degrees to the anaesthesia machine.
▪ Propofol should be readily available to terminate seizures.

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 − Monitoring:
▪ Standard ASA monitor.
▪ Arterial line
▪ Depth of anesthesia: BIS
▪ Urinary catheters

− Wide-bore intravenous access. All lines should be inserted on the ipsilateral side of the brain.

− Regional blocks:
▪ The pain-sensitive structures during craniotomy are the scalp, the periosteum, and the
dura.
▪ Different Techniques for Providing Local Anaesthesia (LA) of the Scalp:
− Direct nerve block:
1. Supraorbital nerve and & Supratrochlear nerve
o Needle is inserted 1 cm medial to the supraorbital notch and
perpendicular to the skin till it contacts bone then 2 mL of LA is injected.
o Needle is then directed 1cm medially, and another 2 mL LA is injected
above the eyebrow line to target supratrochlear nerve.
2. Zygomaticotemporal nerve:
o Needle is inserted at the lateral edge of the supraorbital margin and LA is
infiltrated till the distal side of zygomatic arch.
o Infiltrate 2 mL of LA superficial and 2 mL deep to temporalis muscle
3. Auriculotemporal nerve:
o Inject 2 mL of LA 1 cm anterior to the tragus of the ear at the level of
zygoma.
4. Greater occipital nerve:
o Inject 3 mL of LA is injected midway between the occipital protuberance
and the mastoid process.
o Palpate occipital artery and inject LA medial to it.
5. Lesser occipital nerve:
o 2 mL of LA is infiltrated along superior nuchal line, 2-3 cm lateral from
greater occipital nerve injection site.
6. Great auricular nerve:
o 2 mL of LA is injected about 5 cm posterior to the auricle at the level of the
tragus.

− Ring block:
− Circumferential infiltration of LA around the scalp
− Requires larger dose of LA (40-60 mL) so it can increase the risk for toxicity,
especially in patients with low body weight.
− Surgical-site field block:
− Injection of LA around Mayfield frame pins site as well as surgical site.

Anesthesia techniques:

− Awake craniotomy procedure divided into 3 stages:

1. Craniotomy and exposure of the brain,
2. Cortical and subcortical mapping and excision of the brain lesion.
3. Haemostasis and closure of craniotomy wound.

− The patient needs to be awake and cooperative during stage 2.

The stages before and after can be performed under local
anaesthesia, sedation, or general anaesthesia.

− The anaesthesia techniques are:

▪ The asleep–awake–asleep.
▪ the asleep–awake.
▪ the conscious sedation.
▪ Awake.

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A. Asleep-awake-asleep technique
− Anaesthesia is induced and maintained with a TCI of
propofol and a remifentanil infusion (0.05–1 mcg/kg/min).
− The propofol dose is titrated against the patient’s responses, haemodynamic, and BIS
monitoring.
− The patient’s lungs are ventilated using an LMA.
− Adequate LA infiltration of the Mayfield fixator pin sites and the operative field is essential.
− When the tumour is exposed, the remifentanil is reduced to 0.005–0.01 microgram/kg/min to
allow return of SV. When this occurs, the LMA is removed and the propofol stopped.
− Once the resection is complete, the patient is re-anaesthetized, and the LMA reinserted
until the end of the procedure.

B. Asleep-awake technique:
− The patient is kept awake after brain lesion excision till closure of craniotomy wound.

C. Conscious sedation technique:

− Deeper levels of sedation are needed during the scalp block and initial craniotomy phase
till dural opening.
− Sedation is then stopped or reduced for cortical mapping and testing.
− Once resection is complete, sedation is deepened to ensure patient comfort during the
surgical closure.
− Dexmedetomidine infusion OR a combination of propofol and remifentanil target-
controlled infusions can be used:
Dexmedetomidine infusion
▪ Initial phase:
o Loading 0.5-1 mcg/kg over 10 minutes
o Maintenance: 0.2-1 mcg/kg/h.
▪ Cortical mapping phase: 0.1-0.4 mcg/kg/h
D. Awake technique
− Relies only on effective LA without any sedation. This technique needs a highly motivated
patient and short surgical time to be successful.

97
Anesthesia for neuromuscular
and skeletal diseases

98
 Epilepsy
Considerations
Antiepileptic drugs:
A. Effects of anesthetic agents on epilepsy:
1. Induction and maintenance agents:
− Thiopentone:
▪ Powerfully anticonvulsant in the therapeutic range
▪ Drug of choice in refractory status epilepticus.
− Propofol:
▪ Associated with excitatory effects (not true cortical seizure activity)
▪ Should be avoided unless there is a clinical imperative.
− Ketamine
▪ Has cerebral excitatory effects, should be avoided.
− Etomidate:
▪ Has a high incidence of myoclonus (not centrally mediated) confused with
epileptic activity. Should be avoided.
2. Inhalational anesthetics:
− All are safe EXCEPT enflurane is epileptogenic. Should be avoided.
3. Muscle Relaxants:
− Steroid-based (e.g., vecuronium, rocuronium): Pharmacodynamic resistance due to
enzyme activation.
− Better to use Benzylisoquinolinium: (cis-)atracurium, mivacurium
4. Benzodiazepines:
− All benzodiazepines are potent anticonvulsant.
5. Antiemetics
− Avoid dopamine antagonists: cause extrapyramidal effects and dystonic reactions.
e.g., droperidol, and metoclopramide.
B. Effect of antiepileptics on anesthesia
− Many anti-epileptic medications have sedative action on patients.
− Some of the drugs cause enzyme induction (phenytoin, carbamazepine, primidone, and
barbiturates)
− Others cause enzyme inhibition.

C. Side effects of drugs:

− Hyponatraemia
− Abnormal LFTs
− Anaemia
− Thrombocytopaenia
− Leukopenia

Preoperative assessment
− Nature, timing, and frequency of seizures should be recorded. if not well controlled, refer
to a neurologist
− Drug management:
− Full drug history, including timing should be noted.
− Continued peri-operatively up to the time of surgery.
− Change from oral to parenteral to ensure the patient does not miss any doses.
− Investigations:
− CBC for medication side effects.
− Electrolyte and glucose measurement: Disturbance will alter seizure potential.
− Pre-medication: benzodiazepine.

Intraoperative:
− Regional anesthesia: can be used.
− Early return to oral intake
− Be aware of maximum LA doses.
− GA:
− Avoid: ketamine – Etomidate - vecuronium, rocuronium – enflurane
− Avoid hypocarbia, it lowers the seizure threshold.
− Maintain normothermia and normoglycaemia.

99
Post-operative:
− Early re-introduction of anti-epileptic medication.
− Shift to ICU or HDU if perioperative fits.
− Day-case anesthesia is suitable for those with well-controlled epilepsy.

Perioperative fits:
− Call for help.
− ABC:
▪ Airway: Intubation and ventilation
▪ Breathing – 100% O2, maintain normal PaO2 and PaCO2
▪ Circulation:
o IV access
o Fluid resuscitation to maintain adequate systemic blood pressure and cerebral
perfusion pressure. c
▪ Check and correct hypoglycemia.
− Antiepileptic:
▪ 1st line therapy: IV Benzodiazepines: Diazepam (0.1mg/kg)
▪ 2nd line therapy (if not terminated within 10min): IV Phenytoin (15 mg/kg) by slow
infusion (rate <50mg/min)
▪ If not controlled after 30 minutes with second-line therapy: consider propofol or low-
dose thiopentone infusion.
− Consult neurology for further diagnosis & management.

Parkinson’s disease
Central dopamine deficiency leads to rigidity, tremors & late dementia caused by the degeneration of
dopaminergic neurons in the substantia nigra of the basal ganglia.

Considerations
1. Patient age group:
− Elderly with associated co-morbidities
2. Disease-related:
− Airway:
▪ Potential difficult airway (temporomandibular joint & cervical spine rigidity)
▪ Increased risk of postoperative airway obstruction
− Pulmonary:
▪ Bulbar dysfunction: aspiration and recurrent chest infection.
▪ Chest wall rigidity leads to restrictive lung disease.
− Cardiac:
▪ Autonomic instability
− Neurologic:
▪ Worsening of neurologic symptoms
▪ Postoperative delirium
− GI:
▪ Esophageal dysfunction & gastroparesis
3. Medications:
− Drug therapies:
A. Dopaminergic drugs:
− Dopamine precursors: Levodopa
− Dopamine agonists: Apomorphine.
− MAO-B inhibitors: Selegiline. To prevent the breakdown of dopamine in CNS.
B. Anticholinergics: orphenadrine to antagonize the unopposed excitatory effects of
cholinergic pathways.
− Drug interaction:
Avoid:
− Pethidine: causes hypertension and muscle rigidity in patients on selegiline.
− Antiemetics (Metoclopramide, droperidol, and prochlorperazine): worsen the
symptoms and cause extrapyramidal effects.
− Tricyclic antidepressants: potentiate Levodopa-induced arrhythmias.

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 − Antihypertensives: may cause severe hypotension (due to postural hypotension,
hypovolaemia)
− Centrally acting anticholinergic drugs can precipitate central anticholinergic
syndrome.
− Large dose opioids: ↑ muscle rigidity with fentanyl & morphine.
− Acute withdrawal of drugs may precipitate neuroleptic malignant syndrome.

Preoperative:
− Multidisciplinary team includes a physician with a special interest in Parkinson’s disease.
− Routine preoperative assessment focusing on:
− Dysphagia or excessive salivation: increased risk of aspiration and airway
obstruction.
− Postural hypotension: indicates dysautonomia and drug-induced hypovolaemia.
− Drug-induced arrhythmias: PVCs
− The severity of the underlying disease should be determined.
− Parkinsonism medications to be continued up to the start of anesthesia.
− Premedication:
− Antiemetic: domperidone: the drug of choice.
− Antisialogogues: Glycopyrrolate is the drug of choice.

Intraoperative:
− NO anesthetic technique is superior to any other.
− IF GA: Modifies RSI with cricoid pressure.
− Avoid hypothermia.

Postoperative:
− IN HDU
− physiotherapy if rigidity is disabling.
− Early starting of Parkinson’s medications
− NGT insertion may be needed if GI dysfunction.

Multiple sclerosis

It is an acquired demyelinating disease of the Central nervous system characterized by demyelinated

plaques within the brain and spinal cord with an episodic pattern of symptoms.

Considerations
1. Exacerbations triggers: hyperthermia, stress, spinal anesthesia.
2. Multisystem effects:
− Respiratory:
▪ Bulbar dysfunction increases aspiration risk and recurrent infection.
▪ Central hypoventilation & neuromuscular weakness
▪ Respiratory failure
− Cardiovascular:
▪ Autonomic dysfunction with possible hemodynamic instability
− Limb weakness and paralysis.
3. Medications:
− Immunosuppressive medications (steroids, interferon, methotrexate)
− Baclofen and dantrolene for painful muscle spasms.
4. Anesthesia considerations
A. Neuromuscular blocking drugs:
− Succinylcholine is contraindicated due to the risk of hyperkalemia.
− Sensitive to nondepolarizing muscle relaxants (needs monitoring)
B. Regional anesthesia:
− Avoid spinal anesthesia.
− Epidural is safer and acceptable.
− Peripheral blocks are safe.

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 Preoperative:
− Multidisciplinary team includes neurologist.
− Routine preoperative assessment focusing on:
▪ Detailed neurological examination, and the type of symptoms. (Documentation to
Compare with the post-operative state)
▪ Evaluation and optimization of the chest condition.
▪ Medication history and assessment of its complications
▪ Inform the patient of potential perioperative aggravation of symptoms.

Intraoperative:
− Monitoring:
− Standers ASA +
− NM monitoring
− Arterial line if autonomic dysfunction
− IF GA: Modifies RSI (Avoid succinylcholine)
− Avoid spinal.
− Epidural: keep LA concentration to a minimum
− Avoid and treat hyperthermia aggressively.

Pregnancy Considerations
− The pregnancy improves MS, and relapse decreases.
− The highest relapse risk is in the third trimester.
− Increase in the first 3 months postpartum.
− Better to avoid Spinal anesthesia
− Epidural: keep LA concentration to a minimum

Guillain–Barré syndrome

It is an Acute immune-mediated demyelinating peripheral polyneuropathy in response to viral or

bacterial infection.

Considerations
1. Multisystem effects:
− Respiratory:
▪ Bulbar dysfunction increases aspiration risk and recurrent infection.
▪ Muscle weakness leads to respiratory failure and requires pre-operative MV and
continues post-operative.
− Cardiovascular:
▪ Autonomic dysfunction and autonomic hyperreflexia: lead to:
o Severe hypotension during induction of anesthesia, and initiation of PPV.
o Severe postural changes under anesthesia or recovery.
o Hypertension Tachycardia due to surgical stimulus may be extreme.
o Paroxysmal hypertension, bradycardia, ventricular tachyarrhythmia.
o Atropine may cause paradoxical bradycardia.
− Sensory dysfunction: Neuropathic pain
− ↑ risk of venous thromboembolism
2. Medications:
− IV immunoglobulins & plasma exchange
− Neuropathic pain treatment.
3. Anesthesia considerations
A. Neuromuscular blocking drugs:
− Succinylcholine is contraindicated due to the risk of hyperkalaemia.
− Sensitive to nondepolarizing muscle relaxants (needs monitoring)
B. Regional anesthesia:
− Epidural is acceptable.

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 Preoperative:
− Multidisciplinary team includes neurologist and intensivist.
− Routine preoperative assessment focusing on:
− Detailed neurological examination, and the type of symptoms. (Documentation to
Compare with the post-operative state)
− Evaluation and optimization of the chest condition.
o Indication for preoperative ventilation:
− Forced vital capacity < 20 mL/kg.
− Maximum inspiratory pressure < -30 cmH2O
− Maximum expiratory pressure < 40 cmH2O
− Reduce preoperative fasting period.

Intraoperative:
− Monitoring:
− Standers ASA +
− NM monitoring
− Arterial line if autonomic dysfunction
− Maintain hydration.
− Wide-bore IV access
− IF GA:
− Modifies RSI (Avoid succinylcholine)
− Avoid or use minimal NDMR.
− Pressor agents (ephedrine 3–6mg bolus IV) prepared before induction may be
indicated.
− Multimodal pain management (to reduce opioid usage)
− Epidural: keep LA concentration to a minimum

Postoperative
− In ICU or HDU
− Pain management.

Amyotrophic Lateral Sclerosis (ALS)

It is a degenerative disorder of upper and lower motor neurons in the spinal cord leading to
denervation & atrophy of skeletal muscle and eventual death.
Considerations
1. Multisystem effects:
− Respiratory:
− Bulbar dysfunction increases aspiration risk and recurrent infection.
− Muscle weakness leads to respiratory failure.
− Cardiovascular:
▪ Autonomic dysfunction and autonomic hyperreflexia: lead to:
o Severe hypotension during induction of anesthesia, and initiation of PPV.
o Severe postural changes under anesthesia or recovery.
o Hypertension Tachycardia due to surgical stimulus may be extreme.
o Paroxysmal hypertension, bradycardia, ventricular tachyarrhythmia.
o Atropine may cause paradoxical bradycardia.
− Sensory dysfunction: Neuropathic pain
2. Medications:
− Neuropathic pain treatment.
3. Anesthesia considerations
A. Neuromuscular blocking drugs:
− Succinylcholine is contraindicated due to the risk of hyperkalemia.
− Sensitive to nondepolarizing muscle relaxants (needs monitoring)
B. Regional anesthesia:
− Neuraxial is safe.

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 Preoperative:
− Multidisciplinary team includes neurologist and intensivist.
− Routine preoperative assessment focusing on:
▪ Detailed neurological examination, and the type of symptoms. (Documentation to
Compare with the post-operative state)
▪ Evaluation and optimization of the chest condition.
− Reduce preoperative fasting period.

Intraoperative:
− Monitoring:
▪ Standers ASA +
▪ NM monitoring
▪ Arterial line if autonomic dysfunction
− Maintain hydration.
− Wide-bore IV access
− IF GA:
▪ Modifies RSI (Avoid succinylcholine)
▪ Avoid or use minimal NDMR.
▪ Pressor agents (ephedrine 3–6mg bolus IV) prepared before induction may be
indicated.
▪ Multimodal pain management
− Epidural: keep LA concentration to a minimum
− Spinal is safe.
Postoperative
− In ICU or HDU
− Pain management.

Myasthenia Gravis

It is autoimmune destruction of post-synaptic acetylcholine receptors at the neuromuscular junction

leading to weakness & fatigability of skeletal muscles.
Symptoms range from mild ptosis to life-threatening bulbar palsy and respiratory failure.

Considerations
1. Limited to the motor system:
− Bulbar dysfunction increases aspiration risk and recurrent infection.
− Respiratory muscle weakness leads to respiratory failure.
2. Associated conditions:
− Thymoma (anterior mediastinal mass considerations).

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 − Myocarditis, cardiomyopathy, AF, and heart block.
− hyper/hypothyroidism.
3. Medications:
A. Treatment:
− Anticholinesterases: (Pyridostigmine)
▪ Increased vagal reflexes.
▪ Inhibition of plasma cholinesterase, prolongs the action of ester-type local
anesthetics and suxamethonium.
− Steroids: Consider steroid replacement
− Plasmapheresis depletes plasma esterase levels, prolonging the effect of
suxamethonium, mivacurium, ester linked LAs, and remifentanil.
− Immunosuppressants.
B. Drug interaction: Affect the neuromuscular transmission:
− Procainamide
− β-blockers (especially propranolol)
− phenytoin
− Magnesium
− Aminoglycosides
4. Anesthesia-related considerations
A. Neuromuscular blocking drugs: (need continuous monitoring)
− Very sensitive to NDMR: avoid or use 1/10 normal dose.
− Resistant to succinylcholine (ED95 2.6X normal)
B. Inhalational anesthetics: reduce neuromuscular transmission by up to 50%.
C. Regional anesthesia: Safe (better choice)
D. Local anesthetics:
− Prolonged action
− Increased toxicity in ester-linked agents with anticholinesterase therapy and
plasmapheresis.
− Use the minimum required dose.

Preoperative:
− Routine preoperative assessment focusing on:
− Onset, duration, and severity of the disease.
− Ocular symptoms only or bulbar or respiratory muscles affected.
− Last episode of myasthenic crisis.
− Detailed medication history.
− Admission 48h before surgery for:
▪ Assessment of respiratory muscle and bulbar function
▪ Review of anticholinesterase and corticosteroid therapy.
▪ Presence of thymoma
− Predictors of postoperative respiratory failure (Leventhal score):
− Duration > 6 years (12 points).
− Chronic respiratory disease (10 points).
− Dose of pyridostigmine > 750 mg/ day (8 points).
− Preoperative vital capacity < 2.9 L (4 points)
A total score of ≥ 12 points indicates postoperative ventilation.

Intraoperative:
− Monitoring:
− Standard ASA +
− NM monitoring
− Maintain anticholinesterase therapy up to the time of induction.
− Premedication: minimal sedation.
− Anesthesia technique:
− Regional anesthesia: preferable over GA to avoid:
▪ Muscle relaxation
▪ Instrumenting of the airway
▪ Need for postoperative ventilator support.
− IF GA:
− If RSI: succinylcholine1.50-2 mg/kg (do not use any other NMB until muscle function
has returned).
− Avoid or use minimal NDMR (1/10 normal dose) use drugs with a spontaneous
reversal.

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 − Extubation: using nerve stimulation (TOF> 0.9), best predictor of safe extubation is >5s
head lift.

Postoperative
− In ICU or HDU
− NGT for early administration of anticholinesterases. (if bulbar symptoms)
− Pain management:
▪ Multimodal approach: infiltration of local anesthetic, regular paracetamol, NSAIDs,
and parenteral opioid in the form of PCA morphine.

Myasthenic Crisis Cholinergic Crisis

− Infections
− Electrolyte abnormalities
− Pregnancy,
Excessive cholinesterase
− Surgery
Causes inhibitors
− Emotional stress
− Drugs (aminoglycosides)
− Interruption of immunosuppressants

SLUDGE BBB:
Salivation, lacrimation, urination,
− Severe skeletal muscle weakness
Clinical picture diarrhea, GI symptoms, emesis,
− Respiratory failure
bradycardia, bronchorrhea,
bronchospasm
Edrophonium
(Tensilon test):
Edrophonium 1.5 mg Improvement of symptoms Worsens symptoms
increments up to 10 mg.

− ABC − ABC
− Anticholinesterase: − Atropine
▪ 1st choice: pyridostigmine: − Cessation of cholinesterase
o PO: 30-120 mg/day, onset 15- inhibitors until the crisis is over.
30 min, peak 2 hrs, duration 4
hrs
Management o IV: 1/30 of PO dose
▪ Alternative: Neostigmine
o 0.5-2.5 mg IV/SC q1-3 hours
titrated (max = 10mg/24h)
− Neurology consult: (plex, IVIG,
steroids)

Duchenne Muscular Dystrophy

X-linked recessive degenerative disease of skeletal & smooth muscle affects males.
Considerations
− Risk of rhabdomyolysis/hyperkalaemia: succinylcholine/volatile anesthetics are contraindicated. Use
total IV anesthesia.
− Airway:
▪ Possible difficult airway if macroglossia
▪ Bulbar weakness: aspiration risk.
− Pulmonary:
▪ Possible obstructive sleep apnea:
o Sensitivity to sedatives/hypnotics
o Pulmonary hypertension/RV failure

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 ▪ Restrictive lung disease from scoliosis & respiratory muscle
weakness
▪ Risk of perioperative respiratory failure
▪ Impaired cough reflex (atelectasis, recurrent aspirations)
− Cardiovascular:
▪ Dilated cardiomyopathy:
▪ Mitral regurgitation common (due to papillary muscle
involvement from LV dilation)
▪ Conduction defects & arrhythmias common (atrial, SVT,
AV nodal)
− CNS:
▪ Mild cognitive impairment is common.
− Medications:
▪ ACE inhibitors, beta-blockers, steroids (may need stress
dose)
− GIT:
▪ ↓ gastric motility

Cerebral Palsy (CP)

Considerations
− A disorder of movement & posture due to cerebral insult in the immature brain that occurred
prenatally, perinatally, or during infancy.
− The motor deficit may manifest as: Hypotonia, spasticity, extrapyramidal features.
− Systemic manifestations:
▪ Airway:
▪ Potential difficult intubation (muscle spasticity).
▪ ↓ C-spine mobility
▪ Excessive secretions.
▪ Respiratory:
▪ Recurrent aspiration & pulmonary impairment
▪ poor cough with retention of secretions
▪ Scoliosis: restrictive lung disease, pulmonary HTN, RV failure
▪ CNS:
▪ Communication problems
▪ Seizure
▪ Hydrocephalus
▪ Altered response to anaesthetics:
• ↓ MAC of volatiles & longer emergence
• ↑ sensitivity to muscle relaxants
• Volatiles & succinylcholine NOT contraindicated.
▪ Gastrointestinal
▪ Aspiration risk (GERD/↓lower esophageal sphincter tone)
▪ Medications:
▪ Anticonvulsants
▪ Antispasmodic: baclofen (causes bradycardia & hypotension with induction-
Sudden stopping causes seizures)
▪ Difficult IV access, monitoring, & positioning due to contractures
▪ ↑ risk of hypothermia

− Common surgical procedures: (almost all are non-emergent, optimize first)

▪ Orthopaedic procedures: major multilevel surgery involving tenotomies/osteotomies, soft
tissue release/tendon transfers, and botulinum toxin injections.
▪ Dental extractions and restorations.
▪ Gastrostomy and anti-reflux procedures.
▪ Imaging: MRI, CT.
▪ Other: neurosurgery, urology, ophthalmology, ENT and insertion of infusion devices.

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Anesthesia management:
Preoperatively
− Optimise respiratory functions: physiotherapy, bronchodilators, or antibiotics.
− seizure control
− Aspiration prophylaxis
− Anticholinergics to reduce oral secretions.
− Topicalization: EMLA cream at the venepuncture site to reduce pain and distress.

Intraoperatively:
− Monitoring:
▪ Standard ASA.
▪ Temperature monitoring is crucial.
▪ Neuromuscular monitoring
− Suction of the oro- or naso-pharynx
− RSI if not spastic OR inhalational induction
− LMA is better, if ETT, size should be selected based on age.
− Reduce MAC by 20% and a further 10% if on anticonvulsants.
− Positioning:
▪ Extreme care to avoid nerve damage, muscle damage and pressure ulcers.
Postoperatively:
− Delayed emergence
− Awake extubation
− Best managed in a high dependency or intensive care units because they are prone to
hypoxia, hypovolaemia, and hypothermia.
− Pain assessment and management.

Scleroderma

Considerations
Chronic progressive fibrotic disorder of connective tissue leads to:
− Potential difficult airway: (bag-mask ventilation, laryngoscopy)
▪ Microstomia
▪ ↓ neck mobility
▪ Bleeding nasal/oral (Avoid nasal intubation)
▪ Telangiectasia
− Increased aspiration risk:
▪ Esophageal dysmotility, hypotonic lower esophageal sphincter
− Multi-system disease:
▪ Cardiovascular:
o HTN, IHD, myocardial fibrosis & LV failure, arrhythmia
o Liable for intraoperative hemodynamic instability
o Raynaud’s, vasoconstriction, sensitive to cold:
(Radial arterial line is contraindicated).
▪ Respiratory: Potential for hypoxemia
o Restrictive lung disease
o Pulmonary fibrosis
o Pulmonary hypertension, cor pulmonale
o Consider Postoperative ventilation.
▪ Renal failure & “renal crisis”
▪ Skin:
o Dermal thickening, and contractures lead to:
− Difficult vascular access/positioning/monitoring
− Nerve entrapment/pain syndromes
− Medications:
▪ Immunosuppressant, vasodilators (ACE inhibitors), pain Medications
− Consider regional over GA.

