Practice Guidelines in Anesthesia PDF

PRACTICE GUIDELINES
IN
ANESTHESIA
PRACTICE GUIDELINES
IN
ANESTHESIA
Editor
SK Malhotra MD FICA
Professor
Department of Anesthesia and Intensive Care
Postgraduate Institute of Medical Education and Research (PGIMER)
Chandigarh, India
Editorial Board Members
VP Kumra MD DAc FICA

Emeritus Consultant
Sir Ganga Ram Hospital, New Delhi, India
President
Indian College of Anaesthesiologists
B Radhakrishnan MD MPhil FICA

Principal
Academy of Medical Sciences
Kannur, Kerala, India
SM Basu MD DA (London) FICA

Ex-President
Indian Society of Anaesthesiologists
Indian College of Anaesthesiologists

Whole Constituent of
Indian Society of Anaesthesiologists

(Member of the World Federation of
Societies of Anaesthesiologists)
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Practice Guidelines in Anesthesia

First Edition: 2016
ISBN: 978-93-5152-988-0
Printed at
Contributors
Abdul Qayoom Dar MD FRCA
Bikash Ranjan Ray MD
Professor
Department of Anesthesiology and Critical Care
Sher-i-Kashmir Institute of Medical Sciences
(SKIMS)
Srinagar, Jammu and Kashmir, India
qayoom777@gmail.com
Assistant Professor
Department of Anesthesiology
All India Institute of Medical Sciences (AIIMS)
New Delhi, India
bikashray.aiims@gmail.com
Amit Sharma MD
Assistant Professor
New Delhi, India
Dalimkumarb001@yahoo.co.in
Consultant Anesthesiology
Army College of Medical Sciences and Base
Hospital
New Delhi, India
dramitsharma@gmail.com
Anil Agarwal MD MNAMS FICA

Professor
Sanjay Gandhi Postgraduate Institute of Medical
Sciences (SGPGIMS)
Lucknow, Uttar Pradesh, India
ani_sgpgi@hotmail.com
Anjan Trikha MD FICA

Professor
New Delhi, India
anjantrikha@hotmail.com
Ashok Kumar Saxena MD FAMS FICA

Professor
University College of Medical Sciences and
Guru Teg Bahadur Hospital
New Delhi, India
profashoksaxena@gmail.com
BB Mishra MD
Chief Medical Officer
Dhanwantri Hospital
NTPC, Telangana, India
bbm_58@yahoo.in
Dalim Kumar Baidya MD
Girija Prasad Rath MD DM

Additional Professor
Department of Neuroanesthesiology
New Delhi, India
girijarath@yahoo.co.in
Gundappa Parameswara MD FICA

Senior Consultant Anesthesia
Manipal Hospital Bengaluru
Adjunct Professor (Anesthesia)
Kasturba Medical College
Manipal, Karnataka, India
paramgundappa@gmail.com
Jayashree Sood MD FFARCS PGDHHM FICA

Chairperson
Pain and Perioperative Medicine
Jayashreesood@hotmail.com
JP Sharma MD FICA
Professor and Head
Intensive Care and Pain Management
Himalayan Institute of Medical Sciences (HIMS)
Himalayan Institute of Hospital Trust (HIMT)
Dehradun, Uttarakhand, India
jpshims@gmail.com
vi
Kamal Kishore MD
P Ranjan MD
Assistant Professor
Sanjay Gandhi Postgraduate Institute of Medical
Sciences (SGPGIMS)
kamalkishore2@rediffmail.com
Professor and Head

Division of Pediatric Anesthesia
Institute of Medical Sciences
Banaras Hindu University
Varanasi, Uttar Pradesh, India
pushkarranjanbhu@gmail.com
LD Mishra MD PhD FICA
Parshotam Lal Gautam MD
Professor and Head

Institute of Medical Sciences
Banaras Hindu University
Varanasi, Uttar Pradesh, India
ldmishra@rediffmail.com
Prashant Kumar MD PDFNA
Mahesh Kumar Arora MD

Professor and Head
New Delhi, India
mkarora442@gmail.com
Mridula Pawar MD
Professor
Vardhman Mahavir Medical College and
Safdarjung Hospital
New Delhi, India
mridulapawar@gmail.com
Mritunjay Varma MD FRCA

Consultant
Anesthesia and Intensive Care
Newcastle-upon-Tyne Hospital, New castle, UK
varma.mk@doctors.org.uk
Naresh Dua MD
Consultant
dua14@yahoo.com
Nidhi Kumar MD
Assistant Professor
Department of Anesthesiology, Intensive Care
and Pain Management
Himalayan Institute of Medical Sciences (HIMS)
Himalayan Institute of Hospital Trust (HIMT)
Dehradun, Uttarakhand, India
drnidhiaries@gmail.com
Professor and Head

Department of Critical Care Medicine
Dayanand Medical College and Hospital
Ludhiana, Punjab, India
drplgautam@gmail.com
Professor
Pt BDS Postgraduate Institute of Medical Sciences
University of Health Sciences
Rohtak, Haryana, India
pk.pgims@yahoo.com
Raminder Sehgal MD FICA

Senior Consultant
ramindersehgal@hotmail.com
Rashmi Datta MD DNB

(Gen Medicine and Aviation Medicine)
Consultant Anesthesiology
Army College of Medical Sciences and Base
Hospital
New Delhi, India
rashmidatta@rediffmail.com
RK Tripathi MD FICA
Professor and Head
Department of Anesthesia and Critical Care
Eras Lucknow Medical College
rk_tripathi32@rediffmail.com
Sarla Hooda MD
Professor and Head
sarlahooda@yahoo.com
Contributors
Seema Partani MD
vii
Susheela Taxak MD
Assistant Professor
Department of Anesthesia
Geetanjali Medical College
Udaipur, Rajasthan, India
partaniseema@yahoo.in
Professor
susheela_taxak@hotmail.com
SK Malhotra MD FICA
T Prabhakar VSM MD PDCCC (Neuroanesth), FICA
Professor
Department of Anesthesia and Intensive Care
Postgraduate Institute of Medical Education and
Research (PGIMER)
Chandigarh, India
drskmalhotra@yahoo.com
Sunanda Gupta MD PhD FAMS FICA

Professor
Department of Anesthesia
Geetanjali Medical College
Udaipur, Rajasthan, India
sunanda.gupta@gmail.com
Principal Dean
Eras Lucknow Medical College
prabhu4903@yahoo.com
Vinod Kalla MD
Emeritus Consultant
Sant Parmanand Hospital New Delhi, India
kallavinod@gmail.com
Emeritus Consultant
President
Indian College of Anesthesiologists
ved_kumra@yahoo.com
Foreword
The specialties of anesthesia, intensive care and pain management are becoming dynamic
facets in the field of medicine. Continuous advancement is being made in improving the quality
care of patients undergoing surgical procedures. Practice Guidelines in Anesthesia is an integral
component that provides basic recommendations for anesthetic practice. The Indian College of
Anaesthesiologists (ICA) that is an academic branch of Indian Society of Anaesthesiologists has
come out with the first edition of Practice Guidelines in Anesthesia. The various chapters include the
topics covering preoperative preparations, monitoring, intra- and postoperative problems and their
management. It also covers the chapters dealing with pain management and the field of intensive
care therapy. All the chapters have been meticulously selected and authored by distinguished
clinicians.
The guidelines always provide the basic framework for carrying out the rational and acceptable
patient care. We must permit some amount of flexibility in individual situations and the
anesthesiologists should always exercise his own clinical experience and judgment. Moreover, each
hospital may modify these guidelines as per their local resources and infrastructure.
I applaud the efforts of Indian College of Anaesthesiologists in taking this unique initiative. I wish
to congratulate Dr SK Malhotra (Editor), and the editorial board members for their commendable
job.
I hope that the readers would find all topics interesting and beneficial in day-to-day anesthetic
practice.

Emeritus Consultant
Sir Ganga Ram Hospital
New Delhi, India
President, Indian College of Anaesthesiologists
ved_kumra@yahoo.com
Preface
Practice guidelines in the field of Anesthesia are well established that form the foundation of
recommendations for practicing anesthesiologists at the time of publication. These incorporate
the recent advances in current anesthesia practice and training in the field. It is not feasible to
include all the topics in one issue, therefore 23 topics have been selected in this first edition of
Practice Guidelines in Anesthesia being published by Indian College of Anaesthesiologists (ICA), an
academic wing of Indian Society of Anaesthesiologists. The topics cover the field of anesthesia, pain
management and critical care. It includes the basic principles of providing anesthetic services as
well as those required in specialized areas. The guidelines would be reviewed from time to time and
revised accordingly as per advancement of practice and technology. Similarly, in each subsequent
publication, new chapters would be added.
In the field of preoperative preparation, various chapters have been included such as
preoperative fasting guidelines and checking the anesthesia equipment. A chapter on infrastructure
requirements for operation theater has also been added. The guidelines for perioperative problems
include difficult airway management, central venous access, monitored anesthesia care, toxicity of
local anesthetics, anaphylactic reactions and blood transfusion therapy. The topics of perioperative
fluid therapy and hypothermia are included keeping pediatric patients in mind. A chapter on
obstetric anesthesia guidelines has also been added. In the field of pain management, ultrasoundguided nerve blocks and acute pain management have been highlighted. Management of head
injury and managing postanesthesia care unit (PACU) have also been discussed.
Practice guidelines should always be considered as the studies in their evolution. A balance
must be kept between broad principles and minute detail. The same should be considered between
professional view and the evidence as well as desired and minimum standard of practice. These
guidelines should not replace the need for individual clinical experience of the anesthesiologists
in providing best possible services to the patient. Also, these guidelines may be modified as per
the availability of equipment and infrastructure in an individual hospital. The practice guidelines,
however, do not guarantee any precise outcome.
I hope that the present document on Practice Guidelines in Anesthesia would be useful to the
practicing anesthesiologists. However, suggestions are welcome from readers to improve the
subsequent edition.
We are indebted to all distinguished authors who have spared their time and energy in
contributing to the first edition of Practice Guidelines in Anesthesia.
SK Malhotra
Contents
1. Practice Guidelines for Postanesthesia Care Unit
Abdul Qayoom Dar

History 1;Managing PACU Staffing 1; Design and Staffing 2
Outpatient Surgery 12;Pediatric PACU 14
2. Perioperative Care of Ambulatory Anesthesia
17
Anil Agarwal, Kamal Kishore

Preoperative Assessment 18; Perioperative Care 18
Preoperative Preparation 18; Intraoperative Care 18
General Anesthesia 19; Regional Anesthesia 19
Peripheral Nerve block 19; Local Infiltration 19
Intravenous Regional Anesthesia 19
Postoperative Recovery and Discharge 20; Outcome Measures 20
3. Anaphylactic Reactions During Anesthesia
23
Anjan Trikha
Anaphylaxis 23; Etiology of Perioperative Anaphylaxis 23
4. Acute Pain Management Guidelines and Protocols: Evidencebased
32
Ashok Kumar Saxena

Definition 32; Aims of the Guidelines 33
ASA Task Forces Recommendations for Providing
Postoperative Pain Management 34
5. Monitoring Standards in Anesthesia
45
Gundappa Parameswara
Section 1: Professional Standards 47
Section II: Monitoring the Anesthetic Equipment 48
Section III: Perioperative Care and Monitoring 49
Additional Monitoring 50
Section V: Monitoring during Regional Anesthesia, Anesthesia outside
the Operation Rooms and Monitored Anesthesia Care 51
Section VI: Monitoring during Transportation 51
Section VII: Monitoring in the Postoperative Ward 51
6. Head Injury: Assessment and Early Management
53
Girija Prasad Rath, Bikash Ranjan Ray

Definition and Classification of Head Injury 53
7. Guidelines to Quality Assurance in Anesthesia

Jayashree Sood
Quality Assurance Cycle 60; Provision of Anesthesia Services 61
Preoperative Examination 62; Preoperative Checklist 63
The Intraoperative Period 63;Records 63
60
xiv
8. Preanesthetic Evaluation and Investigation
67
JP Sharma, Nidhi Kumar

Preanesthetic Evaluation 68;Investigation 70
9. Perioperative Fluid Management in Children
73
LD Mishra, P Ranjan
Fluid in Children with Burn Injury 74;Trauma 75
10. Central Venous Catheter Management Guidelines
76
Mahesh Kumar Arora, Dalim Kumar Baidya

Preparation of Resource and Training of Staff 76
Selections of Insertion Site and Type of Catheter 76
11. Inadvertent Perioperative Hypothermia
79
BB Mishra
Risk Factors 80; Patient Characteristics 81
Anesthesia Factors 81; Surgery Factors 82
Other Risk Factors 82;Gender 82
Surgery Risk Factors 83; Environmental Risk Factors 83
Consequences of IPH 83; Treatment of Hypothermia 84
Guidelines Recommendations 84
12. Practical Guidelines for Ultrasound Guided Nerve Blocks
87
Mridula Pawar
Review Basics of Ultrasound 87; Know Your Equipment 87
Anatomical Structures 88; How to Differentiate Tendons from Nerves? 88
How to Differentiate Artery from Vein? 89
Interscalene and Supraclavicular Block 89; Femoral Nerve Block 90
13. Epidural Analgesia: The Practice Guidelines
93
Mritunjay Varma
Complications 93; Catheter Insertion 94;Equipment 95
Patient Monitoring 95; Audit and Critical Incidents 97
Education 97
14. Monitored Anesthesia Care
99
Parshotam Lal Gautam

Monitoring during MAC 104
15. Management of Local Anesthesia Toxicity
109
Raminder Sehgal
General Guidelines 109;Prevention 110
Diagnosis 110; Management of LAST 111
16. Interhospital Transfer of Critically Ill Patients

Rashmi Datta
Transport Triangle 113; Responsibilities of the Transport Triangle 114
Types of Interhospital Transportation Teams 115; Choice of Vehicle 116
113
Contents
xv
Accompanying Medications 117; Accompanying Equipment 117

Aeromedical Considerations 119; Legal Issues 121
17. Practice Guidelines for Management of the Difficult Airway
127
SK Malhotra
18. Practice Guidelines in Obstetric Anesthesia
132
Sunanda Gupta, Seema Partani

Preanesthetic Requirements 132; Aspiration Prophylaxis 133
Guidelines for Regional Anesthesia in Obstetrics 133
Anesthesia for Cesarean Delivery 134; Removal of Retained Placenta 135
Postpartum Tubal Ligation 135
Management of Obstetric and Anesthetic Emergencies 135
Cardiopulmonary Resuscitation in Obstetric Patients 136
19. Checking Anesthesia Equipment
138
Susheela Taxak
Principles138
Anesthesia Delivery System Checks 138
20. Perioperative Blood Transfusion
143
T Prabhakar, RK Tripathi
How Much Hemoglobin is Enough? 144
Blood Component Therapy 144; A Workable Guideline 145
21. Infrastructure Requirements for Operation Theater
148
Naresh Dua, VP Kumra

Utilization of Operation Theater 148; Infrastructure of Operation Theater 148
Aim of Planning 148; Requirements for Designing 149
Basic Architecture of the OT 149;Ventilation 151
Electrical 152
22. Preoperative Fasting Guidelines
155
Vinod Kalla
23. Anesthetic Care for MRI
157
Sarla Hooda, Prashant Kumar

