Chapter 2: Anesthesia

Anesthesia Classifications
General Anesthesia
Intravenous Anesthesia
Local Anesthesia
Special Cases for Lowering the Maximum Allowable
Dose
Pediatric Anesthesia
Lumbar Epidural and Caudal Anesthesia General
Complications of Anesthesia Complications of
Endotrachial Intubation Nerve Injury During Anesthesia
Other Medical Complications From Anesthesia
ANESTHESIA
Anesthesia Classifications

The American Society of Anesthesiologists Physical Status Measure ( A

classification system for patients undergoing surgery)
Class 1 Normal and Healthy - no known diseases
Class 2 Mild Systemic Disease i.e. presence of essential hypertension or mild type
II diabetes
Class 3 Severe Systemic Disease That Is Not Incapacitating i.e. severe diabetes,
type I with vascular complications
Class 4 Incapacitating Systemic Disease That Is A Threat To Life i.e. advanced
cardiac, renal, pulmonary, hepatic or endocrine insufficiency
Class 5 Moribund Patient Who Is Not Expected To Live With Or Without Surgery
EMERGENCY OPERATION- any patient in one of the above classses who is operated
on as an emergency (Letter E is placed next to the classification)

General Anesthesia
A reversible state of unconsciousness produced by anesthetic agents, with loss of
sensation of pain over the whole body. The order of descending depression of the
CNS during anesthesia is: cortical and psychic centers, basal ganglia and
cerebellum, medullary centers, and spinal cord
1. Inhalation agents:
a. Volatile liquids:
i. Chloroform (no longer in use)
 Advantages: Rapid induction and recovery, nonflammable, good muscle
relaxation
 Disadvantages: Myocardial depressant, hepatotoxic
ii. Diethyl ether (no longer in use)
 Advantages: Reliable signs of anesthesia depth, respiration
stimulated, bronchodilator, circulation not depressed, good muscle
relaxation, relatively safe and nontoxic (has lowest death rate
following its use)
 Disadvantages: Prolonged induction and recovery, irritating to
mucous membranes of upper airway, dangerous in patients with full
stomachs (emetic), flammable, and explosive
iii. Halothane (Fuothane®)
 Advantages: Rapid smooth induction and recovery, pleasant
smell, nonirritating (no secretions), bronchodilator, nonemetic,
nonflammable
 Disadvantages: Myocardial depressant, may trigger malignant
hyperthermia reaction, arrhythmia-producing drug, sensitizes the
myocardium to the action of catecholamines, possibly toxic to the
liver, postoperative shivering
iv. Methoxyflurane (Penthrane(r): It is the most potent and least volatile anesthetic
(no longer in use)
 Advantages: Great margin of safety, good muscle relaxant, not sensitive to
 catecholamines, nonflammable
 Disadvantages: Prolonged induction of anesthesia and prolonged
recovery, nephrotoxic
v. Enflurane (Ethraner)
 Advantages: Pleasant smell, rapid induction and recovery, nonirritating (no
secretions), bronchodilator, maintains stability of the cardiovascular system,
nonemetic, compatible with epinephrine
 Disadvantages: Myocardial depressant, smooth muscle relaxant, increase
hypertension with increase depth of anesthesia, CNS irritant, possible
hepatotoxicity

vi. Isoflurane (Forane®): Newest inhalation agent

 Advantages: Rapid induction and recovery, nonirritating, bronchodilator,
excellent muscle relaxation, maintains stable cardiac rhythm, compatible with
epinephrine, nonemetic, nonflammable
 Disadvantages: Depresses the cardiovascular system, shivering postoperatively,
possible acute or delayed liver injury (less likely than with Ethrane or
Halothane)

b. Gasseous anesthetic agents

i. Nitrous oxide: The least potent of the anesthetic gases, and the most frequently
used inhaled anesthetic. In the absence of hypoxia, there is little effect on the
heart rate, myocardial contractility, respiration, blood pressure, liver, kidney or
metabolism. Oxygen 100% must be given at the termination of the surgery to
prevent diffusion hypoxia
 Advantages: Rapid induction of anesthesia and emergence, does not sensitize
the myocardium to epinephrine, nonirritating, intense analgesia, nonemetic
 Disadvantages: No muscular relaxation, possible bone marrow depression and
fatal agranulocytosis from prolonged administration or exposure, and increased
risk of spontaneous abortion with prolonged use
ii. Cyclopropane (no longer in use)