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 Rheumatoid Arthritis

Chronic multisystem autoimmune disease has articular and extraarticular manifestations.

Considerations

1. Difficult airway: (3 joints affected):

− Temporomandibular: limited mouth opening
− Cricoarytenoid arthritis: hoarseness, stridor from glottic stenosis, and airway obstruction
post-extubation.
− Atlantoaxial instability (AAI):
▪ Leads to unstable c-spine and compression of cord or medulla or occlude the
vertebral arteries.
▪ Symptoms: tingling hands or feet and neck pain, and decreased range of neck
movement
2. Systemic diseases
− Cardiovascular:
▪ Pericarditis, AI, pericardial effusions, conduction system defects, LV dysfunction,
accelerated CAD.
− Respiratory:
▪ Diffuse fibrosing alveolitis, pulmonary hypertension, pleural effusions
− Neuro:
▪ Nerve compression leads to peripheral neuropathy.
▪ Carpal tunnel syndrome, & tarsal tunnel syndrome
▪ Chronic pain
− Renal: chronic renal failure.
− Blood: chronic anemia, thrombocytopenia, neutropenia (Felty’s syndrome)
− Skin: thin skin and difficult venous access.

3. Medications
− Steroid: Hypertension, electrolyte imbalance, diabetes, Easy bruising, osteoporosis,
obesity, myopathy, mania, Peptic ulcer disease. Replacement therapy
− Analgesics: NSAIDs: Renal impairment, gastric erosions→bleeding Fluid retention
− Disease-modifying anti-rheumatoid drugs (DMARDs): methotrexate, azathioprine,
cyclophosphamide, ciclosporin: nephrotoxicity, bone marrow depression

Anesthesia management

Goals:
− Safe airway management & c-spine stabilization.
− Optimization of systemic diseases.
− Medications management.

Preoperative
Routine history, examination, and investigation focusing on:
− Detailed airway examination.
− Neurological examination and documentation of deficits.
− Detailed cardiorespiratory assessment.
− Document the head positioning that can be tolerated without discomfort or other symptoms.

Investigations:
− CBC, Kidney function, ECG, CXR, and coagulation studies. Echo if cardiac involvement.
− Lateral X-ray of the cervical spine with flexion/extension views:
▪ Indications:
o Neurological symptoms
o Severe disease requiring steroids, methotrexate, & immunosuppressants
o Disease >10 years

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 ▪ If the gap between the anterior arch of the atlas and odontoid process > 3 mm confirms
the presence of atlantoaxial subluxation.

Intraoperative
GA:
− If suspected difficult or AAI: awake fiberoptic intubation.
− If not: direct laryngoscopy using manual in-line stabilization and a gum elastic bougie (GEB).
− Maintain the neck in a neutral position on transfer and turning.

Regional Anesthesia:
− Suspected difficulty.
− Discomfort from prolonged immobilization.

Positioning:
− Note comfortable position before induction, then try to maintain this during surgery.
− Padding and protection

Avoid hypothermia.

SCOLIOSIS
It is an abnormal lateral curvature of the spinal column.
Considerations
− Emergency Status: correction is never an emergent operation.
− Concerns:
▪ Patient related:
1. Type of scoliosis:
− Idiopathic: (most common form 65%)
− Congenital: syndromic, a greater degree of baseline curvature and pulmonary
dysfunction
− Neuromuscular: (cerebral palsy, Duchenne muscular dystrophy, spinal cord
trauma, spinal muscular atrophy) increased incidence of malignant hyperthermia.
2. Associated comorbidities:
− Respiratory:
o Reduced chest wall compliance.
o Restrictive pulmonary disease with alveolar hypoventilation, arteriovenous
shunting, and V/Q mismatch.
o Decreased lung volumes.
o Inability to cough or clear secretions.
− Cardiac:
o Corpulmonale.
o Pulmonary hypertension leads to right sided heart failure.
o Mitral Valve Prolapse
o If Duchenne muscular dystrophy: Cardiomyopathy, coarctation, CHD
2. Difficult airway:
− Cervical involvement.
− Secondary to back curvature

▪ Surgical related:
1. Positioning:
− Prone:
o Venous air embolism
o Positioning injuries: (forehead, nose,
breast, genitalia, skin over bony
prominences)
o Abdomen to be free.
o Nerve injury:
• Brachial plexus
• Ulnar nerve at the elbow
• Radial and median nerve at
the wrist

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 • Femoral nerve under the inguinal ligament
• Lateral cutaneous nerve of the thigh at the level of the anterior superior
iliac spine.
o Postoperative visual loss (POVL)
o Airway swelling
− lateral:
o OLV if thoracic approach
2. Potential for excessive blood loss:
− Depends on the type and number of vertebrae: (150 - 200 ml/vertebra).
− To reduce transfusion requirements:
Preoperative: autologous donation.
Intraoperative:
o Acute normovolemic haemodilution
o Cell salvage
o Deliberate hypotension (minimize its time to avoid spinal cord injury and POVL)
o Tranexamic acid
o Avoid hypothermia.
o Proper positioning to decrease the abdominal pressure.
3. Prolonged surgery:
− Hypothermia and DVT
4. Need for neurophysiological monitoring.

Anesthesia management:
− Preoperative:
Routine history and examination focusing on:
− Location, extent, and severity of the spinal deformity.
− Detailed airway examination.
− Neurological examination and documentation of deficits.
− Detailed cardiorespiratory assessment:
▪ Exercise intolerance and dyspnea
▪ Optimization of any reversible cause of pulmonary dysfunction as chest infection with
antibiotics, bronchodilators, and physiotherapy.
− Contact the blood bank and prepare a post-operative ICU bed.

Investigations: (Based on the severity of the curve and the degree of cardiorespiratory
impairment)
− CBC, urea and electrolytes, clotting screen, cross-matching of blood and blood products.
− Plain CXR for respiratory and cardiac assessment
− 12-lead ECG to assess cardiac function
− Echocardiogram in patients with long-standing and severe scoliosis
− Lung function tests, ABG.
− If suspected difficult airway, flexion and extension x-ray, and CT/MRI of cervical spines.

− Assess for the need for post-operative ventilation:

A. Patient factors:
▪ Pre-existing neuromuscular disorder
▪ Severe restrictive pulmonary disease (< 35% vital capacity)
▪ Associated cardiac involvement and right heart failure.
▪ Obesity
B. Surgical factors
▪ Invasion of thoracic cavity
▪ Blood loss > 30 mL/kg
▪ Presence of complications such as pneumothorax and haemothorax
▪ Duration and severity of scoliosis.

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 Cobb’s angle:
− It measures the severity of scoliosis.
− It is a measure of the angle of the perpendicular lines of the superior surface of
the most tilted vertebra above the curve and the lower surface of the most tilted
vertebra below the curve.
− 0-10o : Normal
− 40-45o: surgery is indicated.
− 60-65o: pulmonary dysfunction.
− >70o: Pulmonary hypertension on exercise.
− >100o Pulmonary hypertension at rest.

− Discuss the wake-up test with the patient (if planned)

− Intraoperative:
Room preparation:
− Equipment:
▪ Cardiopulmonary resuscitation facilities.
▪ Difficult airway facilities.
▪ Blood transfusion facilities.
▪ Two forced air warming blankets are used to maintain normothermia. One on the
upper extremities and one on the lower extremities below the buttocks.
Positioning: Prone or lateral.
Monitoring:
− Standard ASA monitor +
▪ Arterial line
▪ Central line
▪ Folly’s catheter
▪ Depth of anesthesia: BIS (target 40-60).
▪ Neurologic Monitoring:
− Value:
▪ Monitor the integrity of the entire signal pathway including the cortex, spinal
cord, and peripheral nerves during surgery.
− Types:
▪ Electrophysiological:
• Somatosensory evoked potentials (SSEPs)
• Motor-evoked potentials (MEPs)
• Electromyographic (EMG)
▪ Wake-up test (the most basic and the standard test, but not done for all
cases)

Somatosensory Evoked Potential:

− Monitor the ascending (Posterior) column of the spinal
cord.
− Created by stimulating a peripheral nerve and
measuring signals generated in the somatosensory
cortex.
− Significant changes indicating spinal cord affection:
Decrease the amplitude by 50%, Increase latency by
10%.
Motor evoked Potentials.
− Monitor the descending (anterior) column.
− Created by stimulating near the motor cortex and
measuring signals at the target muscle.
− Significant changes indicating spinal cord affection:
Decrease the amplitude by 50%
Electromyographic (EMG)
− Detects peripheral nerve injury during pedicle screw
placement.

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 − Factors affecting the impulses: (↓amplitude or ↑ latency or both)
▪ Anesthetic agents
• Inhalational agents & NO: Dose-dependent effect (>0.5 MAC)
• Barbiturates.
• Muscle relaxant: obliterate MEPs.
▪ Physiological changes: (affect O2 delivery to the cord)
• Hypoxia, hypercarbia, hypothermia, hypotension (MAP<60), and anemia.

Anesthesia technique:
− Consider awake tracheal intubation If a difficult airway.
− TIVA-based technique: (short-acting agents to facilitate wake-up test)
▪ Propofol (100-250 mcg/kg/min)
▪ Remifentanil (0.05-0.25 mcg/kg/min)
− Multimodal analgesia to reduce narcotic usage (ketamine, lidocaine, dexmedetomidine)
− Use up to 0.5 MAC isoflurane to titrate MAP to desired level.

Intraoperative complications:
− Significant changes in neuromonitoring impulses:
1. Ask the neuromonitoring technician:
− To check all connections
− Type of changes: ↓amplitude or ↑ latency or both.
2. Optimize the O2 delivery to the cord:
▪ 100% Oxygen
▪ Correct Hypoxia, hypercarbia, hypothermia, hypotension (MAP> 75), and anemia
(Hg>7)
3. Turn off volatile anesthetics, if administered and convert to TIVA.
4. Ask the surgeon to roll out the surgical causes:
− Release the distraction.
− Remove the screw (If EMG impulses are changed)
5. If still: Awake up test.
6. If still: CT myelogram under anesthesia to rule out epidural hematoma.

− Hypotension with ↓ EtCO2:

▪ DD VAE detection:
o Top DD is VAE
o Other causes: − TEE: is the most sensitive modality
− Aspiration − Precordial Doppler ultrasound
− Massive hemorrhage − Precordial or oesophageal
− Tension pneumothorax stethoscope to detect a ‘millwheel’
− Heart failure murmur.
− Anaphylaxis − End-tidal Nitrogen concentrations.
− Anesthetic effect
▪ Management:
o Call for help.
o Check the monitor to exclude hypoxia, hypercarpia, and malignant arrhythmia.
o 100% Oxygen
o According to cause:
− VEA:
▪ Inform the surgeon to flood the operative field with fluid.
▪ IV fluids to increase Venous pressure.
▪ Vasopressors.
▪ Aspirate air from the CVP line.
▪ If a large volume of air: turn the patient into the left lateral position to
attempt to keep the air in the right atrium.
▪ Commence CPR, if necessary.

− Postoperative:
− IN ICU or HDU
− Adequate pain management:
▪ Multimodal analgesia using paracetamol, NSAIDs, gabapentin, ketamine, opioids.
▪ Patient-controlled analgesia.
− Cuff leak test before extubation.

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− Postoperative visual loss (POVL)
▪ Etiology:
1. corneal abrasion (CA): due to decreased corneal protection.
2. Ischemic optic neuropathy (ION):
− Not Compression related.
− Causes:
▪ Blood loss > 1000mL or 45% of estimated blood volume
▪ Procedure duration > 6 hours
▪ Intraoperative hypotension
▪ Intraoperative haematocrit < 30.
▪ Periorbital edema from high-volume crystalloid resuscitation.
3. Central retinal artery occlusion (CRAO):
− Direct pressure on the globe or emboli
4. Cerebral visual loss:
▪ Ischemia or extreme hypoperfusion of the occipital lobes.
▪ Management:
− Prevention:
▪ Proper positing - corneal protection - frequent eye checks throughout the
procedure - avoid longstanding hypoperfusion and anemia.
− Reassure the patient and family.
− Urgent ophthalmology consultation.
− Correct the reversible causes.
− MRI to rule out intracranial causes of POVL (if no contraindications).
− Central retinal artery occlusion (CRAO):
▪ Ocular massage to dislodge clot.
▪ Localized hypothermia to affected eye.
▪ Acetazolamide (500mg IV), Inhaled CO2.
▪ Anterior chamber paracentesis
▪ Intraarterial fibrinolysis.

114
Anesthesia for endocrine disorders

115
 Pheochromocytoma

Considerations
1. It increases the risk of perioperative complications.
2. Pathology:
− Catecholamine-secreting tumor of chromaffin cells in the sympathetic nervous system usually
localized to an adrenal gland.
− Secretes any combination of noradrenaline, adrenaline, dopamine. Occasionally vasoactive
intestinal peptide (VIP) or ACTH.
− Has a role of 10% that 10% are bilateral, 10% are extra-adrenal, 10% are malignant, and 10%
are familial.
− C/P:
▪ Sustained hypertension.
▪ Paroxysms of sympathetic crises: severe hypertension, flushing, sweating, palpitations,
headache, anxiety, Weakness.
▪ Relative hypovolemia
− Diagnosis:
▪ Clinical manifestation
▪ Plasma metanephrine level (highest sensitivity)
▪ Elevated urinary VMA and metanephrine levels.
▪ CT or MRI to localize the tumor.
− Complications:
▪ End organ dysfunction:
o Left ventricular hypertrophy and cardiomyopathy, ischemic heart disease, MI,
arrhythmia.
o Hypertensive encephalopathy & CVA
o Renal failure

3. Comorbidities:
▪ MEN 2A: hyperparathyroidism, medullary thyroid carcinoma, pheochromocytoma
▪ MEN 2B: medullary thyroid carcinoma, pheochromocytoma, mucosal neuromas
Neurofibromatosis
▪ Von Hippel Lindau syndrome (cerebellar hemangiomas, renal cell carcinoma).

Anesthesia management
Preoperative:
The aim of pre-operative management is to:
1. Normalize the blood pressure: using alpha blockers then beta blockers.
− Alpha blockers:
▪ Phenoxybenzamine: non-selective (alpha1 and 2), irreversible, and long-acting
drug. It causes tachycardia and postoperative hypotension.
▪ Prazosin and doxazosin are shorter-acting alpha1 selective blocking drugs. Less
tachycardia
− Beta blockers: started once alphareceptors are blocked to control tachycardia caused
by catecholamine from the tumor or secondary to alpha blockaders.
2. Correct hypovolaemia (contracted intravascular volume).
3. Allow the resolution of catecholamine cardiomyopathy if present.

Markers of optimization:
− Patient receiving regular alpha and beta blockers.
− Not hypovolemic
− Fulfils Roizen criteria:
▪ Supine blood pressure under 165/90 mmHg within 48 hours before surgery
▪ Presence of orthostatic hypotension with standing pressure not greater than 80/45
mmHg.
▪ Electrocardiogram without ST segment or T wave changes
▪ No more than one PVC every 5 minutes.

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 Preoperative assessment:
− Multidisciplinary team with cardiologist and endocrinologist.
− General assessment focusing on:
▪ Volume status, blood pressure trends, and symptoms of shortness of breath and chest
discomfort.
▪ Serum electrolytes, renal function, glucose level, a chest X-ray to identify
cardiomegaly, and a recent ECG.

Intraoperative:
− The patient should be admitted 48 hours before surgery.
− Room preparation:
1. Equipment:
o Cardiopulmonary resuscitative facilities.
o Infusion devices.
2. Medications:
o Vasopressors: adrenaline, NA, vasopressin.
o Vasodilators: NGT infusion
o BB: Esmolol, Labetalol
o Alpha blockers: Phentolamine.
o MgSo4 - Ca
o Steroids
− Monitoring:
▪ Standard ASA.
▪ Arterial line before induction.
▪ Central line for fluid monitoring and vasoactive infusion
▪ UOP
▪ TEE if cardiomyopathy.

− Insert wide pores cannulae.

− Type of anesthesia:
▪ GA (balanced anesthesia with smooth deep induction) + Epidural at T8.
▪ Avoid medications which:
− Stimulates the tumor cells: succinylcholine by fasciculations.
− Causes histamine-release: morphine and atracurium.
− Increases sympathetic activity: atropine, ketamine, and ephedrine.

− Intraoperative complications:

1. Hypertension:
▪ Call for help.
▪ Check monitor:
▪ Recycle the non-invasive cuff - arterial wave.
▪ Exclude hypoxia- hypercapnia.
▪ Ensure the level of anesthesia- analgesia – relaxation.
− Manage:
▪ 100% O2.
▪ Ask the surgeon to stop the manipulation of the tumor.
▪ Immediately begin an infusion of sodium nitroprusside 0.3-
3mcg/kg/min (prepare syringe of 100mcg/mL for blousing).
▪ If with tachyarrhythmias: add esmolol 50-250 mcg/kg/min
▪ Phentolamine: 1-2mg boluses; may increase to 5mg/dose;
onset/offset immediately.
▪ MgSO4: 4-6g over 30 minutes then 1-2g/hr.

2. Hypotension:
▪ DD:
Top DD:
▪ Preoperative medication with decreased catecholamine.
▪ Bleeding
▪ Call for help.

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 ▪ Check monitor:
• Recycle the non-invasive cuff - arterial wave.
• Exclude hypoxia- hypercapnia – malignant arrhythmia.
− Exclude bleeding.
− Manage:
• 100% O2.
• IV fluids
• Norepinephrine: 1-20 mcg/min, bolus 20-30mcg/dose.
• Vasopressin: 0.01-0.04 U/min and boluses 4U/dose for
hypotension refractory to norepinephrine
• Consider calcium if magnesium used intraoperatively.

▪ Smooth extubation.

Post-operative:

− In HDU or ICU.
− Post-operative complications:
▪ Hypotension: source of catecholamines has been removed but the adrenergic
blockade remains.
▪ Hypoglycaemia: as catecholamine surges causes hyperglycaemia and following
tumour removal the patients may become hypoglycaemic.
▪ Hypoadrenalism: supplementation with hydrocortisone and fludrocortisone.
▪ Hypertension: if persists for more than a week, it may suggest an incomplete tumor
resection.

Pregnancy Considerations

− Increased incidence of intrauterine fetal demise, growth restriction, abruption

− Often misdiagnosed as pre-eclampsia
− Optimization goals:
A. Blp targets are lower than Roizen criteria:
▪ Upper limit 150/80mmHg.
▪ Avoid orthostatic hypotension to prevent uteroplacental hypoperfusion.
B. Medications:
▪ Same optimization with alpha blockade followed by beta-blockade.
▪ Caution with drugs that cross placenta (esmolol, propranolol).

Operative
− Pregnancy-specific management: (Controversial, based on case reports)
▪ According to gestational age: (gravid uterus >24 weeks obstructs access to tumor resection)
o If <24 weeks: may undergo open or laparoscopic resection of pheochromocytoma.
o If >24 weeks: medical management, wait until fetal maturity & do combined cesarean
section & tumor resection.
− Delivery in patients has pheochromocytoma:
▪ Best NOT TO ALLOW LABOR as abdominal squeeze during labour can precipitate a
hypertensive crisis.
▪ Cesarean section is preferred.
▪ General anesthesia or epidural anesthesia > spinal anesthesia.

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 Carcinoid
Consideration:
Carcinoid tumors are neuroendocrine tumors in GIT and bronchial tumors with metastasis mostly to the liver,
and brain.

Pathology:
− It is a TUMOR with CARDIAC dysfunction:
A. Tumor implications (4M):
− Mass effect: hemoptysis, bowel obstruction
− Metabolic effect:
▪ It secrets serotonin, histamine, catecholamines, bradykinin, prostaglandin, and vasoactive
intestinal peptide.
▪ causes flushing, diarrhea, hemodynamic instability, bronchospasm (serotonin-related)
− Medications: octreotide
− Metastases: liver dysfunction, raised ICP if brain metastases
B. Cardiovascular dysfunction (20-40%):
− Right-sided valvular lesions
− Right ventricular dysfunction
− Dysrhythmias (SVT)
− Constrictive pericarditis

Diagnosis:
▪ Clinical manifestations
▪ Confirmed with urinary 5-hydroxyindoleacetic acid and serum levels of chromogranin A.

− Carcinoid crisis:
▪ Symptoms:
− flushing, diarrhea, hypotension, hyperglycaemia, and bronchospasm.
▪ Precipitating factors:
− Histamine-releasing drugs, vasoactive drugs, succinylcholine.
− Tumour manipulation
− Hypovolemia, hypoxia, hypothermia, hypercarbia
▪ Prevention & treatment:
− Must prophylax with octreotide 300-500mcg IV.
− During crisis:
o Octreotide 100mcg IV boluses titrated to effect, or an infusion.
o H1 antagonists (diphenhydramine 25-50 mg IV).

Anesthetic management:
The main goal is to prevent, recognize & treat perioperative carcinoid crises.

Preoperative
General assessment focusing on:

A. Manifestations of functioning tumor:

− History: of chest tightness, diarrhea, dramatic swings in BP, or any increased heart
rate or palpitations (SVT).
− Examination: evidence of bronchospasm and any heart murmurs and sounds.
− Investigations: MRI to see tumor location (intestinal carcinoid tumors do not have
symptoms because the vasoactive substances are cleared by the portal
circulation) and its overall size.

B. Cardiac dysfunction:
− History: functional capacity, recent episodes of chest pain or shortness of breath.
− Examination: heart murmurs, signs of CHF such as edema, or elevated JVD.
− Investigations: baseline ECG, echo, or recent stress test.

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Intraoperative:
− Room preparation:
▪ Equipment:
o Cardiopulmonary resuscitative facilities.
o Infusion devices.
▪ Medications:
o Octreotide
o Steroids
o Histamine blockade (diphenhydramine)
o Atrovent
o Phenylephrine
o vasopressin
− Monitoring:
▪ Standard ASA.
▪ Arterial line before induction.
▪ Central line for fluid monitoring and vasoactive infusion
▪ UOP
▪ TEE if RVF.

− Insert wide pores cannulae.

− Type of anesthesia:
▪ GA (balanced anesthesia with smooth deep induction).
▪ Avoid medications that:
o Stimulates the tumor cells: succinylcholine by fasciculations.
o Causes histamine-releasing: morphine and atracurium.
o Increases sympathetic activity: atropine, ketamine, and ephedrine.

Intraoperative complications: (ALWAYS CONSIDER OCTREOTIDE)

1. Hypotension:
− DD:
▪ Top DD: Carcinoid crisis - hypovolemia secondary to blood loss.
▪ Cardiogenic shock from acute arrhythmia
▪ RV failure
▪ Anaphylaxis
▪ Anesthetic overdose

− Call for help.

− Check monitor:
▪ Recycle the non-invasive cuff – check arterial wave.
▪ Exclude hypoxia- hypercapnia – malignant arrhythmia.
− Exclude bleeding.
− Manage:
▪ 100% O2.
▪ IV fluids
▪ Octreotide 50–100 mcg every 5–10 min up to 1 mg
▪ Hydrocortisone.
▪ Phenylephrine or vasopressin
▪ lighten anesthetic.
▪ Aprotinin
− AVOID: epinephrine, norepinephrine, ephedrine.

2. Bronchospasm:
− Call for help.
− Check monitor:
▪ Monitor the hypoxia- hypercapnia – malignant arrhythmia.
▪ PIP

− Manage:
▪ 100% O2
▪ Take the patient off the ventilator and begin manual ventilation
to assess for airway compliance.

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 ▪ Increase the depth of anesthesia.
▪ Octreotide: 100 mcg bolus.
▪ Steroids.
▪ Histamine blockade (diphenhydramine)
▪ Atrovent
− Avoid beta-agonists, theophylline, and epinephrine.

Post-operative:

− In HDU or ICU.
− Pain management:
▪ PCA with fentanyl to minimize histamine release.
▪ Epidural can be used with caution as hypotension can precipitate a crisis.
− Tapering octreotide over a week postoperatively.

Hyperthyroidism
Considerations:
1. Emergency status:
It is an elective surgery, needs preoperative optimization.
2. Pathology:
It has concerns regarding systemic manifestation of thyrotoxicosis and compression effect:
A. Systemic effects:
− CVS: tachycardia – HTN – Arrhythmia (AF) – IDH – CHF
− CNS: Anxiety - tremors – muscle weakness.
− Eye: Exophthalmos
− Thyroid storm
B. Compression effects: intra or extrathoracic
− Airway: narrowing – tracheomalacia
− SVC: (if retrosternal extension)
▪ Face edema – Congested neck veins -decreased VR
▪ IV line to be placed in lower extremities.
▪ Epistaxis with nasal FOI
− Recurrent laryngeal nerve: hoarseness of voice.
− Tumor invasion of local tissues.
3. Comorbidities:
− Anaemia – Thrombocytopaenia – Hypercalcaemia - Abnormal glucose tolerance.
− Associated auto-immune disease: diabetes, myasthenia.
− End organ damage if chronic uncontrolled.

4. Medications:
− Side effects of antithyroid drugs.
− Interaction with anesthesia medications:
▪ ↑ anesthetic requirements
▪ Avoid sympathetic stimulants (ketamine, cocaine, epinephrine, etc).