Basic Physics 157; Specific Issues 158
Preparation and Techniques 158; Monitoring Equipment 158
Anesthesia for MRI 160; Planning and Safety 161
Index 163
CHAPTER
Practice Guidelines for

Postanesthesia Care Unit
Abdul Qayoom Dar
Introduction
Recovery from anesthesia is, for most patients,
a smooth, uneventful emergence from an
uncomplicated anesthetic and operation. For
anesthesiologists, involvement in optimizing
safe recovery from anesthesia is a key
component of perioperative medicine. Recovery
is an ongoing process that begins when the
intraoperative period has ended and continues
until the patient returns to the preoperative
physiological state and the process is divided
into three phases:
Early recovery (Phase 1) occurs from the
discontinuation of anesthetic agents until
the recovery of the protective reflexes and
motor function.
Intermediate recovery (Phase 2) is the period
during which the criteria for discharge from
the Ambulatory Surgical Unit (ASU) are
obtained.
Late recovery (Phase 3) lasts for several days
and continues till the patient is back to his/
her preoperative functional status and is able
to resume daily activities.
Phase 1 recovery occurs in the postanesthesia Care Units (PACUs), which often face
the task of simultaneously caring for patients
waking up from routine surgery, patients
recovering from regional anesthesia, critically ill
postoperative patients, and children emerging
from the frightening world of anesthesia and

surgery. The staff must be experienced and
flexible to ensure proper early recovery as the
patient emerges from anesthesia and then
to facilitate intermediate recovery when the
patient achieves criteria for discharge to the
ward or directly home following ambulatory
surgery. These are important first steps to allow
patients to return to their normal activity.
History
Although methods of general anesthesia have
been available for more than 160 years, PACUs
have become common only in the past 50 years.
In 1863 Florence Nightingale wrote It is
not uncommon, in small country hospitals, to
have a recess or small room leading from the
operating theater in which the patients remain
until they have recovered, or at least recovered
from the immediate effects of the operation.
In 1949, the Operating Room Committee for
New York Hospital proclaimed: Today it can be
stated categorically that an adequate recovery
room service is a necessity to any hospital
undertaking modern surgical therapy.
Managing PACU Staffing

Staffing in the PACU has to be flexible to
provide a ratio of one nurse to one patient for
the initial 15 minutes of recovery care, then

one nurse to every two patients.
If critically ill patients are admitted, the ratio
is increased to as high as two nurses to one
patient. A charge nurse should oversee the
nursing care.
In most hospitals, the anesthesiologist
remains responsible for managing the
patient in the PACU.
PACU nurses consider 60 minutes to be a
minimum period of time to check the patient
in, process paperwork, and get the patient
ready for transfer to the floor.
Design and Staffing

Location and Size
The PACU should be located close to the
operating suite to permit anesthesiologists
and surgeons to be nearby and allow rapid
return of the patient to the operating room if
necessary.
The size of the unit is determined by
the surgical caseload of the institution.
Approximately 1.5 PACU beds per operating
room used is generally adequate.
An open ward is optimal for patient
observation; however, at least one positive
pressure and one negative pressure room
is a helpful addition to every PACU for the
management of patients with either severe
immunosuppression or at risk to other
patients.
Facilities
The PACU ward itself should have
large doors, adequate lighting, efficient
environmental control and sufficient
electrical and plumbing facilities.
In addition to bed spaces, there should be a
central nursing station, as well as storage and
utility rooms.
Each bed space should have piped-in
oxygen, air, and vacuum for gastric
suction.
Equipment
An automated blood pressure device, pulse
oximetry, electrocardiographic monitoring,
and intravenous supports should be located
by each bed.
An area for charting and storage of bedside
supplies is also necessary, with sterile
suction catheters, needles, syringes, gloves,
and oxygen flow meter available at every
bedside.
Capability for arterial and central venous
pressure monitoring is also required in
hospitals where critically ill postoperative
patients use the PACU.
A supply of immediately available emergency
equipment should also be located in
the PACU and should include an airway
cart consisting of oral and nasal airways;
orotracheal, nasotracheal, and tracheostomy
tubes; laryngoscopes; and self-inflating bags.
A defibrillator capable of defibrillation,
synchronized defibrillation and external
pacing should be available.
A crash cart containing cardiopulmonary
resuscitation equipment and emergency
drugs should be available and fully stocked
at all times. Chest tube trays, cut-down trays,
and tracheostomy trays are necessary.
Routine Recovery
Some facilities require a minimal period
of PACU observation after all surgical
procedures.
Some patients may meet discharge criteria
on arrival at the recovery room.
Instead of requiring a minimum PACU stay
for all patients, PACU stay can be adjusted
according to patient and surgical factors.
Sicker patients undergoing extensive surgery
will require extended recovery.
Transportation
After tracheal extubation, the patient is
transferred from the operating room table to
Practice Guidelines for Postanesthesia Care Unit
a stretcher with side rails that can be moved

into both the Trendelenburg and head-up
positions, if necessary.
The patient should be transported from the
operating room in the lateral position to
minimize the risk of airway obstruction or
aspiration of gastric contents from vomiting.
Most patients benefit by administration of 2
to 4 of oxygen by nasal prongs or a cannula.
Patients 60 years or older or those weighing
100 kg or more are at higher risk for
desaturation.
PACU, and the patients condition should be

recorded in the chart.
Postanesthesia Recovery Score

(Modified Aldrete Score)
Score
Activity
Moves all extremities voluntarily/on

command
Moves two extremities
Unable to move extremities

Respiration
Report
Breathes deeply and coughs freely
On arrival in the PACU, the anesthesiologist

should give the nurse a full report of the
events during surgery.
This report should include the patients
name, age, surgical procedure, medical
problems,
preoperative
medications,
allergies, anesthetic drugs and methods,
fluid and blood replacement, blood loss,
urinary output, gastric output, and surgical
or anesthetic complications encountered.
Dyspneic, shallow or limited breathing
Apneic
Discharge
Before discharge, a patient who has
undergone anesthesia should meet certain
criteria.
The modified Aldrete score is a simple sum
of numerical values assigned to activity,
respiration, circulation, consciousness, and
oxygen saturation; a score of at least 9 out of
10 indicated patient readiness for discharge.
The Postanesthesia Discharge Scoring
System modifies these required parameters
by including assessment of pain, nausea/
vomiting, and surgical bleeding in addition
to vital signs and activity.
The anesthesiologist should see the patient
again before being discharged from the
Circulation
2
BP + /- 20 mm of preanesthetic level
BP + /-2050 mm of preanesthetic level
BP + /- 50 mm of preanesthetic level
Consciousness
Fully awake
Arousable on calling
Not responding
Oxygen Saturation
SpO2 > 92% on room air
Supplemental O2 req. to maintain SpO2

> 90%
SpO2 < 92% with O2 supplementation.
10 = Total score
Score > 9 required for discharge
Patients who have received regional
anesthesia are less likely to have adverse
events including pain and nausea or vomiting,
but are more likely to have a degree of motor
block. In view of these differences, Regional
Anesthesia PACU Bypass Criteria (RAPBC)
have been devised.
PACU Bypass Score Following

Regional Anesthesia
Within 20% of baseline, without

orthostatic changes
Between 20% and 40% of baseline,

without orthostatic changes
stayed 60% and 26% longer, respectively) and

length (i.e. for each 30-minute increase in
duration of surgery, the length of PACU stay
increased by 9%) of the surgical procedure.
General anesthesia versus sedation, and
American Society of Anesthesiologists (ASA)
status were predictors of PACU length of
stay.
Patients with dizziness, postoperative nausea
and vomiting, cardiovascular events, and
pain stayed 31%, 25%, 23%, and 22% longer,
respectively, than did patients without these
adverse events.
A history of smoking also results in longer
stays in the PACU.
Less than 40% of baseline, or orthostatic

changes
Organizational Factors
Parameters
Score
Movement
Purposeful movement of at least one
lower and one upper extremity
Purposeful movement of at least one upper

extremity but neither lower extremity
No purposeful movement
Blood pressure
Level of consciousness
Awake, follows commands
Arousable, follows commands
Obtunded or persistently somnolent
Respiratory effort
Able to cough involuntary on command
Able to cough involuntary but not on

command
Dyspnea or apnea
Pulse oximeter score

SpO2 95% or more on room air
SpO2 95% or more with face mask or nasal

cannula
SpO2 less than 95%
Total score
10
Minimum Score to qualify for PACU bypass is

8. Patients considered for PACU bypass should
not require interventions for pain, postoperative
nausea and vomiting, or shivering.
Factors Influencing Stay in the PACU
A variety of nonmedical factors are important

predictors of prolonged PACU stay.
No available ward bed, waiting for test results,
transport delay, or lack of physician release
accounts for many delayed discharges from
the PACU.
In the ambulatory setting, even after
discharge criteria are met, delays of longer
than 30 minutes because of nonmedical
reasons occur in 54% of outpatients,
with the most common reason being the
unavailability of escorts to take them home
or lack of their discharge medications.
PACU Standards
The ASA has Standards for Postanaesthesia
Care, updated in October 1994, by the ASA
House of Delegates. These Standards apply
to postanesthesia care in all locations. These
Standards may be exceeded based on the
judgment of the responsible anesthesiologist.
They are intended to encourage quality patient
care. They are subject to revision from time to
time as warranted by the evolution of technology
and practice.
Medical Issues
Standard I
The type (i.e. patients undergoing

ophthalmologic and urologic procedures
All patients who have received general

anesthesia, regional anesthesia or monitored
anesthesia care shall receive appropriate postanesthesia management.

1. A PACU or an area which provides equivalent
postanesthesia care shall be available to
receive patients after anesthesia care. All
patients who receive anesthesia care shall be
admitted to the PACU or its equivalent except
by specific order of the anesthesiologist
responsible for the patients care.
2. The medical aspects of care in the PACU shall
be governed by policies and procedures,
which have been reviewed and approved by
the Department of Anesthesiology.
3. The design, equipment and staffing of
the PACU shall meet requirements of the
facilitys accrediting and licensing bodies.
Standard II
A patient transported to the PACU shall be
accompanied by a member of the Anesthesia
Care Team who is knowledgeable about
the patients condition. The patient shall be
continually evaluated and treated during
transport with monitoring and support
appropriate to the patients condition.
Standard III
Upon arrival in the PACU, the patient shall be
re-evaluated and a verbal report provided to the
responsible PACU nurse by the member of the
Anesthesia Care Team who accompanies the
patient.
The patients status on arrival in the PACU
shall be documented.
Information concerning the preoperative
condition and the surgical/anesthetic course
shall be transmitted to the PACU nurse.
The member of the Anesthesia Care Team
shall remain in the PACU until the PACU
nurse accepts responsibility for the nursing
care of the patient.
Standard IV
The patients condition shall be evaluated
continually in the PACU.
The patient shall be observed and monitored

by methods appropriate to the patients
medical condition. Particular attention
should be given to monitoring oxygenation,
ventilation, circulation and temperature.
During recovery from all anesthetics,
a quantitative method of assessing
oxygenation such as pulse oximetry shall be
employed in the initial phase of recovery.
This is not intended for application during
the recovery of the obstetrical patient in
whom regional anesthesia was used for labor
and vaginal delivery.
An accurate written report of the PACU period
shall be maintained. Use of an appropriate
PACU scoring system is encouraged for
each patient on admission, at appropriate
intervals prior to discharge and at the time of
discharge.
General
medical
supervision
and
coordination of patient care in the
PACU should be the responsibility of an
anesthesiologist.
There shall be a policy to assure the
availability in the facility of a physician
capable of managing complications and
providing cardiopulmonary resuscitation for
patients in the PACU.
Standard V
A physician is responsible for the discharge of
the patient from the PACU.
When discharge criteria are used, they
must be approved by the Department of
Anesthesiology and the medical staff. They
may vary depending upon whether the
patient is discharged to a hospital room, to
the Intensive Care Unit, to a short stay unit or
home.
In the absence of the physician responsible
for the discharge, the PACU nurse shall
determine that the patient meets the
discharge criteria. The name of the physician
accepting responsibility for discharge shall
be noted on the record.
Complications
A large study of 18,473 PACU admissions in
a university hospital in 1986 to 1989 found
the incidence of PACU complications to be
nearly 24%. The most common complications
were nausea and vomiting (9.8%), need for
airway support (6.9%), hypotension (2.7%),
dysrhythmia (1.4%), hypertension (1.1%),
altered mental status (0.6%), and major cardiac
events (0.3%). Greater ASA physical status,
anesthesia duration between 2 hours and 4
hours, emergency procedures, and abdominal
and orthopedic procedures had the highest
incidence of complications.
Respiratory Complications
Nearly two-thirds of major anesthesia-related
PACU incidents may be respiratory. The major
respiratory complications encountered in the
PACU are airway obstruction, hypoxemia,
hypercapnia,
and
aspiration.
Prompt
recognition plus treatment of these lifethreatening problems is crucial.
In an evaluation of 24,157 consecutive PACU
admissions over a 33-month period, it was found
that for patients receiving general anesthesia,
the risk of a critical respiratory event was 1.3%
(hypoxemia, 0.9%; hypoventilation, 0.2%; and
airway obstruction, 0.2%). Risk factors were
age older than 60 years, male gender, diabetes,
obesity, emergencies, surgery longer than 4
hours, opioid or sedative premedication, and
the use of thiopental as opposed to propofol.
Airway Obstruction
The most common cause of postoperative
airway obstruction is pharyngeal obstruction.
A combination of backward tilt of the head
and anterior displacement of the mandible is
often helpful.
If the obstruction is not immediately
reversible, a nasal or oral airway can be
inserted. Patients may better tolerate the
nasal airway. The oral airway may stimulate
gagging and vomiting, as well as laryngeal
spasm.
Laryngeal obstruction occurs secondary

to laryngeal spasm, direct airway injury, or
even vocal cord paralysis.
If the airway obstruction is due to laryngeal
spasm, it can sometimes be relieved by
anterior displacement of the mandible. All
patients with airway obstruction should
receive oxygen by facemask (FiO2 of 1.0).
If the obstruction cannot be relieved by
simple maneuvers, 10 mg dexamethasone
intravenously may reopen the airway.
When the airway cannot be opened
by physical means, positive-pressure
ventilation with a bag, mask, and 100%
oxygen is indicated. If succinylcholine has
been given, assisted ventilation should be
continued for at least 5 to 10 minutes, even if
the obstruction has been relieved.
For all cases of airway obstruction, if an
adequate airway cannot be established by
simple physical or pharmacologic means,
orotracheal intubation is necessary.
The laryngeal mask airway may be helpful in
certain patients and has even been used to
provide pressure support ventilation in the
PACU.
In the very rare case in which the trachea
cannot be intubated, an emergency
cricothyroidotomy
will
relieve
the
obstruction. This procedure is probably
safer than emergency tracheostomy because
excessive bleeding is common with the latter
procedure performed under emergency
conditions.
Patients with obstructive sleep apnea are
at high-risk for airway obstruction when
sedated. Nasal continuous positive airway
pressure (CPAP) can be very useful in these
patients after tracheal extubation.
Hypoxemia
After major surgical procedures, all patients
should receive oxygen therapy by facemask
or nasal prongs. The need for such therapy
can be guided by pulse oximetry and is
needed for all those with SpO2 of less than
92%.
Increased age, postanesthetic shivering, and

