C H A P T E R

ASA Monitoring Standards

Elizabeth E. Holtan, MD

PRI NC IPLES OF MON ITO R I N G rate assessed at least every 5 minutes. Patients must also have
an electrocardiogram continually assessed from the start of
Because o f th e possibility o f frequent alterations o f patient vital the anesthetic until the patient leaves the operating or proce­
signs and physiology due to the administration of anesthesia, the dure room. Lastly, patients under general anesthesia are also
anesthesiologist must monitor the patient to assess for problems required to have assessment of circulation continuously by an
and allow for ample time to intervene. One must apply monitors, additional method. The possible methods are pulse oximetry;
observe, and interpret the data, as well as begin appropriate treat­ intraarterial blood pressure monitor, auscultation of patient's
ment when necessary. The purpose of monitoring is to promote heart, feeling of patient's pulse, or peripheral pulse assessment
optimal care of the patient and notice trends and abnormalities with ultrasound.
before they become irreversible. Even s o, following these guide­
lines does not ensure any particular outcome for patients.
The American Society of Anesthesiologists (ASA) has Oxygenation
developed Standards for Basic Anesthetic Monitoring, which The anesthesia provider must assess that the patient has suffi­
was last updated in 2011. According to this document, an cient oxygen concentration in inspired gas a nd blood. During
authorized anesthesia provider must remain with a patient any general anesthetic that utilizes an anesthesia machine, an
throughout the duration of any general, regional, or moni ­ oxygen analyzer must be used to evaluate the concentration
tored anesthesia care, to administer anesthesia and monitor of oxygen in the breathing circuit. The machine must have a
the patient. In some instances, short lapses in monitoring may working low oxygen concentration limit alarm.
occur and are sometimes inevitable. For certain patients, par­ During any type of anesthesia, blood oxygenation must
ticular monitoring techniques may be unfeasible. I n the rare be measured by certain means, s uch as a pulse oximeter. The
situation where there is an exposure or danger to the anes­ anesthesia provider must be able to hear the variable pitch
thesia care provider, distant discontinuous monitoring may tone, and the alarm must be set if the saturation falls below
be necessary. If there is an emergency that would require the the set level. The patient should also be exposed enough to be
anesthesia provider to temporarily leave the patient, the anes­ able to evaluate color.
thesiologist must determine the importance of the emergency
and its effect on the patient. The anesthesiologist must also
decide who will continue to deliver the anesthetic and monitor Ventilation
the patient until t he anesthesia care provider is able to return. It is imperative that any patient under anesthesia be continu­
These standards apply to patients receiving monitored ally assessed to have satisfactory ventilation. Clinical signs
anesthesia care, general anesthesia, as well as r egional anes­ such as visualizing chest rise and auscultating breath s ounds
thesia. These standards do not necessarily apply to obstetrical are helpful in assessing ventilation in a ll types of anesthesia.
patients or pain management patients. I t is also the anesthesi­ During local anesthesia or regional anesthesia without seda­
ologist's responsibility to determine if additional monitoring tion, these clinical signs must be observed. During moder ­
is required beyond the basic monitors. ate or deep s edation or general anesthesia, clinical signs are
The ASA Standards for Basic Anesthetic Monitoring important, as well as continually assessing end-tidal carbon
emphasizes the assessment of a patient's circulation, oxygen­ dioxide. When using a mechanical ventilator, t idal volumes
ation, ventilation, and body temperature: should be observed.
After insertion of a laryngeal mask airway or an en do ­

Circulation COVT tracheal tube, the proper placement must be confirmed

by clinical signs, as well as by end-tidal carbon dioxide i n
It is important to monitor the patient's circulation while under the expired gas. Capnography to evaluate end-tidal carbon
anesthesia. Every patient must have a b lood pressure and heart dioxide must be monitored from time of insertion of the

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endotracheal tube or laryngeal mask airway until removal temperature are expected, probable, or planned, body tern ­
of the device. The end-tidal CO 2 alarm must be audible when perature should be monitored.
P ET C0 2 is above or below preset levels. The anesthesia b reath­
ing machine must also have an audible alarm t o identify a
circuit disconnect.
S U G G ESTE D READ I N G S
Eichhorn JH. Review article: practical current issues i n periopera­
tive patient safety. Can J Anaesth. 2013;60: 1 1 1 - 1 1 8 .
Body Temperatu re Merry AF, Cooper J B , Soyannwo 0, Wilson IH, Eichhorn J H.
It is important to maintain a patient's body temperature while International Standards for a Safe Practice of Anesthesia 2010.
under anesthesia. When considerable alterations in body Can J Anaesth. 2010;57: 1 027-1034.
 C H A P T E R