2. Preanesthetic or suplementary agents

a. Sedatives
i. Pentobarbital (Nembutal®) and secobarbital (Seconal®): Used before surgery to
relieve anxiety and tension (cerebral cortex depression). Have a short hypnotic
effect and pronounced sedative action. Are used as an inducing agent and have no
analgesic component
ii. Phenobarbital
iii. Chloral hydrate: One of the oldest and best hypnotics, and a very good
alternative to barbiturates in children and the elderly (adult dose is .5-1 gm PO).
Excreted by the lung.
iv. Diazepam (Valium®): Produces a satisfactory sedative and amnesic effect. It is
indicated to prevent and treat convulsions
v. Hydroxazine (Vistaril®): Has sedative antihistaminic, antiemetic, and
bronchodilating properties, but used primarily for its sedative properties.. Excellent
premedication in patients with a history of bronchial asthma
vi. Droperidol-fentanyl (Innovar(r): A 50-1 mixture of droperidol and fentanyl.
Produces effects that are a combination of both drugs
vii. Droperidol (Inapsine®): The main effect is tranquility and peripheral
vasodilation, can cause dysphoria, good antiemetic, and when infused IV produces
sleepiness and mental detachment
b. Narcotic analgesics:
1. Fentanyl (Sublimaze®): Produces depression of ventilation which is short in
duration. Reversed by narcotic antagonist (Naloxone®). Can also produce muscle
rigidity in large doses
ii. Morphine: The standard analgesic narcotic drug for relief of severe pain. It
depresses the CNS, reduces GI motility, constricts the bronchi (due to histamine
release), and lowers the metabolic rate. It has strong sedative and analgesic
properties
iii. Meperedine (Demerol®): Has analgesic, sedative, and spasmolytic properties,
and in conjunction with barbiturates induces amnesia. It can cause tachycardia and
is contraindicated in patients with atrial flutter (and anything that causes increased
intracranial pressure just as with any other narcotic)

NOTE* The adverse side effects from the narcotic analgesics include respiratory
depression, emesis, physical dependence. Asthmatics react poorly to
morphine only due to histamine release (smooth muscle constriction)

c. Tranquilizers:
i. Phenothiazines: Are used for a preanesthetic medication because of their
sedative, antiemetic, antihistaminic, and temperature regulating effects. May
produce postoperative hypertension and lethargy. When given with narcotic
analgesics, increases respiratory depression
 horazine® (15-25 mg)
 ompazine® (5-10 mg)
 henergan® (25-50 mg)

d. Belladonna compounds:
i. Atropine: Decreases secretions and is the drug of choice to reduce bronchial and
cardiac effects of parasympathetic origin. It increases the heart rate by blocking
the vagus nerve, and stimulates the cerebral cortex. Atropine is superior to
scopolamine as a vagolytic agent, therefore, can prevent severe bradycardia and
asystole in the presence of vagotonic agents (halothane). Atropine and
scopolamine are potent bronchodilators. Patients allergic to atropine can be given
scopolamine + benadryl
ii. Scopolamine: An effective drug for psychic sedation and amnesia. The drying
effect is better than atropine
iii. Glycopyrrolate (Robinol)

NOTE* Diprivan is a new sedative/hypnotic (used with Versed and Fentanyl for
balanced anesthesia)