lowered cardiac output may aggravate the
degree of hypoxemia in postsurgical patients.
Atelectasis is the most common cause of
an increased right-to-left shunt. Bronchial
obstruction from secretions or blood is a
frequent cause of atelectasis. Lobar and
segmental collapse often results from
bronchial obstruction with secretions and
is best managed by providing adequate
humidification of inspired gases, coughing,
deep breathing, and postural drainage.
Pneumothorax is another potential cause
of hypoxemia in the PACU. Pneumothorax
occurs as a result of direct lung or airway
injury from trauma, rib fractures, or attempts
at percutaneous vascular cannulation.
Pneumothorax resulting from mechanical
ventilation per se is rare unless airway
pressure is high.
Treatment depends on the size of
the pneumothorax and the patients
condition. A 10 to 20% pneumothorax in
a spontaneously breathing patient can be
observed with frequent upright chest Xrays. A pneumothorax of more than 20% in
a spontaneously breathing patient or any
pneumothorax in a mechanically ventilated
patient should be treated by insertion of a
chest tube for drainage.
Tension pneumothorax leads to circulatory
compromise as a result of the pleural
cavity filling with air and compressing the
mediastinum. A 14-gauge needle inserted
into the second intercostal space can relieve
the tension before chest tube insertion.
Pulmonary edema can also be a cause of
hypoxemia in the postoperative period.
The most common time of appearance of
pulmonary edema was within 60 minutes
of completion of surgery. Pulmonary edema
was frequently detected by the presence of
wheezing. Prolonged airway obstruction can
cause negative-pressure pulmonary edema.
Current treatment of both forms of
pulmonary edema involves lowering
hydrostatic pressure in the lungs to the
lowest possible level consistent with

adequate perfusion of all organ systems.
Such treatment consists of diuretics, fluid
restriction, vasodilators, or dialysis if
associated renal failure is present. Positivepressure ventilation is useful in patients with
severe hypoxemia or respiratory acidosis.
Ventilation with end-expiratory pressure
improves oxygenation by increasing lung
volume, not by decreasing lung water.
Pulmonary embolism occurring in the
immediate postoperative period is a
serious event that can lead to profound
hypoxemia. Patients at bed rest for
prolonged periods before surgery, patients
who have undergone joint replacement
surgery, or parturients are particularly
susceptible to emboli. The diagnosis
is suspected in a patient with sudden
pleuritic chest pain, shortness of breath,
pleural effusion, or tachypnea. Massive
emboli result in hypotension, pulmonary
hypertension, and elevated central venous
pressure. Because the treatment of choice
is anticoagulation, establishment of an
accurate diagnosis is imperative so that
patients in the immediate postsurgical
period are not needlessly exposed to the
risks of anticoagulation.
Diffusion hypoxemia can occur but are rarely
seen in clinical practice because oxygen
administration prevents manifestation of
these conditions. Diffusion hypoxia occurs
when N2O is replaced with air at the end of
the anesthetic.
Treatment of hypoxemia by facemask
oxygen is effective in restoring PaO2 in many
cases.
If hypoxemia persists (PaO2 < 60 mm Hg)
despite maximal oxygen therapy (FiO2 = 1.0),
Tracheal intubation and mechanical
ventilation should be initiated.
The use of CPAP by an external mask
(mask or nasal CPAP) is increasingly being
used for the treatment of patients with
severe hypoxemia who have adequate
carbon dioxide elimination (PaCO2).
Hypoventilation
Hypotension
Hypoventilation is defined as reduced

alveolar ventilation resulting in an increase
in PaCO2.
During
the
postoperative
period,
hypoventilation occurs as a result of poor
respiratory drive, poor respiratory muscle
function, or a high rate of production of
carbon dioxide, or it can be a direct result of
acute or chronic lung disease.
Central respiratory depression is seen
with any anesthetic. Narcotic-induced.
respiratory depression can be reversed with
the use of narcotic antagonists.
When small doses are used, these agents
can reverse the narcotic-induced respiratory
depression without altering pain relief.
Titration of a small dose and increasing
the dose upward until an effect is seen can
avoid the sudden onset of severe pain along
with the profound reflex tachycardia and
hypertension.
Failure of reversal of neuromuscular
blocking drugs may result in inadequate
respiratory muscle function postoperatively.
Hypermagnesemia
potentates
neuromuscular
blockade,
as
does
hypothermia.
Obesity, gastric dilation, tight dressings,
and body casts also inhibit respiratory
muscle function and can predispose to CO2
retention. Measurement of PaCO2 is the best
method of detecting hypoventilation in the
postoperative period.
Treatment of serious respiratory failure
necessitates emergency tracheal intubation.
The recovery phase of anesthesia is usually

associated with decreased ventricular
preload, reduced myocardial contractility,
or a profound reduction in systemic vascular
resistance.
Prompt diagnosis and treatment are
important because prolonged hypotension
can result in hypoperfusion of vital organs
and subsequent ischemic damage.
If hypotension persists despite attempts to
restore intravascular volume, ventricular
preload must be further assessed. During this
time, administration of a vasopressor will
prevent a prolonged period of hypotension
while
hemodynamic
monitoring
is
established.
Hypovolemic shock is characterized by low
PAOP (< 510 mm Hg) with a normal low
cardiac index (normal, 2.54.0 L/min/m2)
and normal or elevated systemic vascular
resistance.
Cardiogenic shock is characterized by
increased PAOP (>15 mm Hg) with a low
cardiac index and elevated systemic vascular
resistance.
Septic shock, PAOP will usually be low with
a very high cardiac output and low systemic
vascular resistance. The patient often has
fever, an elevated white blood cell count, and
some other sign of systemic infection.
Treatment of such prolonged hypotension
is now guided by following the variables of
Ventricular preload, cardiac output, and
urinary output. Hypovolemic shock is treated
by intravenous administration of blood and
crystalloid.
Cardiogenic shock is managed by first
optimizing ventricular preload. Most
patients have optimal cardiac output when
PAOP is increased to 15 to 20 mm Hg.
Occasional patients with severe, longstanding ventricular failure will require a
PAOP of 20 to 25 mm Hg to maintain cardiac
output. In addition to an optimal preload,
these patients also require inotropic
support.
Circulatory Complications
Critical cardiovascular events are the second
major group of life-threatening complications
for patients in the PACU. In a study involving
more than 18,380 patients after general
anesthesia, patients in whom hypertension or
tachycardia developed in the PACU had more
unplanned critical care admissions and a higher
mortality.
Septic shock is managed by replacing the

fluid lost from capillary endothelial leak
with crystalloid. The use of albumin in this
situation is possibly harmful because the
albumin can leak out into the interstitium and
draw intravascular fluid with it. A vasopressor
such as norepinephrine or phenylephrine
could be introduced to improve blood
pressure. Use of vasoconstrictors for more
than 24 hours may result in renal and
gastrointestinal ischemia.
Hypertension
When hypertension develops in a patient in
the PACU, it is often due to pain, hypercapnia,
hypoxemia, urinary retention, or excessive
intravascular fluid volume. These etiologies
need to be ruled out.
Severe hypertension can lead to left
ventricular failure, myocardial infarction, or
a dysrhythmia as a result of a sharp increase
in myocardial oxygen consumption.
Acute hypertension may also precipitate
acute pulmonary edema or cerebral
hemorrhage. Pre-existing hypertension is
present in more than half the patients in
whom hypertension develops in the recovery
room. When hypertension does develop
during recovery from anesthesia, it usually
begins within 30 minutes of the end of the
operation.
-blocking drugs such as labetalol and
esmolol are effective in treating hypertension
during recovery. Labetalol, a combined and -blocking agent, is commonly used in
the PACU.
Labetalol can be given in 5-mg increments
intravenously, with the effect on blood
pressure apparent in several minutes.
Labetalol is also effective in neurosurgical
patients already receiving high doses of
nitroprusside.
Esmolol is an ultrashortacting -blocker. Its
short half-life means that it must be given as
a continuous infusion at rates of 25 to 300 g/
kg/min.
Dysrhythmias
Factors predisposing to the development of
postoperative dysrhythmias are electrolyte
imbalance
(especially
hypokalemia),
hypoxia, hypercapnia, metabolic alkalosis
and acidosis, and pre-existing heart disease.
When a dysrhythmia occurs in a patient in
the PACU, it is often a sign of some metabolic
or perfusion problem.
The most common dysrhythmias are sinus
tachycardia, sinus bradycardia, ventricular
premature beats, ventricular tachycardia,
and supraventricular tachyarrhythmias.
Treatment of predisposing factors usually
will help in resolution of the dysrhythmias.
Failure to Regain Consciousness

Evaluation of a patient who does not regain
consciousness after general anesthesia
requires careful assessment of the patient.
Preoperative factors such as drug or alcohol
intoxication should be sought. The most
common reason for persistent somnolence is
the residual effects of anesthetics, sedatives,
and preoperative medications.
Initial
management
should
include
pharmacologic reversal agents aimed at the
most likely sedative drug.
Naloxone in small doses will increase the
ventilatory rate if narcotic sedation is the
problem.
Physostigmine (1.25 mg intravenously) can
reverse the effects of some sedatives and
inhaled anesthetics.
Flumazenil (up to 1.0 mg intravenously) can
reverse the sedative and amnestic effects of
the benzodiazepines.
Because profound neuromuscular blockade
can make a patient appear unconscious,
such blockade should also be considered.
Profound
hypothermia
(temperature
< 33C) can produce unconsciousness, as can
profound abnormalities in serum glucose
such as hyperglycemia or hypoglycemia.
Blood glucose, electrolytes, and blood gases
should be evaluated in all such cases.
10
If one has reason to suspect hypoglycemia,

50% dextrose should be administered
immediately
and
blood
glucose
determination not awaited. If the diagnosis
remains unclear, a structural neurologic
abnormality should be sought. Raised
intracranial pressure may occur after head
trauma or neurosurgery.
Intraoperative cerebral hypoxia from
hypoxemia or poor cerebral perfusion
can produce a diffuse encephalopathy.
Emergency computed axial tomographic
scanning can be used to evaluate the
presence of raised intracranial pressure or
an acute intracranial hemorrhage as the
cause of the delayed emergence.
Rarely, overdose with lidocaine can be
manifested as unconsciousness. Old age per
se does not account for delayed emergence
from general anesthesia.
Postoperative Pain
One of the important jobs in PACU is
adequate control of pain during rest (rest
pain) and pain with activity (incident pain).
Rest pain is generally easier to alleviate.
Incident pain is more difficult to manage.
The choice of a particular postoperative
pain management regimen depends on
the anticipated pain intensity. Despite new
techniques and increased emphasis on
relieving acute pain, postoperative pain
remains undertreated. Reasons include
confusion about who is responsible for
analgesia, providers lack of knowledge
regarding the effective dose ranges and
duration of action of opioids, and fears of
respiratory depression and addiction.
Risk Factors for Increased Pain

Many factors influence the onset, incidence,
and severity of postoperative pain.
The very young and very old experience less
pain than do people in the middle years of
life.
Preoperative neurotic personality traits tend

to increase postoperative pain, as does the
fear of pain itself.
The site of the operation certainly influences
the severity of pain. In general, thoracotomy
and upper abdominal surgery appear to
be the most painful operations. Lower
abdominal surgery is less painful.
Opioids
Morphine by titration is often the first step in
postoperative pain management.
Intravenous morphine titration every 5
minutes with an unlimited number of boluses
and early subcutaneous administration
provided the best analgesic regimen in a
study investigating different methods of
titration.
Administering morphine at the end of
surgery (13 mg intravenously every 5 or 10
minutes) instead of waiting until the patient
is in the PACU improves pain relief with
less respiratory depression. Patients will
need encouragement to cough and breathe
deeply.
Patient-controlled analgesia permits the
patient to determine the timing of analgesic
doses and allows for improved titration of
analgesia. It also minimizes patient anxiety.
Patients receiving this form of pain therapy
should have it begun in the PACU. Morphine
has been the gold standard for this form of
therapy.
Nonsteroidal Anti-inflammatory Drugs

Nonsteroidal
anti-inflammatory
drugs
(NSAIDs) can be part of an effective
multimodal
analgesia
protocol
that
includes instructing the patient to take pain
medication as soon as discomfort occurs.
NSAIDs are useful for postoperative pain
management because surgery causes both
pain and inflammation.
NSAIDs may be divided into three groups:
NSAIDs with predominant analgesic effect
(ketorolac, naproxen), NSAIDs that are
11
Nerve Blocks
essentially anti-inflammatory (oxicams),

and NSAIDs that have both analgesic and
anti-inflammatory
effects
(diclofenac,
ketoprofen, indomethacin).
Ketorolac, though not as potent as the
narcotics, can be an effective alternative to
narcotic analgesics in the PACU. Depending
on the type of surgery, adding ketorolac
reduces the total opioid dose by a third (with
a range from 0% to 73%, depending on the
type of surgery) and improves pain relief.
The risk for adverse events with ketorolac
increases with high doses, with prolonged
therapy, or in vulnerable patients (e.g. the
elderly). Ketorolac is as safe as ketoprofen
and diclofenac for the treatment of pain after
major surgery.
When a postoperative anticoagulant was
administered, patients who received
ketorolac were likely to have surgical-site
bleeding.
Regional anesthesia has been used for the

relief of postoperative pain to avoid narcoticinduced respiratory depression. Instillation
of local anesthetic into a wound can be very
efficacious and is simple to perform.
Continuous epidural blockade can provide
good postoperative analgesia and, when
done in the thoracic space, can permit early
postoperative ambulation.
Patients receiving epidural pain relief can be
ambulated earlier, thereby permitting earlier
hospital discharge.
The use of regional anesthesia for
postoperative pain relief appears to be
best suited for patients with pre-existing
lung disease in whom narcotics would be
hazardous and when a regional technique
could relieve pain without adversely affecting
respiration.
Epidural Analgesia
Nausea and Vomiting
The use of narcotics in the epidural space to

control postoperative pain is a very effective
approach.
Morphine, 2 to 4 mg diluted to 10 mL,
provides prompt analgesia with duration
of action of about 12 hours. Complications
include late respiratory depression, which
can occur as long as 6 hours after injection
of the morphine. Significant respiratory
depression occurs in less than 1% of patient
receiving epidural narcotics and can be
reversed with naloxone.
Synthetic narcotics have also been used
successfully for epidural analgesia.
About 15 to 20% of patients complain of
pruritus. Nausea and urinary retention have
also been reported to be complications.
The technique is most helpful when used
for patient undergoing major thoracic or
abdominal surgery who are at high-risk
for complications of parenteral analgesic
therapy.
Postoperative nausea and vomiting are

common complications that result in patient
discomfort, prolonged stay in the PACU,
and rarely, one of the pulmonary aspiration
syndromes. Postoperative nausea and
vomiting are multifactorial in etiology.
Propofol-based anesthetics are consistently
associated with a lower incidence of
postoperative nausea and vomiting than
other techniques are, even when potent
antiemetics such as ondansetron are
combined with inhaled drugs.
A literature review of 27 publications found
that all but 3 contained evidence implicating
nitrous oxide in postoperative nausea and
vomiting.
Patients undergoing laparoscopic surgery
and strabismus surgery are at increased risk
for nausea and vomiting. Patients who are
menstruating have a higher risk of nausea
and vomiting after laparoscopy for tubal
ligation.
12
Drug Therapy for Nausea and Vomiting
OUTPATIENT SURGERY
The serotonin antagonists ondansetron,

dolasetron, and granisetron are useful as
first-line drugs.
Adding dexamethasone can reduce the
frequency of nausea and vomiting, even when
compared with the serotonin antagonist
alone. There is little evidence of any clinically
relevant toxicity for dexamethasone in
otherwise healthy patients. Late efficacy
seems to be most pronounced.
Metoclopramide is an effective and safe
antiemetic for both prevention and treatment
of postoperative nausea and vomiting.
Over 50% of all surgical procedures are

performed on an outpatient basis, which
is safe and effective for properly chosen
patients.
These patients will need to be able to leave
the facility shortly after discharge from the
PACU.
Patients should always be accompanied
by another person. Because virtually all
anesthetic techniques impair psychomotor
skills, driving or operating machinery should
not be attempted for 24 hours.
Increasing efforts are being directed at
having patients completely bypass (fast
tracking) the phase 1 PACU after general
anesthesia.
Low-solubility inhaled anesthetics and
propofol, the increasing frequency of
minimally invasive surgery and titration
of anesthetic drugs by using the processed
electroencephalographic bispectral index
(BIS) may allow patients to be awake, alert,
and mobile enough with no bleeding or
nausea at the end of an operative procedure
such that they can safely bypass the
PACU.
A study of 302 patients receiving a propofolalfentanil-nitrous oxide anesthetic at four
institutions found that patients in the BIS
group required lower propofol infusion
rates, were tracheally extubated sooner, had
a higher percentage of patients oriented
on arrival at the PACU, had better PACU
nursing assessments, and became eligible
for discharge sooner.
Patients admitted to the phase 1 PACU have
an average length of stay of 30 minutes.
Patients are typically discharged from the
phase 2 PACU to home in 1 hour.
The potential benefits of fast tracking need
to be considered against any possible
disadvantages such as the perception by
patients that they are being rushed out of the
PACU too quickly.
Hypothermia and Shivering