Stages and Signs of General

Anesthesia
Brian S. Freeman, MD

WHAT I S G E N E RAL AN ESTH ESIA? The Guedel classification for the stages of general anes­
thesia i s based on the administration of a s ole volatile anes ­
The American Society of Anesthesiologists has specific crite­ thetic: diethyl ether. Although patients were commonly
ria for the definition of general anesthesia. General anesthesia premedicated with atropine and morphine, ether was the
is the induction of a loss of unconsciousness by pharmaco ­ only induction agent available at the time. It provided amne ­
logical means. In this state, the patient will be unarousable t o sia, analgesia, a nd muscle relaxation. Ether has not been used
verbal, tactile, and painful stimuli. Because o f upper airway in the United States since the early 1980s. Today, "balanced
obstruction, some form of intervention, usually insertion anesthesia" uses multiple c lasses of drugs (intravenous anes ­
of a laryngeal mask airway or endotracheal tube, is typically thetics, opioids, neuromuscular blocking agents, and benzo ­
required to maintain airway patency. Spontaneous ventilation diazepines) for induction that can easily mask t he classical
is frequently inadequate, necessitating t he use of partial or full clinical signs of each Guedel stage of anesthesia. These drugs
mechanical support with positive pressure ventilation. Car ­ also have a greater s afety profile compared to diethyl ether.
diovascular function may be impaired, often leading to hypo­ In addition, modern monitors of r espiration, circulation, and
tension and dysrhythmias. consciousness add to the clinical i nformation provided by
The primary goals of general anesthesia are to achieve: physical examination of the patient. Some anesthesiologists,
therefore, may consider Guedel's work to be obsolete. Others
Amnesia still use his classification when it comes to describing emer­
Sedation/hypnosis gence from anesthesia a nd inhalation i nductions in children.
Analgesia
Areflexia (motionlessness)
Attenuation of autonomic (sympathetic) nervous system STAG ES AN D S I G N S OF G E N E RAL
responses.
AN ESTH ESIA

Stage 1 (Disorientation)
H I STORICAL PE RSPECTIVE The first stage of anesthesia, s ometimes known as the induc­
tion stage, begins with the initial administration of anesthesia
In 1 846, Dr. William Morton gave the first public demonstra­ and ends with loss of consciousness. The patient experiences
tion of general anesthesia by ether. At the time, physical exam­ sedation, analgesia (but can still feel pain), and eventually
ination of the patient provided the only clues to the depth of amnesia. However, the patient should still be able to maintain
anesthesia. I nexperienced anesthetists could easily overdose a conversation during this stage. Respiration is slow but regu­
the patient. It was not until World War I that the anesthesia lar. The eyelid reflex is intact.
community had the first t rue systematic approach to moni­
toring. Dr. Arthur Guedel, better known for his widely used
oropharyngeal airway, was responsible for this system. As the Stage 2 ( Excitement)
medical officer responsible for supervising anesthesia services The second stage of anesthesia is the period immediately
for the U.S. Army, he was concerned about t he safe adminis ­ following loss of consciousness until regular spontaneous ven­
tration of ether by the nonmedical personnel. Guedel created tilation resumes. The characteristic features are disinhibition,
one of the first safety systems in anesthesiology with his chart delirium, and uncontrolled spastic movements. Examination
that explained the signs of ether anesthesia with increasing of the eyes reveals loss of lash reflex, divergent gaze, and reflex
depth. He published this classification system as an article in pupillary dilatation. The a irway is irritable and has more secre­
1 920 and later in a textbook in 1 937. tions. As a result, there is an increased risk of eliciting intact

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228 PART II Clinical Sciences

reflexes like coughing, vomiting, laryngospasm, and broncho ­ Plane 2-The patient's spontaneous respirations have slight
spasm. Respirations are irregular with periods of breath hold­ pauses between inhalation and exhalation. Additional
ing. Hypertension and tachycardia are common. reflexes are lost (corneal, l aryngeal) while tear secretion
Because of the risk of clinically significant airway com ­ increases. Eyeball movements cease completely: The patient
promise, contemporary anesthetic techniques use rapidly no longer responds to skin stimulation with movement or
acting intravenous hypnotics such as propofol to minimize deep breathing. Intercostal muscles begin to weaken.
time spent i n Stage 2. However, all patients emerging from Plane 3-Intercostal and abdominal muscles are com ­
an inhalation anesthetic, and children who r eceive an i nha­ pletely relaxed, so ventilation is solely controlled by the
lation i nduction, will show evidence of progressing t hrough diaphragm. The light reflex is lost. Surgical anesthesia has
this stage. External stimulation, particularly of t he airway, now been achieved.
should be kept to a minimum. Endotracheal i ntubation and
Plane 4-Respirations become irregular and s hallow with
extubation should never occur during Stage 2.
paradoxical rib cage movement as a result of complete
intercostal muscle paralysis. Eventually, apnea results from
Stage 3 (Surgica l Anesthesia) full paralysis of the diaphragm.
The third stage of anesthesia begins when the patient resumes
spontaneous respiration and ends with respiratory paralysis. Stage 4 (Overdose)
Stage 3 is the period when the target level of surgical anesthe­
This stage of anesthesia begins from the cessation of respira­
sia has been reached. It is also the stage in which it is appro­
tion and ends at death. An overdose of anesthetic, relative to the
priately safe to intubate the patient without neuromuscular
degree of surgical stimulation, results in severe medullar depres­
blocking agents. Characteristic features include cessation of
sion leading to death unless support is provided. Otherwise,
eye movement, skeletal muscle relaxation, and respiratory
respiratory arrest and cardiovascular collapse result. Pupils are
depression. Stage 3 is divided into four planes:
fixed and widely dilated. Skeletal muscles are flaccid.

Plane 1-The patient has regular spontaneous breathing.