Anesthetic management
The main goals:
− Optimize thyroid function & limit end organ effects:
▪ Heart rate <90
▪ Normal TSH
− Identify difficult airway or anterior mediastinal mass.
− Identify & manage thyroid storm.

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Preoperative:
General preoperative assessment focusing on:
A. thyroid status:
− History: Weight loss, diarrhea, vomiting restlessness, tremor, palpitations, heat intolerance
− Examination: Tachycardia – AF – heart failure - Warm, vasodilated peripheries - Eye
complications (Graves’ disease)
− Investigations: TSH - T3, T4 - Free T4
B. Airway and retrosternal: Routine assessment of expected difficulty with intubation focusing on:
− History: Positional dyspnoea – Dysphagia
− Examination: Stridor
− Investigations
▪ Chest X-ray/lateral thoracic inlet – tracheal compression/deviation.
▪ CT scan:
o Extension of retrosternal goitre and site
o Degree of tracheal compression.
o Diameter of airway at narrowest point can also be measured.
▪ Flow-volume loop.
C. Medication optimization:
− Carbimazole:
▪ Inhibits hormone synthesis.
▪ Takes 4–8 weeks to work.
▪ Side effect: Leukopenia – Agranulocytosis.
− Propylthiouracil:
▪ Inhibits hormone synthesis - inhibits peripheral conversion of T4 to more active T3.
▪ Takes 4–8 weeks to work.
▪ Side effect: Leukopenia - aplastic anemia - lupus-like syndrome.
− Iodine (Lugol’s solution)
▪ Reduce the vascularity of the gland.
▪ given for 10 days prior to surgery.
− β-blocker: Propranolol - Atenolol
▪ controls cardiovascular effects and decreases peripheral conversion of T4 to more
active T3.
Continue the medications till the operation morning.

Intraoperative
Room preparation:
− Equipment:
▪ Cardiopulmonary resuscitative facilities.
▪ Defibrillator.
▪ Neuro monitoring integrity (NIM) if planned.
▪ Difficult airway trolly and fibreoptic.
▪ If retrosternal extension:
• Rigid bronchoscopy and thoracic surgeon ready for sternotomy
• Stretcher ready for positioning
• Cardiopulmonary bypass machine (CPB)
− Medications:
▪ Phenylephrine, propranolol, digoxin, and steroids

Monitoring:
▪ Standard ASA (ECG – temp probe)
▪ Arterial line if hemodynamic variation is expected.

Anesthesia management:
Airway: (if retrosternal goitre): The main goal is to keep the patient spontaneous, avoid positive
pressure ventilation and muscle relaxant till securing the airway by placing the tip of the tube
distal the obstruction. ENT with rigid bronchoscopy, a thoracic surgeon, stretcher, and CPB
machine are available.
− How:
▪ Awake fiberoptic tracheal intubation
▪ Inhalational induction: using balanced inhalation + narcotic + lidocaine IV. Esmolol in
hand.

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 − After securing the airway, start balanced anesthesia.
− Avoid Pancratium – ketamine desflurane - ephedrine.
− Eye protection.

Intraoperative complications:
− Hypertension: Labetalol or esmolol.
− Hypotension:
▪ IV fluid
▪ Direct sympathomimetics; phenylephrine
− Arrhythmia:
▪ Avoid amiodarone.
▪ Digoxin is a good choice.
− Thyroid storm

Extubation:
− Awake extubation is the ideal.
− Suspected postoperative upper airway obstruction due to:
▪ Edema
▪ Heamtoma
▪ RLN injury.
▪ Tracheomalacia. Postoperative hematoma.

Postoperative
− Better to be in HDU if intraoperative complications
− Post-operative stridor:
▪ DD: on top of DD:
− Surgical site hematoma
− Laryngeal edema
− RLN injury
− Tracheomalacia
− Residual from anesthesia or MR.
− Hypocalcemia (typically after hours)

▪ Management:
− Immediately attend to the patient
− Assess and manage simultaneously following ABC.
− Apply 100% O2.
− Upright position.
− Send blood sample for: ABG – electrolyte (Ca) – CBC –
Chest Xray
− According to the cause:
▪ If hematoma:
o Inform the surgeon.
o Line its borders to monitor if it increases in size.
o If causes airway obstruction: immediate suture
removal, evacuation and intubation FOLLOWING
SCOOP TECHNIQUE.
▪ If tracheomalacia: intubate, then tracheostomy.
▪ If RLI: intubate.
▪ If hypocalcemia: 10 ml ca gluconate 10% 0ver 10 min.
▪ If laryngeal edema:
Scoop technique
o Nebulizer, steroid, adrenaline
o If failed: intubation.

Thyroid Storm
Life-threatening syndrome, typically 6–24 hours post-operatively, it may occur intra-operatively.
− Manifestations:
▪ Hyperpyrexia
▪ Tachycardia
▪ Hypotension
▪ Altered consciousness.

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 − DD:
▪ Malignant hyperthermia: but there is NO muscle rigidity or a rise in CK.
▪ Neuroleptic malignant syndrome
▪ Pheochromocytoma
▪ Carcinoid crisis

− Management:
▪ Call for help.
▪ Assessment and management simultaneously according to ABC protocol.
▪ Cool (blankets, IV solutions, acetaminophen)
▪ Control hemodynamic:
o Esmolol 0.25-0.5 mg/kg bolus or 50-200 mcg/kg/min infusion
o Propranolol 10-40 mg PO or up to 1 mg/min IV (1st choice)
o IV fluids.
▪ Consider endocrinology consultation.
▪ Antithyroid:
o Stop conversion of T4 to T3 by:
• Propylthiouracil: 200-400 mg PO/NG/PR q6h
• Hydrocortisone 100-200 mg IV q8h
o Stop synthesis & release of new hormones:
• Potassium iodide 5 gm PO/NG q6h or sodium iodide 0.25 g IV q6h (1 hr after PTU)
▪ Look for & treat complications:
o CVA, loss of consciousness
o Myocardial infarction, congestive heart failure, atrial fibrillation: (avoid amiodarone
because of iodide content) use digoxin instead.
o Hypoventilation & hypercarbia
o Electrolyte abnormalities
▪ If no improvement, consider plasmapheresis, dantrolene, lithium, neuraxial blockade to T4.

Hypothyroidism

Considerations:
1. Emergency status:
It is an elective surgery, needs preoperative optimization.
2. Pathology:
− It has concerns regarding systemic manifestation of hypothyroidism and its compression effect:
A. Systemic effects:
▪ CVS: congestive heart failure, ↓ CO (↓ contractility/rate), hypotension,
pericardial effusion, autonomic instability, hypovolemia
▪ Respiratory: hypoventilation, ↓ response to hypoxemia/hypercarbia
▪ Electrolytes: hyponatremia
▪ Endocrine: hypoglycemia, adrenal insufficiency (cortical atrophy).
▪ Hypothermia.
▪ Potential for myxedema coma.
B. Compression effect
C. Possible difficult airway due to:
▪ Enlarged gland, anatomical deviation/obstruction.
▪ Anterior mediastinal mass
▪ Recurrent laryngeal nerve involvement
▪ Prior neck radiation
− Increased aspiration risk.

3. Medications:
− Side effects of replacement hormones.

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 − Interaction with anesthesia medications:
▪ ↓ MAC
▪ Delayed emergence
▪ Sensitivity to respiratory depressants.
▪ Perioperative endocrine supplementation (thyroid, steroids)

Preoperative optimization
− Patient to be euthyroid.
− Optimize volume status.
− give steroids.
− Manage glucose & sodium abnormalities.

Myxedema Coma

Life-threatening form of hypothyroidism (mortality > 50%) precipitated by stress.

Manifestations:
− Exaggerated features of hypothyroidism:
▪ ↓ Level of consciousness.
▪ ↓ cardiac output/heart rate, congestive heart failure, pulmonary edema
▪ Respiratory depression
▪ Hypothermia
▪ Metabolic: SIADH, hypoglycemia, adrenal suppression
− Increased risk of aspiration
− ↑ sensitivity to neuromuscular blockers & sedatives
− High risk for delayed emergence & requires post-operative ventilation

Treatment:
− IV thyroxine:
▪ T3: 0.2mcg/kg q6h (onset 6-24 hrs)
▪ T4: 200-300mcg IV over 5-10 mins then 100mcg IV q24
− Hydrocortisone 100mg IV then 25mg q6h.
− Passive rewarming with blankets
− Post-operative ventilation, fluids, pressors, inotropes
− ICU & endocrinology consult

Diabetes Mellitus

Considerations:
− End organ disease:
▪ CVS: hypertension, coronary artery disease, left ventricular hypertrophy & cardiomyopathy.
▪ Peripheral vascular disease
▪ Renal: diabetic nephropathy.
▪ Neuropathy:
o Aspiration risk with gastroparesis
o Autonomic instability
o Postural hypotension.
o Chronic pain
▪ Airway and respiratory:
o Stiff joint syndrome (↓TMJ and atlantoaxial joint mobility) potentially difficult airway.
o Decrease FEV1- FRC

− Perioperative complications & management of blood glucose & medications:

▪ DKA or HONK
▪ Hypoglycaemia
▪ Related to end-organ disease.
− Associated endocrine disorders.

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Preoperative assessment:
− Check HbA1c: if uncontrolled: increased incidence of complications.
− Look for end-organ damage:
▪ CVS: functional capacity – ECG
▪ Renal: CRF – urea, creatinine.
▪ Autonomic neuropathy: Chronic pain medications, may be opioid.
− Careful airway assessment.
− Medications management: (On day of surgery)
▪ Type II diabetes, on oral hypoglycemics: fast, hold pills the morning of surgery, check blood
glucose.
▪ Type l, type II on insulin: according to insulin type:
o Long-acting insulin: give 75% of AM dose on the day of surgery.
o Intermediate-acting and combination insulin: give 50% of the morning dose on the
day of surgery.
o Short-acting insulin: Hold the dose.
o start D5W infusion.

Intraoperative:
− Goals of perioperative diabetic management:
▪ primary goal: avoidance of hypoglycemia.
▪ Prevention of DKA – HONK.
▪ Maintenance of fluid and electrolyte balance.
▪ Avoidance of marked hyperglycaemia.
− Early scheduled: prior to 9 AM
− Optimal intraoperative blood glucose level: 110 - 180 mg/dL (6.1 to 10 mmol/L).
− Management of elevated blood glucose:
▪ If only on PO hypoglycaemics at home: start IV insulin infusion at 1-2 units/hr.
▪ If on insulin at home, divide 24 hr dose by 24 & give 1/2 to 2/3 that per hour as an IV insulin
infusion.

Cushing’s syndrome

Considerations

− Increases the risk of perioperative complications.

− Pathology:
A syndrome due to excess plasma cortisol caused by iatrogenic steroid administration (commonest),
pituitary adenoma or adrenal tumors.

A. systemic manifestations:
▪ Airway and respiratory:
o Possible difficult airway
o Obstructive sleep apnea (OSA)
▪ Cardiovascular:
o Left ventricular hypertrophy, pulmonary hypertension - right ventricular failure, systolic
and diastolic dysfunction.
o Hypertension, volume overload (↑ renin & glucocorticoid vascular reactivity)
▪ Metabolic:
o Hypokalemia.
o Hypernatremia.
o Hypokalemic metabolic alkalosis: mineralcorticoid effect of glucocorticoids
o Diabetes: insulin deficiency
o Osteoporosis: need for careful positioning
▪ CNS: possible psychosis

B. Pharmacologic considerations:
▪ Perioperative steroid replacement (stress dose & post-operative replacement).
▪ Sensitivity to neuromuscular blockers (due to possible muscle weakness, hypokalaemia,
catecholamines)

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 Adrenocortical Insufficiency (Addisonian crisis)
Considerations

1. A potentially life-threatening situation increases the risk of perioperative complications.

2. Pathology
− Types:
▪ Primary Addisonian crisis: due to autoimmune destruction of adrenal gland;
mineralocorticoid activity also lost.
▪ Secondary Addisonian crisis: ↓ ACTH production either from hypothalamic pituitary disease
or from adrenal suppression from chronic steroids, mineralocorticoid activity usually
preserved.

− Presentations:
▪ Shock, dehydration, hypotension
▪ Physiologic abnormalities:
▪ Cardiovascular: Impaired myocardial contractility, arrhythmias secondary to
hyperkalemia
▪ Volume status: dehydration can occur (2-3 L)
▪ Electrolyte imbalance:
o Hyperkalemia
o Hyponatremia (↓ level of consciousness, seizures
o Hypoglycemia (↓ level of consciousness, seizures)
− Pharmacologic concerns:
▪ ↓ circulating catecholamines (consider vasopressin for hypotension)
▪ Succinylcholine-induced hyperkalemia.

Management:
− Emergency condition: ABC approach
− Goals:
▪ Prevent perioperative cardiovascular collapse:
o Steroid supplementation
o Volume resuscitation
o Correction of electrolyte abnormalities
− Medication:
▪ Preoperative: Stress dosing of steroids:
o Hydrocortisone 100mg IV q6-8h
o Fludrocortisone if 1° adrenal insufficiency
▪ Postoperative:
o Hydrocortisone: 100mg IV q6-8h for 24h then taper to maintenance of 15- 20mg
PO at morning & 5-10mg PO at night.
o Add maintenance fludrocortisone 0.05-0.2mg PO daily if aldosterone deficient (1°
adrenal insufficiency) when tapering hydrocortisone.

Perioperative Steroids
Suppression of HPA axis expected if patient:
▪ On prednisone > 5mg/day for any duration
▪ On steroids > 3 weeks in last year.
▪ Inhaled/topicals rarely cause suppression.

A. For normal HPA axis: No additional steroid cover is required.

B. For suppressed HPA axis: additional steroid cover is required according to surgery type:
▪ Minor surgery, e.g. hernia:
o Routine preoperative steroid or hydrocortisone 25mg IV at induction
▪ Intermediate surgery, e.g. hysterectomy:
o Routine preoperative steroid.
o Hydrocortisone 25mg IV at induction, and then 6-hourly for 24hr
▪ Major surgery, e.g. cardiac:
o Routine preoperative steroid
o Hydrocortisone 25mg IV at induction, then 6-hourly for 48–72hr

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 C. High-dose immunosuppression:
− Continue usual immunosuppressive dose until
able to revert to normal oral intake, e.g. 60mg
prednisolone/24hr = 240mg hydrocortisone/24hr

Steroid rotation

Acromegaly

Hypersecretion of growth hormone with resultant soft-tissue overgrowth.

Considerations
Airway + systemic manifestation
A. Airway:
− Macroglossia & enlarged epiglottis Lead to:
▪ Difficult mask ventilation.
▪ Difficult intubation.
− Recurrent laryngeal nerve palsy
− Narrow glottic opening, subglottic narrowing (stridor):
− Needs smaller size ETT.
− Nasal turbinate enlargement: caution with nasal intubation.

B. Systemic manifestation
− Cardiovascular:
▪ Hypertension, left ventricular hypertrophy, diastolic
dysfunction, arrhythmias, coronary artery disease,
cardiomyopathy.
− Respiratory: Airway changes
▪ Obstructive sleep apnea
▪ Pulmonary hypertension, right ventricular dysfunction
− CNS:
▪ Pituitary dysfunction
▪ Potential for raised ICP.
▪ Peripheral neuropathies common
− Endocrine:
▪ Diabetes mellitus/hyperglycaemia.
− Procedures:
▪ Difficult patient positioning, access, monitoring, regional anesthesia.
▪ Radial arterial line contraindicated due to poor collateral circulation.

Goals
− Safely secure difficult airway: consider awake fibreoptic intubation with stridor & voice changes.
− Thorough cardiopulmonary examination, including volume status assessment.

Postoperative
− Avoidance of CPAP following trans-sphenoidal surgery
− Post-operative pain vs. enhanced sedation/respiratory depression
− Post-operative stridor (subglottic edema, vocal cord paralysis)
− Endocrine emergencies: Diabetes insipidus, SIADH

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Anesthesia for blood diseases

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 Sickle Cell Disease
Considerations
Pathology
− Abnormal hemoglobin known as Hb S. Occurs when valine replaces the glutamine at the 6th position
of the beta chain of the hemoglobin molecule.
− When Hb S is exposed to certain conditions, it forms sickle shaped Hb leads to:
▪ Increased blood viscosity, and endothelial damage, leads to multisystem diseases:
o CNS: stroke
o CVS: LV hypertrophy, myocardial infarction without coronary artery disease
o Respiratory: acute chest syndrome (ACS), restrictive lung disease (pulmonary fibrosis),
pulmonary hypertension, cor-pulmonale.
o Renal: infarction and failure.
o Spleen: sequestration, infarcts; if splenectomy → ↓ immunity.

▪ Premature destruction of RBCs:

o Chronic hemolytic anemia, repeated transfusion.
o High-output cardiac failure
o Iron overload, hemosiderin deposition

▪ Chronic pain & potential opioid tolerance

Medications:
− Immunosuppressants, antineoplastics

Sickle cell crises:

− Vaso-occlusive crisis (the most common)
▪ Presented as an acute abdomen, priapism or acute pain in the hands and feet (dactylitis).
− Aplastic crisis (caused by parvovirus B19): Anemia without reticulocytes.
− Sequestration crisis (mainly in children):
▪ Painful splenomegaly
▪ Hypovolaemia and circulatory collapse.
− Haemolytic crisis: Anemia + reticulocytes and bilirubin.
− Acute chest syndrome
▪ Respiratory symptoms, fever, pain, hypoxia, infiltrates on CXR.

Precipitating factors:
− Hypoxia
− Vascular stasis
− Hypothermia
− Hypovolemia/hypotension
− Acidosis
− Anemia

Only low-risk patients should be considered for outpatient surgery.

Anesthesia management
Goals
− Pre-operative optimization
− Avoid and manage sickle cell crises.
− perioperative pain control and opioid management

A. Pre-operative optimization:
− Haematology consultation
− Prophylactic antibiotic cover
− Optimization:
A. Transfusion therapy: simple or exchange transfusion
▪ Goal:
o Correct pre-existing anemia: target hemoglobin 10gm/dl or hematocrit 30%.
o ↓ hemoglobin S concentration (target <30%) by exchange transfusion.
o ↑ adult hemoglobin (target >50%)

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 B. Maintain hydration:
▪ Allow oral fluids as late as possible.
▪ IV fluid to avoid dehydration while NPO.
− Hydroxyurea to ↑ fetal hemoglobin production.
− Blood available for rapid correction of anemia.

B. Management of sickle cell crises

Acute pain crisis Acute pain crisis (Vaso-occlusive crisis)

− Prevention:
▪ Avoid hypoxia.
▪ Ensure adequate hydration.
▪ Maintain normothermia:
o Warming the operating room
o Using a fluid warmer
o Active warming as a bair hugger.
▪ Optimal analgesia.
▪ Avoid oxidant drugs: prilocaine, nitroprusside, vitamin K, aspirin, and penicillin.
▪ Consider regional anesthetic techniques.
▪ Avoid venostasis (caution with tourniquets).

− Treatment:
▪ Rest, warming, reassurance, fluid replacement and analgesia:
o Acetaminophen & NSAIDs
o Opioids (IM, SC, IV, PO): PCA opioids with baseline analgesia
o Ketamine as an adjunct.
o Regional blocks as appropriate.

Acute chest syndrome

− Presentations:
▪ Dyspnoea, cough, haemoptysis, and pleuritic chest pain
▪ Radiological finding of a new infiltrate on X-ray
− Management
▪ Broad-spectrum antibiotics
▪ fluid management
▪ Oxygenation, chest physiotherapy, bronchodilators, and intermittent, and Incentive
spirometry.

C. Perioperative pain control and opioid management

Two main goals:

1. Maintain efficient perioperative analgesia: using a multimodal approach:
− Regional anesthesia
− Ketamine
o NMDA receptor antagonist.
o Reverse the opioid tolerance and decrease hypersensitivity surrounding a
surgical wound.
o Dose: IV infusion 5-15 mg/h, Start pre-operative for 24-48 hours post-operative.
− Alpha-2 agonists
o Clonidine: 1-2 mcg/kg
o Dexmedetomidine: 0.5 mcg/kg loading over 10 min – 0.3 – 0.7mcg/kg/hr
infusion.
− Paracetamol and NSAIDs
o At least for 48 hours.
− Gabapentin
o Anticonvulsant: Dose: 600 or 900mg pre-operatively. Postoperative: 300-
600mg.

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 2. Avoid withdrawal:
− Daily background oral opioids provided over 24 hours if oral intake is allowed.
− Transdermal patches shift to the IV infusion (fentanyl patch 25 mcg to infusion 25mcg/h)
− Opioid rotation
o Switch to an alternative strong opioid if:
▪ NO improvement of pain.
▪ Oral intake is not allowed.
o Avoid agonist antagonists.
o Use conversion tables for equivalent doses to convert the current opioid to
oral morphine then divide by 3 to get the IV dose.
o Start at 75-80% of that recommended dose IV infusion over 24 hours and the
remnant as boluses for breakthrough pain.

Opioid rotation

Thalassemia

Considerations
Pathology:
− Absent or ↓ synthesis of α- or β-globin chains of Hb → Premature RBC destruction leads to:
▪ Chronic hemolytic anemia
▪ Sequelae of multiple transfusions/iron overload
− Diagnostic test
▪ Blood smear: microcytic/hypochromic anemia
▪ Hb electrophoresis (HbA2, HbF)
▪ Iron stores elevated.

− types:
1. Beta thalassemia major:
▪ Potential difficult airway due to maxillary overgrowth (from bone marrow stimulation)

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 ▪ Hemochromatosis (deposition of hemosiderin into cardiac muscle → dilated
cardiomyopathy, heart failure, arrhythmia, pulmonary hypertension)
▪ Hemolytic anemia and jaundice.
▪ Potentially difficult regional due to vertebral destruction
2. Beta thalassemia minor:
▪ Mild hemolytic anemia & iron deficiency
3. Alpha thalassemia major: incompatible with life
4. Alpha thalassemia minor: mild anemia

Anesthesia management
− Assessment of the degree of major organ impairment (heart, liver, pancreas, endocrine)
− Correct anemia: typical goal hemoglobin > 10gm/dl.
− Anticipate difficult airway in beta-thalassemia major.

Hemophilia
Considerations
Pathology:
− X-linked recessive disorder characterized by a deficiency of coagulation factors leads to:
▪ High risk for perioperative bleeding
▪ Sequelae of bleeding into enclosed spaces (joints, intracranium, pericardium, thorax)
▪ Potential contraindication to neuraxial anesthesia

− Types:
▪ Type A: defect in factor VIII activity
▪ Type B: defect in factor IX activity

− Severity classification: according to factor levels:

▪ Mild: 5-25%
▪ Moderate: 1-5%
▪ Severe: <1%

Anesthesia management
Goals
− Optimize factor activity & coagulation profile in perioperative period:
▪ the factor level should be 50–100% of normal and maintained for 2–7d post-procedure.
− Minimize perioperative blood loss: consider blood conservation strategies.
− Avoid airway bleeding during manipulation (intubation by the most experienced anesthetist).

Management
− Multidisciplinary with Haematology and surgery
− Investigations:
▪ Routine coagulation profile: ↑ PTT, normal INR
▪ Plasma factor VIII & lX concentration
▪ Factor VIII & lX inhibitors.

Optimization:
1. Hemophilia A:
− In mild cases:
▪ Desmopressin infusion of 0.3 mcg/kg in 50–100mL of 0.9% NaCl over 30min.
− Factor VIII concentrates
− Recombinant factor VIII
− Recombinant factor VIIa for inhibitors
− In Emergencies: Cryoprecipitate & FFP

2. Hemophilia B
− Factor IX concentrates
− Recombinant factor IX
− In Emergencies: FFP (no Cryoprecipitate)

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Minimize perioperative blood loss:
− Tranexamic acid
− Avoid NSAIDs, other anticoagulants, antiplatelet drugs.
▪ Cryoprecipitate contains factor VIII, fibrinogen, von Willebrand factor, fibronectin, factor XIII.
▪ FFP contains factors II, VII, VIII, IX, X, XI, vWF, and fibrinogen.

Von Willebrand's Disease

Considerations
Pathology:
− Function of vWF: stabilizes factor VIII which promotes clotting.
− vWD: is a qualitative and/or quantitative defect in vWF leads to:
▪ High risk for perioperative bleeding
▪ Sequelae of bleeding into enclosed spaces (joints, intracranium, pericardium, thorax)
▪ Potential contraindication to neuraxial anesthesia
− Types:
▪ Type 1: (the most common) due to a decrease in actual vWF (quantitative defect).
▪ Type 2 (A,B,M,N): is due to abnormal vWF (qualitative defect).
▪ Type 3: (the most severe form) due absence of vWF (quantitative defect).

Anesthesia management
Goals
− Optimize factor activity & coagulation profile in perioperative period:
▪ Monitor factor levels 48h prior to OR & after initial administration (within 2 hours of
expected OR start), and intra-operatively.
▪ Targets:
o Restore vWF levels to 40% of normal prior to surgery.
o Factor VIII levels:
• Obstetric > 50%
• Minor surgery > 30%
• Major surgery > 50%
− Minimize perioperative blood loss; consider blood conservation strategies.
▪ Tranexamic acid
▪ Avoid NSAIDs, other anticoagulants, antiplatelet drugs.