Surgical patients may be admitted to the
PACU with inadvertent hypothermia (i.e.
core temperatures < 36C).
Mild perioperative core hypothermia
may increase the risk of wound infection,
bleeding, cardiac complications, and
prolonged PACU stay.
The major adverse effects are patient
discomfort, vasoconstriction, and shivering.
Full recovery sometimes takes many hours.
Shivering increases the metabolic rate and
hence the need to increase cardiac output
and minute ventilation.
Hypothermic
patients
should
have
supplemental oxygen, warm intravenous
fluids and blood, and external warming.
External warming can be accomplished with
forced hot air blown with use of Bair Huggers.
Patients in whom shivering develops should
receive supplemental oxygen.
Although many drugs have been used to
treat postanesthetic shivering, Pethidine
(2530 mg intravenously) is very effective in
both stopping the shivering and decreasing
oxygen consumption. In some patients a
second dose is necessary.
Fentanyl is also effective, but for a shorter
interval.
13
Fast Tracking
(Contd...)
Fast tracking is a clinical pathway that

involves transferring patients from the
operating room to ASU directly without
entering the PACU.
Achieving an Aldrete score of 9 or 10 in the
operating room has been used to bypass the
PACU. However, the Aldrete scoring system
does not address pain, nausea and vomiting,
which are common side effects in the PACU.
White and Song have devised a scoring
system that includes pain and emetic
symptoms within the Aldrete scoring system.
Under this system, a score of 12 with no score
less than 1 in any category provides criteria
for bypassing the PACU (White PF, Song D
Anesth Analg. 1999;88:106972)
White and Song Scoring System

Parameters
Score
Level of Consciousness
Awake and oriented
2
Arousable with minimal stimulation
1
Responsive only to tactile stimulation
0
Physical Activity
Able to move all extremities on command
2
Some weakness in movement of extremities
1
Unable to voluntarily move extremities
0
Hemodynamic Stability
Blood pressure less than 15% of baseline
2
MAP value
Blood pressure 15%30% of baseline MAP
1
value
Blood pressure more than 30% of baseline
0
MAP value
Respiratory Stability
Able to breathe deeply
2
Tachypnea with good cough
1
Dyspnea with weak cough
0
Oxygen Saturation Status
Maintains value > 90% on room air
2
Requires supplemental oxygen (Nasal
1
Prongs)
(Contd...)
Saturation < 90% with supplemental oxygen

Postoperative Pain Assessment
None or mild discomfort
Moderate to severe pain controlled with
intravenous analgesics
Persistent severe pain
Postoperative Emetic Symptoms
None or mild nausea with no active vomiting
Transient vomiting or retching
Persistent moderate to severe nausea and
vomiting
Total Possible Score
0
2
1
0
2
1
0
14
Discharge Criteria from Ambulatory

Surgical Unit (ASU)
Discharge of patients home from ASU
requires strict adherence to validated criteria
to ensure safety and to prevent litigation.
Criteria for safe discharge home from ASU
have been developed as postanesthesia
discharge score system (PADS) by Chung
et al. and subsequently modified by Awad
and Chung (Chung F, et al. Can J Anaesth,
1995;42:1056-8 and Awad IT, Chung F Can J
Anaesth. 2006; 53: 858-72).
Postanesthesia Discharge Score

System (PADS)
Parameters
Score
Vital Signs
Within 20% of preoperative baseline
2040% of preoperative baseline
40% of preoperative baseline
Activity Level
Steady gait, no dizziness, consistent with
preoperative level
Requires assistance
Unable to ambulate/assess
Nausea and Vomiting

(Contd...)
14
(Contd...)
Minimal: Mild, no treatment needed
Moderate: Treatment effective
Severe: Treatment not effective
Pain
VAS = 03
VAS = 46
VAS = 710
Surgical Bleeding
Minimal: Does not require dressing change 2
Moderate: Required upto two dressing
changes with no further bleeding
Severe: Required three or more dressing

changes and continues bleeding
Total Score
10
Patient score > or equal to 9 are fit for discharge.

Patients are often discharged in 1 to 2 hours or
less following ambulatory surgery. Many ASUs
use outcome based criteria for discharge instead
of numerical scoring like PADS and include the
following:
Alert and oriented to time and place
Stable vital signs
Pain controlled by oral analgesics
Nausea or emesis controlled
Able to walk without dizziness
Regional anesthesia block appropriately
resolved
No expected bleeding from the operative site
Given
discharge
instructions
and
prescriptions
Patient accepts readiness for discharge
Adult present to accompany patient home.
PEDIATRIC PACU
Caring for a pediatric patient after anesthesia
requires special preparation and knowledge
of the potential postoperative complications
specific to children.
Not all PACUs are dedicated solely to
pediatric recovery, so it is important that staff
with pediatric experience be available.
Children can be safely fast-tracked after
ambulatory surgery.
In addition to basic PACU equipment, an

air-O2 blender is necessary so that a 100%
inspired O2 concentration can be avoided
in preterm infants at risk for retrolental
fibroplasia.
Code carts should be stocked with
equipment specific to children, including
cuffed and uncuffed endotracheal tubes,
several sizes of pediatric masks, oral and
nasal airways, laryngoscopes, and a carbon
dioxide detector.
The cart should also have intraosseous
needles in the event that the code team is
unable to start an intravenous line.
A drug manual (e.g. a laminated sheet
attached to the code cart) with common
pediatric dosages should be immediately
available.
Parental Presence
Although parental presence in phase 2 or
step-down recovery is common, parental
visitation in the phase 1 PACU remains
somewhat controversial.
Particular subsets of patients, especially
those who suffer from developmental delay
or sensory deficit, may benefit from having
their parents close by to help calm them
when they awaken.
Visitation in the PACU may also reduce
parental anxiety and increase parental
satisfaction.
Parents in the PACU should be allowed to see
their child only after the child has regained
consciousness and no longer requires the
staffs immediate attention.
The nursing staff must be comfortable
with having parents in the recovery area.
Parents need to be made aware that they
may be asked to leave if the child becomes
unstable.
Specific Postoperative Problems

Emergence Delirium
Pediatric patients will on occasion
emerge from anesthesia disoriented and
inconsolable. This phenomenon is termed
emergence delirium and may even require

restraint of the patient.
Emergence delirium has been associated
with the use of less soluble anesthetics as
opposed to more soluble anesthetics such as
halothane.
Adequate analgesia with opiates or NSAIDs
may reduce the incidence of delirium.
Inviting the parents to visit in the PACU may
help calm a child.
When evaluating a patient with suspected
emergence
delirium,
life-threatening
complications such as hypoxia, acidosis, or
increased intracranial pressure should be
ruled out.
Postintubation Croup
Postintubation subglottic edema is a
complication that can occur in 1 to 6%
of patients younger than 4 years. Even a
minimal amount of airway edema can cause
significant obstruction, especially at the level
of the cricoid cartilage, the narrowest section
of the pediatric airway.
Patients who have a history of Downs
syndrome or other congenital airway
stenosis, a surgical procedure in and
around the airway, recent upper respiratory
infection, coughing on the endotracheal
tube, prone position, or traumatic intubation
are at increased risk.
Appropriate therapy includes cool mist by
face tent and nebulized racemic epinephrine
(0.5 mL of 2.25% epinephrine in 2.5 mL of
normal saline).
Corticosteroids such as dexamethasone
have also been used to treat airway edema,
but no data support their routine use for
postintubation subglottic edema.
Rarely does a patient require reintubation.
Postanesthetic Apnea
Former preterm infants (born before 37
weeks gestation) are at increased risk
for apnea and bradycardia after even
15
uncomplicated anesthesia. These events

may be secondary to underlying neurologic,
cardiac, or pulmonary disease.
Patients with anemia are at higher risk for
apnea.
Ex-preterm infants who are less than 45 to
60 weeks postconceptual age are admitted
for monitoring after surgery for at least 12
to 18 hours. The overall risk of apnea in
patients less than 48 weeks postconceptual
age is 5%, and this risk does not decrease to
less than 1% until patients reach 54 weeks
postconceptual age.
Intravenous caffeine, 10 mg/kg, has been
used to treat apneic episodes in preterm
infants and has been recommended for
prophylaxis against postoperative apnea.
Conclusion
Recovery from anesthesia is, for most patients,
a smooth, uneventful emergence from an
anesthetic. Recovery is an ongoing process
that begins when the intraoperative period has
ended and continues until the patient returns
to the preoperative physiological state. Trained
nursing personnel look after the patients
airway, breathing, circulation and provide
comfort in the form of pain relief and warmth
till they are ready for discharge from PACU.
Before discharge, a patient should meet certain
criteria referred to as The modified Aldrete
score and the patients condition at discharge
should be recorded in the patients notes and
handed over to the nursing personnel from the
respective wards.
PACU should have facilities to take care of
patients with hypoxia and other respiratory
complications,
hypotension
and
other
circulatory complications, delayed awakening
from anesthesia, treat nausea and vomiting if
any and prevent and treat hypothermia and
shivering.
It should be a safe process from anesthesia
and surgery in the operating room to discharging
a fully awake, stable and pain free patient back
to the ward.
16
Further Suggested Reading

1. American
Society
of
Anesthesiologists:
Practice guidelines for postanesthetic care.
Anesthesiology. 2002; 96:742-52.
2. Practice Guidelines for Postanaesthetic Care
An Updated Report by the American Society of
Anesthesiologists Task Force on Postanaesthetic
Care Anesthesiology. 2013;118:291-307.
3. Nicholau TK. The postanesthesia care unit. In:

Miller RD, editor. Millers Anesthesia. 8th edn.,
Philadelphia, PA: Elsevier; 2015.pp.2924-46.
4. Cohen IT, Deutch N, Motoyama EK. Induction,
maintenance and recovery. In: Smiths
Anesthesia for infants and children, 8th edn.,
Philadelphia, PA: Elsevier, 2015.p.365-94
CHAPTER
Perioperative Care of
Ambulatory Anesthesia
Anil Agarwal, Kamal Kishore
Ambulatory surgery is defined as any operation

or procedure or any outpatient intervention
where the patient is discharged on the same
working day. It gained popularity in 1960
when first unit of ambulatory anesthesia was
established but formal development occurred
with the formation of Society for Ambulatory
Anesthesia (SAMBA) in 1984.
The need for day care surgery is expanding
with the change in financial situation of the
world. Recent advances of anesthesia, surgery
and pain management have resulted in a vast
expansion of this modality and resulted in
decreased hospitalization.1 The availability of
rapid, short acting anesthetic, analgesic and
muscle relaxant drugs have clearly facilitated the
recovery process after surgery and development
of minimally invasive surgical procedures
have added wings to ambulatory anesthesia.2
The facilities of ambulatory anesthesia can
be attached to main hospital or office based
which involves the conduct of anesthesia in
a location that is integrated to a physicians
office. The advantages of ambulatory anesthesia
are personal attention, care, service, ease
of scheduling, greater privacy, lower cost,
increased efficiency and decreased nosocomial
infection. Despite advantages of ambulatory
anesthesia one must remember that it is not
for every anesthesiologist or surgeon nor
appropriate neither for every patient nor for

every surgical procedure.
As far as the data is concerned National
health statistics report USA state that among all
surgical procedures more than 60% of surgeries
were conducted on ambulatory basis and
less than 0.8% needed inpatient admission.3
Although data is not available for India, there is
huge potential for ambulatory anesthesia and
surgery in view of large population and massive
growth of private sector.
For providing optimal perioperative care
during ambulatory surgery and anesthesia
one should always consider patient selection
criteria
and
preoperative
assessment,
surgical procedures and their duration,
preparation, anesthetic management, recovery,
postoperative complications and organization.
Patient selection: Ambulatory surgery should
be accompanied by minimum disturbances in
postoperative physiology and uncomplicated
recovery.4 There must be certain criteria
for determining patient selection for
ambulatory procedures. It is recommended
that multidisciplinary approach, with agreed
protocols for patients assessment including
inclusion and exclusion criteria for day
care surgery, should be agreed locally with
anesthesia department. These should take into
account:
18
Patient medical status (specific diagnosis,

co-morbid conditions and duration of
therapy)
Degree of stability of medical status
Patients psychological status
Patients support system at home
Intensity and duration of postprocedural
monitoring
Risk of developing complications [deep vein
thrombosis (DVT) and pulmonary embolism
(PE)].
Mostly patients being treated in ambulatory
surgical units belong to ASA physical status I
and II but with the improved anesthesia and
surgical techniques, patients with medically
stable ASA physical status III and IV are also
being allowed with the same low incidence of
morbidity.5 The complications and the duration
of stay can be minimized if pre-existing medical
conditions are stable for more than three
months before scheduled operation.6 Now a
days a full term infant for more than one month;
an elderly patient with multiple comorbidities
are acceptable for day care procedures. It is ideal
for children because of minimum separation
from their parents and risk for hospital acquired
infection.7,8
There are few contraindications for
ambulatory procedures:9
Potentially life-threatening chronic illnesses
Morbid obesity complicated by symptomatic
cardiorespiratory problems (e.g. angina,
asthma)
Multiple chronic centrally active drug
therapies or active cocaine abuse
Ex-premature infants less than 60 weeks
postconceptual age requiring general
endotracheal anesthesia
No responsible adult at home to care for the
patient on the evening after surgery.
Preoperative Assessment
Preoperative assessment of outpatients is
increasingly important to avoid costly delays
or last minute cancellations. The assessment of
the medical condition of the patient should be
based on recent history, physical examination
and laboratory investigations.10 Although