A number of reflexes (eyelid, conjunctival, swallowing) S U G G ESTE D REA D I N G
disappear. Ocular muscles become less active. The patient Urban BW, Bleckwenn M . Concepts and correlations relevant to
has constricted pupils and central gaze. general anaesthesia. Br J Anaesth. 2002;89:3-16.
 C H A P T E R

Awareness Under General

Anesthesia
Hiep Dao, MD

I N CI DENC E intraoperative awareness. Such measures include checking

the functioning of the anesthesia machine and the prophy­
Th e advent o f movies and media reports have brought the fear lactic administration of benzodiazepines. There have been
of awareness under anesthesia into t he forefront of patients' reported cases of intraoperative awareness resulting from
anxiety going into surgery. Intraoperative awareness under low inspired volatile anesthetic concentration or drug errors.
general anesthesia rarely occurs, with a reported incidence of Double-blind randomized clinical trials have shown a
0 . 1 %-0.2%. While rare, significant psychological consequences lower frequency of i ntraoperative awareness, with t he pro ­
may occur after such an occurrence and t he patient may be phylactic administration of midazolam a s an anesthetic adju­
affected for some time. Oftentimes intraoperative awareness vant. Consultants from ASA agree that benzodiazepines or
may be unavoidable in hemodynamically unstable patients, scopolamine should be used in patients requiring smaller
such as patients in trauma or cardiac surgery. dosages of anesthetics, c ardiac surgery patients, and patients
undergoing trauma surgery. Caution should be taken with
D E F I N ITION benzodiazepines due to delayed emergence.

Intraoperative awareness occurs when a patient becomes con ­

scions during a procedure performed under general anesthe ­
I NTRAOPE RATIVE MON ITO R I N G
sia, and subsequently has recall of these events. Recall can take
the form of explicit memory (assessed by patient's ability to Intraoperative awareness cannot be measured during the
recall specific events that took place during general anesthesia) intraoperative phase of general a nesthesia because the recall
and implicit memory (assessed by changes in performance or component of awareness can only be determined postopera ­
behavior without the ability to recall specific events that took tively by speaking to the patient. Clinical t echniques used
place during general anesthesia that led to those changes). to assess intraoperative consciousness include checking for
patient movement, response to voice commands, eye open ­
R I S K FACTO RS ing, eyelash reflex, papillary response, perspiration, and tear­
ing. Furthermore, conventional monitoring systems s uch as
Studies have suggested that certain procedures such as cesarean ECG, blood pressure, heart rate, end-tidal anesthetic ana ­
delivery, cardiac surgery, emergency surgery, trauma surgery lyzer, capnography are also valuable and help assess intraop­
as well as anesthetic techniques (rapid sequence inductions, erative depth of anesthesia.
reduced anesthetic doses with or without paralysis, difficult intu­ There are a multitude of devices designed to monitor
bations, total intravenous anesthesia, use of nitrous oxide-opioid brain electrical activity for the purpose of assessing anes ­
anesthetic technique) may be associated with an increased risk thetic effect. They record electroencephalographic activity
of intraoperative awareness. Furthermore, certain patient char­ from electrodes placed on t he forehead. Several systems pro ­
acteristics may place a patient at risk for intraoperative aware­ cess spontaneous electroencephalographic and electromyo -
ness including substance abuse ( eg, opioids, benzodiazepines, graphic activities, and others acquire evoked responses to
cocaine), American Society of Anesthesiologists (ASA) physical auditory stimuli (auditory evoked potentials [AEPJ ). Various
status of IV or V, limited hemodynamic reserve, and history of signal processing algorithms are applied to the frequency,
awareness. amplitude, and latency relationship derived from the raw
electroencephalography (EEG) or AEP to generate an "index"
PRE I N DUCTION PREVENTION number, typically scaled from 0 to 100 indicating the pro ­
gression of states of consciousness from awake to deep anes­
Preventive measures in the preinduction phase o f anes ­ thesia ( 100 associated with awake state and 0 occurring with
thesia management may minimize the occurrence of an isoelectric EEG and deep sedation).

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Bispectral l ndex delivery, and total intravenous anesthesia). There is insuffi­