3. Stages of Anesthesia
a. Stage 1: Analgesia (characterized by variable degrees of analgesia and amnesia)
i. Plane 1- Preanalgesia (normal memory and sensation)
ii. Plane 2- Partial analgesia and amnesia
iii. Plane 3-Total analgesia and amnesia
b. Stage 2: Delirium (extends from the loss of consciousness until the beginning of
surgical anesthesia) (excitement and voluntary activity marked)
i. Unconsciousness, irregular breathing pupils dilated
c. Stage 3: Surgical anesthesia (4 planes)
i. Plane 1 (sleep)-Rhythmical breathing, eyeball centrally fixed, faint lid reflex
ii. Plane 2 (sensory loss)-Pupils slightly dilated, pulse and blood pressure normal
iii. Plane 3 (muscle tone loss)-lntercostal paralysis begins, increased pulse rate &
decreased BP
iv. Plane 4 (intercostal paralysis)-Provides cessation of all respiratory effort and
requires artificial ventilation for life support
d. Stage 4: Medullary paralysis
i. Plane 1: reversible respiratory failure
ii. Plane 2: irreversible cardiovascular collapse

Intravenous Anesthesia
1. Ultrashort-acting barbiturates: In sufficient amounts these can provide all
the anesthetic stages (may produce serious cardiovascular depression) for short
minor procedures that do not require muscle relaxation
b. Neuroleptoanalgesia: A neuroleptic drug (tranquilizer) plus a narcotic analgesic,
when administered together produce the following psychophysiologic state:
somnolence without total unconsciousness, psychological indifference to the
environment, no voluntary movements, analgesia, and satisfactory amnesia
c. Neuroleptoanesthesia: Combination of nitrous oxide, droperidol, fentanyl and
muscle relaxants (a good choice for patients with little cardiac reserve)
d. Dissociative anesthesia (Ketamine®): Produces a state where the patient
becomes mentally dissociated from the environment

Local Anesthetics
Function in such a way as to prevent sodium migration through the nerve
membrane which, therefore prevents depolarization of the nerve with inhibition of
nerve conduction
1. Chemical Classifications
a. Esters of para-aminobenzoic acids
i.. Procaine (Novocaine): most toxic, and is considered the standard in comparing
the potency and toxicity of other local anesthetics used for injections
ii. Chlorprocaine (Nesacaine®): least toxic, and rapid plasma hydrolysis by pseudo-
cholinesterase
b. Esters of Benzoic Acid
i. Hexylcaine (Cyclaine®)
ii. Tetracaine (Pontocaine): longest duration

NOTE* Esters are hydrolized by pseudocholinesterase in the plasma

Have a high potential for allergenicity due to PABA moiety c.
Amides
i. Lidocaine (Xylocaine®): shortest duration & fastest action
ii. Mepivicaine (Carbocaine®): do not use in presence of renal disease
iii. Bupivicaine (Marcaine®): longest duration, least placental transfer, should not
be used in children under the age of 12 years old (package insert), and greatest
cardiac toxicity if given IV
iv. Etidocaine (Duranest®): four time more potent than lidocaine, but only twice as
toxic

NOTE* Amides are hydrolized in the liver. There is no cross sensitivity between
amides and esters- can be substituted in case of allergy. Should use 1 /2 dose
in elderly, debilitated patients, and patients with hepatic disease. Pain 8
temperature lost first following nerve block, with loss of touch & motor
function later. Injection into an acidic area (infection) converts the anesthetic
chemically and does not allow for penetration into the cell membrane, and
lessens its effectiveness
2. Vasoconstrictors (Epinephrine)
a. Advantages
i. Reduces the vascularity locally at the site of the injection (due to
vasoconstriction)
ii. Reduces the absorption rate of the local anesthetic
iii. Permits a higher allowable single dose dose of local anesthetic to be used
iv. Increases duration of action of the block
b. Disadvantages
i. Use cautiously in patients with hyperparathyroidism, arteriosclerotic
cardiovascular disease, hypertension, and peripheral vascular disease
ii. Creates vasospasm in the end arterioles which could lead to tissue necrosis,
so should be diluted in the digits to 1:200,000-1:400,000 or not used
iii. Can create reactive hyperthermic reaction
iv. Should be avoided in patients receiving Halothane (since Halothane
sensitizes the myocardium in the presence of exogenously administered
catecholamines)