the National Institute of Health and Clinical
Excellence (NICE) guidance on preoperative
investigations is widely used, one recent study
showed no difference in the outcomes of day
surgery patients even when all preoperative
investigations were omitted.11 The concerned
anesthesiologist should carefully consider
the following specific factors while deciding
anesthesia in their ambulatory unit:12
Abnormalities of major organ systems, and
stability and optimization of any medical
illness.
Difficult airway, morbid obesity and/or
obstructive sleep apnea.
Previous adverse experience with anesthesia
and surgery.
Current medications and drug allergies,
including latex allergy.
Time and nature of the last oral intake.
History of alcohol or substance use or abuse.
Presence of a adult who assumes
responsibility specifically for accompanying
the patient from the ambulatory unit.
Perioperative care
The anesthesiologist providing patient care in
the ambulatory setting should adhere to the
standard protocols and guidelines to assure
optimal safety and comfort of the patient.
Preoperative preparation
Optimal preoperative preparations reduce the
risks adherent to ambulatory surgery, improve
patient outcome and make surgery more safer
and acceptable for the patient. Appropriate
fasting protocol and medications (to be taken or
withheld) before surgery should be ascertained.
Measures should be taken to minimize the
patients anxiety.
Intraoperative care
Appropriate selection and patient preparation
is very important for ambulatory surgery.
The ideal outpatient anesthetic should have
Perioperative Care of Ambulatory Anesthesia
a rapid and smooth onset of action, produce

intraoperative amnesia and analgesia, provide
optimal surgical conditions and adequate
muscle relaxation with a short recovery period,
and have no adverse effects in the postdischarge
period. Standard intra-operative monitoring
guidelines for ambulatory surgery should be
followed.
The choice of anesthesia technique depends
on surgical and patient factors. Anesthetic
technique should ensure minimum stress
and maximum comfort for the patient along
with considering the risk and benefit of that
technique. The anesthetic technique in
ambulatory anesthesia can range from local
anesthetic infiltration to sedation to general
anesthesia. Although there is no ideal technique
or drug for day care procedures, a knowledge
of options available is important for optimal
surgical conditions and fast-track recovery.9
General anesthesia
General anesthesia remains the most widely
used anesthetic technique for ambulatory
surgery despite higher incidence of side effects
than regional anesthesia. LMA insertion shows
minimal cardiovascular response, better
tolerance and less airway complications in
lighter plane of anesthesia than endotracheal
intubation. Total intravenous anesthesia (TIVA)
is an advantageous technique in ambulatory
anesthesia using propofol and fentanyl
(remifentanyl is preferred if available) utilizing
a computer based drug delivery system. It
avoids the risk of failure of regional block,
residual muscle paralysis and lesser side effects
in the form of decreased postoperative nausea
vomiting (PONV). Use of newer inhalational
agents like sevoflurane and desflurane shows
faster emergence than intravenous agents.13,14
Regional Anesthesia
Regional anesthesia can offer advantages for
ambulatory surgery with respect to speed of
recovery, decreased nursing care and more
effective analgesia in early post operative
19
period.15 Central neuraxial blocks (spinal and

epidural anesthesia) are offered commonly in
day care surgery. Residual blockade in spinal
or epidural anesthesia may cause problem like
postural hypotension and urinary retention
despite return of sensory or motor function. So
it is important to choose the most appropriate
local anesthetic and adjuvant combination
so as to avoid prolonged local anesthetic
effect. Suggested criteria before attempting
ambulation after neuraxial block include the
return of sensation in the perianal area (S4-5),
plantar flexion of the foot at preoperative levels
of strength and return of proprioception in the
big toe.16
Peripheral Nerve block

The peripheral nerve blocks like bracheal
plexus or femoral sciatic nerve block can
provide profound and prolonged anesthesia
to an extremity and are very popular in
ambulatory anesthesia. Use of ultrasound
enhances the accuracy of block. Continuous
infusion local anesthetic can decrease the
need for intravenous opioid analgesics and
enhance the patient satisfaction and mobility.17
In paediatric patients peripheral nerve block
can be performed immediately after general
anesthesia and caudal nerve block is most
preferred in this segment of patients.
Local Infiltration
Infiltration of local anesthetic at the surgical
site is the simplest and safest method of
postoperative pain relief. Patient comfort can be
improved if intravenous sedation and analgesia
is used to complement it. It can be used as a sole
anesthesia technique for superficial procedures
(inguinal hernia, breast lump, few plastic
surgery procedures).18
Intravenous regional
anesthesia
The intravenous regional anesthetic (IVRA)
technique with 0.5% lidocaine is a simple and
20
reliable technique for short superficial surgical

procedures (< 60 minutes) limited to a single
extremity. It is more cost effective technique
for outpatient hand surgery than general
anesthesia.9
criteria and this resulted in earlier discharge

for up to 20% of the outpatients studied (Table
2.1).21
Postoperative recovery
and discharge
The ambulatory surgery continues to grow

but ambulatory centers should develop the
methods to measure the outcome during early
and late postoperative period. The incidence of
major morbidity is very low but certain clinical
anesthesia outcome like incision pain, nausea,
vomiting preoperative anxiety and pain of
intravenous line insertion should be avoided.22
Delayed discharge and unexpected hospital
admission after outpatient surgery are the most
commonly identified outcome measures after
ambulatory anesthesia (Table 2.2).23
There are three phases of recovery after

ambulatory anesthesia, i.e. early, intermediate
and late.
During early recovery phase the patient
emerge from anesthesia, recover their protective
reflexes and resume early motor activity. As per
the patients need, the oxygen supplementation,
analgesic or antiemetic medications are
administered. Modified Aldrete score is
commonly used to assess the fitness of patient
to shift to recovery area.
During intermediate phase patient start
voiding, ambulate, drinks fluid and prepare
for discharge. Anesthesia technique and
medications used mainly affect the intermediate
phase. Other factors that prolong this phase
are female gender, advanced age, prolonged
surgery, larger blood loss, postoperative
pain and nausea and vomiting and spinal
anesthesia.19,20
The late recovery phase starts after
the discharge of the patient till complete
physiological and psychological recovery and
patient resumes their normal daily activity. The
surgical procedure itself has the highest impact
on late recovery.
Another objective discharge criteria has been
developed for patient readiness for discharge
is called as Postanesthesia Discharge Scoring
System (PADSS). It is based on five major
criteria which include (a) vital signs, including
blood pressure, heart rate, respiratory rate, and
temperature; (b) ambulation and mental status;
(c) pain and postoperative nausea and vomiting;
(d) surgical bleeding; and (e) fluid intake/
output. This was later modified by Chung F et al
who eliminated input and output as a discharge
Outcome measures
TABLE 2.1
Modified postanesthesia
discharge scoring (PADS) system.
Vital Signs
2
1
0
Ambulation
2
1
0
Nausea and Vomiting
2
1
0
Pain
2
1
0
Surgical Bleeding
2
1
0
Within 20% of the

preoperative value
20%40% of the
preoperative value
40% of the preoperative
value
Steady gait/no dizziness
With assistance
No ambulation/dizziness
Minimal
Moderate
Severe
Minimal
Moderate
Severe
Minimal
Moderate
Severe
Perioperative Care of Ambulatory Anesthesia

TABLE 2.2
21
Factors alleged to delay discharge and lead to unanticipated admissions after ambulatory
surgery
Delayed Discharge
Preoperative
Female gender
Increasing age
Congestive heart failure
Intraoperative
Long duration of surgery
General anesthesia
Spinal anesthesia
Postoperative
Postoperative nausea and vomiting
Moderate-to-severe pain
Excess drowsiness
No escort
Unanticipated Admissions
Surgical
Pain
Bleeding
Extensive surgery
Surgical complications
Abdominal surgery
Otorhinolaryngology and urology surgery
Anesthesia
Nausea and vomiting
Somnolence
Aspiration
Social
No escort
Medical
Diabetes mellitus
Ischemic heart disease
Sleep apnea
Conclusion
Ambulatory anesthesia is a faster growing
subspecialty of anesthesia. One should be
careful about choosing the patients, optimizing
them preoperatively, planning optimal
anesthesia technique, using appropriate
monitoring system, caring their postoperative
complications and discharging them with
optimal advice to make it more beneficial for
them. In future the ambulatory care will reach

people in geographically distant areas as well.
References
1. Gangadhar S, Gopal T, Sathyabhama, Paramesh
K. Rapid emergence of day-care anesthesia: A
review. Indian J Anaesth. 2012;56(4):336-41.
2. Michaloliakou C, Chung F, Sharma S. Anesth
Analg. Preoperative multimodal analgesia
22
facilitates recovery after ambulatory laparoscopic

cholecystectomy. 1996;82(1):44-51.
3. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory
surgery in the United States, 2006. Natl Health
Stat Report. 2009;28(11):1-25.
4. Duncan PG. Day surgical anesthesia: Which
patients? Which procedures? Can J Anaesth.
1991;38:881.
5. Warner MA, Shields SE, Chute CG. Major
morbidity and mortality within 1 month of
ambulatory surgery and anesthesia. JAMA. 1993;
270:1437.
6. Junger A, Klasen J, Benson M, et al. Factors
determining length of stay of surgical day-case
patients. Eur J Anaesthesiol. 2001;18:314.
7. Verma R, Alladi R, Jackson I, Johnston I, Kumar
C, et al. Day case and short stay surgery:
2. Anesthesia. 2011;66(5):417-34.
8. Collins CE, Everett LL. Challenges in pediatric
ambulatory anesthesia: kids are different.
Anesthesiol Clin. 2010;28(2):315-28.
9. Paul F White, Matthew R Eng. Ambulatory
(Out Patient) anesthesia. Miller 7th edn, 2010.
pp.2419-2460.

10.
Borkowski
RG.
Ambulatory
anesthesia:
preventing perioperative and postoperative
complications. Cleve Clin J Med. 2006;73
(Suppl 1):S57-61. Review.
11. Chung F, Yuan H, Yin L, Vairavanathan S, Wong
DT. Elimination of preoperative testing in
ambulatory surgery. Anesthesia and Analgesia.
2009;108:467-75.
12. Office based surgery guidelines. Massachusetts
Medical society. Update 2011.
13. Reader J. Clinical ambulatory anaesthesia book.
Cambridge University press; Cambrideg, UK.
2010.pp.1-185.
14. Elliott RA, Payne K, Moore JK. Clinical and

economic choices in anesthesia for day surgery:
A prospective randomized controlled trial.
Anesthesia 2003; 58:412.
15. Liu SS, Strodtbeck WM, Richman JM, Wu
CL. A comparison of regional versus general
anesthesia for ambulatory anesthesia: A metaanalysis of randomized controlled trials. Anesth
Analg. 2005; 101:1634-42.

16. British Association of Day Surgery. Spinal
Anesthesia for Day Surgery Patients. London:
BADS, 2010.

17. Hadzic A, Arliss J, Kerimoglu B, et al. A
comparison of infraclavicular nerve block versus
general anesthesia for hand and wrist day-case
surgeries. Anesthesiology. 2004; 101:127-32.
18. Kehlet H, White PF. Optimizing anesthesia for
inguinal herniorraphy: General, regional, or
local anesthesia? (Editorial). Anesth Analg. 2001;
93:1367-69.
19. Edler AA, Mariano ER, Golianu B, et al. An analysis
of factors influencing postanesthesia recovery
after pediatric ambulatory tonsillectomy and
adenoidectomy. Anesth Analg. 2007; 104:784-9.
20. Chung F, Mezei G. Factors contributing to a
prolonged stay after ambulatory surgery. Anesth
Analg. 1999; 89:1352.
21. Chung F, Chan VW, Ong D. A postanesthetic
discharge scoring system for home readiness
after ambulatory surgery. J Clinical Anesth. 1995;
7:500-6.
22. Macario A, Weinger M, Carney S. Which clinical
anesthesia outcomes are important to avoid?
The perspective of patients. Anesth Analg.1999;
89:652.
23. Chung F. Factors affecting recovery and discharge
following ambulatory surgery. Can J Anaesth.
2006; 53:858-72.
CHAPTER
Anaphylactic Reactions
During Anesthesia
Anjan Trikha
Anaphylaxis
Anaphylaxis represents the most severe form of
immediate hypersensitivity reaction.
The World Allergy Organization and
the European Academy of Allergology and
Clinical Immunology defined anaphylaxis in
20031 as a severe, life-threatening generalized
or systemic hypersensitivity reaction. They
classified anaphylaxis into two typesallergic
anaphylaxis (mediated by an immunological
mechanism) and non-allergic anaphylaxis
(mediated by non-immunological mechanisms
which were previously known as anaphylactoid
reactions).
The American Academy of Allergy, Asthma
and Immunology, in 2010 defined anaphylaxis
as one of the three clinical scenarios(1) The
acute onset of a reaction (minutes to hours)
with involvement of the skin, mucosal tissue
or both and at least one of the following
(a) respiratory compromise, (b) reduced
blood pressure or symptoms of end-organ
dysfunction, (2) Two or more of the following
that occur rapidly after exposure to a likely
allergen for that patientinvolvement of the
skin/mucosal tissue, respiratory compromise,
reduced blood pressure or associated symptoms
and/or persistent gastrointestinal symptoms,
(3) Reduced blood pressureafter exposure to
a known allergen. It continued to use the term
anaphylactoid reactions for non-IgE mediated

reactions producing the same clinical picture as
anaphylaxis.2
Anaphylaxis occurring during anesthesia is
a life-threatening complication. The incidence
of such perioperative anaphylactic reactions
is estimated to be between 1 in 10000 and 1 in
20000 anesthetic administrations3,4 and the
mortality is estimated to be 3 to 9%.5
etiology of Perioperative
Anaphylaxis
Anaphylactic reaction can occur to almost all
agents to which the patient is exposed during
the perioperative period. Neuromuscular
blocking agents (NMBA) are the most common
cause, with the most frequently reported
drug being succinylcholine.6 The incidence of
anaphylactic reactions to NMBAs vary between
different countries, which could be explained
by varying levels of environmental exposure
to chemicals containing the same quaternary
ammonium structure as NMBAs. For instance,
extensive use of pholcodine containing cough
syrup in Norway had resulted in increased
rates of sensitization to NMBAs, especially
rocuronium.7
Atracurium and mivacurium can lead to
direct release of histamine from mast cells
and can cause nonallergic anaphylaxis.
24
Pancuronium, cisatracurium and vecuronium