cient evidence that such a monitor truly reduces the risk of
The bispectral index (BIS) is a proprietary algorithm that con­
intraoperative awareness for all patients undergoing gen ­
verts a single channel of frontal electroencephalograph into
eral anesthesia. Furthermore, maintaining l ow brain func­
an index of hypnotic level. BIS values are scaled from 0 to 1 00,
tion monitor values in an attempt to prevent intraoperative
with specific ranges (40-60) indicative of a low probability of
awareness may conflict with other important anesthetic goals
consciousness under general anesthesia. In some randomized
(hemodynamic stability).
controlled trials, the BIS monitor has decreased the incidence
of explicit recall, times to awakening, first response, or eye
opening and consumption of anesthetic drugs. Other studies
I NTRAOPE RATIVE A N D
have shown no decreased incidence of intraoperative aware ­
ness with its use. Thus, the current data and recommendations POSTOPERATIVE I NT E RVENTI O N S
on its use are mixed. Intraoperative events unrelated to titra­
1 . Intraoperative administration o f benzodiazepines to
tion of anesthetic agents can produce rapid changes in BIS val ­
patients who may become conscious.
ues (cerebral hypoperfusion, gas embolism, and hemorrhage).
2. Providing a postoperative i nterview to patients to define
Other routine intraoperative events (use of depolarizing mus ­
the episode of awareness.
cle relaxants, activation of electromagnetic equipment, patient
3. Providing a postoperative questionnaire to patients with
warming, or hypothermia) may interfere with BIS functioning.
intraoperative awareness.
4. Offering postoperative counseling or psychological support.
Auditory-Evoked Potentia l Mon itor
Auditory-evoked potentials (AEP) are the electrical responses
of the brainstem, auditory radiation, and auditory cortex t o S U G G ESTE D READ I N G S
auditory sound stimuli (clicks) delivered via headphones. The Bergman IJ, Kluger MT, Short TG. Awareness during general
typical AEP response to increasing anesthetic concentrations anaesthesia: a review of 81 cases from the Anaesthetic Incident
Monitoring Study. Anaesthesia 2002;57:549-556.
is increased latency and decreased amplitude of the various
Domino KB, Posner KL, Caplan RA, Cheney FW. Awareness
waveform components. From analysis of the AEP waveform,
during anesthesia: a closed claims analysis. Anesthesiology
the monitor generates an "AEP index" that correlates anes ­
1999;90:1053-1061.
thetic concentration to a level of consciousness (low probability Sandin RH, Enlund G, Samuelsson P, Lennmarken C. Awareness
of consciousness with values < 25). during anaesthesia: a prospective c ase study. Lancet
The ASA states that a brain electrical activity moni­ 2000;355:707-71 1 .
tor should be used in patients on a case-by-case basis with Sebel P S , Bowdle TA, Ghoneim M M , e t a!. Th e incidence o f aware­
conditions that may place them at risk and patients requir­ ness during anesthesia: a multicenter United S tates study.
ing smaller doses of anesthetics (trauma surgery, cesarean Anesth Analg. 2004;99:833-839.
 C H A P T E R

Techniques of General
Anesthesia
Brian S. Freeman, MD

General anesthesia is a state of unconsciousness in which phar­ Rapid induction and easy titration.
macological agents produce hypnosis, amnesia, and analgesia. Rapid emergence even after long infusions due to favor­
Other endpoints met during most general anesthetics include able context-sensitive half-times.
muscle relaxation, imm obility, and attenuation of sympathetic No risk of malignant hyperthermia.
and somatic reflexes. The induction of general anesthesia Minimal suppression ofneurophysiologic-evoked potentials.
is achieved by either intravenous or inhalation routes. The Avoidance of occupational exposure or environmental
"maintenance'' phase begins when the amnestic patient is not pollution by volatile agents.
only unconscious, but also unable to produce movements in No need for gas delivery or scavenging systems.
response to surgery. At this point, there are several techniques No expansion of gas cavities.
available for the anesthesiologist to maintain general anesthe­ May reduce intracranial pressure (propofol).
sia during a given operation or procedure.
TIVA is used quite extensively for deep sedation and
maintenance in ambulatory surgery. It is a simple technique
TOTAL I N HALATION AN ESTH ESIA that leads to rapid and clear emergence with minimal post ­
operative nausea and vomiting. TIVA i s especially useful for
This technique involves the sole administration o f potent vola­ maintaining general anesthesia i n patients for whom delivery
tile agents such as sevoflurane to maintain general anesthesia. of inhalation anesthetics may be compromised or difficult.
Advantages of this approach include the ability to maintain For example, pulmonary diseases that impair ventilation and
spontaneous ventilation and satisfactory blunting of sympa­ perfusion to the lung can lead to inconsistent drug uptake.
thetic responses to noxious stimulation. Modern inhalation TIVA allows for a much more r apid onset of action that does
agents are easier to titrate to the patient's blood pressure, pulse, not depend on the adequacy of alveolar ventilation. TIVA
minute ventilation, and movements. The major disadvantage is also suitable for operations in which ventilation is inter­
of this technique is significant dose-dependent cardiovascular rupted, such as laser airway surgery or bronchoscopy.
depression. In addition, volatile anesthetics do not p rovide any There are several disadvantages to TIVA for maintenance
degree of analgesia. This approach is most amenable for short or deep sedation:
procedures for which intraoperative and postoperative pain
is expected to be minimal, such as myringotomy, cystoscopy, Need for multiple i nfusion pumps (compared to j ust one
and examinations under anesthesia. agent vaporizer).
More expensive: is the cost worth the benefit?
Variability in patient dose requirements and
TOTAL I NTRAVE NOUS AN ESTH ESIA
pharmacokinetics.
Th e technique of "total intravenous anesthesia'' (TIVA) can be Inability to measure blood concentration of i ntravenous
used for the complete maintenance o f general anesthesia or for anesthetics.
the administration of deep s edation. TIVA utilizes continuous Greater incidence of patient movement.
infusions or repeated doses of a short -acting sedative-hypnotic
drug. Opioids, either in b olus form or through an infusion, are Many different drugs can be chosen to provide total
often added for these procedures that may produce more than intravenous anesthesia. The most popular combination is a
minimal stimulation. sedative-hypnotic plus opioid. Propofol ( 75 - 1 50 f.l,g/kg/min)
There are several advantages to TIVA: has become the mainstay of TIVA infusions. It provides
amnesia, hypnosis, and e ven antiemetic properties-all with
Decreased incidence of postoperative nausea and a short duration of action. Adding a c oncurrent opioid infu­
vomiting. sion, usually remifentanil, allows for short-acting analgesia.