3. Hyaluronidase (Wydase)
a. Permits more rapid spread of solutions into the tissues, to facilitate regional
block anesthesia.
b. There is increased incidence of toxic reactions caused by local anesthetic drugs
when hyaluronidase is used
c. Reduces the duration of action when used with local anesthetics for nerve blocks

4. Regional Nerve Blocks

a. Advantages
i. Causes minimal interference with such preexisting diseases as diabetes, renal
failure, or heart conditions
ii. Eliminates the risk of pulmonary aspiration during induction of general
anesthesia
iii. Requires little postoperative nursing
b. Ankle Block
i. Saphenous nerve: the only nerve at the ankle that comes from the femoral
nerve, lies medial to the greater saphenous vein at the ankle
ii. Posterior Tibia] nerve: branch of sciatic nerve, lies in 3rd compartment of
lacinate lig.
iii. Sural nerve: made up from branches of the tibial and common peroneal nerves
iv. Superficial Peroneal nerve: becomes superficial 7-8cm above the ant-lat ankle
v. Deep Peroneal nerve: lies between the EHL and the anterior tibial

5. Maximum Allowable Single Dose in Normal Adults:

a. Novocaine® (1-2%): 750mg plain 1000mg w/epinephrine
b. Pontocaine® (0.1-0.25%): 75mg plain 100mg w/epi
c. Xylocaine® (1-2%): 300mg plain 500mg w/epi
d. Carbocaine® (1-2%): 500mg plain
e. Marcaine® (0.25-0.75%): 175mg plain 225mg w/epi

NOTE* There is no advantage in using a higher % solution- there is no stronger or

longer anesthesia, therefore, with a lower % solution you can inject more
volume.
One must know how to convert % solutions to mg/cc (.25% Marcaine= 2.5mg/cc,
0.5%= 5mg/ cc 1 % Xylocaine= 10mg/cc, 2%= 20mg/cc)

6. Complications due to local anesthetics: See Chapter, Medical

Emergencies
a. Systemic reactions are associated with high blood levels which ordinarily result
from overdoses, rapid systemic absorption, or inadvertent I.V. administration. The
adverse reactions mainly effect the heart, circulation, respiration, and CNS
i. Effects on the heart and vessels: Direct myocardial depressant , hypertension,
bradycardia, thready pulse, pallor, clammy skin, sweating, cardiac arrhythmias
possibly leading to cardiac arrest
ii. Effects on medullary centers: depressed respiration, apnea, vascular collapse
iii. Effects on the CNS: Nausea, emesis, talkativeness, euphoria, perioral tingling,
restlessness, dizziness, anxiety, excitement, and disorientation. This can be
followed by muscle twitching, convulsions, coma, respiratory failure and heart
failure
b. Vasovagal Reflex (Syncope)
c. Anaphylactic Reaction
d. Allergic Reaction (mostly due to esters due to PABA moiety)
e. Reactions. due to epinephrine
f. Local reactions : Skin slough, swelling, abcess, ulceration
 NOTE* Therapy for these reactions includes:
a. For convulsions: Valium®, ultrashort-acting barbiturates and artificial ventilation
b. For respiratory depression: Oxygen and artificial ventilation and control of
airway
c. For cardiovascular collapse: Vasopressors, IV fluids, and CPR

NOTE* When an allergy is suspected (but unknown) then an amide (frequently

lidocaine) should be chosen. If the patient has a history to paraben sensitivity,
preparations without araben should be tested (single dose vials). Preparations
without epinephrine should be used because it may mask a positive skin test
Special Cases For Lowering Maximum allowable Dose
1. Debilitated geriatric patient: 1 /2 or less of the adult dose
2. Pediatric Patient:
i.. Clark's Rule: used for children older than 1 year