seem to have lower potential for causing
anaphylactic reactions.6 Allergy to one NMBA
can also cause cross sensitization to other
NMBAs.8
Natural rubber latex is the second most
common agent involved in perioperative
anaphylaxis. IgE antibodies to water soluble
Hev b (Hevea brasiliensis) proteins present in
latex are responsible for causing such reactions.
Patients with atopy, children undergoing
multiple surgical procedures, such as for spina
bida, or patients with allergy to certain fruits
are at increased risk for latex allergy.9
Antibiotics are an important cause of
anaphylaxis showing an increasing trend over
the years in many studies.6 The most commonly
implicated agents are beta-lactam antibiotics
(penicillins and cephalosporins), followed by
quinolones.10
Anaphylactic reactions to intravenous
induction agents are rare. Anaphylaxis to
thiopentone has been reported in the past,
but presently the incidence is rare probably
because of the declining use of thiopentone.11
Anaphylaxis with the present preparation of
propofol is rare as cremaphor EL (a potent
anaphylactic agent) is no longer used in it.10
Similarly anaphylactoid reactions to etomidate
have been reported but are rare.12
Opioids like morphine, pethidine and
codeine can lead to direct histamine release and
cause nonallergic anaphylaxis whereas this is
not seen with fentanyl and other newer agents.10
Local anesthetics are a rare cause of
anaphylactic reactions, but they can lead to
type 4 delayed hypersensitivity reactions.10 The
ester group of local anesthetics are potentially
immunogenic while the amide ones are usually
not.10 The preservative methyl paraben used in
many local anesthetic preparations could be
responsible for anaphylaxis.
Intravenous colloids have been implicated in
perioperative anaphylaxis, the incidence being
greatest with gelatin based colloid solutions.
It is lower with dextran and rare with hydroxyl
ethyl starch.10
Nonsteroidal
anti-inflammatory
drugs
(NSAIDs) inhibiting COX1 enzyme can cause
non-immunogenic anaphylactic reactions.11
Paracetamol can be rarely involved while
selective COX-2 inhibitors appear to be safe.
Antiseptic solutions containing chlorhexidine,
cetrimide, and povidone iodine, dyes such
as methylene blue and Patent Blue V, radiocontrast agents, blood and blood products
are other agents implicated in perioperative
anaphylaxis.11 Reports of anaphylaxis to many
other drugs including protamine sulfate,
heparin, ranitidine, ondansetron, tranexmic
acid, neostigmine and even to the newer reversal
agent sugammadex have been published.
Inhalational anesthetics are an exception and
no case of anaphylaxis to such agents has been
reported till date.
Some patients are more prone to develop
perioperative anaphylaxis. The risk factors for
developing anaphylaxis to specific agents are
summarized in Table 3.1.
Clinical Features
The grading of severity of anaphylactic reactions
is given in Table 3.2.
The most commonly reported signs in
severe grade III or IV reactions are absence of
peripheral pulse, desaturation and difficulty to
ventilate.15 Itching, cough, nausea, vomiting,
difficulty in breathing, and abdominal cramps
are some other common symptoms in a awake
patient.
Cardiovascular manifestations are the
most common signs during perioperative
anaphylaxis.16
These
are
hypotension,
tachycardia or bradycardia (the latter
representing a more severe reaction), cardiac
arrhythmias, anaphylactic shock, acute
coronary events and cardiac arrest. In many
cases cardiovascular collapse may be the
sole manifestation. An acute coronary event
associated with a hypersensitivity reaction is
known as Kounis syndrome.17 Mucocutaneous
signs might not be present initially in grade
III or IV reactions as there will be cutaneous
Anaphylactic Reactions During Anesthesia

TABLE 3.1
Risk factors for developing perioperative anaphylaxis11,13
Anesthetic agent
For all anesthetic
medications
Neuromuscular
blocking agents
Latex
Antibiotics
Colloids
Propofol
TABLE 3.2
Grade
25
Risk factors
1.Previous unexplained reaction during general anesthesia
2.Female sex
3.Hereditary angioedema
4.Multiple drug allergy syndrome
5.Mastocytosis
Exposure to quaternary ammonium ion containing compounds, e.g. Cough syrups
containing pholcodine and cosmetics
1.History of atopy
2.Children with spina bifida
3.History of multiple surgeries, multiple urinary catheterizations
4.Food allergy especially to fruits such as banana, papaya, chestnut, etc.
5.Healthcare professionals
1.History of penicillin allergy
2.Multiple episodes of infection and exposure to antibiotics, e.g. chronic smokers with
repeated lung infections
Gelatin allergy
Allergy to soy or egg (doubtful)
Grading of severity of anaphylactic reactions14
Features
Mucocutaneous signs: erythema, urticarial rash, with or without angioedema
II
Moderate multisystem involvement: Mucocutaneous signs with cardiovascular and/or respiratory

changeshypotension/ tachycardia/ difficulty to ventilate/dyspnea/cough/gastrointestinal
disturbances
III
Severe life-threatening mono or multisystem involvement: Cardiovascular collapse with tachycardia

or bradycardia, with or without bronchospasm/mucocutaneous signs/gastrointestinal disturbances
IV
Cardiac arrest
vasoconstriction due to cardiovascular

collapse.14 Commonly seen respiratory findings
during anaphylaxis are bronchospasm,
difficulty to ventilate and desaturation. Usually
bronchospasm is associated with cardiovascular
signs.14
The timing of anaphylactic reactions
is generally within seconds to minutes of
administering an intravenous agent, most
commonly at induction. In case of latex allergy,
it is delayed and occurs intraoperatively. The
timing of the reaction and its relation to the
etiology is shown in Table 3.3 as given by the
BSACI guidelines 2009.18
Differential Diagnosis
Signs and symptoms similar to those occurring
during an anaphylactic reaction can occur
due to many other reasons during anesthesia
such as hypotension due to exaggerated
drug effects/overdose or drug interactions.
Other common causes areparasympathetic
responses to laparoscopy, peritoneal traction,
flushing of the skin due to venous obstruction
or head down position, shock due to blood
loss, bronchospasm, hypoxia or difficulty in
ventilation due to asthma, blocked endotracheal
tube, esophageal intubation or pulmonary
26
TABLE 3.3
Timing of anaphylactic reaction and the associated etiologies
Within minutes of induction
Intraoperative
Towards end of surgery
NMBAs
IV induction agents, opioids,
antibiotics
IV NSAID /paracetamol
IV opioids, antibiotics
Local anesthetics
Colloids; with in few minutes from
start of infusion
Latex rubber allergy
Dyes/contrast media
Chlorhexidine
Povidone iodine
Rectal NSAID
IV opioids
Colloids
Neostigmine
Latex rubber allergy
edema and cardiovascular collapse due to

myocardial infarction or air embolism. Often, it
becomes difficult to diagnose an anaphylactic
reaction during anesthesia and it requires a high
level of suspicion along with clinical correlation.
Management Guidelines
The latest guidelines for treatment of immediate
hypersensitivity reactions during anesthesia
was published in 2011 by the French Society
for Anesthesia and intensive care and the
French Society of Allergology,15 approved
by the members of European Network for
Drug Allergy. The management will depend
upon whether the patient is under regional
or general anesthesia and also on the severity
of the reaction. The management is outlined
in Table 3.4 and specific strategies depending
on the severity5 are discussed here. The doses
recommended for pediatric use are shown in
Table 3.5.
Grade I Reactions
General measures such as 100% oxygen,
stopping the suspected agent and administering
intravenous fluids are usually sufficient for the
management of grade I reactions. Additionally,
a H1 antihistaminic (diphenhydramine 0.5
1 mg/kg) together with H2 antihistaminic
(ranitidine 1 mg/kg) can be used.5
TABLE 3.4
Immediate management of
perioperative anaphylaxis
I ncrease FiO2 to 100%

Rapid airway control (intubate if necessary)
Stop the suspected agents if possible
Inform the surgical team and end surgery as
soon as possible.
Intravenous fluids, elevate lower limbs
Maintain anesthesia with inhalational agents
Drugs depending upon the severity (adrenaline,
beta agonists, antihistaminics, vasopressin,
steroids)
Close monitoring (institute invasive monitoring
if needed)
Call for help whenever necessary
Grade II and III Reactions

Intravenous boluses of adrenaline should be
given. Dose depends on the severity (1020
mcg for grade II and 100200 mcg for grade
III reactions). This can be repeated every 1
to 2 minutes till adequate blood pressure
is achieved. When repeated boluses are
required, an intravenous infusion of 0.05 to
0.1 mcg/kg/min can be used as an alternative.
When there is no intravenous access, 0.3 to
0.5 mg of adrenaline can be administered
intramuscularly and repeated depending on the
response. Intratracheal route in an intubated
patient is an alternative. In patients on betablockers, if the first dose of adrenaline (100

TABLE 3.5
27
Management of perioperative anaphylaxis in childrenrecommended drug doses5
Drug
Dose
Adrenaline
Grade IV reaction10 mcg/kg boluses

Grade II or III reactionsstart at 1 mcg/kg and titrate according to response
Glucagon
2030 mcg/kg (infusion rate5 mcg/min)
Inhaled salbutamol 50 mcg/kg which can be repeated every 1015 minutes (maximum dose1500 mcg/kg)
mcg) is not effective, it should be increased

without delay to 1 mg at 1 to 2 minutes intervals.
If not responding, intravenous glucagon 1 to 2
mg is to be given at 5 minutes intervals. Instead,
an infusion of glucagon 0.3 to 1 mg/hour (5 to 15
mcg/kg) can be used.
Infusion of large volumes of intravenous
crystalloids may be necessary to replenish the
intravascular volume. Colloids can be used
when the requirement of crystalloids exceeds
30 mL/kg. If a colloid is suspected of causing
the reaction, it should be avoided. The infusion
set is to be changed when an intravenous fluid
is suspected of causing the reaction. In case
of bronchospasm, inhaled beta agonists like
salbutamol can be administered. Intravenous
beta agonists can be used in refractory cases.
In case of no response to high dose of
adrenaline, other drugs can be used. Intravenous
noradrenaline can be started at the rate of 0.1
mcg/kg/min or terlipressin can be used in a
2 mg bolus. Steroids are not important in the
immediate management. Hydrocortisone 200
mg bolus every 6 hours can be used to attenuate
late manifestations of shock.
Grade IV ReactionCardiac Arrest

External cardiac compressions are to be
initiated along with intravenous adrenaline 1 mg
boluses every 1 to 2 minutes. Cardiopulmonary
resuscitation is to be continued as per guidelines
for circulatory failure.
Investigation of a Suspected
Perioperative Anaphylaxis5,18
The initial diagnosis of a perioperative
anaphylactic reaction is presumptive. The final
diagnosis of the reaction and the etiology rests

upon collective evidence from an accurate
clinical history, tests performed in the acute
phase and tests performed later. It is the
anesthetists responsibility to direct the patient
for a complete work-up.
Clinical History
A detailed clinical history of all the risk factors
has to be obtained including history of previous
exposure to suspected agents and comorbid
conditions like mastocytosis or asthma. An
accurate history of the anaphylactic event has to
be obtained and the anesthetic chart has to be
reviewed if available.
Tests in the Acute Phase

Serum Tryptase
Tryptase is an enzyme specific to mast cells
and the serum levels increase during an allergic
anaphylactic reaction. It has a short half-life and
serum samples for tryptase estimation should
be collected early after the reaction. The AAGBI
guidelines recommend collecting three samples
for serum tryptase estimationfirst sample
immediately after the initial resuscitation,
second sample after 1 hour and the third sample
after 24 hours of the reaction.18 The third sample
gives the baseline tryptase values of the patient
which may be increased in some patients (e.g.
Mastocytosis). An increased tryptase level
suggests an anaphylactic reaction but a negative
result does not exclude it. False positive
results are seen in the following conditions
mastocytosis, myocardial ischemia, severe
trauma, hypoxia, end stage renal failure, heroin
28
toxicity, blood dyscrasias such as acute myeloid

leukemia, myelodysplastic syndrome.19
Histamine Levels
Plasma histamine levels are elevated in both
allergic and nonallergic anaphylactic reactions.
The half-life is very short and sample for
histamine estimation should be preferably
collected within the first 30 minutes of the
reaction. Similarly, urine histamine levels are
also elevated after an anaphylactic reaction.
IgE assay
The measurement of specific IgE in the serum
by radioallergosorbent test (RAST) is a valuable
test while investigating the etiology of an
anaphylactic reaction, especially when skin
tests are negative. They can be tested either
during an acute reaction or later along with
skin tests. Currently specific IgE assays have
been described for latex, NMBAs, thiopentone,
chlorhexidine and penicillin group of drugs.5
Late Investigations
Skin Tests
Skin tests are the reference tests for diagnosing
immediate hypersensitivity reactions. There
are two types of skin tests which act as an
indirect evidence of IgE mediated allergyskin
prick tests (SPT) and intradermal tests (IDT).
They are to be performed 4 to 6 weeks after
the occurrence of the anaphylactic reaction.
When performed earlier the probability of false
negative tests increases.
For anesthetic drugs SPT or IDT or both in
succession can be done. For latex allergy, SPT is
to be done and for antibiotics, IDT is to be done.
The concentrations of different agents used for
skin tests should be according to a standardized
protocol to avoid false positive results. The
recommended concentrations5 for various
agents are listed in Table 3.6.
A positive SPT result is dened as the
appearance of a wheal after 20 minutes that
has a diameter 3 mm greater than that of the
negative control or a diameter of at least half the

diameter of the positive control wheal. A positive
IDT result is the appearance of an erythematous
wheal (often pruritic) after 20 minutes, the
diameter of which is at least equal to twice that
of the postinjection wheal.5 As cross reactivity
is quite common with NMBAs, after a positive
test to one NMBA, all other available NMBAs
should be tested.
Provocative Tests
They are the gold standard tests for diagnosing
hypersensitivity to an agent. They can be used
when skin tests are negative or not validated
(e.g. NSAIDs). The test involves reproduction
of allergic symptoms by providing a challenge
dose of the suspected agent. But provocative
tests have a limited role in perioperative
anaphylaxis as anesthetic agents have potent
pharmacological effects and challenge tests can
lead to catastrophic consequences. Their role is
therefore limited to latex allergy, NSAIDs, local
anesthetics and beta lactam antibiotics.5
All testing should be done at a place where
necessary personnel and facilities exist for
resuscitation of the patient in case of an
anaphylactic reaction during testing.
Administering Anesthesia to a
Patient with History of Drug Allergy/
Anaphylaxis5
Preanesthetic Allergy Work-up
Routine screening is not recommended for
all patients scheduled for a surgery under
anesthesia. However, it is important to
identify patients with risk factors during the
preanesthetic visit. Allergy workup should
be done in patients with a previous history of
anaphylaxis during anesthesia and in those
with a history of latex allergy. If the patient has
not been worked up previously, allergy testing
to all NMBAs and latex has to be done. If the
patient has been investigated previously, then
the results of the drug allergy tests are to be
documented. If the previous reaction was to

TABLE 3.6
29
Recommended concentrations of various agents for skin tests5
Agents
Skin prick tests
Intradermal tests
mg/mL
Dilution
mg/mL
Dilution
mcg/mL
Atracurium
10
1/10
1/1000
10
Pancuronium
Undiluted
1/100
20
Rocuronium
10
Undiluted
10
1/200
50
Vecuronium
Undiluted
1/10
400
Suxamethonium
50
1/5
10
1/500
100
Thiopentone
25
Undiluted
25
1/10
2500
Propofol
10
Undiluted
10
1/10
1000
Etomidate
Undiluted
1/10
200
Midazolam
Undiluted
1/10
500
Ketamine
10
1/10
10
1/10
1000
Morphine
10
1/10
1/1000
10
Fentanyl
0.05
Undiluted
0.05
1/10
Bupivacaine
2.5
Undiluted
2.5
1/10
250
Lidocaine
10
Undiluted
10
1/10
1000
Ropivacaine
Undiluted
Chlorhexidine
0.5
Undiluted
1/10
200
1/100
Povidone iodine
100
Undiluted
1/10
1000
Methylene blue
10
Undiluted
1/100
100
a NMBA, all new NMBAs are to be tested. In

patients with a history of allergy to NSAIDs or
paracetamol, provocative testing can be done if
the intervention is not an emergency.
Allergy work-up is not necessary for
patients with a history of allergy to a drug not
used during anesthesia. All patients with a
documented allergy should be educated about
the problem and should be advised to wear
bracelets or carry cards indicating their drug
allergy at all times.
Premedication
Routine premedication is not recommended.
Premedication with H1 antihistaminics has been
shown to decrease the severity of nonallergic
anaphylactic (anaphylactoid) reactions but it
is ineffective in allergic anaphylactic reactions.
Combination of H1 and H2 antihistaminic has

not been found superior to H1 antihistaminic
alone.5 Current evidence suggests that
premedication with steroids is of limited value
in preventing anaphylaxis.20
Anesthetic Technique
In an Emergency
Local and regional techniques are preferred
in patients with history of hypersensitivity
reaction during previous anesthesia with no
allergy work-up. A latex-free environment has
to be provided. If general anesthesia is needed,
then muscle relaxants and histamine releasing
agents are to be avoided. AntiCOX-1 NSAIDs
are to be avoided and selective COX-2 inhibitors
can be used.5
30
In a Patient with Documented Allergy Work-up