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232 PART II Clinical Sciences

Titration of drug dosages can take place against measure - N ITROUS OXI DE-OPI O I D - R E LAXANT
ment of the bispectral index (BIS), for propofol, and hemo ­
TECH N IQ U E
dynamic changes to surgical stimulation, for opioids. Other
options for TIVA include infusion of dexmedetomidine, a Because o f their low solubility, volatile agents such a s des­
central acting alpha-2 adrenergic agonist and low-dose ket­ flurane and sevoflurane are key agents used today during
amine, an NMDA receptor antagonist. inhalation anesthesia. Back in t he days when more soluble
drugs such as enflurane and halothane were the only options,
nitrous oxide was the most commonly administered inhala ­
BALANCED AN ESTH ESIA tion anesthetic. Nitrous oxide has a very low potency (MAC
1 04%) but extremely favorable pharmacokinetics due t o its
General anesthesia using a single drug may require doses
low solubility. One technique of general anesthesia less com­
that produce excessive cardiovascular compromise. Providing
monly used today is the administration of high dose nitrous
"balanced" anesthesia is probably the most common approach
oxide along with intravenous opioids and muscle r elaxants.
to maintenance of general anesthesia. The concept of balanced
The patient receives an inspired gas mixture of about 70%
anesthesia is based on combining multiple classes of drugs to
nitrous oxide with 30% oxygen. Opioids are administered
achieve the desired endpoints of general anesthesia. Targeting
in response to changes in the pulse and blood pressure due
different receptors enables lower dosages and fewer side effects
to surgical stimulation. It is important to dose opioids reg­
for each type of medication. A balanced anesthetic will often
ularly throughout the case to prevent delayed emergence.
produce less hypotension and cardiovascular depression than
Muscle relaxants are necessary to prevent patient movement.
a pure inhalation or intravenous technique. This concept is not
Controlled mechanical ventilation is necessary to prevent
a new one. As new drugs were synthesized over the past cen­
hypercapnia.
tury, they quickly became part of the administration of anes­
Using this technique, emergence from general anesthesia
thesia. For instance, meperidine was often used a s an adjunct
is usually quite smooth (due to the opioids) and rapid (due
to the administration of nitrous oxide anesthesia starting back
to the nitrous oxide). In addition, patients tend to have less
in the 1 940s.
anesthetic-induced vasodilation and hypotension during t he
A typical balanced a nesthetic i ncludes:
case. However, the potential for intraoperative awareness
is an important concern when using t his "light" anesthesia
a potent inhalation agent such as sevoflurane (amnesia,
technique (especially when combined with muscle relaxants).
unconsciousness, immobility, autonomic attenuation);
Benzodiazepines should be considered.
a benzodiazepine such as midazolam (amnesia);
an opioid such as fentanyl (analgesia);
a muscle relaxant such as rocuronium (immobility);
COM B I N E D G E N E RAL- REGIO NAL
an intravenous sedative-hypnotic such as propofol
(unconsciousness). AN ESTH ESIA
General anesthesia may b e combined with regional anesthesia
Opioids are one of the key components of a balanced
to maximize the advantages of both techniques while minimiz­
anesthetic. Their primary function is reduction of pain. Opi­
ing the potential complications. The most common approach
oids also decrease requirements for both intravenous and
involves the administration of an epidural anesthetic or
inhalation anesthetics, attenuate autonomic responses to
peripheral nerve block followed by the induction of general
airway and surgical stimulation, a nd help to maintain hemo ­
anesthesia (or deep sedation) . Epidural catheters should be
dynamic stability. These drugs s hould be given prior to the
placed at the appropriate level depending on the type of sur­
onset of t he noxious stimulus. For i nstance, if fentanyl is not
gery (TS-T6 for thoracic surgery, T7-T8 for upper abdominal
given at least 5 minutes before surgical i ncision, it is much
surgery, T9-T l 0 for lower abdominal surgery) . For epidural
less effective in suppressing hemodynamic surges now that
catheters, this technique assumes that local anesthetics will be
catecholamines have been released. Sufficient time is neces­
administered during the procedure.
sary for opioids to be truly effective. The most rapidly titrat­
Advantages to a combined general-regional technique
able opioids are remifentanil and alfentanil (1-2 minutes
for maintenance include:
before onset of peak effect). With more favorable kinetics
and better hemodynamic stability, fentanyl and its deriva­
Avoidance of opioids;
tives are generally found to be superior to morphine, meperi ­
Less postoperative nausea a nd vomiting;
dine, and hydromorphone i n the administration of balanced
Higher quality of postoperative a nalgesia;
anesthesia.
 CHAPTER 80 Techniques of General Anesthesia 233

Preemptive analgesia; This approach may yield several disadvantages, s uch as:
Maintaining a secure airway with an endotracheal t ube
or laryngeal mask airway ( LMA) device; Greater degree of hypotension due to the sympathec ­
Less patient movement; tomy (neuraxial technique only);
Improved suppression of endocrine stress response to Nerve injury;
surgery; Epidural hematoma;
Faster return of bowel function; Higher risk of local anesthetic systemic toxicity;
Lower incidence of postoperative pulmonary complications. Time consuming placement.
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 C H A P T E R