Management
− Multidisciplinary with Haematology and surgery
− Investigations:
▪ Routine coagulation profile: ↑ PTT & bleeding time, normal INR
▪ Plasma factor VIII & vWF
− Schedule OR early in the week & early in the day
− Ensure all lab/blood bank/consultant resources are available.

Optimization:
− For Type 1 & 2A:
Desmopressin:
▪ Stimulating the release of vWF from endothelial cells (provides 3-5 fold increase in
activity).
▪ Dose: 0.3 mcg/kg in 50–100mL of 0.9% NaCl over 30min.
▪ Maximum effect 30 min post dose, remain elevated for 6-8 hours.
− If other types:
▪ Factor VIII-vWF concentrates (Humate P)
▪ Platelet concentrates (contains vWF)
▪ Recombinant factor VIII
▪ Recombinant factor VIIa
− In Emergencies: cryoprecipitate & FFP

134
 Massive transfusion protocol (MTP)
It is a set of medical procedures and guidelines that are used to treat patients who have massive blood loss
to avoid transfusion complications.
− Indications:
▪ Blood loss 40% or more of blood volume.
▪ High risk for massive blood loss, such as traumatic injuries or major surgery.
− MTP component:
1. Contact the blood bank for activation of MTP and contact HAEMATOLOGY.
2. Start initial management: Follow the ABC approach:
− Airway: maintain the airway.
− Breathing: maintain oxygenation.
− Circulation:
▪ Assess: Vital data, Signs of shock: (capillary refill time, moisture of mucous
membranes, skin turgor, decreased UOP)
▪ IV access - Two14G cannula
▪ Take blood samples for:
o DIC panel: PT -PTT, INR fibrinogen and D dimer
o ABG
o CBC
o Match 6 units.

3. Control the bleeding: by

− Direct pressure or damage control surgery.
− Tranexamic acid 1gm IV infusion over 10 min then 1 gm over 8 hours for 3 times
− Reverse anti-coagulant if the patient is on anticoagulant.

4. Resuscitation:
− Start with WARMED crystalloid up to 2000ml - colloid up to 1500ml.
− Blood transfusion:
▪ ABO Type: O-negative blood (if no time for testing) or group-specific blood until
crossmatched red blood cells are available.
▪ Blood product ratio protocol:
▪ Empiric ratios of [Link] of red cells, FFP, and platelets
▪ Point of care: (based on TEG, ROTEM) or lab testing:
After 4U RBCs give:
o FFP (1 unit for each PRBs unit) If INR >1.5
o Platelets if <50x109/l.
o Cryoprecipitate 1 unit per 5kg, if fibrinogen <1.5 gm/L
o If DIC is suspected, transfuse platelets and cryoprecipitate early.
▪ Consider recombinant factor Vlla 90mcg/kg.
▪ Consider 10 ml Calcium chloride 10% over 10 mins.

5. Monitor:
− Blood work should be checked every 2 to 4 hours.
− Coagulation status should be checked every 1 to 2 hours.
− Vital signs should be checked every 15 minutes.

Goals of management
− Temperature >35°C
− Metabolic:
▪ pH >7.3
▪ Base excess < –6
▪ Lactate < 4 mmol/L
▪ Ionised calcium >1.1 mmol/L
− Blood
▪ Hb: >7gm/dl
▪ Platelet count > 50 × 109/L
▪ PT, APTT <1.5 × normal
▪ INR <1.5
▪ Fibrinogen level >1.5 g/l (2.0 g/L in obstetrics).

135
 Massive blood transfusion

Definition:
Loss of one blood volume in <24hr OR 50% within 3hr OR >150mL/min.

Complications of massive transfusion

− Coagulopathy:
▪ DIC
▪ Dilutional thrombocytopaenia
− Biochemical complications
▪ Hyperkalaemia
▪ Citrate toxicity
▪ Hypocalcaemia
▪ Metabolic alkalosis
− Other problems
▪ Hypothermia
▪ Hypervolemia.
▪ Haemolysis
▪ Incompatibility
▪ Air embolism: with the use of pressure bags
▪ Anaphylaxis
− Delayed complications
▪ Disease transmission HIV/hepatitis/malaria/bacteria → sepsis
▪ ARDS - Pulmonary edema.

Perioperative management of patients receiving anticoagulants

Consideration:
For anticoagulation management, consider the following:

− Type of anticoagulant
− Indications of anticoagulant.
− Bleeding risk of both patient and procedure: (To decide stooping anticoagulant or not)
− Thrombotic risk: (to decide bridging or not)

Management approach:
1. Estimate the bleeding risk: (if high bleeding risk STOP the anticoagulant before the procedure)
− Surgery related high bleeding risk:
▪ Abdominal surgery with liver biopsy, extracorporeal shockwave lithotripsy
▪ Extensive cancer surgery (e.g., pancreas, liver)
▪ NEURAXIAL (SPINAL OR EPIDURAL) ANAESTHESIA
▪ Neurosurgery (intracranial, spinal)
▪ Major orthopaedic surgery
▪ Procedures with vascular organ biopsy (kidney or prostate)
▪ Reconstructive plastic surgery
▪ Specific interventions (colon polypectomy, lumbar puncture, endovascular
aneurysm repair)
▪ Thoracic surgery, lung resection surgery
▪ Urological surgery (prostatectomy, bladder tumour resection)
▪ Vascular surgery (e.g., AAA repair, vascular bypass)
− Patient related high bleeding risk:
▪ HAS BLED score ≥ 3.
▪ On antiplatelet therapy or low platelet count.

136
2. Estimate the thrombotic risk: (If high consider bridging)

− Patient with high thrombotic risk:

▪ Atrial fibrillation:
▪ CHADS2 score 5-6
▪ CHA2DS2-VASc score 7-9
▪ Recent (within 3 months) stroke or transient ischemic attack
▪ Rheumatic valvular heart disease

▪ Mechanical heart valve

▪ Any mitral valve prosthesis
▪ Any caged-ball or tilting disc aortic valve prosthesis.
▪ Recent (within 6 months) stroke or transient ischemic attack
▪ VTE
▪ Recent (within 3 months) VTE
▪ Severe thrombophilia (e.g., deficiency of protein C, protein S, or antithrombin;
antiphospholipid antibodies; multiple abnormalities).

3. Type anticoagulant: (when to stop – when to restart)

▪ New Oral Anticoagulants:
Must be stopped before surgery:
▪ On operation morning: low bleeding risk surgery
▪ One day before + operation day: moderate bleeding risk surgery
▪ Two days before + operation day + one day after in high bleeding risk surgery
▪ Vitamin K antagonists:
▪ No stopping: in minimal bleeding risk surgery.
▪ If high bleeding risk:
o Stop with bridging: in high thrombotic risk patients.
o Stop without bridging: low and moderate thrombotic patients.

Bridging:

Administration of a short-acting anticoagulant (LMW heparin or unfractionated

heparin (UFH)) during the interruption of a longer-acting agent, typically warfarin.
1. Initiation:
Three days before a planned procedure (two days after stopping warfarin).
2. Dose:
▪ LMW: enoxaparin, 1 mg/kg subcutaneously twice daily.
▪ UFH: 250 international units/kg twice daily.
3. Stop:
▪ LMW: the last dose can be given the evening before the procedure. Or
24h if a single dose.
▪ UFH:
o IV: 4 Hours
o SC: evening before the procedure.
4. Restart:
Heparin and warfarin 12–24 h after the invasive procedure
(multidisciplinary with the surgeon)

137
 Medication Reversal Agent Dose Time to anticoagulation reversal Comments
Minor bleed: 2–5 mg PO/IV
6 to 24 hours to correct the INR, Recovery of factors X and II (prothrombin) takes longer than
Vitamin K Major bleed: 5–10 mg IV
longer to fully reverse anticoagulation 24 hours Risk of anaphylaxis with intravenous injection
INR 2–<4 = 25 units/kg
INR 4–6 = 35 units/kg 15 minutes after 10-minute to 1-hour Effect is transient, and concomitant vitamin K must be
Warfarin 4F-PCC
infusion administered; limited availability
INR >6 = 50 units/kg

typically 12 to 32 hours for complete Effect is transient and concomitant vitamin K must be
FFP 10–30 mL/kg
reversal administered
Anticoagulant reversal
25–50 units/kg based on actual body
4F-PCC
weight
Medication Reversal Agent Dose Time to anticoagulation reversal Comments
If rivaroxaban >10 mg, apixaban >5
Rivaroxaban Minor bleed: 2–5 mg PO/IV
Apixaban mg, or dose unknown within the
6 to 24 hours to correct the INR, Recovery of factors X and II (prothrombin) takes longer than
Edoxaban Vitamin K previous 8 hours:
Major bleed: 5–10800
mgmg
IV bolus at 30
Andexanet alfa longer to fully reverse anticoagulation 24 hours Risk of anaphylaxis with intravenous injection
mg/minute followed by 960 mg
INR 2–<4at= 25
infusion units/kg for up to 120
8 mg/minute
INR 4–6 = 35 units/kg 15 minutes after 10-minute to 1-hour Effect is transient, and concomitant vitamin K must be
Warfarin 4F-PCC minutes.
infusion administered; limited availability
INR >6 units/kg
25–50 = 50 units/kg
based on actual body
4F-PCC
Dabigatran weight typically 12 to 32 hours for complete Effect is transient and concomitant vitamin K must be
FFP 10–30 mL/kg
Idarucizumab 5 g IV bolus reversal administered
For UFHunits/kg
25–50 reversal:
based on actual body
4F-PCC
weight
1 mg for every 100 units when used
within 2–4 h from
If rivaroxaban >10the
mg,last UFH exposure
apixaban >5
UFH and LMWH
Rivaroxaban Protamine sulfate
Apixaban mg,LMWH
For or dosereversal:
unknown within the
Edoxaban Andexanet alfa 1previous 8 hours:
mg for each 800administered
1 mg mg bolus at 30
mg/minute
within followed
the prior eight by 960 mg
hours
infusion at 8 mg/minute for up to 120
Argatroban;
minutes. Effect is transient, and concomitant vitamin K must be
Fondaparinux. rFVIIa 70–90 mcg/kg 15 minutes after bolus infusion
administered
Bivalirudin; 25–50 units/kg based on actual body
4F-PCC
Dabigatran weight
Idarucizumab 5 g IV bolus
138
For UFH reversal:

1 mg for every 100 units when used

 Perioperative management of patients receiving antiplatelet

Antiplatelet bridging: In time sensitive procedure with high both thrombotic and
bleeding risks

139
 Guidelines for Neuraxial Anesthesia and Anticoagulation
It is considered high bleeding risk procedure, therefore both anticoagulant and antiplatelet
(except ASA) must be stopped before the procedure.
Last dose before neuraxial First dose after
w hile neuraxial/nerv e
injection or neuraxial injection or
Anticoagulant catheters are in place and
neuraxial/nerv e catheter neuraxial/nerv e
prior to their remov al
placement catheter remov al

ANTICOAGULANTS, INJECTABLE
Wait until PTT <40
Hepar i n IV
U sual hold time: 4-6 hours
4-6 hours prior to catheter
Hepar i n SC 5000 units BID or TID 4-6 hours OR check PTT <40
remov al 1 Hour
Hepar i n SC 7500-10,000 units BID Av oid w hile catheter is in
12 hours AND PTT < 40
(or < 20,000 units per day)
place - Frequent
Hepar i n SC >20,000 per day 24 hours AND check PTT< 40 neuological assessment
M ay be maintained w ith once daily
Enoxapar i n (Clexan) 40 mg SC
dosing, w ithout administration of any
daily
≥ 12 hours other antihemostatic drugs
Enoxapar i n (Clexan) 30 mg SC
q12h 4 Hours

Enoxapar i n (Clexan) 1.5 mg/kg Contraindicated

≥ 24 hours
SC daily or 1 mg/kg SQ q12h

Fondaparinux (Arixtra) 36-42 hours 6 Hours

ANTICOAGULANTS, ORAL

War far i n (Coumadin) 4-5 days v erify normal I NR remov e w hen I NR < 1.5 I mmediately

Api xaban (Eliquis) 2.5 mg BID - 5

mg BID

Ri var oxaban (Xarelto) 15-20 mg

daily 3 days
Betr i xaban (Bevyxxa) 80 mg daily

Contraindicated 6 Hours
Edoxaban (Savaysa) 30-60 mg
daily

CrCl < 30 mL/min: av oid

CrCl 30-49 mL/min: 5 days
Dabi gatr an (Pradaxa) 75-150 mg
CrCl 50-79 mL/min: 4 days
BID
CrCl ≥ 80 mL/min: 3 days
Renal fxn unknow n: 5 days
DIRECT THROMBIN INHIBITORS, INJECTABLE

Ar gatr oban IV infusion

Av oid neuraxial techniques
Bi val i r udi n (Angiomax) IV infusion

DIRECT THROMBIN INHIBITORS, INJECTABLE

Argatroban IV infusion
Av oid neuraxial techniques
Bivalirudin (Angiomax) IV infusion

ANTIPLATELET AGENTS, ORAL

Aspirin Av oid neuraxial techniques

M ay continue dosage if early postoperativ e use M ay continue dosage
NSAIDs of other anti-hemostatic

Aspirin/dipyridamole (Aggrenox) 24 hours 6 hours

Without Loading dose:

Clopidogrel (Plavix)
5-7 days Contraindicated immediate
Ticagrelor (Brilinta) With Loading dose:
Prasugrel (Effien 7-10 days 6 hours

ANTIPLATELET AGENTS, INJACTABLE

Cangrelor (Kengreal) IV infusion 3 hours 8 Hours

Tirofiban (Aggrastat) IV infusion Contraindicated for 4

4-8 hours Contraindicated w eeks after surgery;
Eptifibatide (Integrelin) IV infusion monitor neurologic
status if giv en after
Abciximab (Reopro) IV infus 24-48 hours neuraxial technique

THROMBOLYTIC AGENTS
Streptokinase
10 days 48 hours + normal
Alteplase
clotting studies including Contraindicated Check Fibrinogen Lev el
Tenecteplase
fibrinogen
Reteplase

140
Urological anesthesia

141
 Transurethral resection of the prostate (TURP)
Considerations
− Geriatric patients with multiple coexisting diseases.
− Operative Considerations
▪ Positioning:
o Lithotomy with nerve injury; hemodynamic & respiratory effects of Trendelenburg
position
▪ Complications
o TURP syndrome o Hypothermia
o Fluid overload/pulmonary o Concealed hemorrhage
edema o Bladder perforation
o Electrolyte abnormalities, o Septicaemia
dysrhythmias o DIC

▪ Fluids used for irrigation:

o Ideal: Isotonic, non-hemolytic, non-toxic, allow clear visibility, and rapidly excreted
o Used:
− Glycine 1.5%: causes temporary blindness, hyperammonaemia.
− Normal saline: causes greater volume expansion, and hyperchloremic acidosis.
− Sterile water: causes greater cerebral edema, haemolysis.
− Type of anesthesia: spinal anesthesia or GA.

Anesthesia management:
Goals
− Optimization of co-existing diseases
− Prevention and early recognition of TURP syndrome and other complications.

Preoperative:
Routine preoperative assessment focusing on:
− Geriatrics comorbidities and medications.
− Optimal control of heart failure or uncontrolled AF preoperatively.
− Assess mental state and communication.
− Check creatinine and serum Na+
− Tumor size:
▪ To predict the length of operation and blood loss.
▪ If > 100 gm consider open prostatectomy.

Intraoperative:
− Monitoring:
▪ Standard ASA monitors (Temperature)
▪ Arterial line in place if indicated.

− Premedication:
▪ Be cautious with sedation.
▪ Antibiotic prophylaxis

− Type of anesthesia:
▪ If no contraindication for neuraxial anesthesia, Spinal anesthesia (block up to T10 level), is
the technique of the choice.
▪ Advantages of SA:
o Intraoperative:
− Early detection of TURP syndrome and bladder perforation.
− Reduction in blood loss.
− Avoidance of the effects of general anesthesia and airway instrumentation
on the cardiorespiratory system.
o Postoperative:
− Analgesia during the early postoperative period (to avoid narcotics)
− Reduced incidence of postoperative DVT and PONV.
− Rapid return to normal oral intake (particularly important for patients with
diabetes).

142
− Intraoperative complications:

1. TURP Syndrome:
It is a combination of fluid overload and hyponatremia, caused by absorption of large
volumes of irrigation fluid via open venous sinuses.

− Manifestations:
▪ Cardiovascular system:
o Hypertension with a wide pulse pressure (fluid overload), then hypotension
(cardiac failure).
o Bradycardia.
o Chest pain, pulmonary edema.
o Arrhythmias.
o Collapse.
▪ Central nervous system
o Nausea and vomiting, caused by hyponatraemia and cerebral edema.
o Altered level of consciousness, and coma when the Na <100mmol/L.
o Convulsions.
o Visual disturbance and transient blindness caused by glycine toxicity.

− DD:
▪ Cardiac ischemia, cerebral vascular event, hypoxia, pulmonary edema,
hyperglycaemia, or bladder perforation.

− Management:
A. Prevention:
▪ Appropriate irrigation agent
▪ Minimize resection time (< 1 hour)
▪ Avoid high irrigating pressures (limit bag height <60 cm, frequent drainage)
▪ Avoid hypotonic IV fluids.
▪ Avoid hypovolemia.
▪ Correct pre-existing hyponatremia and pulmonary edema.
B. Treatment:
▪ Call for help.
▪ Inform the surgeon to terminate procedure ASAP.
▪ ABC approach:
o Intubation if required.
o Ensuring adequate oxygen delivery.
o Maintaining adequate circulation
o Consider invasive monitoring if hemodynamically unstable: arterial
line, CVP.
o 12 lead ECG
o Blood work (electrolytes, creatinine, glucose, CBC, ABG)

▪ Correcting hyponatremia and acid-base imbalance:

o According to presentation and Na level:
• Mild hyponatremia & asymptomatic: no interventions
• Mild symptoms (serum Na > 120 mEq/L): fluid restriction & loop
diuretic (furosemide 40-120 mg).
• Symptomatic, life-threatening hypoosmolality & serum Na < 120
mEq/L: hypertonic saline:
− Start by 100cc bolus then 50-100 cc/h and monitor hourly.
− The rate of correction:
− <1mmol/L/hour and < 20mmol/L in the first 48
hours
− To avoid central pontine myelinolysis and brain
edema.
− Stopped when symptoms subsided, or the sodium level
reaches 120mmol/L then continue correction by diuresis &
normal saline or fluid restriction.

▪ Controlling convulsions. benzodiazepine or small doses of thiopentone

143
 2. Bladder perforation
− Manifestations:
▪ Under spinal anesthesia:
o Pain:
▪ Peri-umbilical or suprapubic if Extraperitoneal rupture
▪ Generalized abdominal pain referred to the shoulder if
Intraperitoneal.
o Pallor, sweating, hypotension, and nausea and vomiting.
▪ Under GA:
o Suspected when there difference between infused and drained fluids.
o Abdominal distension
o Pallor, sweating, hypotension
3. Bleeding
Blood loss is difficult to be assessed.
− Assessment of blood loss:
▪ Serial haemoglobin
▪ Rough estimation depending on:
o Duration of procedure: 2-5ml per minute of resection time.
o Extent of resection: 20-50ml per gram
4. Hypothermia
Large volumes of cold irrigating fluid may contribute to peri-operative hypothermia.

Chronic renal failure

Considerations
1. Multi-system disease with coexisting diseases & end-organ complications:
− Cardiac:
▪ LV dysfunction, hypertension, coronary disease, heart failure, pericarditis, pericardial
effusion, arrythmias.
▪ Dysregulation of volume status.
▪ Autonomic dysfunction with hemodynamic instability.
− Metabolic:
▪ Acid-base (metabolic acidosis).
▪ Electrolytes (↑ K, ↓ Na, ↓ Ca, ↑ PO4, ↓ glucose, ↑ triglycerides).
− Pulmonary:
▪ Pulmonary edema from low albumin, ↓ forced vital capacity, atelectasis.
− Hematologic: anemia/thrombasthenia.
− Altered pharmacokinetics due to ↓ elimination, acidosis, hypoalbuminemia.
− Gastroparesis & risk of aspiration.
− Potential difficult IV access, avoid cannulation and non-invasive BP (NIBP) in the arm with A-V
fistula.
− Dialysis considerations:
▪ Check the type of dialysis: peritoneal or haemodialysis, dialysis line or fistula.
▪ Determine the residual urine output per day.
▪ Examine for fluid overload or hypovolaemia.
▪ Allow 4–6hr to elapse after haemodialysis before surgery.
− If major surgery, plan post-operative care with renal/ICU team.

2. Medication:
− Avoid: Enflurane, pancuronium, pethidine, codeine, tramadol, and NSAIDs
− Suxamethonium elevates serum K+ by 0.5mmol/l.

3. Preoperative investigations
− CBC: Aim for Hb 8–10g/dL; transfusion can worsen hypertension and precipitate heart failure.
− Electrolytes: serum K+ (if >6.0mmol/L, dialysis), Ca, and Na.
− ABG
− Coagulation:
▪ INR, APTT, and platelet count usually normal.
▪ Prolonged bleeding time: give desmopressin (0.3 mcg/kg in 30mL of saline over 30min).

144
 Geriatric considerations

Considerations
Aging is associated with progressive deterioration of function in all systems.

Airway
− Potential difficult airway (both mask ventilation and intubation) due to:
▪ Osteoporotic mandibles
▪ Edentulous.
▪ Temporo-mandibular joint stiffness
▪ Lax oropharyngeal muscle tone and edentulous jaws
▪ Cervical spondylosis
▪ Arthritis of atlanto-occipital joint

Respiratory
− The closing capacity approaches functional residual capacity even in the sitting
position leads to atelectasis, shunt, hypoxia.
− Can tolerate a longer period of apnoea following preoxygenation as O2 consumption
and CO2 production fall.
− Blunted response to hypoxia and hypercarbia.
− Smoking and COAD may lead to a marked decrease in respiratory reserve.
− Decrease in total thoracic compliance may fall.
− Airway protective reflexes decline, increasing the risk of post-operative pulmonary
aspiration.

Cardiovascular
− Reduced ventricular compliance and myocardial contractility.
− Reduced arterial compliance causes systolic hypertension, widened pulse pressure, and swings in
blood pressure.
− Capillary permeability is increased, leading to a greater risk of pulmonary edema.
− Reduced autonomic responsiveness affects CVS responses to hypotension.
− Atherosclerosis and ischaemic heart disease
− Arrhythmias (particularly AF).

Musculoskeletal
− Degenerative changes in the vertebral column leads to difficult neuraxial anesthesia.
− Arthritic joints or joint replacements are susceptible to damage or dislocation.

CNS
− Decreased brain size and density of neurons.
− More sensitive to opioid analgesics and sedatives, susceptible to respiratory depression
− Post-operative delirium (POD) and cognitive dysfunction (POCD) are common.
− Reduced thirst response to hypovolemia makes them susceptible to fluid depletion.

Pharmacokinetics
− Volume of distribution for drugs is altered due to:
▪ Reduced TBW
▪ Greater proportion of adipose tissue
▪ Reduced initial volume of distribution due to reduction in cardiac output.
▪ prolonged arm–brain circulation time.
− Implications:
▪ Reduced dose requirements of water-soluble drugs.
▪ Reduced induction agent dose.
▪ Increased the time taken for induction agents to take effect.
▪ Reduced MAC of inhalational agents (6% reduction per decade)

145
Renal
− Reduced renal mass and number of glomeruli lead to reduced GFR and Creatinine clearance.
− Susceptible to fluid overload and hypovolaemia.
− Hypo- and hypernatremia
− Reduced clearance of renally excreted drug

Thermoregulation
− Impaired thermal regulation, increasing the risk of hypothermia.
− Post-operative shivering increases skeletal muscle O2 consumption.

Others
− Hypercoagulability and DVT liability.
− Impaired immune responses increase the risk of infection.
− Hypothyroidism and diabetes mellitus are common.
− Reduction in liver size leads to prolonged effects of opioids, propofol, benzodiazepines, and
NDMRs.
− Vascular access
− Regional anesthesia
− Positioning

146
 Obesity

Definitions
− Normal: BMI 20–24.9
− Overweight: BMI ≥25.0 to 29.9
− Obesity: BMI ≥30
− Obesity class I: BMI of 30.0 to 34.9
− Obesity class II: BMI of 35.0 to 39.9
− Obesity class III (severe obesity, massive obesity): BMI ≥40

Considerations
Obesity increases the risk of perioperative morbidity & mortality.
Airway
− Potential difficult airway (both mask ventilation and intubation) due to:
▪ Short neck
▪ Increased fat tissue in the pharyngeal wall
▪ Limited movement of the atlantooccipital joint
▪ Large chin, breasts, and thoracic fat

Respiratory
− Obstructive sleep apnoea
− Reduced FRC (encroach upon the closing capacity): leads to
▪ Atelectasis, shunt, hypoxia
▪ Rapid desaturation despite preoxygenation.
− Increased work of breathing.
− Reduced compliance (both chest wall and lung): heavy chest wall.
− Obesity hypoventilation syndrome (OHS), and Pickwickian syndrome lead to:
▪ Hypoxia, cor pulmonale, and polycythemia.

Cardiovascular
− Increased metabolic demands increase blood volume and cardiac output leading to:
▪ Left ventricular hypertrophy left ventricular failure.
▪ Biventricular failure
▪ Cardiomegaly
− Hypertension and ischaemic heart disease.
− Increased risk of Thromboembolism.