Weight of child in pounds X The adult dose= ADJUSTED DOSE 150

ii. Fried's Rule: used for infants

Age in months X The adult dose= ADJUSTED DOSE 15

iii. Cowling's Rule: Age (next birthday) = Percent Adult Dose 24

Pediatric Anesthesia
1. Preoperative medications: Given up to 1 hour prior to surgery, to decrease
anxiety and to calm the child as well as dry secretions and decrease vagal
stimulation.
a. Sedative/hypnotics: Barbiturates, Chloral hydrate
b. Anticholinergic agents: Scopolamine, atropine
c. Narcotics: Meperidine, morphine

2. Anesthesia:
a. Create a warm environment during anesthesia as children have poor
autothermoregulation mechanisms (inability to shiver)

NOTE* The infant and child lose much of their ability to maintain normal body
temperature during and after anesthesia and their temperature fluctuates
with that of the environment. In most cases, unless vigorous attempts are
made to conserve body heat, the child may become cold and even cyanotic,
especially after 2 hours of surgery. Hypothermia leads to depressed
respiration and hypoxia follows. This predisposes the child to arrhythmias
and V-fibrillation, and is the most common cause of cardiac arrest and shock
in the very young
b. Inhalation agents: Halothane and nitrous oxide with .neuromuscular blockade
remain the principle agents (Enflurane® and lsoflurane® are now being used
frequently). The margin of safety of volatile agents is very low, and deep levels of
inhalation anesthesia for intubation of the infant can be quite hazardous
c. Fetanyl in conjunction with halothane-nitrous oxide induction is good for short
surgical procedures. This regimen reduces inhalation requirements, intraoperative
movement, coughing, and laryngospasm while' producing postoperative analgesia
and shortened discharge times. The halothane dosage is then gradually reduced as
the narcotic effects are noted

NOTE Fetanyl is given 1 microgram per kg IV 20 minutes prior to the end of the
surgery (must be administered cautiously to premature infants)

d. Succinylcholine: A muscle relaxant used to quickly establish an airway especially

when regurgitation and aspiration pneumonitis is a real risk. Its downside is:
masseter spasm when used in conjunction with halothane (difficult to differentiate
from malignant hyperthermia), rhabdomyolysis, and cardiac dysrhythmias

Lumbar Epidural and Caudal Anesthesia

Lumbar epidural anesthesia is accomplished by injecting the local anesthetic
solution into the epidural space of the lumbar area of the vertebral canal. Entrance
to the epidural space is usually made at or below the level of the second lumbar
vertebrae

1. Indications:
a. Lower extremity surgery when a general anesthetic may be risky for the patient
due to a preexisting medical -problem (i.e. asthma, rheumatoid arthritis affecting
the cervical spine, bronchitis, or emphysema, etc.) b. Patients who are not suitable
candidates for muscle relaxants (myasthenia gravis)

2. Contraindications:
a. Severe hemorrhage or shock
b. Local infection at the proposed puncture site
c. Septicemia
d. Preexisting neurologic disease
e. Extremes of age
f. Chronic backache or preoperative headache
g. Hypotension or marked hypertension

3. Advantages of epidural anesthesia over spinal anesthesia:

a. Allows segmental anesthesia
b. Postoperative headache does not occur
c. Hypotension is less likely
d. Can be maintained 1-2 days into the postoperative period as a useful method for
relief of pain
e. Do not have to remain In bed as long as with spinal anesthesia, therefore, can
be used in outpatient surgery

4. Advantages of spinal anesthesia over epidural anesthesia:

a. Less local anesthetic drug is needed than with epidural
b. Less time is needed to achieve an adequate block than with epidural
c. The level of anesthesia is more predictable d. Easier to perform