Assessment and Identification

of the Difficult Airway
Raymond A. Pla, Jr. MD

The American Society of Anesthesiologist's (ASA) Closed premise is that during direct laryngoscopy, the base of the
Claims Project reports that difficult intubation leading to death tongue obscures the view of the larynx. Thus, a higher ratio
or brain injury account for 9% of all claims. Some were clas ­ would suggest a greater l ikelihood of difficult laryngos­
sified as preventable. Preoperative evaluation with medical, copy. This test is performed with the patient's head in the
surgical, and anesthetic history as well as physical examina­ neutral position without phonation. A class I view includes
tion and radiographic study evaluation minimizes the chances the entire uvula, hard, and soft palates; class II-only a
of unrecognized difficult intubation. No single factor reliably partial uvula v iew in addition to the hard and soft palates;
predicts difficult airway management. The more t he predic­ class I II-hard and soft palates with base of uvula visible;
tors of difficulty in a g iven patient, the greater the likelihood of and class IV-hard palate only is visualized. Classes III
difficult airway. Once difficult intubation i s recognized, prac­ and IV are associated with a higher i ncidence of difficulty
titioners may prepare additional equipment, modify induction with intubation (see Chapter 64).
agents, and s ecure backup support as necessary. 2. Macroglossia-Macroglossia predicts difficult intubation
as a l arge tongue is difficult to be completely displaced by a
rigid laryngoscope into the submandibular space.
D E F I N ITIONS 3. Thyromental distance-Thyromental distance is the dis­
tance between the t hyroid cartilage and t he mentum of
Difficult mask ventilation i s a n inability t o face mask
the mandible. It is normally greater than 6.5 em; t hyro ­
ventilate the patient.
mental distance predicts difficulty with i ntubation when
Difficult laryngoscopy is an inability to visualize the
less than 6 em. This measurement suggests that the man­
vocal cords after multiple laryngoscopy attempts.
dibular size is measured with the head extended at the
Difficult intubation is encountered when multiple attempts
atlanto-occipital j oint.
are required to intubate the trachea.
4. Mandibulohyoid distance-The mandibular-hyoid dis ­
Failed intubation is the inability to place an endotracheal
tance predicts a large, hypopharyngeal tongue blocking
tube despite multiple attempts.
visualization of the glottic opening; hence, direct l aryn­
goscopy and i ntubation difficulty i s increased. This dis ­
These definitions presume best operator and optimized
tance should be greater than 4 em.
positioning (ie, sniff position).
5. Neck circumference-A short, thick neck with a circum­
ference greater than 44 em predicts difficulty with ventila­
tion and intubation.
PRE D I CTION CRITERIA
6. Cervical spine range of motion -Decreased cervical
Although n o single criterion envisages difficulty, a history of spine mobility predicts difficult i ntubation on the basis
difficult airway is the single best predictor of future difficulty. of an inability to extend the atlanto-occipital j oint and
Consequently, a thorough anesthetic history should include achieve an optimal "sniff position." This c ondition makes
previous airway concerns. Interval change in the patient's bringing t he visual axes of the mouth, pharynx, and t he
medical history or condition, such as new oral or pharyngeal larynx into alignment difficult or impossible. Sitting upright
pathology, significant weight or height gain (ie, previous s ur­ with the head in a neutral position, the neck is maximally
gery as a child) , cervical spine injury, or pregnancy discounts extended and t he examiner estimates the angle traversed
previous airway success. by the occlusal surface of the maxillary incisors. This
angle is normally g reater than 35 degrees. Extension deficit
1. Mallampati/Samsoon-Young S coring-The Mallampati/ may be graded: grade I greater t han 35 degrees; grade I I
Samsoon-Young scale classifies airways according to the 22-34 degrees; grade I I I 12-21 degrees; and grade I V less
base of tongue to overall open mouth ratio. The underlying than 1 2 degrees.

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236 PART II Clinical Sciences

7. Temporo-mandibular joint (TMJ) translation-TMJ 3. Burns, thermal injury, and smoke inhalation-These
translation is necessary for mouth opening and l aryngos­ injuries are often associated with a irway edema.
copy. Inability to extend the mandibular i ncisors anterior 4. Cervical spine injury Instability of the c-spine
-