The agent for which allergy is documented has
to be avoided. Antibiotic prophylaxis should
be preferably administered before induction
of anesthesia. In case of an adverse reaction,
it is easier to resuscitate an awake patient
when compared to an anaesthetized patient,
as anesthetic drugs can profoundly alter the
cardiovascular physiology. If the previous
reaction was to a muscle relaxant, all muscle
relaxants are preferably avoided or a NMBA to
which skin test was negative can be used.5
In case of latex allergy, the patient should be
kept as the first case in the operation list and
a latex-free environment has to be provided.
Latex containing things in the operating room
could be gloves, foleys catheters, suction tubes,
nasogastric tubes, nasopharyngeal airways,
breathing circuits, masks, reservoir bag,
ventilator bellows, blood pressure measuring
cuff, wires of monitors, injection ports of
infusion sets, syringes, multi dose injection
vial stoppers, adhesives, elastic bandages, etc.
It is important to identify the latex containing
things and provide a latex-free alternative
wherever possible. Other strategies to minimize
contact with latex containing items should be
carried out when latex-free alternative cannot
be provided for certain items, e.g. Wires/cords
of monitoring devices (pulse oximeter/ECG/
non invasive blood pressure) can be placed in
stockinet and secured with tapes.21
Conclusion
Anaphylaxis is a life-threatening complication
and it is imperative that every anesthetist
must be well prepared to handle it when the
situation arises. Also, it is the responsibility
of the anesthetist to direct such a patient for a
complete allergy work-up as a future exposure
to the same agent can be catastrophic.
References
1. Johansson SG, Bieber T, Dahl R, et al. Revised
nomenclature for allergy for global use: Report
of the Nomenclature Review Committee of the
World Allergy Organization, October 2003. J

Allergy Clin Immunol. 2004;113(5):832-6.
2. Lieberman P, Nicklas RA, Oppenheimer J, et al.
The diagnosis and management of anaphylaxis
practice parameter: 2010 update. J Allergy Clin
Immunol. 2010;126(3):477-80
3. Fisher MM, Baldo BA. The incidence and
clinical features of anaphylactic reactions during
anesthesia in Australia. Annales Francaises
dAnesthesie et de Reanimation 1993;12: 97-104.
4. Laxenaire MC. Epidemiology of anesthetic
anaphylactoid reactions. Fourth multicenter
survey (July 1994-December 1996). Annales
Francaises dAnesthesie et de Reanimation.
1999;18: 796-809.

5. Mertes PM, Malinovsky JM, Jouffroy L;
Working Group of the SFAR and SFA, Aberer
W, Terreehorst I, Brockow K, Demoly P; ENDA;
EAACI Interest Group on Drug Allergy. Reducing
the risk of anaphylaxis during anesthesia: 2011
updated guidelines for clinical practice. J Investig
Allergol Clin Immunol. 2011;21(6):442-53.
6. Dong SW, Mertes PM, Petitpain N, et al.GERAP:
Hypersensitivity reactions during anesthesia.
Results from the ninth French survey (20052007). Minerva Anestesiol. 2012;78(8):868-78.
7. Florvaag E, Johansson SG, Irgens , de Pater
GH. IgE-sensitization to the cough suppressant
pholcodine and the effects of its withdrawal from
the Norwegian market. Allergy. 2011;66(7):955-60.
8. Mertes PM, Laxenaire MC, Alla F. Anaphylactic
and
anaphylactoid
reactions
occurring
during anesthesia in France in 19992000.
Anesthesiology. 2003;99(3):536-45.
9. Niggemann B, Breiteneder H. Latex allergy
in children. Int Arch Allergy Immunol.
2000;121(2):98107.
10. Mertes PM, Tajima K, Regnier-Kimmoun MA, et
al. Perioperative anaphylaxis. Med Clin North
Am. 2010;94(4):761-89.
11. Harper NJ, Dixon T, Dugu P, et al; Working Party
of the Association of Anaesthetists of Great.
Britain and Ireland. Suspected anaphylactic
reactions associated with anesthesia. Anesthesia.
2009;64(2):199-211.

12. Moorthy SS, Laurent B, Pandya P, et al.
Anaphylactoid reaction to etomidate: report of a
case. J Clin Anesth. 2001;13(8):582-4.
13. Liccardi G, Lobefalo G, Di Florio E, et al. Cardarelli
Hospital Radiocontrast Media and AnestheticInduced Anaphylaxis Prevention Working
Group. Strategies for the prevention of asthmatic,
anaphylactic and anaphylactoid reactions
during the administration of anesthetics and/or

contrast media. J Investig Allergol Clin Immunol.
2008;18(1):1-11.

14. Dewachter P, Mouton-Faivre C, Emala CW.
Anaphylaxis and anesthesia: controversies
and new insights. Anesthesiology. 2009;111
(5):1141-50.

15. Mertes PM, Laxenaire MC. Allergy and
anaphylaxis in anesthesia. Minerva Anestesiol.
2004;70(5):285-91
16. Laxenaire M, Mertes PM, GERAP. Anaphylaxis
during anesthesia. Results of a 2 year survey in
France. Br J Anaesth. 2001;21(1):54958.
17. Kounis NG. Coronary hypersensitivity disorder:
the Kounis syndrome. Clin Ther. 2013;35
(5):563-71.
31
18. Ewan PW, Dugu P, Mirakian R, et al. BSACI.

BSACI guidelines for the investigation
of suspected anaphylaxis during general
anesthesia. Clin Exp Allergy. 2010;40(1):15-31.
19. Michalska-Krzanowska G. Tryptase in diagnosing
adverse suspected anaphylactic reaction. Adv
Clin Exp Med. 2012 May-Jun;21(3):403-8.
20. Sheikh A. Glucocorticosteroids for the treatment
and prevention of anaphylaxis. Curr Opin Allergy
Clin Immunol. 2013;13(3):263-7.

21. American association of nurse anesthetists:
Latex allergy protocol. http://www.aana.com/
resources2/professionalpractice/Documents/
PPM%20Latex%20Allergy%20Protocol.pdf
CHAPTER
Acute Pain Management Guidelines

and Protocols: Evidencebased
Ashok Kumar Saxena
Work over the past thirty years has rejected the model of a pain mechanism as caused by a fixed rigid
modality dedicated mechanism. The process, which produces pain, is plastic and changes sequentially
with time. That essential mobility of mechanism exists in damaged tissue, in the peripheral nerves
and spinal cord. This movement of pathology from periphery to center proceeds with the triggering of
reactive processes in the brain. It presents the therapist with a migrating distributed target.
Professor Patrick Wall
Underassessment and undertreatment of

pain appears to be common in the developing
nations and even in the developed world.
Definition
ASA Task Force defines acute pain as pain that is
present in a surgical patient after a procedure.1
In the opinion of ASA Task Force, acute
pain management in the perioperative setting
is referred to as actions done before, during,
and after a procedure to reduce or eliminate
postoperative pain before discharge.1
Acute pain management guidelines are
being developed as a measure of providing
optimum pain relief. They need to be reviewed at
regular intervals and can be adopted, modified
or rejected with the changing and upcoming
evidence which emerges from time to time.1
They may or may not be adopted completely
in a particular set-up, and can be modified in
a specific set-up depending on the availability
of resources and clinical requirements. It is for

sure that these guidelines being developed are
based on the available evidence in the literature.
We have to accept that even their application
cannot guarantee any specific outcome.1
Acute pain is the most frequently
encountered variety of pain all over the world.
It is an important and significant aspect of
childbirth, surgeries, trauma and acute medical
illness.2 Acute pain is also responsible for
being the reason in more than two-thirds of
consultations in emergency department.3
Whereas pain is considered to be an
experience with sensory, cognitive, and
emotional components, nociception refers to
neural process by which stimuli that can elicit
pain are detected by the nervous system.
Despite recent advances in the development
of newer opioids and non-opioids molecules,
and despite the use of minimally invasive
surgery, millions and millions of people not only
in developing nations, but also in developed
Acute Pain Management Guidelines and Protocols: Evidencebased
world continue to suffer because of inadequate

assessment and undertreatment.
It is very well established that uncontrolled
and unrelieved acute pain not only results
in high degree of suffering and discomfort,
but also results in terrible consequences like
delayed wound healing, loss of body weight,
increased hospital stay, and the ultimate risk of
development of chronic persistent postsurgical
pain.4-7
Aims of the Guidelines

1. To facilitate the safety and effectiveness of
acute pain management in the perioperative
setting.
2. To reduce the risk of adverse outcomes.
3. To maintain the patients functional
abilities, as well as physical and psychologic
well-being.
4. To enhance the quality of life for patients
with acute pain during the perioperative
period.1
Scientific Evidence
All these guidelines are based on scientific
evidence which have been defined as follows:
Category A
Supportive literaturebased on randomized
controlled trials (RCT)1
a. Level 1: The literature contains multiple
RCTs and findings are supported by
meta-analysis.
b. Level 2: The literature contains multiple
RCTs, but the number of studies is insufficient
to conduct a viable meta-analysis
c. Level 3: The literature contains a single
randomized controlled trial.
Category B
Suggestive literature information obtained
from observational studies.1
33
a. Level 1: The literature contains observational

comparisons (e.g., cohort, case-control
research designs) of clinical interventions
or conditions and indicates statistically
significant differences between clinical
interventions for a specified clinical outcome.
b. Level
2:
The
literature
contains
noncomparative observational studies with
associative (e.g., relative risk, correlation) or
descriptive statistics.
c. Level 3: The literature contains case reports.
Category C
Equivocal literatureindeterminate information
in the literature which can be beneficial and
harmful in various interventions.1
a. Level 1: Meta-analysis did not find significant
differences among groups or conditions.
b. Level 2: The number of studies is insufficient
to conduct meta-analysis, and (1) RCTs
have not found significant differences
among groups or conditions or (2) RCTs
report inconsistent findings.
c. Level 3: Observational studies report
inconsistent findings or do not permit
inference of beneficial or harmful
relationships.
Category D
Insufficient evidence from literature.1
The lack of scientific evidence described as
inadequate or silent.
Opinion-based Evidence
Obtained from survey data, open-forum
testimony, internet-based comments, letters,
editorials.1
Category A
Expert opinion1
In this category, survey responses can be
obtained from the Task force appointed expert
consultants.
34
Category B
Membership based opinion.1
In this category, survey responses can be
obtained from the active ASA members using a
5 point score:
1. Strongly agree
2. Agree
3. Equivocal
4. Disagree
5. Strongly disagree
Category C
Consensus based opinion.1
In this category, information can be obtained
through open forum testimony from previous
updates, internet based comments, letters, and
editorials informally evaluated and discussed.
ASA Task Forces

recommendations for
providing post operative
pain management
Institutional Policies and Procedures
Providing Perioperative Pain
Management.1
It includes:
1. Education and training for healthcare
providers
2. Monitoring of patient outcomes
3. Documentation of monitoring activities
4. Monitoring of outcomes at an institutional
level
5. 24-hours availability of anesthesiologists
providing perioperative pain management
6. Use of a dedicated acute pain service.
In the opinion of Gleman et al, Harmer et
al, Rose et al and White anesthesiologists
offering perioperative analgesia services
as a perioperative physician should be
knowledgeable and skilled with regard
to the effective and safe use of the
available treatment options (Category
B2 evidence).8-11
Briggs et al, Camp et al, Clarke et al,

Davis et al, Enhfors et al and Bardiau
et al, suggest that educational content
should range from basic bedside pain
assessment to pharmacological as well
as nonpharmacological techniques.12-18
The above authors also recommends
that anesthesiologists and healthcare
personnel should use standardized and
validated instruments for evaluation and
documentation of pain intensity.12-18 At
every cost, pain should be implemented
as a 5th vital sign in each hospital.
In the opinion of Bardiau et al, Gould et
al, Mackintosh et al, Miaskowski et al ,
Pesut et al, Sartain et al, Stacey et al and
Stedler et al, anesthesiologists should
be available all the time (24 hours
availability) to consult with ward nurses,
surgeons or other physicians involved
in providing perioperative pain services
(Category D evidence). Adverse effects
associated with the analgesic therapy
should be documented and promptly
dealt with.19-27
The above authors also recommends
that
anesthesiologists
providing
perioperative
analgesia
services
should do with in the frame work of
the acute pain services. Observational
studies indicate that acute pain
services are associated with reduction
in perioperative pain (Category B2
evidence). They should participate in
developing standardized institutional
policies and procedures.19-27
Preoperative Evaluation of the Patient