5. Anatomy of the epidural space:

a. The spinal cord is located within the spinal canal and is enveloped by the
meninges, the dura being the outermost. The spinal cord seldom extends below
the L1 vertebrae but occasionally extends to the upper level of L2
b. The dura is attached to the margins of the foramen magnum; this prevents the
passage of drugs from the peridural space into the cranial cavity. The dura sac
ends at the lower border of S2
c. The epidural space is located between the spinal dura centrally, and the
ligamentum flavum and the periosteal lining the spinal canal peripherally. It
extends from the base of the skull (foramen magnum), where the periosteum of
the skull and the dura fuse, to the coccyx
d. The epidural space contains areolar connective tissue and fat, arterial and
venous networks, Iymphatics, and the spinal nerve roots

Anatomy of the epidural space: The spinal cord ends at L2. The subarachnoid
space ends at S2

General Complications of Anesthesia

1. Awareness under anesthesia: Frequency of occurrence is greatest in
obstetric procedures, and patients having emergency surgery for trauma have a
higher incidence
a. Periods at risk: Induction, intraoperatively (light anesthesia), postop (muscle
relaxants used without sufficient sedation)
b. Monitoring: EEG, pulse volume plethysmography, clinical signs (decreased chest
compliance, bronchospasm, lacrimation, hypertension,
pupil size, eye movement)
2. Hypoxemia:
a. Definition: Deficient oxygenation of the blood (hypoxia: is reduction of oxygen
supply to a tissue below physiologic levels despite adequate perfusions of tissue by
blood)
b. Control of ventilation:
i. PaCO2 is the most important regulator of ventilation
ii. The respiratory response to hypoxemia is located solely in the peripheral
chemoreceptors, most importantly the carotid bodies
c. Causes of hypoxemia:
i. Hypoventilation: Drugs, medullary disease (encephalitis), anterior horn
cell disease (polio), disease of nerves to the respiratory muscles (Guillain
Barre', diptheria), disease of the neuromuscular junction (myasthenia
gravis) respiratory muscle disease (muscular dystrophy), and sleep apnea
ii. Absolute shunt: perfusion without ventilation
iii. Relative shunt: ventilation perfusion inequality
iv. Diffusion block: impaired diffusion of 02 from alveolus into the pulmonary
capillary blood
d. Biochemical changes of hypoxia: The main effect is cessation of oxidative
phosphorylation at the mitochondria) level, causing conversion to anaerobic
metabolism, reduced energy production and increased production of H+ and
lactate
i. Cerebral effects (loss of autoregulation, loss of electrical activity)
ii. Cardiovascular effects (increased heart rate)
iii. Pulmonary effects (pulmonary vasoconstriction)
iv. Renal effects (acute renal failure)
v. Hepatic effects (decreased portal circulation)
e. Compensatory mechanisms:
i. Hyperventilation
ii. Pulmonary redistribution
iii. Increased cardiac output
iv. Increased hemoglobin concentration
v. Changes in oxygen hemoglobin dissociation curve

3. Hyponatremia: Serum sodium less than 136 mEq/L

a. Symptoms: The severity of symptoms depends upon the the rate of decrease of
serum sodium as well as the actual decrease in the serum sodium
i. Symptoms occur when serum sodium falls below 120 to 125 mEq/L
ii. Symptoms include confusion, anorexia, lethargy, nausea, vomiting, coma, and
seizures
b. Treatment:
i. Correct underlying disorder (give insulin if due to hyperglycemia)
ii. If hypovolemic-hypotonic: treat with isotonic saline
iii. If hypervolemic-hypotonic: treat with restriction of water and consider diuretics
iv. Symptomatic hyponatremia: treat with hypertonic saline

4. Hypokalemia: Serum potassium less than 3.5 mEq/L

a. Signs and symptoms: Results in disorders of muscle physiology
i. Respiratory arrest may occur with potassium concentration less than 2 mEq/L
ii. Depressed myocardial contractility
iii. Cardiac arrhythmias
iv. Renal effects (decreased glomerular filtration rate, increased ammonium
production)
v. Endocrine effects (decreased aldosterone and insulin release)
b. Causes of potassium loss:
i. GI
ii. Diuretics
iii. Renal tubular acidosis
iv. Cushing syndrome