Gastrointestinal
− Increased risk of regurgitation and aspiration due to:
▪ Increased acidity and volume of gastric contents.
▪ Increased intra-abdominal pressure.
▪ Hiatus hernia is common association.

Endocrine and metabolic

− High incidence of diabetes and hypercholesterolaemia.

Pharmacokinetics
− Volume of distribution for drugs is altered due to:
▪ Smaller proportion of TBW
▪ Greater proportion of adipose tissue
▪ Increased lean body mass.
▪ Increased blood volume and cardiac output.
− Implications:
▪ Hydrophilic drugs (e.g., competitive neuromuscular blockers such as rocuronium, vecuronium,
and atracurium), the dose based on the ideal body mass.
▪ Lipophilic drugs (e.g., thiopental, propofol, opioids, and benzodiazepines), the dose based on
lean body weight.
▪ Increased plasma cholinesterase activity. Suxamethonium dose should be based on the total
body weight to a maximum of 200mg.
▪ ↓ neuraxial dose

147
Technical difficulties:
− Vascular access − Positioning
− Monitoring (NIBP) − Transferring
− Regional anesthesia

Anesthesia management
Goals:
− Safe airway management
− Regional anesthesia is preferable.
− Minimize postoperative airway obstruction/hypoventilation.
− Avoid thrombotic complications.
− Avoid peripheral nerve injury.

Preoperative:
− Routine history, examination, and investigations focusing on evaluation of physiologic impact
and comorbidities of obesity.
− Consider:
▪ Echocardiography and cardiac referral if poor functional capacity, metabolic
syndrome, abnormal ECG, uncontrolled BP, CHF, and IHD.
▪ Preoperative CPAP – ABG if: SpO2 <94% on room air, OHS likely.
▪ Sleep Studies: STOP-BANG  5.
− Experienced Anaesthetist to help.
− Consider ICU or HDU bed

Intra-operative
− Room preparation:
▪ Difficult airway equipment
▪ Suitable bed/trolley and operating table, pressure areas protection devices.
▪ Appropriately sized calf compression devices
▪ Ventilator capable of PEEP & pressure modes
▪ Long spinal, regional, and vascular needles
▪ Neuromuscular monitoring.
▪ Enough staff for positioning.

− Premedication:
▪ Aspiration prophylaxis
▪ DVT prophylaxis
▪ Avoid sedation.

− Induction:
▪ Preoxygenation (Consider CPAP and/or HFNO)
▪ Intubate in ramped/sitting position.
▪ If difficult airway: awake FOI
▪ If assured: RSI + cricoid pressure.
▪ Caution with SAD in BMI >40
▪ Avoid spontaneous ventilation, use PEEP.
▪ Short-acting inhalational or TIVA
▪ Short-acting opioids & multimodal analgesia
▪ Pressure areas protection
− Extubation:
▪ Fully awake
▪ Ensure full NMB reversal.
▪ Extubate and recover in sitting up position.

Post-operative
− HDU care
− Apply CPAP if used preoperatively.
− Oxygen and oximetry.
− Adequate analgesia to allow deep breathing/coughing. Ramp position
− Physiotherapy
− DVT prophylaxis

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 Obstructive sleep apnea (OSA)

Definitions:
− Apnea: cessation of airflow for >10 seconds for 5 or more times per hour during sleep, Spo2
decreased by >4%
− Hypopnea: Decrease in airflow of >50% for more than 10 seconds, 15 or more times per hour
during sleep, Spo2 decreased by >4%
− Obstructive sleep apnea syndrome: Apnea + clinical comorbidities.

1. Screening of OSA:
A. Clinical manifestation:
− Snoring.
− Observed apnea during sleep.
− Daytime somnolence.
− Early morning headaches.
− Dry or sore throat upon waking.
− Poor concentration and irritability
B. Scoring systems:
− STOP BANG questionnaire:
▪ Snoring
▪ Tired—daytime tiredness or fatigue
▪ Observed apnoea during sleep.
▪ Pressure (blood)—treatment for hypertension
▪ BMI more than 35 kg/m2
▪ Age over 50 years
▪ Neck circumference greater than 40 cm
▪ Gender—high prevalence in male gender
Low Risk: Yes to 0 - 2 questions
Intermediate Risk: Yes to 3 - 4 questions
High Risk: Yes to 5 - 8 questions
− Berlin questionnaire

2. Severity classification:
A. Apnoea–hypopnoea index (AHI):
− <5 normal
− 5–15 mild
− 15–30 Moderate
− >30 severe.
B. Oxygen Desaturation: Overnight oxygen saturation is measured:
− >90% mild.
− 80%–89% moderate
− < 80% severe.

3. Definitive Diagnosis:
− Polysomnography (PSG) examinations include recordings of ECG, electroencephalography
(EEG), eye movements, and electromyography. Snoring volume, oronasal airflow, and
peripheral pulse oximetry are usually also recorded.

Considerations
− Comorbid disease:
▪ Cardiorespiratory:
o Hypoxia, hypercarbia (chronic)
o Obesity hypoventilation syndrome
o Polycythemia
o Pulmonary hypertension, RV hypertrophy, RV dysfunction
▪ Endocrine:
o Diabetic instability
▪ CNS
o Impaired cognition
o Chronic headache

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 ▪ GIT: Gastro-oesophageal reflux

− Difficult airway (mask ventilation + intubation)

▪ Ramp position if obese.
▪ Awake intubation is the safest.
▪ Adequate preoxygenation
▪ Consider CPAP.
▪ Aspiration prophylaxis
− Sedative premedication
▪ ↑ sensitivity to sedatives/hypnotics
▪ Avoid sedating premedication.
▪ Alpha-2 adrenergic agonists (clonidine, dexmedetomidine) may reduce
intraoperative anaesthetic requirements and have an opioid-sparing effect.
− Analgesia
▪ Minimise use of opioids for the fear of respiratory depression
▪ Use short-acting agents (remifentanil)
▪ Regional and multimodal analgesia (NSAIDs, acetaminophen, tramadol,
ketamine, gabapentin, pregabalin, dexamethasone)
▪ Consider opioid-free analgesia.
− Anaesthetic technique
▪ Propofol/remifentanil for maintenance of anaesthesia
▪ Insoluble potent anesthetic agents (desflurane, sevoflurane)
▪ Regional blocks as a sole anesthetic technique.
− Monitoring
▪ Intraoperative capnography for monitoring of respiration
▪ Arterial line if OSA associated with cardiac dysfunction.
▪ NM monitoring
− Postoperative period
▪ Verification of full reversal of neuromuscular blockade
▪ Ensure patient fully conscious and cooperative prior to extubation.
▪ Non-supine posture for extubation and recovery
▪ Resume use of CPAP device with close monitoring
▪ Require HDU/ITU admission.
▪ NOT SUITABLE FOR DAY CASE SURGERY.

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Airway assessment and management

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 Airway assessment

Proper airway assessment through:

1. History
2. Examination
3. Imaging
To detect the predictors for difficult intubation, mask ventilation, SGA insertion, and front-of-neck access

− Previous anaesthetic problems:

▪ Difficulty notification card, and anesthesia records.
▪ Dental damage or severe sore throat.

− Congenital airway difficulties

▪ Down’s, Klippel–Feil, craniofacial syndromes.
History
− Acquired airway difficulties:
▪ Pregnancy, obesity, diabetes, RA, ankylosing spondylitis, acromegaly, Still’s
disease, snoring, OSA
− Iatrogenic problems
▪ C-spine fusion, oral/pharyngeal radiotherapy, laryngeal/tracheal surgery,
temporomandibular joint (TMJ) surgery.

− General
▪ Level of consciousness + co-operation
▪ BMI
− Face
▪ Beard
▪ craniofacial deformity
− Mouth
▪ Mallampati grade: divided as:
o 1: Soft palate, fauces, uvula, and tonsillar pillars seen.
o 2: Soft palate, fauces, some of uvula seen.
o 3. Soft palate and only base of uvula seen.
o 4. Soft palate is not visible at all.
Classes 3 and 4 are associated with increased difficulty in intubation.

Examination

▪ Mouth opening (Inter-incisor distance)

o > 3cm (> 3 fingers): suitable for both intubation and SGA insertion
o < 3 cm: difficult laryngoscope insertion
o < 2.5 cm: difficult SGA insertion
o < 1.5 cm: difficult video-assisted laryngoscope insertion.
▪ Shape of palate.

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 ▪ Jaw protrusion
Ask the patient to protrude their lower jaw: if class 3: predict difficulty.
− Teeth
▪ Edentulous
▪ Dentures/ caps/ crowns/ loose teeth
▪ Buck teeth.
▪ Upper lip bite test
o 1: Upper lip mucosa is invisible
o 2: Upper lip mucosa partially visible
o 3: Fail to bite the upper lip. (Predict difficulty)

− Neck
▪ Range of motion of head and neck
o <90 degrees extension and flexion range: Predict difficulty.
▪ Thyro-mental distance:
o >6.5 cm: rarely associated with difficulty.
o <6 cm: predict difficulty.

▪ Sternomental distance: <12.5 cm (Predict difficulty)

▪ Neck circumference/ thickness

− Nasal endoscopy
− Awake laryngoscopy
Investigations − Lateral neck x-ray
− CXR
− CT neck
− MRI neck

A- Predictors of difficulty

1. Predictors of difficult bag-mask ventilation (ROMAN)

− Radiation (head and neck)/Restriction (poor lung compliance)
− Obesity/Obstruction (upper airway)/Obstructive sleep apnea
− Mask seal/Mallampati (class III or IV)/Male
− Age over 55 years
− No teeth

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2. Predictors of difficult Intubation (LEMON)

− Abnormal facies or body habitus

L Look externally − Unusual anatomy
− Facial trauma, burn

Evaluate − Mouth opening: 3 fingers

E (3-3-2 fingers rule)
− Hyoid- mental distance: 3 fingers
− Thyrohyoid distance: 2 fingers

M Mallampati score − Class III predicts difficulty.

− Class IV predicts extreme difficulty.

− Upper airway obstruction:

▪ Supraglottic mass
▪ Infection
O Obstruction/Obesity ▪ Trauma with hematoma
▪ Injury with disruption of the upper airway
▪ Vocal cord masses
− Obese patient

− Flexion and extension range of the neck.

− Reduced neck mobility
N Neck mobility ▪ Rheumatoid arthritis, Ankylosing spondylitis
▪ Degenerative joint disease
▪ Aging

3. Predictors of SAD insertion difficulty (RODS)

− Restricted lungs (poor compliance) or mouth opening
− Obstruction
− Disrupted airway.
− Short thyromental distance

4. Predictors of difficult cricothyrotomy (SHORT)

− Surgery on the neck.
− Hematoma, abscess, or other mass
− Obesity, poor landmarks
− Radiation (or other tissue deformity or scarring)
− Tumor (including intrinsic airway tumor)

5. Predictors of awake tracheal intubation

− Uncooperative patient
− Oropharyngeal bleeding or excessive secretions.
− Inadequate topicalization.
− Severely distorted anatomy
− Severe glottic or tracheal narrowing

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B- Combined Tests:
Wilson score

0 1 2
Weight (Kg) <90 90 - 110 >110

Head & neck movement >90 = 90 <90

Jaw movement >5 =5 <5

Receding mandible None Moderate Severe

Buck teeth None Moderate Severe

− 0-1 points: Not difficult

− 2-3 points: possible difficult intubation (75%)
− >3 points: difficult intubation.

The double setup

− The double setup is simultaneously set up for orotracheal intubation and for a cricothyroidotomy.
− The anesthetist is at the head of the bed with the orotracheal airway equipment, while the ENT
surgeon is completely prepared for the crich with the scalpel in hand at the neck of the patient.
− The neck should already be prepped, and the landmarks should be identified.

Pierre Robin Syndrome

Considerations
1. Pediatric considerations:
− Obstructive sleep apnea
− Pulmonary hypertension, cor pulmonale
− GERD, aspiration pneumonias
2. Airway considerations:
− Difficult bag mask ventilation & intubation due to:
▪ Micrognathia, mandibular hypoplasia,
glossoptosis, and OSA
▪ Prone for upper airway obstruction.
▪ Negative pressure pulmonary edema
▪ May need to be nursed prone.
3. Improves with age.

Airway Management
− Maintain spontaneous ventilation, Inhalational induction and
ENT surgeon equipped with a rigid bronchoscope on standby.
− Avoid upper airway obstruction by:
▪ Oral & nasal airways
▪ Pull tongue forward, consider suturing it to the lip.
▪ Prone position
▪ Paraglossal laryngoscopy
▪ LMA placement
− Intubation options:
▪ Asleep oral fibreoptic intubation (can be through the LMA).
▪ Nasal fiberoptic bronchoscopy
▪ Light wand
Light wand

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 Awake fiberoptic intubation

Preparation
A. Room preparation:
− Resuscitation medications and devices (including intralipid)
− Difficult airway trolly including tracheostomy kit.
− Local anesthetics with different concentrations for topicalization
B. Patient preparation, to be:
− Consented
− Educated: the procedure was explained
− Monitored
− Sedated and received aspiration prophylaxis.
− Connected to O2
− IV line.
− Positioned in a suitable and comfortable position.
C. Device preparation: the scope should be:
− Tested
− Lubricated
− Tube loaded on the cord.
D. Anesthetist: should consider:
− Careful airway assessment
− Stand in position he can see the patient, monitor, and the screen.

Intubation: Using DAS protocol (STOP):

− Sedate: IV infusion of remifentanil with TCI of 1-3 ng/ml OR intravenous infusion of
dexmedetomidine 0.5 mcg/kg over 10-15 min as loading then 0.2-0.7 mcg/kg/h as
maintenance.
− Topicalise: The dose of topical lidocaine should not exceed 9 mg/kg lean body weight.
▪ Nebulise 2ml 4% Lidocaine.
▪ Nose and nasopharynx: Soak cotton bud with 2% Lidocaine then
Insert the cotton buds gauze into the nasal cavity (inferior nasal
meatus) and posterior nasal space, leaving it in situ for around 3
minutes.
▪ Tongue and oropharynx: 4 puffs 10% Lidocaine to throat (2 on each
side, tonsillar pillows, and back of the throat.
▪ Pharynx and Larynx above cords: can be anesthetized by 1-4%
Lidocaine via metered spray.
▪ Larynx below the vocal cords, and tracheo- bronchial tree, using:
“Spray as you go” technique during endoscopy using an epidural
catheter or a 3 ml syringe containing the Lignocaine with 1-1.5ml of
air.
▪ Cricothyroid (trans-tracheal) injection, to anaesthetise subglottic
region, vocal cords, and trachea.

Regional nerve blocks:

Can be performed for: glossopharyngeal, superior laryngeal and recurrent laryngeal nerve blocks
(AVOID IN EMERGENCY, FULL STOMACH SITIUATIONS).

Translaryngeal block of recurrent Glossopharyngeal n. block Superior laryngeal n. block.

laryngeal n.

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 − Oxygenate: Apply low flow or high-flow nasal cannula titrated from [Link] early
and continue through the procedure.
− Perform:
▪ Choose the appropriate tube size.
▪ Patient sitting up.
▪ Ensure that you can see the patient, monitor, infusion pumps, and video
screen.
▪ Clear secretions.
▪ Positioned facing the patient.

Complications during the procedure:

Hypertension:
▪ Immediately withdraw the scope
▪ Call for help.
▪ Check monitor:
o Recycle the non-invasive cuff - arterial wave.
o Exclude hypoxia, and malignant arrythmia.
▪ Assess the patient:
o If uncomfortable: more topicalization
o If anxiety: Reassure the titrated small dases of midazolam.
▪ If failed Esmolol bolus.
▪ Reinsert the scope.

Cases based, airway management.

Trauma patient
Assess the airway:
− If assured:
Modified rapid sequence induction with inline manual stabilization, our goal is to avoid
increasing ICP by avoiding pressor response on intubation and maintaining CPP, using:
− Etomidate + Succ (avoid in severe crush injury and after 24 hours) or rocuronium (if
sugammadex is available) + Fentanyl.
− If difficult:
Drug-assisted AWAKE fiber optic intubation, our goal is to avoid increasing ICP by avoiding
pressor response on intubation and maintaining CPP, using:
1. Remifentanil infusion with TCI of 1- 3 ng/ml.
2. Dexmedetomidine: 0.5 mcg/kg over 10-15 min as loading then 0.3-0.7 mcg/kg/h as
maintenance.

Airway trauma
According to the location:
1. Supraglottic (including the maxillofacial trauma): (KEYWORD: TRACHEOSTOMY)
Keep the patient spontaneous and check the field, if there is bleeding or distorted anatomy,
consider awake tracheostomy by the ENT, if no blood, intubate him using AFO or video-
laryngoscopy with double setup, and the ENT is scrubbed and ready for urgent tracheostomy.

2. Glottic and tracheal: (KEYWORD: Awake Fiberoptic)

Keep the patient spontaneous, avoid PPV and MR, and perform AFO intubation to place the
tip of the tube distal to the injured site.

3. Infracrinal: (KEYWORD: lung isolation)

Keep the patient spontaneous, avoid PPV and MR, till lung isolation using DLT, bronchial
blocker, or single lumen tube advanced to non-injured lung.

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Anterior mediastinal mass
The keywords: is to Maintain spontaneous ventilation and avoid positive pressure ventilation &
muscle paralysis until placing the ETT distal to the obstruction, while ENT is ready with a rigid
bronchoscope and cardiothoracic surgeon is ready for urgent sternotomy and stretcher ready for
positioning.

Bullous Lung Disease

It is an absolute indication for lung isolation, maintain spontaneous ventilation, avoid positive
pressure ventilation & muscle paralysis before lung isolation, with skilled thoracic surgeon ready for
urgent chest tube insertion if rupture bullae.

Bronchopleural Fistula (BPF)

It is an absolute indication for lung isolation, maintain spontaneous ventilation, avoid positive
pressure ventilation & muscle paralysis lung isolation. Have a surgeon skilled in chest tube placement
immediately available if needed, but do not place a prophylactic chest tube.

Emergent CS
Modified rapid sequence induction with cricoid pressure and left uterine displacement after
preoxygenation and aspiration prophylaxis, with fetal monitoring and informing the pediatrician if
the narcotics are planned.

Foreign body aspiration

Maintain spontaneous ventilation by inhalational induction + topicalization. Avoid MR and PPV to
avoid hyperinflation/barotrauma, FB dislodgement/airway obstruction, with the availability of ENT for
rigid bronchoscopy, and difficult airway equipment.

Before advancing the scope assess the depth of anesthesia by staged stimulation approach:
1. Jaw thrust.
2. Insert oral airway.
3. Do direct laryngoscopy & spray with lidocaine.
4. Rigid bronchoscopy

Adenotonsillectomy
− For OSA: Inhalational induction, avoid MR, consider using of nasopharyngeal airway, two hands
technique.
− For tonsillitis: Inhalational OR IV induction.

Post tonsillectomy bleeding

Modified RSI with cricoid pressure. In lateral position (if severe bleeding) with ENT surgeon
scrubbed and prepared to perform a tracheostomy.
If no venous access: Inhalational induction in the supine position with the head down or in the left
lateral position with suction ready.

Down Syndrome
Inhalational induction with maintaining cervical spine stabilization, use jaw thrust, oropharyngeal
airway to maintain patent airway. Avoid extensive flection or extension of the neck (tilt the table not
the head.

Tracheoesophageal Fistula
Spontaneous inhalational induction, place the ETT down to the right mainstem with bevel forward,
slowly withdraw the ETT until breath sounds become equal bilaterally. Avoid muscle relaxation and
PPV until the ETT position confirmed.

Epiglottitis
Maintain spontaneous ventilation inhalational induction using styletted, cuffed, and smaller
endotracheal tubes (1-3mm smaller) with ENT is scrubbed and ready for tracheostomy.

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Rheumatoid arthritis
− If suspected difficult or AAI: awake fiberoptic intubation.
− If not: direct laryngoscopy using manual in-line stabilization and a gum elastic bougie (GEB).
− Maintain the neck in a neutral position on transfer and turning.

Scleroderma (and other cases with limited mouth opening)

− Retromolar laryngoscope
− Illuminating stylet
− Video-assisted fast track.
− Tracheostomy

Intubation of suspected covid patient

− Preparation:
▪ COVID-19 specific intubation trolley:
o Bag-mask with HEPA filter
o Video laryngoscope with clear, disposable cover for the device
▪ Greatest intubation experience should manage the airway.
▪ The team should consist of intubator, intubation assistant, drug administrator and a runner.
− Intubation technique:
▪ Preoxygenate for 3-5 minutes using a 2-handed technique to ensure a tight fit of mask.
▪ Perform RSI using:
o Ketamine 1-2 mg/kg or Etomidate 0.3 mg/kg
o opioid such as fentanyl 1 mcg/kg.
o High dose MR: Rocuronium 1mg/kg or suxamethonium 1.5 mg/kg.
▪ Use video-assisted laryngoscopy.
▪ Avoid CE hand mask ventilation. If needed, use a 2 handed, 2-person technique with low
flow and low pressure.
▪ Inflate the cuff prior to ventilation.

Burn
Modified RSI with etomidate and succinylcholine (in 1st 24 hours) after administering GI prophylaxis
while ENT on standby and neck is draped the neck for an emergency tracheotomy. Have the
difficult airway cart in the room with different sizes of ETT and LMAs.

Extubation: after leak test.

Hypoxia during tracheostomy insertion

− Start manual ventilation through the tracheostomy to check the resistance and bilateral air entry
▪ If high resistance and no air entry, false passage: remove it and try to insert again with
different sizes.
▪ If unilateral air entry, consider tension pneumothorax.
− Try to insert a bougie and check the level of advancement, if endobronchial, reinsert a longer
tracheostomy set.
− If still hypoxic remove and insert ETT through the larynx and place its tip distal to the tracheal
incision using FOB

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A

160
Obstetrics DAS Algorithm

161
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Critical Care

165
 Acute Respiratory Distress Syndrome
Definition:
Berlin definition: the four key diagnostic criteria must be present:
1. Acute onset: within 7 days of a defined trigger (e.g. pneumonia).
2. Degree of hypoxia: a PaO2:FiO2 ratio of <300 mm Hg) on at least 5 cm H2O of
positive end-expiratory pressure (PEEP).
3. Bilateral lung infiltrates on either chest x-ray or CT scan.
4. Not fully explained by cardiac failure or fluid overload.

Severity classifications:
▪ Mild ARDS: PaO2:FiO2 is 200 - 300 mmHg.
▪ Moderate ARDS: PaO2:FiO2 is 100 - 200 mmHg.
▪ Severe ARDS: PaO2:FiO2 is ≤100 mmHg.

Precipitating Conditions
− Pulmonary: − Extrapulmonary
▪ Pneumonia ▪ Sepsis
▪ Aspiration of gastric contents ▪ Massive transfusion.
▪ Inhalational injury ▪ Non-cardiogenic shock
▪ Near drowning ▪ Multiple trauma
▪ Toxins
▪ Burns

Management:
A. VENTILATORY STRATEGIES
− Low-Tidal-Volume Ventilation
▪ Tidal volume 6 ml/kg based on ideal body weight.
▪ Plateau pressure <30 cm H2O
▪ Permissive hypercapnia tolerated as long as pH >7.2.

− Positive End-Expiratory Pressure

▪ Using high PEEP (average 15 cm H2O)

− Prone-Position Ventilation
− Airway Pressure Release Ventilation (inverse ratio ventilation):
▪ Most of the respiratory cycle (usually around 90%) is spent at a high pressure with
a brief drop to lower pressure to allow expiration to occur.

− High-Frequency Oscillatory Ventilation

▪ Small tidal volumes of 1 to 3 ml/kg at a frequency between 3 and 15 Hz.

− Recruitment Manoeuvres
▪ Methods:
o Continuous positive airway pressure at 30-40 cm H2O for 30-40 seconds.
o Stepwise increase in peak pressure and/or PEEP.

− Extracorporeal Membrane Oxygenation (ECMO):

▪ Venovenous: use of large-bore central venous
access to remove blood, pass it through a gas
exchanger, and return it to the venous circulation.

B. NONVENTILATORY STRATEGIES
− Conservative Fluid Therapy
− Neuromuscular Blockade
− Corticosteroids: Methylprednisolone 1 mg/kg/day
− Other Adjunctive Therapies:
▪ Inhaled NO - Inhaled prostacyclin - β2 agonist.

Venovenous ECMO 166

 Management of suspected COVID-19 patients in ER

− The patient should be placed in an airborne isolation room, especially during airway
procedures.
− All team in the room should use airborne and contact precautions.
− Personal protective equipment (PPE) includes:
▪ Either an N95 mask, for which one has been fit-tested, or a powered air-purifying
respirator (PAPR).
▪ A face shield or goggles.
▪ A gown
▪ Gloves.
− Avoid nebulized bronchodilators unless bronchospasm or COPD.
− Targeting SpO2: 90 - 96%.

− Oxygen support: Shift from one step to the next if SpO2 <90%
1. Low-flow oxygen:
▪ Nasal cannulae up to 4 L/minute
▪ Face mask up to 10L/min
▪ Non-rebreathing mask 15L/min.
2. High-flow oxygen via nasal cannulae (HFNC):
▪ Initial settings: Flow 20 l/min - FiO2 0.4.
▪ Up to Flow 60 l/min - FiO2 1.0
3. Non-invasive ventilation (NIV)
▪ Continuous positive airway pressure (CPAP): Initial settings are CPAP 10 cm H2O.
▪ Bi-level positive airway pressure (BIPAP): Initial settings: 12/5 cm H2O.