to the maxillary i ncisors suggests difficult i ntubation. decreases the degree of safe neck extension. This makes
8. Dentition-The state of dentition can predict difficulty. alignment of the three principal axes (oral, pharyngeal,
Several dental conditions warrant particular concern: and laryngeal) difficult. I ntubation requires in-line sta­
(1) loose or broken teeth, especially maxillary or mandib ­ bilization to prevent neck extension.
ular i ncisors; (2) interincisor distance l ess than 3 em; and 5. Acromegaly Acromegaly i s caused by excessive growth
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(3) maxillary i ncisors that override mandibular i ncisors, hormone production. It is associated with macroglossia
commonly referred to as an overbite. Edentulous patients and prognathism.
carry higher risk for difficult ventilation and i ntubation 6. Epiglottitis-Epiglottitis is a life-threatening infec ­
as well. tion of the epiglottis and periepiglottic structures t hat
causes upper airway edema and potentially complete
airway obstruction. Airway instrumentation can completely
obstruct the airway and is contraindicated in the awake
M E D I CAL H I STO RY
patient. If emergent i ntubation is required, they should
A number of disease states, syndromes, and conditions predict be performed in a setting with emergency t racheostomy
difficulty. The following conditions are often associated with immediately available.
difficult airway management: 7. Submandibular cellulitis (Ludwig angina) -The infec­
tion and resulting swelling of the submandibular space
1. Obesity Obesity is defined as a body mass i ndex (BMI)
- forces the tongue in a cranial and caudad direction
greater t han 30. The BMI is calculated as weight i n kg/ blocking the airway. The infection causes pharyngeal
height in meters2 • Obese patients have adipose deposits and tongue swelling. Like epiglottitis, t his disease can
in the pharynx, which protrude and narrow t he airway. cause life-threatening airway compromise and requires
Additionally, obesity is associated with macroglossia and emergent intubation, preferably in the operating room.
a short, large neck. Ventilation and intubation may be 8. Rheumatoid arthritis Limitations in cervical range
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difficult in obese patients. They quickly desaturate 0 2 of motion and TMJ mobility may compromise mouth
following induction of anesthesia due to lower func ­ opening. Cervical spine arthritis l imits the neck's degree
tional residual capacity (FRC); consequently, difficult of extension, preventing axis alignment and l aryngeal
airway management decisions are t ime-sensitive in this view. Additionally, atlanto-axial (Cl-C2) subluxation
population. and separation of t he odontoid process can occur. The
2. Pregnancy Airway difficulties pose a particular r isk in
- free-floating odontoid process can impinge upon the
the parturient, r esulting in pulmonary aspiration of gas ­ spinal cord or vertebral arteries during i nduction and
tric contents, hypoxia, cardiac arrest, and even death. intubation. This diagnosis can be made with lateral, flex­
Parturients suffer from edematous and friable airways. ion-extension radiographs of the neck.
Large, pendulous breasts make placing t he laryngoscope 9. Diabetes-Patients with long-term, insulin-dependent
difficult as the long handle contacts t he chest wall. The diabetes present with diabetic stiff j oint syndrome. This
parturient risks rapid arterial desaturation with apnea occurs as a result of glycosylation of collagen and i ts
due to reduced FRC. Further, delayed gastric emptying deposition in j oints. Consequently, achieving optimal
and inadequate esophageal sphincter tone predispose intubating sniff position is difficult.
parturients to aspiration. 10. Beards-Facial hair can make mask ventilation difficult.
 C H A P T E R

Approaches to Difficult
Airway Management
Raymond A. Pla, Jr., MD

Analysis of the American Society of Anesthesiologist's (ASA) through which an endotracheal tube (ETT) can be passed
Closed Claims database ( 1 985- 1 992) focusing on manage ­ (either blindly or fiberoptically) into t he trachea. As there is
ment of difficult airway, in part, led to development of the ASA no subglottic cuff, LMAs do not provide definitive airway pro ­
Difficult Airway Algorithm in 1 993. Subsequently, death and tection from aspiration.
brain damage claims resulting from difficult airway manage ­
ment on induction of anesthesia decreased. In contrast, claims
associated with the other phases of anesthesia (maintenance, Flexible Fiberoptic I ntu bation
emergence, and recovery) did not change. Over the years, This technique uses a fiberoptic bronchoscope (FOB) as a
many techniques have been developed to manage a difficult visually guided stylet over which an ETT is directed into the
airway. Each technique has been proven valuable. However, trachea. This technique can be administered nasally or orally,
anatomy and disease state of an individual patient and t he when the patient i s asleep or awake. Supplemental oxygen,
clinical j udgment and experience of the operator influence the either via a nasal cannula or through the bronchoscope itself,
technique applied to each patient. maintains oxygenation during intubation. If performed with
Managing a patient with a known or s uspected difficult anesthetized patient, j aw-thrust or gentle anterior traction on
airway has, as its central goal, to avoid major complications, the tongue opens the pharynx, raises the epiglottis, and aids in
including, but not limited to: injury to airway structures, glottic opening visualization.
hypoxic brain injury, cardiopulmonary arrest, unnecessary If attempted in an awake patient, psychological and
tracheostomy, or death. To this end, securing the airway anesthetic (topically and/or airway nerve blocks) preparation
while the patient is awake and breathing spontaneously may is necessary. Psychological preparation of the patient begins
be indicated or necessary. with an explanation of what is to occur and why. While
physical preparation i ncludes the j udicious use of anxiolyt­
ics (while maintaining airway protective reflexes and s pon­
I N DUCTION taneous ventilation). Anti-sialagogue pretreatment is critical
to the success of the procedure as oral secretions prevent
Airway Avoidance mucosal contact of topically applied local anesthetic. Further,
This technique involves the exclusive use of regional or neur­ saliva obscures visualization of the larynx. Anticholinergics
axial anesthesia, avoiding the use of apnea-inducing sedatives such as glycopyrrolate are effective i n this regard, as is suc­
or protective airway reflex compromise. While this technique tion capability via t he FOB.
poses the risks of incomplete block, local anesthetic systemic If the nose is chosen, topical anesthetic to the nasal
toxicity, and patient anxiety, it effectively achieves the goal of mucosa, i nnervated by the greater and lesser palatine nerves
anesthesia while maintaining a patent a irway: Before attempt­ and the anterior ethmoid nerve, all branches of t he trigemi­
ing, practitioners should consider: regional anesthetic con ­ nal nerve, must be applied. Further, local anesthetic may be sup­
traindications, patient anxiety level, duration, and anatomic plemented by a vasoconstrictor t o shrink the nasal mucosa.
extent of the surgery relative to the duration and anatomic dis­ This facilitates passage of t he ETT and reduces the risk of
tribution of the block and intraoperative airway access. traumatic epistaxis. Phenylephrine or oxymetazoline effec ­
tively induces vasoconstriction. Due to bleeding risk, the
nasal approach is not advised in pregnancy (engorged-friable
Laryngeal Mask Ai rway mucosa) and in those with coagulopathy or receiving antico ­
Laryngeal mask airway (LMA) is an inflatable, supraglottic agulant therapy.
device that overlies the laryngeal inlet and seals the hypophar­ Orally inhaled nebulized or atomized local anesthetic
ynx, allowing for delivery of positive pressure (up to 20 em should be administered to the posterior oropharynx to inhibit
H 2 0). Since it overlies the larynx, an LMA serves as a conduit the gag reflex and allow FOB passage t hrough the pharynx