5. Hyperkalemia:
a. Etiology:
i. Decreased excretion (renal failure, hypoaldosteronism)
ii. Extracellular shift (acidosis, ischemia, rhabdomyolysis, drugs such as
succinylcholine)
iii. Administration of blood, potassium penicillins, salt substitutes iv. Hemolysis
b. Signs and symptoms:
i. Muscle weakness
ii. Paresthesias
iii. Cardiac conduction abnormalities (become dangerous as K+ levels
reach 7 mEq/L)
c. EKG:
i. Peaked T waves
ii. ST segment depression
iii. Prolonged P-R intervals
iv. Loss of P wave
v. QRS widening
vi. Prolonged Q-T interval
d. Treatment:
i. EKG changes treated with CaCl2
ii. NaHCO2
iii. Glucose and insulin
iv. Kayexalate
v. Dialysis

6. Hypothermia:
a. Effects:
i. Decreases 02 consumption and CO2 production by 7-9%/°C in all
tissues
ii. Effects blood gas transport: shifts the oxygen dissociation curve to the left,
hemoglobin's affinity for oxygen increases 6%/°C decrease in temperature (may
put oxygen delivery at risk)
iii. Respiration: hypoxic ventilatory drive may be depressed or absent in presence
of hypothermia
iv. Cardiovascular function in the anesthetized patient:
 Heart rate and cardiac output decrease as temperature falls
 EKG changes (sinus bradycardia, prolonged PR interval, widened QRS complex,
 prolonged QT interval, dysrhythmias at 28°C, ventricular fibrillation or asystole
below 28°C)
 Blood viscosity increases 2-3%/°C decrease in temperature v. Renal and
Hepatic:
 Kidneys have largest proportionate reduction in blood flow with glomerular
filtration rate decreased by 60%
 Hepatic blood flow is decreased
vi. Central nervous system
 Function is altered (sedation, cold narcosis, progressive slowing of EEG, or EEG
becoming flat)
b. Treatment: Warming of patient

Complications of Endotracheal Intubation

1. Airway reflexes
2. Laceration or bruising
3. Dental trauma
4. Retropharyngeal dissection
5. Aspiration
6. Esophageal intubation
7. Endobronchial intubation
8. Dislocation of the mandible or arytenoid cartilages
9. Increased airway resistance
10. ET tube obstruction
11. ET tube cuff rupture
12. Laryngeal/tracheal/pulmonary Infection
13. Laryneal or vocal cord ulceration
14. Chronic hoarseness/vocal cord paralysis
Nerve Injuries During Anesthesia
1. Factors predisposing to nerve injury:
a. Tourniquets
b. Hypotension
c. Pre-existing ischemic disease (diabetes)
d. Use of muscle relaxants allowing overstretching of limbs
e. Positioning of the patient which results in stretching or prolonged pressure on a
nerve

2. Postoperative upper extremity complications: a. Brachial plexus injuries

are the most common

3. Postoperative lower extremity injuries:

a. Sciatic nerve injury occurs with external rotation of thighs and legs, or if the
knees are extended
b. Femoral nerve due to excessive angulation of the thigh
c. Common peroneal nerve is most frequently damaged (compressed in a brace of
lithotomy equipment)
d. Saphenous nerve is damaged by compression against the medial tibia] condyle
e. Obdurator nerve is compressed by undue flexion of the thigh to the groin
Other Medical Complications from Anesthesia
1. Pulmonary embolism:
a: Etiology and risk factors:
1. 95% of PE arise from deep venous thrombosis in the lower extremities
ii. PE is responsible for 20% of postoperative deaths.
iii. Older patients undergoing more extensive surgery are at high risk
iv. Highest risk patients have a history of thrombophlebitis, hip or pelvic
fractures, and major lower extremity orthopedic procedures
v. Other risk factors include acute M1, prolonged immobilization major
trauma, oral contraceptive use, CHF, pregnancy
b. Diagnosis: Remains problematic
i. Signs and symptoms:
 Dyspnea, pleuritic chest pain. hemoptysis, tachypnea, cough, wheezing and
fever
ii. Major emboli may cause syncope and cardiovascular collapse
iii. Lab studies:

2. Postoperative nausea and vomiting: The vomiting center of the brain is

located in the reticular formation of the medulla. Impulses transmitted by fibers of
sympathetic and parasympathetic nervous system initiate the process of vomiting.
Motor impulses that initiate vomiting are carried in Cranial nerves V, VII, X, and XII
to the upper GI tract and through cervical and thoracic nerves to the diaphragm
and abdominal muscles
a. Predisposing factors:
i. Females more prone (probably estrogen related)
ii. Obesity
iii. Certain anesthetics (opioids, nitrous oxide, volatile anesthetics, barbiturates)
iv. Pain, hypotension, or hypoglycemia in postop period
v. Type of surgery (middle ear, ophthalmic, peritoneal irritation, surgery that
results in blood in the stomach)
b. Effects:
i. Autonomic:
 Tachycardia or bradycardia
 Hypotension or hypertension
ii. Disruption of suture lines
iii. Aspiration
iv. Prolonged hospitalization
c. Prevention:
i. Metroclopramide 10-20 mg IV
ii. Droperidol 0.63-1.25 mg IV
iii. Cimetidine 300 mg IV or po
iv. Ranitidine 150 mg po or 50 mg IV
v. Scopolamine 1.5 mg transdermally (patch)
d. Treatment:
i. Keep patient supine
ii. Antiemetics

3. Malignant hyperthermia: Thought to be due to reduction in the

reuptake of Ca by the sarcoplasmic reticulum necessary for the termination
of muscle contraction
a. Clinical features:
i. Unexplained tachycardia
ii. Hypercarbia or tachypnea
iii. Acidosis
iv. Muscle rigidity even in the presence of neuromuscular blockade
v. Hypoxemia
vii. Ventricular arrythmias
viii. Hyperkalemia
ix. Fever is a late sign
b. Treatment:
i. Discontinue all anesthetics
ii. Dantrolene 2.5 mg/kg IV initially
iii. NaHCO3
iv. Hyperkalemia corrected with insulin and glucose (no calcium)
v. Arrhythmias treated with procainamide
vi. Hyperthermia treated with refrigerated IV fluids, gastric, rectal and
bladder lavage with cold saline, surface cooling with ice
vii. Maintain urine output
c. Anesthesia for MI-L suseptible patients
i. Possible pretreatment with Dantrolene
ii. Local or regional anesthesia should be considered or
iii. General anesthesia with non-triggering agents such as:
 Barbiturates
 Propofol
 Benzodiazepines -Narcotics
 Nitrous oxide
d. Associated syndromes: An increased risk of MH reported in association
with a number of disorders, and therefore, these patients should be treated
as suseptible to MH:
• Duchenne muscular dystrophy
• King-Denborough syndrome (dwarfism, mental retardation, and
musculoskeletal abnormalities)
• Central core disease

4. Pulmonary aspiration:
a. Pathophysiology: Due to passive regurgitation and seen more
commonly in unconcious, obese, pregnant, and patients with full
stomachs
b. Types of pulmonary aspirate:
i. Particulate matter
ii. Liquid gastric contents iii. Blood
c. Incidence: About 10-20% perioperatively and intraoperatively (5%
mortality)
d. Diagnosis: Difficult to differentiate from other causes of pulmonary
insufficiency. Signs and symptoms are tachypnea, tachycardia, cyanosis
and respiratory acidosis
e. Treatment:
i. O2
ii. Tracheal intubation
iii. May need intravascular fluid replacement
iv. Antibiotics if bacterial infection develops
v. Bronchoscopy may be necessary to relieve airway obstruction