4. Intubation:
▪ Indications:
o Rapid progression of hypoxia.
o Persistent need for high flows/FiO2 (>60 L/minute and an FiO2 >0.6) or
high-pressure support level in NIV.
o Evolving hypercapnia, increasing work of breathing, decreasing tidal
volume.
o Worsening mental status.
o Hemodynamic instability or multiorgan failure.

▪ Preparation:
o COVID-19 specific intubation trolley:
− Bag-mask with HEPA filter
− Video laryngoscope with clear, disposable cover for the device
o Ventilator and tubing with in-line adaptors (for suctioning and
bronchoscopy) and HEPA filters.
o Greatest intubation experience should manage the airway.
o The team should consist of intubator, intubation assistant, drug
administrator and a runner.

▪ Intubation technique:
o Preoxygenate for 3-5 minutes using a 2-handed technique to ensure a
tight fit of mask.
o Perform RSI using:
− Ketamine 1-2 mg/kg or Etomidate 0.3 mg/kg
− Opioid such as fentanyl 1 mcg/kg.
− High dose MR: Rocuronium 1mg/kg or suxamethonium 1.5 mg/kg.
o Use video-assisted laryngoscopy.
o Avoid CE hand mask ventilation. If needed, use a 2 handed, 2-person
technique with low flow and low pressure.
o Inflate the cuff prior to ventilation.

167
 ▪ Airway management plan:
o Plan A: Videolaryngoscopy with bougie/stylet.
o Plan B: Supraglottic airway.
o Plan C: 2 person technique + OPA
o Plan D: Front of neck surgical airway (Scalpel, Bougie, tube)

− Management of Lung injury: As for ARDS.

Sepsis management

Considerations
− Emergency surgery: Always consider optimization before induction unless life threatening condition.
− Critically ill patient, high mortality
− Distributive shock with severe hypovolemia
▪ Requiring:
o Early goal-directed therapy & early antibiotics/source control.
o Invasive monitoring
o ICU postop
▪ Potential for cardiovascular collapse on induction
− Multi-organ failure:
▪ ARDS – AKI – DIC.

− Signs of severe sepsis:

▪ Hypotension ▪ Deranged liver function
▪ Arterial hypoxemia ▪ Altered mental status.
▪ Raised lactate. ▪ Coagulation abnormalities
▪ Acute oliguria (UOP < 0.5 ml/kg/h) ▪ Hyperglycaemia in absence of diabetes

Management
(Following Surviving Sepsis Guidelines)
A. Goal-directed resuscitation: (within 6 hours)
− Resuscitation goals:
▪ CVP: 8 – 12 mmHg
▪ MAP ≥ 65 mmHg
▪ UOP ≥ 0.5 ml/kg/h
▪ Central venous (superior vena cava) ≥ 65% or mixed venous oxygen saturation ≥ 70%

− Resuscitation measures:
1. Fluids therapy:
− 1st line: Crystalloids: start by 30cc/kg then use dynamic or static
variables to guide further fluid therapy.
− Consider albumin.
− Avoid synthetic colloids.

2. Vasopressors/inotropes:
− 1st line: Norepinephrine.
− 2nd line: Epinephrine
− Vasopressin (NOT recommended alone)
− Phenylephrine: if
o Excessive arrythmia from other vasopressor
o Very high cardiac output states
− Dobutamine as first line inotropic agent if:
o Reduced cardiac output - low mixed venous -
myocardial dysfunction.

168
 − Dopamine is not routinely recommended.

3. Corticosteroids:
− NOT indicated if fluids/vasopressors have restored hemodynamic.
− Consider IV hydrocortisone 200mg daily if refractory shock.

4. Blood product administration to maintain:

− Platelets > 50 x 109 /l.
− Hgb ≥7 gm/dl.

5. Glucose control
− An infusion regimen to keep the blood glucose <10 mmol/l.
A. Elimination the underlying infection using appropriate antibiotics and/or surgery:
− Broad spectrum antibiotics within 1 hour

Burns
Considerations
− Trauma patient, assess and manage following ATLS approach.
− Multisystem dysfunction:
1. Airway:
▪ Threatened and potentially difficult airway (more in inhalational injury)
▪ Causes: Edema, secretions, bleeding.
2. Respiratory:
▪ Pulmonary edema – aspiration - restrictive lung
▪ If Inhalational Injury (burned nose and face hair- blackish nostril – history):
o Tracheobronchial thermal & chemical injury resulting in:
− Alveolar collapse/atelectasis & airway plugging.
− Bronchospasm
− Pneumonia
− ALI/ARDS
3. Cardiovascular:
▪ Hypovolemic/cardiogenic shock/low cardiac output state → septic shock/high
cardiac output state (Leaky capillaries).
4. Other system:
▪ Carbon monoxide/cyanide poisoning
▪ Hyperkalaemia/myoglobinuria/AKI
▪ DIC, anemia of burns
▪ Impaired thermal regulation
▪ Delayed gastric emptying.
▪ Pain (multimodal approach +/- antidepressants)
▪ Late:
o Sepsis
o DVT/PE
o Stress ulcers, adynamic ileus, hypermetabolic/catabolic state
− Medications:
▪ MR:
o Succinylcholine contraindication (>24 hours to 1year)
o NDMR resistance (>60 days)
▪ Opioid tolerance
− Technical:
▪ Difficult monitoring (ECG patches, BP cuffs, etc)
▪ Need co-oximeter for CO poisoning.
▪ Difficult IV access

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Management:

Following ATLS approach with special consediraations:

A. Airway:
− Indication for intubation:
▪ Airway protection: facial or neck burn - Inhalational injury - Major burn.
▪ Lung injury.
− Airway Management:
▪ Prep and drape the neck for an emergency tracheotomy.
▪ Have ENT on standby.
▪ Have the difficult airway cart in the room with different sizes of ETT and LMAs.
▪ RSI with etomidate and succinylcholine (in 1st 24 hours) after administering GI
prophylaxis.
▪ Extubation: after leak test.

B. Breathing:
− lung protective ventilation strategies:
▪ Tidal volume ≤ 6cc/kg
▪ Plateau pressure < 30cm H2O
▪ PEEP & FiO2 to achieve adequate oxygenation (PaO2
≥55 to 80 mmHg).

C. Circulation:
− Goal-directed volume resuscitation using Parkland formula:
▪ 4cc X %BSA X weight (kg)
▪ ½ calculated volume in first 8 hrs, ½ in next 16 hrs
▪ Crystalloid (LR) – avoid colloids.
− Clinical end points:
▪ Urine output >0.5cc/kg/hr
▪ MAP >60
▪ Lactate <2
▪ Mixed venous saturation >65%.
− Preinduction arterial line
− Complications of resuscitation:
▪ Abdominal compartment syndrome

o Avoid hypothermia.

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Anesthesia Emergencies

171
 Anaphylaxis

Presentation:
− Cardiovascular:
▪ Hypotension
▪ Tachycardia
− Respiratory:
▪ Hypoxemia
▪ Bronchospasm/wheezing
▪ ↑ peak inspiratory pressure
− Rash - urticaria - erythema
− Angioedema

Management
1. Immediately:
− Stop offending agent.
− Call for help and inform the surgeon.
− Check the monitor to exclude hypoxia, hypercarpia, and malignant arrhythmia.
− Discontinue or ↓ all anesthetic agents.
− Check ABC
− 100% O2 and secure airway.
− Epinephrine:
▪ IV in escalating doses: until pulse pressure or bronchospasm improves.
o Start at 50-100 mcg & ↑ as necessary.
o Infusion (start at 2-20 mcg/min)
▪ IM: 0.5-1 mg and repeat after 10 min if required
− Fluid resuscitation (crystalloid or colloids) and elevate legs.

2. Subsequently:
− Bronchodilator: salbutamol PRN
− Antihistamines:
▪ H1 antagonist: diphenhydramine 25-50mg IV.
▪ H2 antagonist: ranitidine 50mg IV.
− Corticosteroids:
▪ Methylprednisolone 1-2mg/kg IV per day.
▪ Dexamethasone 20mg IV.
− Consider invasive lines: arterial line, central line.
− Check ABGs for acidosis (bicarbonate 0.5–1.0mmol/kg)

3. If refractory hypotension:
− Vasopressin: 1- 40 units bolus, 0.01-0.04 units/min infusion.
− Noradrenaline: 0.05–0.1 micrograms/kg/min.
− Glucagon: 1-2 mg over 5 min IV then 5-15 mcg/min IV infusion:
▪ Has inotropic & chronotropic effects not mediated through beta receptors.
▪ For patients on beta blockers
− Methylene blue: 1-2mg/kg IV
▪ Inhibits nitric oxide synthase & guanylate cyclase.
− Consider ECMO.

4. Confirm diagnosis:
− Serum tryptase levels: 15 minutes and 3 hours after the onset of symptoms
− Serum histamine levels: 15 minutes after onset of symptoms.

5. Post-event care:
− Has a biphasic nature: needs close observation and monitoring for at least 24 hours.
− Discharge to ICU intubated & ventilated.
− Leak test before extubation
− Consult allergist.

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 Local Anesthetic Toxicity (LAST)

Presentation:
− Early:
▪ Tinnitus, metallic taste, circumoral numbness.
▪ Visual disturbances Verbal or vocalization problems
− CNS:
▪ Altered mental status and severe agitation.
▪ Seizures
▪ Apnea
− Cardiovascular:
▪ Hypotension
▪ Bradycardia
▪ Ventricular arrhythmias
▪ Cardiovascular collapse

Management
Immediately:
− Stop local anesthetic injection.
− Call for help.
− Check the monitor to exclude hypoxia, hypercarpia, and malignant arrhythmia.
− Check ABC:
▪ Airway: ensure airway patency, consider early intubation.
▪ Breathing:
o 100% oxygen
o Maintain ventilation to prevent hypoxia & acidosis (aggravate LAST)
▪ Circulation:
o If circulatory arrest:
− Start CPR, using standard protocols with adjustment epinephrine doses to <1
mcg/kg (small boluses of 10-100 mcg IV)
o Manage arrhythmias:
− Avoid vasopressin, calcium channel blockers, beta-blockers, & local anesthetics
− If ventricular arrhythmias occur, amiodarone is preferred; avoid lidocaine &
procainamide.
− Control seizures:
▪ Benzodiazepines is preferred.
▪ Avoid/minimize propofol (20mg) if hemodynamically unstable.
▪ If persist, small doses of succinylcholine to minimize acidosis & hypoxia.
− Alert the nearest facility having cardiopulmonary bypass capability.

Lipid emulsion (20%) therapy:

− When to start:
▪ Rapidly at the first signs of LAST.
− Regimen:
▪ Initial bolus: 1.5ml/kg bolus over 1 minute.
▪ Then start infusion at 0.25mL/kg/min.
After 5 min: (if persistent cardiovascular collapse)
▪ Repeat bolus for maximum 2 times with 5 min in between.
▪ Double the infusion rate to 0.5mL/kg/min.
− Maximum dose:
▪ 10mL/kg over the first 30 minutes.
− When to stop?
▪ At least 10 minutes after attaining circulatory stability.
− Propofol is not a substitute for lipid emulsion.

Failure to respond to lipid emulsion & vasopressor: cardiopulmonary bypass (ECMO)

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 Bronchospasm

Presentation:
− Monitor
▪ Change in EtCO2:
o Upsloping waveform
o Severe ↓ or absent waveform
▪ ↓ oxygen saturation
− Ventilator:
▪ Slow or incomplete expiration
▪ ↓ tidal volume
▪ ↑ peak airway pressure
− Auscultation: wheezing

Differential Diagnosis
− Increased resistance:
A. Bronchial:
▪ Bronchial asthma
▪ COPD with reversible component
▪ Laryngospasm (if supraglottic airway)
▪ Anaphylaxis
B. Airway devices
▪ ETT/supraglottic airway:
o Kinking
o Malposition
o Endobronchial/esophageal/submucosal
o Herniated cuff
▪ Circuit/machine problems
− Decreased compliance:
▪ Aspiration.
▪ Pulmonary edema.
▪ Pulmonary embolism/fat embolism/amniotic fluid embolism.
▪ Pneumothorax
▪ Opioid-induced chest wall rigidity
▪ Inadequate muscle relaxation
▪ Foreign body/secretions

Management
− Call for help.
− Check the monitor to exclude hypoxia, hypercarpia, and malignant arrhythmia.
− Check ABC.
− 100% oxygen.
− Deepen anesthesia and remove irritants.
− Disconnect & hand-ventilate to assess compliance and rule out other possibilities.
− Treatment:
▪ 1st line: Beta 2 agonists:
o Salbutamol 4-8 puffs via ETT OR 2.5-5mg via nebulizer q 20min PRN.
o Epinephrine infusion 0.5-2mcg/min in severe, refractory cases.
▪ Anticholinergics: ipratropium 4-8 puffs via ETT OR 0.5 mg via nebulizer q 20min PRN
▪ Steroids:
o Methylprednisolone 125mg IV.
o Dexamethasone 8mg IV.
▪ Appropriate ventilation to avoid dynamic hyperinflation:
o Longer expiratory time (I: E 1:3-1:5).
o Low/normal respiratory rates (8-12/min).
o Permissive hypercapnia.
▪ Adjuncts:
o Bronchodilating anesthetics: volatiles > ketamine > propofol.
o Magnesium sulphate: 2g IV over 20min.
o Heliox (does not reverse bronchospasm but can be used as a temporizing measure).
o Neuromuscular blocking drugs (may improve mechanics of ventilation & lower peak
inspiratory pressures).
− If failed: Extracorporeal membrane oxygenation (ECMO).

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 Increased Airway Pressure

Differential diagnosis
− Circuit or machine problem:
▪ Ventilator/bag switch in wrong position
▪ Valves:
o Malposition: PEEP valve placed in inspiratory limb.
o Failure: check valve failure.
o Stuck: inspiratory, expiratory, APL and oxygen flush.
▪ Kinked tubes.
▪ Misconnected hose in circuit - scavenge limb.

− Airway devices problem:

▪ Kinked tube
▪ Malpositioned supraglottic airway
▪ Endobronchial, esophageal, submucosal intubation
▪ Herniated cuff obstructing end of tube
− ▪ Dissection of interior surface of tube leading to airway narrowing.

− Decreased pulmonary compliance:

▪ Laryngospasm (if using supraglottic airway)
▪ Bronchospasm
▪ Pulmonary aspiration
▪ Pulmonary edema
▪ Pneumothorax
▪ ↓ chest wall compliance
▪ Drug-induced:
o Opioid-induced chest wall rigidity
o Inadequate muscle relaxation
o Malignant hyperthermia
▪ ↑ intra-abdominal pressure

Management
− Call for help.
− Check the monitor to exclude hypoxia, hypercarpia, and malignant arrhythmia.
− Check ABC
− 100% oxygen.
A. Disconnect & hand-ventilate to assess compliance:
▪ If low PIP: machine problem, change it by an assistant.

B. Auscultate chest & neck for:

▪ Symmetry: endobronchial, tension, or simple pneumothorax.
. ▪ Adventitious sounds: pulmonary edema, bronchospasm.
▪ Stridorous sound of laryngospasm

C. Exclude ETT obstruction:

▪ Pass suction catheter down ETT & apply suction to clear secretions.
▪ If ETT obstructed, deflate cuff & repeat.
▪ Consider fiberoptic bronchoscopy.
▪ Remove & reintubate if necessary.

D. Check for other causes of↓chest compliance and manage accordingly.

Venous air Embolism

Presentation:
▪ ↓ ETCO2
▪ Hypotension – tachycardia
▪ ↑ CVP
▪ Hypoxia - bronchospasm
▪ Dyspnea & respiratory distress or cough in awake patient
▪ Monitoring
▪ TEE: is the most sensitive modality.
▪ Precordial Doppler ultrasound.
▪ Precordial or oesophageal stethoscope to detect a ‘millwheel’ murmur.
▪ End-tidal Nitrogen concentrations.

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Management
▪ Call for help.
▪ Check the monitor to exclude hypoxia, hypercarpia, and malignant arrhythmia.
▪ 100% Oxygen.
▪ Stop nitrous oxide.
▪ Ask the surgeon to:
▪ Flood the operative field with fluid.
▪ Occlude bone edges with wax to prevent further entrance of air.
▪ IV fluids to increase Venous pressure.
▪ Vasopressors: epinephrine, norepinephrine, dobutamine.
▪ Gentle compression of the jugular veins (in sitting position).
▪ Aspirate air from the CVP line.
▪ If a large volume of air: turn the patient into the left lateral position to attempt to keep the air in the right
atrium.
▪ Hyperbaric oxygen therapy (especially if paradoxical air embolism)
▪ Commence CPR, if cardiac arrest.

Fat Embolism
Presentation:
▪ Hypoxemia (most common early sign).
▪ Neurological abnormalities: agitations, irritability.
▪ Petechial rash: on conjunctiva, oral mucosa, skin folds of neck & axilla.

Management
A. Prevention:
− Early immobilization of fractures.
− Operative correction rather than traction alone.
− Limitation of the intraosseous pressure during orthopaedic procedures.
B. Treatment:
− Call for help.
▪ − Check the monitor to exclude hypoxia, hypercarbia, and malignant arrhythmia.
− 100% Oxygen
− Supportive treatment:
▪ Respiratory: intubation/ventilation, treat as ARDS (lung protective strategy).
▪ Hemodynamic: fluid resuscitation, vasopressors, invasive monitors, TEE.
− Steroids in refractory cases.

Hypoxemia

Differential Diagnosis
A. Artifacts:
− Poor waveform (probe malposition, cold extremity, light interference, cautery).
− Dyes (methylene blue, indigo carmine, blue nail polish).
− Confirm by ABG.

B. Failure of oxygen (from oxygen source to the capillary alveolar membrane):

− Low FiO2:
▪ Oxygen failure or pipeline crossover of gases
▪ Hypoxic mixture
− Hypoventilation:
▪ Central:
o Respiratory depression
o Upper airway obstruction due to DCL
▪ Ventilator:
o Low TV or RR
o Ventilator dyssynchrony.
o Circuit leak
− Circuits and tubes:
▪ Kinked, disconnected.
▪ Obstructed: HME – ETT.
− Airway:
▪ Bronchospasm
▪ Mainstem intubation

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 − Alveolar:
▪ Pulmonary edema ▪ Atelectasis
▪ Aspiration ▪ Alveolar
▪ Haemorrhage
− Pleura:
▪ Pneumothorax
▪ Pleural effusion
C. Failure of oxygenation: (from capillary alveolar membrane to the tissue)
− Lung diffusion diseases.
− Pulmonary embolism
− Hypoperfusion
− ↑metabolic O2 demand: malignant hyperthermia, thyrotoxicosis, sepsis, hyperthermia, neuroleptic
malignant syndrome.

Management
− Call for help.
− 100% Oxygen
− Check the monitor for:
▪ Level of hypoxia.
▪ Gas analyser to rule out low FiO2 or high N2O.
▪ ETCO2: hypercarbia, extubation or disconnection.
▪ Other vitals, cycle NIBP, check peak inspiratory pressure,

− Manage the causes accordingly.

− Consider termination of surgery if refractory hypoxia.

Laryngospasm

Management
− Call for help.
− Check monitor for hypoxia, hypercarbia, Blp, and malignant arrhythmia.
− Remove the stimulus that precipitated the laryngospasm.
− Check that the airway is clear of obstruction or potential irritants.
− 100% oxygen.
− Maintain CPAP: with the expiratory valve of the circuit closed and maintain a close seal by mask with
two hands.
− IV lidocaine 0.5-1 mg /kg.
− If the laryngospasm has occurred at induction, deepening anaesthesia by:
▪ Propofol increments.
▪ Increasing the volatile agent concentration.
− If the laryngospasm fails to improve, remove any airways that may be stimulating the pharynx.
− IF failed, relaxing dose of suxamethonium 0.25–0.5mg/kg IV or 2–4mg/kg IM or sublingually.
− If failed. Intubating dose of suxamethonium and intubate with smaller size tube.
− Search for the cause and manage it accordingly.

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 Hypotension
Differential Diagnosis

Management
▪ Call for help.
▪ Check monitor:
▪ Recycle the non-invasive cuff – check arterial wave.
▪ Exclude hypoxia- hypercapnia – malignant arrhythmia.
▪ Ensure level of anesthesia
▪ Check pulsation (If absent start CPR)
▪ Check surgical field for bleeding.
▪ Manage:
▪ 100% O2.
▪ IV fluid bolus and check response.
▪ Vasopressor bolus
o Phenylephrine 100 mcg IV PRN.
o Norepinephrine 5 mcg IV PRN.
o Ephedrine 5-10 mg IV PRN.
o Epinephrine 1-10 mcg IV PRN.
▪ Search for a cause by targeted physical exam:
▪ Urticaria, flushing, angioedema
▪ Tracheal deviation, jugular venous distention, subcutaneous crepitus, bilateral air entry
▪ JVP / CVP / PCWP
o ↑CVP / PCWP = obstructive or cardiogenic.
o ↓CVP / PCWP = hypovolemic or distributive.
▪ Peripheral perfusion (↑ in distributive, ↓ in others)

Hypertension
Differential Diagnosis
A. Pre – postoperative:
▪ Equipment error (falsely high reading)
▪ Hypoxemia, hypercarbia
▪ Pain
▪ Distended bladder
▪ Drug-related:
− ▪ Vasopressors, cocaine, MAOIs, stimulants
▪ Acute withdrawal: EtOH, benzodiazepines, opioids, clonidine, betablockers
▪ Coexisting diseases:
▪ Pre-existing hypertension
▪ Pre-eclampsia
▪ High ICP (Cushing reflex)
▪ Autonomic dysreflexia

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 ▪ Endocrine:
o Hyperthyroidism o Serotonin syndrome
o Pheochromocytoma o Hyperaldosteronism
o Carcinoid o Cushing syndrome
o Malignant hyperthermia

• B. Intraoperative:
Same as pre and postoperative +
▪ Inadequate anesthesia:
▪ Laryngoscopy/intubation
▪ Surgical stimulation, laparoscopy
▪ Awareness

Management
▪ Call for help.
▪ Check monitor:
▪ Recycle the non-invasive cuff – check arterial wave.
▪ Exclude hypoxia- hypercapnia – malignant arrhythmia.
▪ Ensure the level of anesthesia
▪ Antihypertensive:
▪ Labetalol 5-20mg IV q10 min (max total 300mg)
▪ Esmolol 0.5mg/kg IV over 1 minute; start infusion at 50mcg/kg/min.
▪ Hydralazine 5-20mg IV (max 30mg) slow IV push every 20 minutes.
▪ Nitroglycerin 50-100mcg IV; start infusion at 10mcg/min.
▪ Treat underlying cause

Intraoperative Myocardial Ischaemia

Presentation:
− ST segment changes:
− Elevation
− Down sloping depressions.
− New ventricular regional wall motion abnormalities identified with echocardiography.

Management

− Call for help.

− Check monitor for hypoxia, hypercarbia, Blp, and malignant arrhythmia.
− Stop surgery if appropriate or ask the surgeon to finish early as possible.
− Consult Cardiologist
− Confirm Diagnosis:
▪ 12-lead ECG.
▪ Baseline and 4-hour troponin levels.
▪ Consider TEE or transthoracic echocardiogram if hemodynamic instability.
− Manage:
▪ Hemodynamic management:
− Tachycardia with normo or hypertension:
o BB: metoprolol tartrate 5 mg IV every 5 minutes for 3 doses.
o CCB
o Nitrates:
• 0.4 mg IV every 5 minutes
• 1 aerosol spray under the tongue every 5 minutes for 3 doses
o Manage AF or flutter if present.

− Tachycardia with hypotension:

o Vasopressors to maintain blood pressure then β-blockers to slow heart
rate.
o Avoid CCB
o If AF or flutter: cardioversion

▪ Aspirin (after discussion with cardiology and surgeon)

▪ Morphine:5-10 mg
▪ Consider use of intra-aortic balloon pump, as guided by cardiologists.

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 Delayed Emergence

Differential Diagnosis: (DIMS)

− Drugs:
A. Anesthesia related:
▪ Sedatives & narcotics
▪ Residual paralysis, pseudocholinesterase deficiency
▪ Drug error
B. Non-anesthesia related:
▪ Street drugs, alcohol
▪ Herbal medicines (valerian root, St. John's wort)

− Infection:
▪ Encephalitis, meningitis
▪ Sepsis

− Metabolic:
▪ Hypoxia ▪ Hypothermia.
▪ Hypercarbia ▪ Uremia.
▪ Electrolyte abnormalities ▪ Hepatic encephalopathy.
▪ Hypoglycemia or hyperglycaemia ▪ Osmolality problems.
(DKA or HONK) ▪ Myxedema coma.

− Structural:
▪ Stroke (ischemic or haemorrhagic).
▪ Hydrocephalus.
▪ Diffuse anoxic injury.
▪ Cerebral edema.
▪ Seizure or post-ictal.
▪ Pneumocephalus.
▪ Cerebral hyperperfusion syndrome (post carotid endarterectomy).