237
238 PART II Clinical Sciences

and larynx. Finally, the larynx and trachea should be anes­ vertical incision through the aforementioned location. This
thetized using a transtracheal i njection of local anesthetic technique is useful when unable to ventilate or intubate.
through the cricothyroid membrane, thereby minimizing the
cough response to FOB and ETT advancement. These topical
techniques can be accomplished using l idocaine 1%, 2%, or Transtracheal Jet Venti lation
4% or cocaine, paying close attention to the toxic dose oflocal Transtracheal j et ventilation i s a form of cricothyrotomy in
anesthetic as there can be fairly rapid and significant absorp­ which a catheter is introduced into the cricothyroid mem ­
tion into systemic circulation from airway mucosa. Airway brane as described previously and attached to a high-pressure
nerve blocks, specifically the superior laryngeal nerve block oxygen source (25-50 psi) . The patient's lungs are ventilated at
and the glossopharyngeal nerve block can supplement airway a rate of 1 2- 1 6 times per minute, leaving adequate time for gas
anesthesia for sensitive patients. exhalation. Exhalation must be ensured passively so as to pre­
vent barotrauma. This technique can be life-sustaining until a
more definitive airway is established.
Video Laryngoscopy
Video laryngoscopy is a form of indirect laryngoscopy, in
which the clinician views the larynx with a fiberoptic or digital EXTU BATION
rigid laryngoscope. Video laryngoscopy has recently provided
a viable alternative to oral FOB. Indirect view of the glottic Th e patient who presented difficulty with intubation at induc­
opening may be obtained with video l aryngoscopy in cases tion must be considered a difficult extubation. Difficult extuba ­
where direct laryngoscopy visualization is difficult or impos­ tion refers to the risk of premature or inadvertent extubation
sible. Specially designed stylets allow for anterior, acute-angle that may result in hypoxic brain injury or death. Clinical
ETT placement. situations include, but are not limited to: ( 1 ) recurrent laryn­
geal nerve damage, tracheomalacia or hematoma from thy­
roidectomy; (2) hematoma from carotid endarterectomy;
Lighted Stylet and Gum Elastic Bougie (3) hematoma or subglottic edema from cervical vertebral
Lighted stylets such as light wands provide trans-illumination decompression; (4) airway edema from prone position, ana­
of the anterior neck, demonstrating ETT position. These can phylaxis, or thermal injury; and (5) bleeding, laryngospasm or
be used blindly or in conjunction with direct or video laryn­ edema from laryngeal biopsy or tonsillectomy.
goscopy. The tip of a gum elastic b ougie or Eschmann catheter Options to consider in managing potential difficult
can be manipulated to an angle that allows for anterior manip­ extubation i nclude ensuring routine extubation criteria have
ulation in the larynx. Bougie stylets are used in conjunction been met, such as: (1) following commands, i ncluding sus­
with laryngoscopy and allow for ETT placement over the tained head lift for 5 seconds to verbal command; (2) i ntact
stylet as a guide. gag reflex; (3) adequate pain control; ( 4) airway clear of secre­
tions and blood; (5) adequate ventilatory mechanics-tidal
volume greater than 5 mL/kg, vital capacity greater than
Retrograde Technique 10 mL/kg; (6) controlled respiratory and cardiac rate and
Retrograde wire intubation involves percutaneous passage of rhythm; (7) hemodynamic stability; and ( 8) normothermia.
a guide wire into the trachea through the cricothyroid mem ­ Negative i nspiratory force measurements, arterial blood gas
brane, in a retrograde direction, emerging from the mouth values, and ETT cuff leaks are additional considerations for
or nose. An ETT is then placed over the wire and passed in extubation management of difficult airway patients. Once
an anterograde direction, over the wire and into the trachea. extubation conditions have been satisfied, location should
This technique can be performed electively or emergently. be considered: operating room, postanesthesia care unit or
It can be particularly helpful when blood or copious secretions intensive care unit. Equipment and personnel availability
in the airway would make fiberoptic intubation very difficult should aid t he decision regarding location of extubation.
or impossible. Though safe, complications such as pneumo ­ Finally, a stylet can be placed in the ETT and left in place
thorax, bleeding, and coughing (a sign of distal passage of t he to assist with reintubation if the need arises after extuba­
wire toward the carina) exist. tion. Extubation stylets called exchange catheters provide
the advantage of s erving as a conduit for 02 administration.
The gum elastic bougie, or Eschmann catheter can be used
Cricothyrotomy as a stylet, but oxygen cannot be administered with this
Cricothyrotomy involves either: ( 1 ) percutaneous, Seldinger type of stylet. Equipment for immediate reintubation should
technique placement of a catheter through the cricothyroid be available and close monitoring should be maintained i n
membrane; or (2) surgical placement of a catheter using a the hours immediately following extubation.