Malignant Hyperthermia (MH)

Presentation:
− Early
▪ ↑EtCO2
▪ Tachycardia
▪ Tachypnea
▪ Mixed acidosis
▪ Masseter spasm/trismus
▪ Sudden cardiac arrest due to hyperkalaemia.
− Later
▪ Hyperthermia
▪ Muscle rigidity
▪ Myoglobinuria
▪ Arrhythmias
▪ Cardiac arrest

Differential Diagnosis
− Neuroleptic malignant syndrome:
▪ Similar presentation
▪ Associated with use of antipsychotic neuroleptic medications (also treated with dantrolene).
− Thyroid storm:
▪ Fever, tachycardia, altered mental status.
− Anaphylaxis:
▪ Cardiovascular collapse without hypermetabolic features.
− Pheochromocytoma:
▪ Significant hypertension.
− Drug toxicity:
▪ Consider clinical context, screen urine/plasma.

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Management
− Call for help.
− Check monitor for hypoxia, hypercarbia, Blp, and malignant arrhythmia.
− Stop surgery if appropriate or ask the surgeon to finish early as possible with non-triggering anesthetic.
− Stop anesthetic triggers (volatiles & succinylcholine)
− Increase fresh gas flow to 10L/min; do not change machine or circuit.
− If available, insert activated charcoal filters into the inspiratory & expiratory limbs of the breathing
circuit.
− ↑ to 100% FiO2 & ↑ minute ventilation
− Dantrolene:
▪ 2.5 mg/kg IV bolus:
▪ Dilute each 20 mg dantrolene vial in 60 mL preservative-free sterile water (may need > 10
mg/kg)
▪ Rapidly administer dantrolene & continue giving until patient stable.
▪ continue dantrolene 1 mg/kg q 4-6 hours x 24 hours.

− Cool patient: IV fluids, ice packs, gastric/peritoneal lavage

− Treat arrhythmias: avoid calcium channel blockers.
− Treat metabolic acidosis:
▪ Sodium bicarbonate 1 to 2mEq/kg PRN for base excess greater than -8 (max dose 50mEq)
− Treat hyperkalaemia:
▪ Hyperventilation
▪ Calcium chloride 10mg/kg (max dose 2g) or calcium gluconate 30mg/kg (max 3g)
▪ D50 1 amp IV (25g dextrose) + regular insulin 10 units IV → monitor glucose
▪ Correct acidosis: sodium bicarbonate 1 amp
▪ Furosemide 0.5-1mg/kg once
▪ For refractory hyperkalaemia, consider beta-agonist, kayexalate, dialysis, or ECMO if in cardiac
arrest.
− Follow-up:
▪ Temperature, electrolytes, arterial/venous blood gases, creatine kinase, urine output,
coagulation studies, lactic acid, and urine output
− When stable, transfer to post anesthesia care unit or intensive care unit for at least 24 hours
− Refer for genetic counselling for in-vitro muscle contracture testing.

Transfusion hemolytic reactions

Presentation:
− Chills, fever, nausea.
− Chest & flank pain
− −Tachycardia, hypotension
− Hemoglobinuria, diffuse oozing in surgical field

Management
− Call for help.
− Stop transfusion immediately.
− Check monitor for hypoxia, hypercarbia, Blp, and malignant arrhythmia.
− Manage following ABC approach.
▪ 100% oxygen.
▪ Support blood pressure with IV fluids, vasoactive medications if needed.
− Notify blood bank of all possible reactions.
− Recheck unit against blood slip & patient’s identity bracelet.
− Draw bloodwork to identify hemoglobin in plasma, repeat compatibility testing, obtain coagulation
studies & platelet count.
− Insert urinary catheter & check urine for hemoglobin.
− Initiate osmotic diuresis with IV fluids +/- mannitol.
− Monitor for hyperkalaemia, DIC.

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Advanced Trauma life support

182
 Advanced trauma life support

Management consists of:

1. Rapid primary survey, resuscitation of vital functions
2. Secondary survey
3. Tertiary survey and initiation of definitive care.

1. Primary survey
Goal: Identification of life-threatening conditions by adhering to ABCDE sequence:

− Airway maintenance with cervical spine protection

− Breathing and ventilation
− Circulation with hemorrhage control
− Disability: Neurologic status
− Exposure/Environmental control.

A Airway maintenance with cervical spine protection

1. Assessment:
− Check airway patency.
− Airway obstruction by debris, foreign bodies, teeth, and vomits.

2. Management:
− Establish a patent airway by:
▪ Perform a chin-lift or jaw-thrust manoeuvre.
▪ Clear the airway of foreign bodies.
▪ Insert an oropharyngeal airway.
− Establish a definitive airway by:
▪ Intubation
▪ Surgical cricothyroidotomy
− Maintain the cervical spine in a neutral position:
▪ with manual immobilization during airway management.
▪ Appropriate devices after establishing airway.

B Breathing: ventilation and oxygenation

Assessment
− Expose the neck and chest.
− Determine the rate and depth of respirations.
− Inspect and palpate the neck and chest for tracheal deviation, unilateral and bilateral chest
movement, use of accessory muscles, and any signs of injury.
− Percuss the chest for presence of dullness or hyperresonance.
− Auscultate the chest bilaterally.
− Exclude Pneumothorax.

Management:
− Administer high-concentration oxygen.
− Ventilate with a bag-mask device.
− Treat pneumothorax:
▪ Alleviate tension pneumothorax: cannula decompression in the 2 nd intercostal space
midclavicular line (UPDATES: 4th – 5th in anterior to midaxillary line specially in obese patients
▪ For pediatrics: 2nd intercostal space midclavicular line.
− Attach pulse oximeter.

C Circulation with hemorrhage control

Assessment:
− Signs of shock:
▪ Pulse: Quality, rate, regularity, and paradox.

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 ▪ Skin colour.
▪ Blood pressure
▪ UOP
− Identify source bleeding: external, and internal hemorrhage.

Management
− Apply direct pressure to external bleeding site(s).
− Consider presence of internal hemorrhage and potential need for operative intervention and
obtain surgical consult.
− Insert two large-caliber IV catheters.
− Initiate IV fluid therapy with warmed crystalloid solution and blood replacement.
− Prevent hypothermia.

Disability: brief neurologic examination

D − Determine the level of consciousness using the GCS.
− Check pupils for size and reaction.
− Assess for lateralizing signs and spinal cord injury.

E Exposure/environmental control
− Completely undress the patient.
− Prevent hypothermia.
▪ Ensure a warm environment.
▪ Use warm blankets.
▪ Warm fluids before administering.

Adjuncts to primary survey and resuscitation:

− ABG.
− Monitor exhaled CO2.
− ECG.
− Blood sample for:
▪ Hematologic, cross match and blood grouping, coagulation profile.
▪ chemical analyses: electrolytes, toxicology, glucose, lactate.
▪ pregnancy test
− Insert urinary catheter and monitor UOP hourly.
− gastric catheters unless contraindicated.
− AP chest and AP pelvic x-rays.
− FAST or DPL.

2. Secondary Survey

− Does not begin until the primary survey (ABCDEs) is completed.

− Head-to-toe evaluation of the patient by:
▪ History
▪ Physical examination.

1. History and mechanism of injury

AMPLE Menominee for history:

− Allergies
− Medications currently used.
− Past illnesses/Pregnancy
− Last meal
− Events/Environment related to the injury to identify injury mechanisms.

184
2. Physical examination:

− Head and maxillofacial

Assessment:
▪ Lacerations, contusions, fractures, and thermal injury.
▪ Re-evaluate pupils and LOC.
▪ Eyes, mouth, cranial-nerve function
▪ CSF leakage.

Management
▪ Maintain airway, and continue ventilation and oxygenation as indicated.
▪ Control hemorrhage.
▪ Prevent secondary brain injury.
▪ Remove contact lenses.

− Cervical spine and neck

Assessment
▪ Palpate for tenderness, deformity, swelling, subcutaneous emphysema, tracheal deviation,
and symmetry of pulses.
▪ Accessory respiratory muscles.
▪ CT or a lateral x-ray of the cervical spine

Management:
▪ Maintain adequate in-line immobilization and protection of the cervical spine.

− Chest
Assessment
▪ Inspection:
o Chest wall for signs of blunt and penetrating injury
o use of accessory breathing muscles.
▪ Auscultation:
o Bilateral breath sounds and heart sounds.
▪ Palpitation:
o For evidence of blunt and penetrating injury
o Subcutaneous emphysema
o Tenderness and crepitation.
▪ Percussion:
o Hyperresonance or dullness.

Management
▪ Chest tube if indicated.
▪ Dress an open chest wound.
▪ Pericardiocentesis, as indicated.
▪ Shift the patient to OR if required.

− Abdomen
Assessment
▪ Inspection:
o For signs of blunt and penetrating injury.
▪ Auscultation:
o Presence of bowel sounds.
▪ Percussion:
o Rebound tenderness.
▪ Palpatation:
o Tenderness
o Involuntary muscle guarding
o Gravid uterus.
▪ Pelvic x-ray film.
▪ Abdominal ultrasound – DPL
▪ CT of the abdomen if the patient is hemodynamically normal.

Management
▪ Transfer the patient to the operating room, if indicated

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 ▪ IF pelvic fracture: Wrap a sheet around the pelvis or apply a pelvic compression binder as
indicated to reduce pelvic volume and control of bleeding.

− Perineum/rectum/vagina
▪ Perineal assessment.
o Contusions and hematomas, lacerations urethral bleeding
▪ Rectal assessment in selected patients.
o Rectal blood
o Anal sphincter tone
o Bowel wall integrity
o Bony fragments
o Prostate position
▪ Vaginal assessment in selected patients.
o Blood in vaginal vault, lacerations

− Musculoskeletal
Assessment
▪ Upper and lower extremities for blunt and penetrating injury.
▪ Complete neurovascular examination of the extremities.
▪ Thoracic and lumbar spines for tenderness, deformity, and sensation.
▪ X-ray films of suspected fracture sites as indicated.
▪ CT for spines.

Management
▪ Splinting devices for extremity fractures.
▪ Maintain immobilization of the patient’s thoracic and lumbar spines.
▪ Administer tetanus immunization.
▪ Consider the possibility of compartment syndrome.

− Adjuncts to secondary survey

▪ Contrast urography
▪ Angiography
▪ Transoesophageal ultrasound
▪ Bronchoscopy
▪ Esophagoscopy

3. Tertiary survey
− An approach to address the undiagnosed injuries in trauma patients.
− consists of re-evaluating patients 24 hours after admission by means of an anamnesis protocol,
physical examination, review of complementary tests and request for new tests when
necessary.

Top DD of hypotension in trauma patients: Top DD of hypoxia in trauma patients:

− Bleeding − Tension pneumothorax

− Tension pneumothorax − Flail chest
− Cardiac tamponade − Upper airway obstruction (central, airway
− Spinal shock (if spinal cord injury) trauma)
− Malignant arrhythmia − Neurogenic pulmonary edema.
− Fat embolism − Bleeding

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 Advanced Trauma life support (summary)

Advanced
Primary survey: Totrauma
identify andlife support
manage the life-threatening conditions by adhering to ABCDE sequence.

Assessment Management
− Check airway patency. − Maintain patient airway: Suction, jaw thrust, intubation.
Airway − Airway obstruction by debris, foreign bodies, teeth, and vomits. − Maintain the cervical spine stabilization in a neutral position

− Expose the neck and chest. − High Fio2, bag-mask ventilation.

− Determine the rate and depth of respirations. − Treat tension pneumothorax: cannula decompression in the
Breathing − Inspect and palpate and auscultate chest. 2nd intercostal space midclavicular line (UPDATES: 4th – 5th in
− Exclude Pneumothorax. anterior to midaxillary line specially in obese patients)

− Apply direct pressure to external bleeding sites.

− Signs of shock: pulse, Blp, skin colour, UOP, LOC.
Circulation − Insert 2 large-bore cannulae, start warm IV fluid.
− Identify source bleeding: external, and internal hemorrhage
− Consult surgeon, prepare for intervention if internal bleeding

− Determine the level of consciousness using the GCS.

Disability − Check pupils for size and reaction.
− Assess for lateralizing signs and spinal cord injury.

Exposure − Completely undress the patient. − Prevent hypothermia

Monitors: Blood sample: Insert: − X-ray: AP chest, AP pelvic x-rays.
− EtCO2. − ABG, lactate − Urinary catheter − FAST or DPL.
Adjunct − ECG. − Hematologic, chemical analyses, glucose. − Gastric tube
− Pregnancy test

Secondary survey: Head-to-toe evaluation of the patient by history and physical examination. (After complete 1ry)

Assessment Management
− Allergies − Last meal
History (AMPLE) − Medications currently used. − Events/Environment related to the injury to identify injury
− Past illnesses/Pregnancy mechanisms.

− Lacerations, fractures, and thermal injury.

− Prevent secondary brain injury.
− Eyes, mouth, cranial-nerve function
Head and maxillofacial − Treat siuzers
− CSF leakage
− Control bleeding
− CT brain if indicated
− Palpate for tenderness, deformity, swelling, emphysema,
Maintain adequate in-line immobilization and
Cervical spine and neck tracheal deviation.
protection of the cervical spine
− CT cervical spine
− Chest tube if indicated.
− Inspection, auscultation, palpitation, and percussion − Dress an open chest wound.
Chest − CT chest − Pericardiocentesis, as indicated.
− Shift the patient to OR if required.
− Transfer the patient to the operating room, if
indicated
− Inspection, auscultation, palpitation, and percussion
Abdomen − If pelvic fracture: Wrap a sheet around the pelvis or
− CT of the abdomen.
apply a pelvic compression binder to reduce
pelvic volume and bleeding control
− Perineal assessment.
− Rectal assessment (in selected patients) for:
− Vaginal assessment (in selected patients) for blood in
Perineum/rectum/vagina ▪ Rectal blood
vaginal vault, lacerations
▪ Anal sphincter tone
▪ Prostate position
− Splinting devices for extremity fractures.
− Upper and lower extremities.
− Maintain immobilization of thoracic and lumbar
− Neurovascular.
Musculoskeletal spines.
− Thoracic and lumbar spines for tenderness, deformity.
− Administer tetanus immunization.
− CT for spines.
− Consider compartment syndrome.

− Contrast urography
− Bronchoscopy
Adjunct − Angiography
− Esophagoscopy
− Transoesophageal ultrasound

Tips:
− MRI in not a part of 1ry or 2ry survey: don’t shift the patient to the MRI if the surgeon asked for.
− CT is a part of the 2ry survey: to be done only after completing the 1ry survey and the patient is
haemodynamically stable.
− If the patient needs surgical intervention for management of life-threatening event, push the patient to the OR
while optimizing the patient.

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 Airway management in trauma patient

Indications for intubation in trauma patients:

Airway protection Need for ventilation or oxygenation.

− Severe maxillofacial fractures: ▪ Tachypna
▪ Risk for aspiration from bleeding and/or ▪ Hypoxia
vomiting. ▪ Hypercarbia
− Neck injury ▪ Cyanosis
▪ Neck hematoma ▪ Combativeness
▪ Laryngeal or tracheal injury. − Inadequate respiratory efforts
− Burn ▪ Progressive change Accessory muscle
▪ Inhalation injury use
▪ Facial or neck burns ▪ Respiratory muscle paralysis
▪ Stridor ▪ Abdominal breathing
▪ Voice change − Acute neurological deterioration or
▪ Circumferential chest burn. herniation
− Head injury − Apnea:
▪ Unconscious ▪ Loss of consciousness
▪ Combative ▪ Neuromuscular paralysis.

Airway management algorithm in (Non-airway) trauma patients

− Assess the airway:

A. If assured:
Modified rapid sequence induction with inline manual stabilization, our goal is to avoid
increasing ICP by avoiding pressor response on intubation and maintaining CPP, using:
− Etomidate + Succ (avoid in severe crush injury and after 24 hours) or rocuronium (if
sugammadex is available) + Fentanyl.
B. If difficult:
Drug-assisted AWAKE fiber optic intubation, our goal is to avoid increasing ICP by avoiding
pressor response on intubation and maintaining CPP, using:
− Remifentanil infusion with TCI of 1- 3 ng/ml.
− Dexmedetomidine: 0.5 mcg/kg over 10-15 min as loading then 0.3-0.7 mcg/kg/h as
maintenance.

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Airway management algorithm in (airway) trauma patients

− According to the location:

a. Supraglottic (including the maxillofacial trauma): (KEYWORD: TRACHEOSTOMY)

Keep the patient spontaneous and check the field, if there is bleeding or distorted anatomy,
consider awake tracheostomy by the ENT, if no blood, intubate him using AFO or video-
laryngoscopy with double setup, and the ENT is scrubbed and ready for urgent tracheostomy.

b. Glottic and tracheal: (KEYWORD: Awake Fiberoptic)

Keep the patient spontaneous, avoid PPV and MR, and perform AFO intubation to place the
tip of the tube distal to injured site.

c. Infracrinal: (KEYWORD: lung isolation)

Keep the patient spontaneous, avoid PPV and MR, till lung isolation using DLT, bronchial
blocker, or single lumen tube advanced to non-injured lung.

Management of surgical emphysema

− Stop PPV
− 100% oxygen: to replace air the subcutaneous tissue.
− Exclude pneumothorax.
− Advance ETT tip distal to the tear
− Fasciotomy in severe cases

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 ATLS for pregnant female

− For optimum outcomes for the mother and fetus, next sequence should be followed:
1st: Primary assessment and resuscitation of the mother
2nd: Assessment of the fetus.
3rd: Conducting a secondary survey of the mother.
− Multidisciplinary approach:
▪ Trauma, obstetrical and neonatal teams should be activated early.
▪ Neonatal intensive care unit should be consulted as early as possible.

Primary Survey

Goal: Identification of mother life-threatening conditions by adhering to ABCDE sequence:

Airway

− Check airway patency.

− Airway obstruction by debris, foreign bodies, teeth, and vomits.
− Maintain the cervical spine in a neutral position.
− If Intubation is required, consider:
▪ Preoxygenated adequately
▪ Airway management is further complicated due pregnancy-related changes.
▪ Aspiration prophylaxis.
▪ Modified rapid sequence induction with cricoid pressure and manual inline stabilization.
▪ NGT after intubation.
Breathing

− Expose the neck and chest.

− Inspection, palpation, and percussion as non-pregnant.
− Exclude Pneumothorax.
− Management of a pneumothorax: cannula decompression then a tube thoracostomy 1 to 2
intercostal spaces higher, anterior to the mid-axillary line.

Circulation Causes of shock:

− Signs of shock developed late despite loss of a large − Hemorrhage

amount of blood due to physiological changes of − Direct cardiac injury
pregnancy.
− Obstructive mechanisms such
− Identify source bleeding: external, and internal
hemorrhage. as tamponade
− Tension pneumothorax
− 2 large-bore IV cannulas placed supradiaphragmatic.
− Uterine displacement manually or by placing the patient in left lateral position.
− Initiate IV fluid therapy with warmed crystalloid solution and blood replacement.
− Vasopressors as a last resort to avoid reduction in uterine blood flow.
− Un-crossmatched type O, Rh (-) blood reduces the risk of alloimmunization until type specific
blood is available.

Disability
Trauma triad of death
− GCS, pupillary examination, signs of lateralization.
− Hypothermia
Exposure and environmental control − Coagulopathy
− Acidosis.
− As in the general population
− Prevent hypothermia.

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 Fetal assessment

− Ultrasound for: − Cardiotocographic (CTG): if 24 weeks for a

▪ Fetal heart rate minimum of 4 hours.
▪ Fetal movement − The presence of prolonged, painful, and/or
▪ Amniotic fluid quantity regular contractions necessitates further
▪ Position of the placenta monitoring and obstetric intervention.
▪ Gestational age

Secondary Survey

History
− use the mnemonic AMPLE.

Physical exam
− As non-pregnant.
− Uterine and vaginal examination

Imaging Studies
− Focused assessment with sonography for trauma (FAST) to replace Xray if possible.
− X-ray: if required, consent - use abdominal and pelvic shields
− CT scan:
▪ Selective CT rather than pan CT.
▪ Reduce radiation dose.
▪ Use abdominal and pelvic shield.
▪ Consent.

Laboratory Testing

− Rh status
− CBC
− The Kleihauer-Betke (KB) test: to detect the approximate the volume of fetal-maternal
hemorrhage (FMH)
− INR, PTT, fibrin degradation, Fibrinogen.

Medications
− Rh-negative: RhIG 1 ampule (300 g) IM.
− Corticosteroids: between 24- and 34-weeks gestational age.
− Tocolytics
▪ Magnesium sulphate.
▪ Corticosteroids.
▪ Avoid beta adrenergic activity (e.g. terbutaline), causes tachycardia and/or hypotension.
− Tranexamic Acid:1 g infused over 10 minutes, followed by an infusion of 1 g over eight hours.

Complications Specific to Trauma in Pregnancy

− Placental abruption:
▪ The second highest cause of perinatal mortality from trauma.
▪ Diagnosis:
o Clinically with cardiotocographic fetal monitoring
o CT imaging is more sensitive for diagnosis than ultrasonography.

− Uterine rupture:
▪ Irregularly shaped uterus, palpable fetal parts, or abdominal tenderness.
▪ Treatment: laparotomy with fetal delivery and either hysterectomy or uterine

191
 − Amniotic fluid embolism:
▪ Sudden hypoxemia and cardiovascular collapse and can progress to DIC and multi-organ
failure.
▪ The mechanism: amniotic fluid entering the maternal circulation and leading to either
vascular obstruction or anaphylaxis.
▪ Treatment is supportive with resuscitation and potential delivery of the fetus.

− Preterm labour.
− Preterm premature rupture of membranes (PPROM)

Cardiac arrest

Modifications of ACLS in maternal cardiac arrest:

6. Chest compression is higher and deeper.
7. Early intubation (suspected difficult intubation, most experienced should perform)
8. IV line to be supradiaphragmatic.
9. Relieving aortocaval compression.
10. If No ROSC in 4 min, Perimortem CS over one min.

Other considerations:
▪ If on mgSo4, stop and start Ca chloride or gluconate.
▪ Remove fetal monitoring.

Common causes of maternal cardiac arrest:

− Anesthesia complications − Drugs

▪ High neuraxial block ▪ Oxytocin
▪ Aspiration ▪ Magnesium
▪ Local anesthetic toxicity ▪ Opioids
▪ Hypotension ▪ Anaphylaxis
▪ Respiratory depression ▪ Drug administration error
− Accidents − Embolism
▪ Trauma ▪ Pulmonary embolus
▪ Suicide ▪ Amniotic fluid embolus
− Bleeding ▪ Venous air embolism
▪ Uterine atony ▪ Cerebrovascular event
▪ Placenta accreta − Fever
▪ Placental abruption and previa ▪ Sepsis
▪ Uterine rupture ▪ Infection
▪ Coagulopathy − General
▪ Transfusion reaction ▪ Hypoxia
− Cardiovascular ▪ Hypovolemia
▪ Arrhythmia ▪ Hypokalemia/hyperkalemia
▪ Myocardial infarction ▪ Tamponade
▪ Congenital heart disease ▪ Toxins
▪ Aortic dissection − Hypertension
▪ Heart failure ▪ Pre-eclampsia and eclampsia
▪ HELLP syndrome

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 Traumatic brain injury (TBI)

− Classifications of Brain injury:

▪ Mild: GCS 13-15
▪ Moderate: GCS 9-12
▪ Severe: GCS 3-8

Management of trauma patients with TBI

1. Primary survey, adhering to the ABCDE approach.

− If intubation is required:
▪ Perform and document neurological examination before administering drugs for
intubation.
▪ Avoid increasing ICP during intubation.
▪ Airway management:
o If airway is assured: Modified rapid sequence induction with manual inline
stabilization while avoiding of sympathetic stimulation or increasing ICP.
o If not: Drug-assisted awake tracheal intubation.
▪ Assess the adequacy of breathing and monitor oxygen saturation.
− Treat hypotension, hypovolemia, and hypoxia
− Focused neurological examination.
− Type and crossmatch, coagulation studies

2. Assessment of severity.
3. Secondary survey
− AMPLE history
− CT scan:
▪ To be done after patient stabilization (Systolic Blp >100 mmHg)
▪ If cannot achieve SBP target search for cause of hypotension and manage (fluids,
pressors or surgical intervention) then CT.
− Frequent serial neurological examinations with GCS. Goals of treatment of brain injury

The primary goal is to avoid secondary

brain injury caused by hypotension,
hypoxia, hypercapnia.
Management of ICP
Systolic BP ≥ 100 mm Hg
− CPP = MAP – ICP.
− To maintain adequate CPP, both (MAP – ICP) are to be CPP ≥ 60 mm Hg
strictly optimized.
▪ Keep SBP > 100 mmHg. Intracranial pressure 5–15 mm Hg
▪ Decreases ICP:
Regarding Monro- kellie doctrine: the total volume Oxygen saturation ≥ 95%
of the intracranial contents (brain, blood and CSF)
must remain constant. Temperature 36–38°C

Glucose 80–180 mg/dL

Haemoglobin ≥ 7 g/dl

(INR) ≤ 1.4

Na 135–145 mEq/dL

PaO2 80-100 mm Hg

PaCO2 35–45 mm Hg

PH 7.35–7.45

Platelets ≥ 75 X 103/mm3

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 The ICP can be controlled by controlling these 3 components:
1. Blood:
▪ Elevate head of the bed 30O
▪ Loosen collars, ETT ties to promote venous drainage.
▪ Decrease intrathoracic pressures (change ventilator settings, decrease PEEP)
▪ Head midline
▪ Avoid internal jugular venous cannulation.
Mnemonic decrease ICP
▪ Hyperventilation: Pco2 35-40 mmHg.
▪ Sedate 5Hs:
▪ Analgesia ▪ Head of bed elevated.
▪ Hypertension: keep MAP >7o mmHg
2. Brain tissue: ▪ Hyperventilation: Pco2 35-40mmhg
▪ Mannitol (0.5-1 g/kg) ▪ Hypertonic saline
▪ Furosemide (0.25-0.5 mg/kg) ▪ Hypothermia
▪ Hypertonic saline 6-8 ml/kg of 3% saline
▪ Correct sodium and osmolality 5Ds
▪ Drugs: Sedation, relaxants, diuretics,
3. CSF drainage anti-seizures.
▪ Drain: EVD
If failed: ICP >20 mmHg. ▪ Discontinue inhalational.
▪ Paralysis ▪ Decompress
▪ Increase analgesia and sedation. ▪ Deliberate hypotension
▪ Hyperventilation: Pco2 30-35 mmHg
▪ Hypothermia (or at least normothermia)
▪ Barbiturate coma: 1-5 mg/kg sodium thiopental then 1-3 mg/kg/hr.
▪ Surgical decompression: head, abdomen.

− Consider:
▪ Seizure prophylaxis and management
▪ Shivering treatment
▪ Glycaemic control

Brain protection methods

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Complications of TBI

− CNS: herniation, seizures

− CVS: myocardial dysfunction and ST changes, arrhythmias
− Pulmonary: neurogenic pulmonary edema
− DIC (disseminated intravascular coagulopathy)
− DI (diabetes insipidus), SIADH (syndrome of inappropriate ADH), CSW (cerebral salt wasting)

Causes of polyuria post TBI

− Cerebral salt wasting syndrome (CSWS)
▪ High urinary osmolality.
▪ Low plasma Na+.
▪ Plasma osmolality may be high or normal.
▪ Treatment: monitor for hypovolaemia, give normal saline.
− Diabetes insipidus
▪ High Na+
▪ Low urinary osmolality (<350)
▪ High plasma osmolality
▪ Treatment: replace H2O or D5W- DDAVP 0.5mcg
− Diuretics – hypertonic saline - hyperglycaemia

Causes of hyponatremia post TBI:

− Cerebral salt wasting syndrome.
− Syndrome of inappropriate secretion of antidiuretic hormone (SIADH):
▪ The same biochemical of CSWS but with normo or hypervolemia
▪ Treatment: Fluid restriction (800-1000 mL/24 h) Slow sodium replacement with
normal saline or hypertonic (3%-5%) saline.

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Pain and regional anesthesia

196
 Acute pain management

Pain pathways
− The response to a painful stimulus involves the processes of:
transduction, transmission, modulation, and perception.
− Acute pain can consist of both somatic and visceral components,
which travel via different paths to reach the spinal cord.
A. Somatic pain: skin and deep tissue (tendon, joints, vessels)
1. Tissue trauma releases local inflammatory mediators
(histamine, bradykinin, leukotrienes, and
prostaglandins) leads to activation of nociceptors (a
specific sensory nerves)
2. These receptors originate the pain signal (transduction
process).
3. Then signals are transmitted to the central nervous
system through primary afferent neurons: (A-delta and
C fibers - the cell bodies located in the dorsal root
ganglion) (Transmission process).
4. Then the signal is transmitted through secondary
afferent neurons: (the dorsal horn of the spinal cord)
B. Visceral pain: deeper internal structures (organs)
1. Pain signals from abdominal organs arrive first at the
parasympathetic ganglia (e.g., celiac for the
pancreas).
2. Then to prevertebral and paravertebral ganglia and
eventually to the dorsal root ganglion and to the
spinal cord.
− Then both somatic and visceral pain signals are transmitted from
dorsal horn to the thalamus through contralateral spinothalamic
tract.
− In the spinal cord, the Modulation process occurs via complex
mechanisms to control the pain signals and reduce the pain
intensity.
− Then the signals transmitted from the thalamus to the limbic and
cortical areas (Perception process).

Pain assessment (in awake patients)

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 Perioperative opioid management
Two main goals:
1. Maintain efficient perioperative analgesia: using a multimodal approach:

− Regional anesthesia
− Ketamine
o NMDA receptor antagonist.
o Reverse the opioid tolerance and decrease hypersensitivity surrounding a
surgical wound.
o Dose: IV infusion 5-15 mg/h, Start pre-operative for 24-48 hours post-operative.
− Alpha-2 agonists
o Clonidine: 1-2 mcg/kg.
o Dexmedetomidine: 0.5 mcg/kg loading over 10 min – 0.3 – 0.7mcg/kg/hr
infusion.
− Paracetamol and NSAIDs
o At least for 48 hours.
− Gabapentin
o Anticonvulsant: Dose: 600 or 900mg pre-operatively. Postoperative: 300-
600mg.

2. Avoid withdrawal:

− Daily background oral opioids provided over 24 hours if oral intake is allowed.
− Transdermal patches shift to the IV infusion (fentanyl patch 25 mcg to infusion 25mcg/h)
− Opioid rotation
o Switch to an alternative strong opioid if:
▪ NO improvement of pain.
▪ Oral intake is not allowed.
o Avoid agonist antagonists.
o Use conversion tables for equivalent doses to convert the current opioid to
oral morphine then divide by 3 to get the IV dose.
o Start at 75-80% of that recommended dose IV infusion over 24 hours and keep
the remnant as boluses for breakthrough pain.

198
Opioid rotation
 Perioperative pain management

A multimodal analgesic plan is tailored for each patient according to the severity of pain:

Complex regional pain syndrome

Definition
Painful conditions that are continuing (spontaneous and/or evoked) regional pain
disproportionate in time or degree to the usual course of any known trauma or other lesion.

Types:
− Type I: (reflex sympathetic dystrophy): without evidence of peripheral nerve injury (the most
common)
− Type II: (causalgia): peripheral nerve injury is present.

Clinical diagnostic criteria:

The Budapest criteria:
1. Continuing pain, which is disproportionate to any inciting event.
2. At least one symptom in three of the following four categories:
− Sensory: Hyperesthesia and/or allodynia
− Vasomotor: temperature asymmetry, skin colour changes.
− Sudomotor: edema, sweating.
− Motor/trophic: decreased range of motion, motor dysfunction, trophic changes
(hair, nail, skin).

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 3. At least one sign in two of the four following:
− Sensory: hyperalgesia and/or allodynia.
− Vasomotor: temperature asymmetry (>1°C), skin colour changes.
− Sudomotor: edema, sweating.
− Motor/trophic: decreased range of motion, trophic changes (hair, nail, skin).
4. There is no other diagnosis that better explains the signs and symptoms.

Treatment:
− Multidisciplinary therapeutic approach: include patient education, physical therapy, and
occupational therapy.
− Psychosocial and behavioral therapy
− Pharmacotherapy
▪ Ibuprofen 400 to 800 mg three times a day
▪ Adjunctive medication: gabapentin, amitriptyline, or nortriptyline
▪ Bisphosphonate.
▪ Topical lidocaine cream (2 to 5%) or topical capsaicin cream
− Sympathetic block.

Regional anesthesia
Preparation
Check the following before block performing:
A. Patient:
− Patient data and planned surgical procedure.
− Consent.
− Revise history and investigations.
− Monitoring: standards ASA monitoring.
− IV access.
− Supplemental oxygen.
B. Room
− Standard and emergency anesthesia equipment including
airway equipment, and medications.
− Check intrepid 20% availability.
− Aseptic skin preparation.
− Sterile gloves, masks, and surgical drapes.
− Block equipment (US machine, nerve stimulator, needles, syringes) and medication
(LAs and Additives).

Upper extremity blocks

Planned Surgery location Suitable block

Anesthesia: interscalene + superficial cervical plexus blocks.

Shoulder Analgesia: (Needs GA)
− As above
− Phrenic sparing: Axillary n. + suprascapular n. blocks.
Clavicle Interscalene + superficial cervical plexus blocks.
Proximal humerus Interscalene block + intercostobrachial n. block (for the arm medial side).
Distal humerus Supraclavicular OR Infraclavicular brachial blocks.
Elbow, forearm, and hand Supraclavicular OR Infraclavicular OR Axillary brachial blocks

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 Interscalene brachial plexus block

A. Indications:
Shoulder, proximal humerus, and clavicle (if
supplement with superficial cervical).
B. Positioning:
Supine, beach chair, or semi-lateral decubitus with
the patient’s head facing away from the side to be
blocked.
C. Landmark:
− LA injected at the level of cricoid, between
anterior and middle scalene muscles lateral to
carotid artery and internal jugular vein
− The nerve bundles are seen as a traffic light.
− To block distal roots and proximal trunks.
D. Ultrasound:
High-frequency probe, In-plane, from lateral to
medial direction
E. Local anesthetic:
7–15 mL of 0.5% bupivacaine.
F. Complications
− Horner’s syndrome
− Hoarseness can occur.
− Dural cuff puncture
− Vertebral artery
− Ipsilateral hemi diaphragmatic paralysis

Supraclavicular brachial plexus block

A. Indications:
Arm, elbow, forearm, hand surgery; anesthesia
for shoulder surgery is also possible.
B. Positioning:
Supine or semi-sitting position with the head
turned toward the contralateral side with a
folded blanket between shoulders.
C. Landmark:
− Place the probe in the supraclavicular fossa.
Identify the subclavian artery which usually passes
under the clavicle at its midpoint.
− The nerves usually appear superior and lateral to
the artery enclosed in a sheath.
D. Ultrasound:
High-frequency probe, In-plane, from lateral to
medial direction
E. Local anesthetic:
15 - 20 mL of 0.5% bupivacaine.
F. Complications
− Pneumothorax – Vascular injury
− Horner’s syndrome
− Hoarseness of voice.
− Ipsilateral hemi diaphragmatic paralysis

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 Infraclavicular brachial plexus block

A. Indications
Arm, forearm, and hand surgery
B. Positioning:
Supine with arm abducted and externally
rotated.
C. Landmark:
− Place the probe below the distal part of clavicle.
− Look for subclavian artery under pectoralis major
and minor muscles, surrounded by the 3 cords of
the brachial plexus contained within a sheath.
D. Ultrasound:
− Deeper may need a curved probe.
− Parasagittal orientation, In-plane technique
E. Local anesthetic
15 - 20 mL of 0.5% bupivacaine.
F. Complications
− Pneumothorax
− Vascular injury (difficult compression)

Axillary brachial plexus block

A. Indications
Elbow, forearm, and hand surgery
B. Positioning:
Supine with arm abducted to 90 degrees,
externally rotated at the shoulder, and the
elbow flexed.
C. Landmark:
− Place the probe in the mid-axillary line to identify
the axillary artery within the axillary sheath.
− Identify the hyperechoic median, ulnar, and
radial nerves.
− Blocking the radial nerve (usually located below
the artery) leads to a spread of local around the
circumference of the artery.
− Musculocutaneous nerve located between the
biceps and coracobrachialis muscles.
D. Ultrasound:
− High-frequency linear ultrasound transducer
Initial depth at approximately 3 to 4 cm.
− In plain, perpendicular to the long axis of the
humerus
E. Local anesthetic
15 - 20 mL of 0.5% bupivacaine.
F. Complications
− Vascular injury

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 Lower extremity blocks

Planned Surgery
Suitable block
location
Anesthesia:
− Epidural
− Lumbosacral plexus block
Analgesia
Knee surgeries − Femoral block (3 in 1) – Fascia iliaca block
− Femorosciatic nerve block
− Motor sparing:
▪ Adductor canal block (saphenous n. and nerve to vustus medialis) +
iPACK block OR genicular nerve blocks
Toes – Distal tarsal Ankle block
Feet Femoral + Popliteal sciatic n. block

Femoral nerve block

A. Indications:
Femur, patella, quadriceps tendon, and knee
surgery; analgesia for hip fracture
B. Positioning:
Supine
C. Landmark
− Place the probe in the inguinal crease.
− Identify the femoral artery.
− The femoral nerve will be lateral to the artery.
And covered by the fascia iliaca.
D. Ultrasound:
High-frequency linear ultrasound Transverse,
femoral crease, in-plain injection.
E. Local Anesthetic:
20 ml 0.5% Bupivacaine

(Adductor Canal) Saphenous nerve block

A. Indications:
− Saphenous vein stripping or harvesting
− Supplementation for medial foot/ankle surgery in
combination with a sciatic nerve block
− Analgesia for knee surgery in combination with
multimodal analgesia.
B. Positioning:
Supine, the thigh abducted and externally rotated.
C. Landmark
− Place the probe on the anteromedial thigh at
the junction between the middle and distal third
of the thigh.
− Locate femoral artery and vein, Inject LA lateral
to the artery and deep to the sartorius muscle.
D. Ultrasound:
High-frequency linear ultrasound Transverse, in-
plain injection
E. Local Anesthetic: Local anesthetic: 5–10 mL

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 Popliteal Sciatic Nerve Block
A. Indications:
− Foot, ankle, and Achilles tendon surgery
− Analgesia for total ankle replacement (with
femoral block)
B. Positioning:
− Lateral position and the leg is flexed.
− Prone position with a footrest.
C. Landmark
− Start with the transducer in the transverse position
at the popliteal crease.
− Identify the popliteal artery and popliteal vein
posterior to it.
− Lateral to the artery: biceps femoris muscles
− Medially: semimembranosus and semitendinosus
muscles
− Locate the tibial nerve superficial and lateral to
the vein.
− Locate the common peroneal nerve.
− Slid proximally until the tibial and peroneal nerves
are coming together to form the sciatic nerve
before its division (at 5–10 cm from the popliteal
crease)
− Inject LA Local anesthetic around the sciatic
nerve.
D. Ultrasound:
High-frequency linear ultrasound Transverse, in-
plain injection
E. Local Anesthetic:
Local anesthetic: 15–20 mL

Infiltration between the Popliteal artery and Capsule of the Knee

(IPACK block)
A. Indications:
Motor-sparing technique that anesthetizes the
small articular sensory nerves from the popliteal
plexus and obturator nerve resulting in
analgesia of the posterior knee capsule.
B. Positioning:
Supine position with flexed Knee.
C. Landmark
− Place the transducer transversely over the medial
aspect of the knee, 2-3 cm above the patella.
− Slide proximal and distal to identify the distal
femoral shaft and popliteal artery.
− Insert the needle, from the anteromedial aspect
of the knee, toward the space between the
popliteal artery and femur, and inject local
anesthetic.
D. Ultrasound:
Curved probe, in-plane orientation
E. Local Anesthetic:
15-20 mL of bupivacaine.

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 Ankle Nerve Block
A. Indications:
Distal foot and toe surgery
B. Positioning:
Supine, with a pillow under the calf.
C. Technique:
− Separate blocks of five nerves:
▪ Four branches of the sciatic nerve (superficial
and deep peroneal nerves, tibial nerve, and
sural nerve)
▪ One of the femoral nerve (saphenous nerve)
1. Deep peroneal nerve block
Locate dorsalis pedis artery, the nerve is
lateral to the artery at the mid-tarsal portion
of the foot.
2. Superficial peroneal nerve block
At the site for deep peroneal nerve block, LA
is injected subcutaneously over the dorsum of
the foot medially and then laterally from the
site of needle insertion to the level of the
malleoli.
3. Tibial nerve block:
▪ Palpate posterior tibial artery behind the
medial malleolus.
▪ Insert the needle posterior to it, towards the
malleolus at a 45-degree angle, and
advanced until contact with bone, withdraw
the needle and inject.
4. Sural nerve block
Inject the LA behind the lateral malleolus as a
subcutaneous wheal.
5. Saphenous nerve block
Insert the needle medial and superior to the
medial malleolus and directed posteriorly
towards the Achilles tendon, a wheal of LA is
injected around the great saphenous vein.
D. Local Anesthetic:
Local anesthetic: 3–5 mL per nerve

Transversus abdominis plane (TAP)

A. Indications:
Postoperative analgesia for laparotomy,
appendectomy, laparoscopic surgery,
abdominoplasty, and cesarean delivery
B. Positioning:
Supine
C. Technique:
− Block the anterior rami of the lower six thoracic
nerves (T7-T12) and the first lumbar nerve (L1).
− Locate the probe transverse on the abdomen, at
the anterior axillary line, between the costal
margin and the iliac crest.

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 − Identify the three muscle layers of the anterior
abdominal wall: External oblique, internal
oblique, and transversus abdominis muscles.
− Insert the needle, from lateral to medial and
inject the LA between the transversus abdominis
and internal oblique muscle planes.
D. Ultrasound:
Curved probe, in-plane orientation
E. Local Anesthetic
Local anesthetic: 20 – 30 mL of 0.25%
bupivacaine per side

Thoracic paravertebral block

A. Indications:
− Analgesia or anaesthesia for breast surgery
− Analgesia for thoracic surgery, open
cholecystectomy, renal surgery, or fractured ribs.
B. Positioning:
Sitting or lateral position (block side uppermost)
C. Landmarks:
− Palpate the spinous processes, insertion point is
2.5cm lateral to it.
− Insert the needle till contact the transverse
process (depth of 2–4cm)
− Withdraw the needle slightly and change the
angle and pass it cephalad to the transverse
process.
− Feel a loss of resistance (costotransverse
ligament puncture) and inject LA.

− Ultrasound technique:
▪ Locate the probe over the spinous
processes, with its axis parallel to them.
▪ Move the probe 2–3cm laterally to the
operative side,
▪ Locate the transverse processes
(hyperechoic edged ovals over large dark
shadows).
▪ Locate internal intercostal membrane and
the pleura.
▪ Deposit the LA between the internal
intercostal membrane and the pleura.
D. Ultrasound:
Curved or linear probe, out of plane orientation
E. Local Anesthetic
− 5mL per level OR
− 15–20mL at a single level will block up to 3–5
levels.
F. Complications:
− Pneumothorax, LA toxicity, intravascular injection.
− Epidural spread, sympathetic block.

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 Remote areas anesthesia

Considerations
Challenges are related to: Room Preparation
A. Equipment
− Anaesthesia machines are basic models
with minimal monitors.
− Unfamiliarity with the anesthesia
machine, monitors, and medication.
− Poor accessibility to the patient.
− Require special equipment as for MRI.
B. Staff
− Lack of numbers.
− Unfamiliar with the requirements for safe
anesthesia.
C. The procedure
− Poor illumination: darkened rooms, can’t
see the patient.
− May require special positions, leading to
difficult resuscitation and early
intervention.
− Unpredicted duration of the procedure:
may finish very abruptly or very long
time.
− Post-procedure care:
▪ In the same location in a separate
prepared room
▪ Transferred to the recovery room of
operating theatres or ICU in critical
cases.
D. The patient:
− Uncooperative patients or in an
emergency condition (not prepared for
anesthesia)
− If suspected difficult airway, the airway is
to be secured in the main OR and then
safely shift to the remote location.

− Choice of anesthetic technique: Consider short-

acting medication:
− Sedation
− Regional anaesthesia
− General anaesthesia.

Lung cryoablation
Considerations
It is a minimally invasive treatment for patients with non-small cell lung cancer or pulmonary metastases.
1. Cancer considerations: 4M (mass, metabolic, metastatic, and medications) effects
2. Remote area: in the CT unit.
3. Patient comorbidities.
4. Can be done either under:
− LA + sedation
− GA:
▪ Conventional ETT, may require lung isolation.
▪ If suspected difficult airway: secure the airway in the OR, then safely shift to the CT.

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 Day Case surgery

Contraindications for day-case surgery

A. Medical:
- Respiratory:
▪ Absolute CI ▪ Relative CI
o Marked dyspnea on mild o Untreated moderate dyspnea
exertion. o Poorly controlled asthma
o Exercise tolerance < 2 METs o OSA

- Cardiac:
▪ Absolute CI ▪ Relative CI
o MI < 6 months o Patients on warfarin
o Angina (NHYA) class III and o Poorly controlled angina,
IV o Mild non-limiting cardiac
o Exercise tolerance < 2 METs failure
from any cardiac cause
o Complete heart block
o Symptomatic first/second-
degree heart block

- Endocrine
▪ Absolute CI
o Uncorrected Addisonian or Cushingoid disorders
▪ Relative CI
o Poorly controlled diabetes
o Super morbid obese
- Renal and hepatic failure
- Neurological
o Uncontrolled epilepsy
o Stroke or transient ischaemic attack within1year
- Pediatrics:
o Neonates
o Ex-premature infants (<60 weeks post gestational age)
o Young sibling (< 2 years) of sudden infant death syndrome (SIDS) child
o Child with severe sleep apnea undergoing tonsillectomy.
B. Psychological:
- Psychologically unstable, e.g., Psychosis
- The concept of day surgery is unacceptable to patients.
C. Social:
- Lives over one hour away from the unit.
- No reliable person to drive patients home after surgery and look after them for the first 24-
48 hours postoperatively.
- At home, no access to a lift, telephone, or indoor toilet and bathroom

Discharging patients from day surgery:

- Patient is awake and orientated.
- Stable vital signs
- No acute surgical complications
- No excessive pain
- Patient can take fluids well.
- Patient passing urine.
- Leave with a responsible adult.
- Understand limitations of activity post-anaesthesia.

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 Decision-making scenarios

The patient is in the ICU on full support, but still unstable and the surgeon wants to push the
patient to the OR for surgical correction (abscess drainage, perforated viscus, bleeding)

− As the patient is on the maximum support, and the source control by surgical intervention is a
definitive treatment, I will:
A. Ask for a multidisciplinary team meeting, including the surgeon, intensivist,
cardiologist. If the team finds that it is more beneficial to push to the OR, I will conduct
a family meeting explaining to them the risk and benefits and I will take the consent
up to death.
B. Prepare for safe transfer to the OR: 2nd anesthetist, monitoring, infusion pumps, patient
fully relaxed and sedated, oxygen source, and elevators are ready.
C. Be sure that OR is prepared, and the staff are ready for rapid start of the procedure.

Broken tooth during intubation, and the patient or his relatives are shouting.

A. Regarding the broken or missed tooth:

− I will search for it (do an Xray if not found)
− Preserve it in milk for reimplanting again.
− Control the bleeding by direct compression and local vasopressor.
− Make a consultation for maxillofacial surgeon or dentist (as per hospital policy).
B. Regarding the patient or the family:
− In the attendance of social workers or administration member, I will inform them
politely that it is an expected complication on intubation, and we considered all
precautions to avoid this event.
− If they said, we would make a complaint, I will not struggle with them and inform them
that is your right to do.
− If my resident is the one who did intubation:
▪ If they don’t know that: I will not tell them, as all the procedure is under my
responsibility, and this will make them more stimulated.
▪ If they know: I will inform them that he is a part of the team, and he must
practice this procedure under my observation to get the experience to be an
qualified consultant in the future.
C. I will document the incidence as per the hospital policy.

The patient is not fasting in non-emergency situations (appendectomy) and the surgeon
informed the relative that you are lax and refused to anesthetize the patient, and you want to
slide him to next shift.

− I will go to the relatives and discuss with them that, regarding the hospital policy and the
safest practice guidelines, it is better to wait for fasting hour and you are observing the patient
condition. If any emergent condition requires earlier intervention, I will push him to the OR.
− I will discuss with the surgeon (not in front of the relative) that we are following the policy and
the guidelines. If he gives aggressive behavior or insists to bush the patient, I will inform the
head of the department and initiate an OVR and wait for fasting hours.

The circulating nurse informed you that there is a missed towel or gauze, and the surgeon is
insisting that he didn’t leave any towels in the wound.

− Regarding the role of “the missed towel must be found” we will recount, search for towel in
the room, and request bed side X-ray to detect the radio-opaque line in the towel.
− If the surgeon insisted to close the wound or he refused to reopen it again, I call the head of
the surgery department, and I will inform my head of the department and the medical
director. Then I will initiate an OVR as per hospital policy.

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Wrong-side LA injection

− Firstly, I will assess the patient for any immediate complications and manage them
accordingly.
− Then I discuss with the surgeon to change the anesthesia plan to the GA, and I will take
consent from the relative for GA if not taken, then I will give him GA.
− I will report this event as per hospital policy.

You give the patient (spinal anesthesia – sedation) and the patient is stable. The anesthesia
technician, who has good experience, asked you to go out to have a drink. What is your
response?

I will not do. The anesthetist attendance beside the patient is a standard 1 ASA monitoring. The
patient is under my responsibility which obligate my physical attendance beside the patient since
he shifted to the OR till transferring him to the recovery room.

The patient has severe aortic stenosis. His son is a consultant in another specialty, and he
asked you to give his father spinal anesthesia for better post-operative pain management.

− I will discuss with him the risk-benefit of both regional and general anesthesia for the patients
with severe AS, and inform him that is the safest practice according to evidence-based
medicine is GA.
− I will reassure him regarding post-operative pain management, as I will provide him with
multimodal analgesia for satisfactory post-operative pain management.

Your resident learned a new regional technique and he asked you to help him during
performing it on the patient.

− If I have experience with this technique, I will guide him to do it.

− If I have no experience, I will ask him to give me time to get knowledge about it or I will ask the
regional anesthesia team to guide us during performing this technique.

Your colleague advised you to take a rest in your heavy-duty and he will replace you, then
he told you that he gave an old patient 300 mcg of fentanyl, what is your response?

− I will immediately attend to the patient and assess him according to the ABC approach and
give him the antidote if indicated.
− I will report the incidence as per the hospital policy.

During patient transfer to the OR, the patient fallen from the trolley, what is your response?

− I will immediately attend to the patient, and I will assess and manage him according to ATLS
protocol, if no harm was occurred, I will reassure him, then proceed to the planned procedure.
− I will initiate an incident report as per hospital policy.

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