It includes:
1. Directed history and preoperative pain
mapping.
2. Directed physical examination and relevant
investigations.
3. Acute pain control plan
Furdon et al suggest a directed
pain history and preoperative pain
mapping (e.g. medical record review,

current medications, adverse effects,
pre-existing pain conditions, medical
conditions that would influence a
pain
therapy,
nonpharmacologic
pain
therapies,
alternative
and
complementary therapies.28 (Category
D evidence).
Furdon et al emphasise on a directed
physical examination and relevant
investigations.28
In the opinion of Anderson and Daltroy
et al, acute pain control plan should be
included in the anesthetic preoperative
evaluation.29,30 Implementation of pain
management protocol is associated
with reduced analgesic use, shorter
time to extubation, and shorter time to
discharge (Category B2 evidence).
Preoperative Preparation
of the Patient
It includes:
1. Adjustment or continuation of medications
whose sudden cessation may provoke a
withdrawal syndrome
2. Treatments to reduce pre-existing pain and
anxiety
3. Premedications before surgery as part of a
multimodal analgesic pain management
program
4. Patient and family education, including
behavioral pain control techniques.30-36
Appropriate titration, adjustment or
continuation of medications in order
to avert withdrawal syndrome should
be included in patient preparation
(Category D evidence).
Daltroy et al and Egbert et al emphasize
on the treatment of pre-existent
pain, preoperative education by
encouragement
and
instructions
of postoperative pain management
therapy.30,31
Anesthesiologists offering perioperative
analgesia services should impart, in
collaboration with other healthcare
35
personnel, patient and family education

regarding their important roles in
achieving comfort, reporting pain, and
in proper use of the recommended
analgesic methods (Category C2
evidence).
Overestimation of the risk of adverse
events and addiction are the common
misconceptions
that
should
be
dispelled.
Optimal use of PCA and other
sophisticated methods, such as patient
controlled epidural analgesia (PCEA)
depending on the infrastructure
available.
And other analgesic methods should be
discussed at the time of the preanesthetic
evaluation through brochures and
videotapes to educate patients about
therapeutic options.
In the opinion of Elsass et al, Griffin
et al, Knoerl et al, Lam et al, and Lilja
et al such structured preoperative
education may also include instruction
in behavioural modalities for control of
pain and anxiety.32-36
Perioperative Techniques
for Pain Management
Perioperative techniques for postoperative pain
management include, but are not limited to the
following single modalities:
1. Central regional (i.e. neuraxial) opioid
analgesia.37,38
2. PCA with systemic opioids.40,41 RCTs
report equivocal findings regarding the
analgesic efficacy of IV PCA techniques
when compared with nurse or intravenous
analgesia (Category 2 evidence). Metaanalyses of RCTs report improved pain
scores when IV PCA morphine is compared
with intramuscular morphine (Category
A1 evidence). Meta-analyses of RCTs
indicate more analgesic use when IV PCA
with a background infusion of morphine is
compared with IV PCA without background
infusion (Category A1 evidence).
36
3. Peripheral regional analgesic techniques,

including but not limited to intercostal
blocks, plexus blocks, and local anesthetic
infiltration of incisions.41,42 Meta-analyses
of RCTs report improved pain scores when
preincisional infiltration of bupivacaine
is compared with saline (Category A1
evidence).
Meta-analyses of RCTs are equivocal
for pain scores and analgesic use when
post-incisional infiltration of bupivacaine
is compared with saline (Category C1
evidence). Meta-analyses of RCTs report
improved pain scores when preincisional
infiltration of ropivacaine is compared
with saline (Category A1 evidence). Metaanalyses of RCTs report less analgesic use
when preincisional plexus blocks with
bupivacaine are compared with saline
(Category A1 evidence).
4. TAP blockCarney et al have recently
shown that transversus abdominis plane
block (TAP) provides effective postoperative
analgesia with reduced pain scores at rest
and with movements in patients undergoing
total abdominal hysterectomy. Perhaps the
block of the abdominal wall (musculature
and skin) is a more strategic and effective
approach than simple skin infiltration.43
Boldt et al and Murphy et al suggest
that anesthesiologists who manage
perioperative
pain
should
use
therapeutic options such as epidural
or intrathecal opioids, systemic opioid
PCA, and regional techniques after
considering the risks and benefits for the
individual patient.39,40
RCTs comparing preoperative or
preincisional intrathecal morphine or
epidural sufentanil with saline placebo
report inconsistent finding regarding
pain relief (Category C2 evidence). RCTs
comparing preoperative or preincisional
epidural morphine or fentanyl with
postoperative
epidural
morphine
or fentanyl are equivocal regarding
postoperative pain scores (Category C2
evidence).
These modalities should be used in

preference to intramuscular opioids
ordered as needed.
Therapy should be selected according to
individual anesthesiologists skills and
the safe application of the modality.
Special caution should be applied when
continuous infusion modalities are
used because drug accumulation may
contribute to adverse events.40,42
Multimodal Approach for

Pain Management
Multimodal
techniques
for
pain
management include the administration
of two or more drugs that act by different
mechanisms and at different sites in the
nervous system, resulting in additive
and synergistic analgesia with lowered
adverse effects of sole administration of
individual analgesics. These drugs may
be administered via the same route or by
different routes.44-46
Schmid et al47 and Subramaniam et al48
have shown that low dose Ketamine play a
significant role in providing postoperative
pain relief when used as an adjuvant
analgesic to local anesthestic, opioids and
other analgesics. In the opinion of Aubrun
et al, and Engelhardt et al, sometimes lack
of effect of Ketamine may be due to too
low dose of Ketamine or not planning to
continue the dose in the postoperative
period.49,50
Regional blockade with local anesthetics
should be considered.51,52
Tramer et al53 and Koinig et al54 observed
that at very high doses, perioperative
intravenous Magnesium sulfate reduces
postoperative morphine consumption but
not the pain scores.
Latest ASA Task Force Practice guidelines for
acute pain management in the perioperative
setting state that unless contraindicated,
patients should receive an around the clock
regimen of NSAIDs, Cyclooxygenase-2selective inhibitors, or acetaminophen.55-58
Improved pain scores reported when

intravenous morphine is combined with
ketorolac (Category A1 evidence). Findings
for acetaminophen are equivocal (Category
C2 evidence).
Andrieu et al59 and Lavand et al60 have
shown efficacy of intrathecal Clonidine for
postoperative analgesia following radical
prostatectomy58 and elective cesarean.59
Also Famery et al observed lower pain scores
following epidural Clonidine infusion for
spine surgery.61
Dexmedetomidine may be given during
the postoperative period to reduce PCA
morphine requirements. Lin et al62 and
Tufanogullari et al63 observed that patients
on dexmedetomidine required less
morphine.
Dosing regimens should be administered to
optimize efficacy while minimizing the risk
of adverse events.55-58
Alpha 2 ligands like gabapentin or
pregabalin alone or in combination
with dexamethasone can also be used
perioperatively in adequate doses for their
opioid sparing effects. Clinical trials with
gabapentin or pregabalin for postsurgical
pain have been conducted by Mathiesen
et al,64,65 Jokela et al,66 Agarwal et al67 and
Gilron.68 IV opioids combined with alpha 2
ligands like gabapentin or pregabalin, report
lower pain scores (Category A1 evidence).
Huang et al noticed lower pain scores
following
perioperative
Celecoxib
administration for pain management
in patients undergoing total knee
arthroplasty.55
The choice of medication, dose, route, and
duration of therapy should be individualized.
Moodie et al observed lower mean
morphine consumption in the intranasal
Ketorolac group patients undergoing major
abdominal or orthopedic surgery.69
In patients undergoing total hip arthroplasty
under spinal anesthesia, perioperative
intravenous Dexamethasone can be
considered as Kardash et al have shown that
it reduces pain upon standing at 24 hours.70
37
Types of Multimodal Techniques

Two or more analgesic agents, one route versus
a single agent, one route1
Epidural or intrathecal analgesia with
opioids combined with:
Local anesthetics versus epidural
opioids
Local anesthetics versus epidural local
anesthetics
Clonidine versus epidural opioids
IV opioids combined with:
Clonidine versus IV opioids
Ketorolac versus IV opioids
Ketamine versus IV opioids
Oral opioids combined with NSAIDs,
COXIBs, or acetaminophen versus oral
opioids
Dexamethasone.
Two or more drug delivery routes versus a
single route1
Epidural or intrathecal analgesia with
opioids combined with IV.
Intramuscular, oral, transdermal, or
subcutaneous analgesics versus epidural
opioids.
IV opioids combined with oral NSAIDs,
COXIBs, or acetaminophen versus IV
opioids.
Nonpharmacologic,
alternative,
or
complementary
pain
management
combined with pharmacologic pain
management versus pharmacologic pain
management.
Continuous Multimechanistic
Post-operative Analgesia
Pergolizzi et al suggest rationale
for
transitioning
from
intravenous
Acetaminophen and opioids to oral
formulations.71
Pergolizzi et al emphasize that the use of
IV. Acetamoniphen and opioids in the
preoperative period could transition to
oral formulations of the same agents in
the same proportions for postsurgical pain
management.71
38
Oral fixed dose combination (Tramadol

+ Acetamoniphen) or loose dose
combinations could be used, as appropriate
to meet the needs of individual patients.72-78
Special Populations
Pediatric patients
Childrens pain mattersfor the child, For the
family, and for the society
Very low birth weight infants may be
admitted in the neonatal ICU for months
together, and obviously they are highly
vulnerable to pain from recurring procedures
due to immaturity of their CNS and rapid brain
development occurring in the last trimester
of fetal life.79 Also Grunau et al80 suggest that
prolonged untreated pain suffered early in life,
independent of morphine exposure, may have
long lasting effects on the individual pattern of
stress hormone responses in vulnerable infants.
Optimal care for infants and children
requires special attention to the biophysical
nature of pain. Pediatric population
presents developmental differences in
their experience and expression of pain
and sufferings, their response to analgesic
pharmacotherapy.
Caregivers may assume that pain is not
present and defer treatment. Safe methods
of providing analgesia are underutilized
for fear of opioid-induced respiratory
depression. However the emotional
component of pain is particularly strong in
infants and children.
The task force (of American Pain Society) on
pain in infants recommended that aggressive
and proactive pain management is essential
to streamline the undertreatment of pain in
children.81,82
The task force (of American Pain Society)
on pain in infants recommended that
perioperative care for children undergoing
painful procedures or surgery requires
detailed pain assessment and therapy.82
Each analgesic administration should be
based on body weight and comorbidity, and
pharmacokinetics as applicable to children,

should preferably involve a multimodal
approach.82
Behavioral techniques addressing the
emotional component of pain should be
adopted whenever feasible.81,82
Kokki, Dalens and Kawaraguchi et al
emphasize that in the multimodal approach,
sedative, analgesic, and local anesthetics
are all essential components of analgesic
regimens for painful procedures.83-85
There is substantial body of evidence
that various analgesic medications are
synergistic with sedative agents, it is
important that appropriate monitoring be
used during the procedure and recovery.83-85
The emotional component of pain is
essentially strong in infants and children
and presence of parents in familiar
surroundings makes all the more difference.
Millions of children undergo surgery
each year in developing nations and
assessment of their pain has its own unique
problems. Despite the limited resources,
a successful pain management protocol
was developed and tailored to the specific
setting of the Medical Research Council
pediatric ward in the Gambia, West
Africa.86 This protocol would serve as an
example for other developing nations in
similar settings. Also regional anesthetic
techniques can be utilized to provide more
effective multimodal postoperative pain
management.87
Geriatric Patients
Elderly patients are more likely to undergo
surgery because of various underlying
medical and surgical conditions.1
Pain is often undertreated and elderly
patients are more vulnerable to the
detrimental effects of such undertreatment.88
Bergh et al observed that the physical,
social, emotional, and cognitive changes
associated with aging have an impact on
perioperative pain management.88
These geriatric patients may have all

together different attitudes than younger
adult patients in expressing pain and
seeking appropriate therapy.
Altered pharmacokinetics in geriatric
patients as based on physiological changes
in the drug distribution and metabolism
of analgesic drugs and local anesthetics
requires frequent dose alterations.
Pain assessment and therapy should be
integrated into the perioperative care of
geriatric patients.
Pain assessment tools and methods
appropriate to a patients cognitive abilities
should be used. Extensive and proactive
evaluation and questioning may be
necessary to overcome barriers that hinder
communication
regarding
unrelieved
pain.88,89
Anesthesiologists should recognize that
geriatric patients may respond differently
than younger patients to pain and analgesic
medications, often because of comorbidity.
Strict dose titration is essential for
minimizing the adverse effects such as
somnolence in this vulnerable group,
because of concomitant medication with
some complimentary agents.
Critically Ill and Cognitively

Impaired Patients
Recently Sandra et al in a systematic review
of behavioral pain assessement tools noted
that patients who are critically ill, cognitively
impaired (e.g. Alzheimers disease/ dementia),
or who otherwise have difficulty communicating
(e.g. cultural or language barriers) present
unique challenges to perioperative pain
management.89
Techniques that reduce drug dosages
required to provide effective analgesia may
be suitable for such patients (e.g. regional
analgesia and multimodal analgesia).
Behavioral modalities and techniques such
as PCA that depend upon self-administration
39
of analgesics are usually not suitable for the

cognitively impaired.89
The literature is insufficient to evaluate the
application of pain assessment methods or
pain management techniques specific to
these populations.
This special population may require
additional interventions to ensure optimal
perioperative pain management.
Anesthesiologists should consider a
therapeutic trial of an analgesic in such
patients with increased blood pressure and
heart rate or agitated behavior when causes
other than pain have been excluded.
Pain in Childbirth
Acute pain during childbirth is a well
established cause of pain in a parturient.
Obviously in developing world, analgesia
during labor is a luxury that is not
readily available due to shortage of drugs,
equipment and medical personnel and poor
infrastructure.
Epidural block cannot be offered to the
majority of mothers in developing nations
as it is expensive (especially in hospital
with poor infrastructure and in the absence
of health insurance facilities). Hence
Kuczkowsi and Chandra innovated a
single shot spinal anesthetic during labor.90
They achieved high degree of maternal
satisfaction with minor side effects in
majority of women. This technique could
be adopted by other developing nations
also.
Genetics and Gender

ASA Task Force believes that patients
race, ethnicity, culture, gender and
socioeconomic status have significant
bearing on access to the treatment as well as
pain assessment by the doctors and nurses.
The genetic predisposition and single
nucleotide polymorphism may influence
40
the doses and pharmacokinetics of few

analgesics.
Conclusion
With the background of barriers to optimal acute
pain management in the developing countries,
it is not surprising that acute pain in several
settings is not well managed in the developing
world. With the shortage of anesthesiologists
around, the surgeons still play a major significant
role in postoperative pain management and
intramuscular injections are still the preferred
route of analgesic administration by the
surgeons. Acute pain services and dedicated
acute pain nurse are available in majority of
large hospitals in China, while they are only
available in selected hospital in India (mainly
corporate hospitals and premier medical
institutions), Thailand, Philippines, Indonesia
and Nigeria. Pain is monitored as the 5th vital
sign in majority of hospitals in Thailand, and a
few hospitals in China, Philippines, and Nigeria,
but generally speaking there is no such policy
in India (except for corporate hospitals) or
Indonesia. The Indian Society for Study of Pain
(ISSP) is trying its best to convince the health
officials and administrators in Ministry of Health
and Family Welfare, Government of India for
implementation of pain as the 5th vital sign in
each and every hospital in the country. We do
hope that our good intentions shall manifest
into equally good deeds of implementation of
pain as the 5th vital sign. Putting into action
what we hear is real adoption of the truth.
The Declaration of Montreal91 holds that
access to pain management is a fundamental
human right. It recognizes the intrinsic
dignity of all persons, and that withholding of
pain treatment is profoundly wrong, leading to
unnecessary suffering which is harmful. Various
scientific bodies and government agencies
must provide greater funding for research
on pediatric pain, along with the funding
for infrastructure and resources to translate
research finding into practice. However in the
developing nations there appears to be a ray
of hope and a silver lining in the dark clouds,
that many anesthesiologists and institutions

are taking initiative to overcome some of these
barriers and may be in a couple of years, we can
look forward to optimal acute pain management
in the developing world.
All things are possible for those who believe,
Believe and your belief will create the fact
References
1. American Society of Anesthesiologists Task Force
on Acute Pain Management: Practice guidelines
for acute pain management in the perioperative
setting: An updated report by the American
Society of Anesthesiologists Task Force on
Acute Pain Management. Anesthesiolgy. 2012;
116:248-73.
2. Vijayan R. Managing acute pain in the developing
world. Pain Clinical Updates. 2011;19(3):1-7.
3. Cordell WH, Keene KK, Glies BK, Jones JB, et
al. The high prevalence of pain in emergency
medical care. Am J Emerg Med. 2002; 20:165-9.
4. Macrae WA. Chronic postsurgical pain; 10 years
on. Br J Anaesth. 2008; 101:77-86.
5. Anderson KG, Kehlet H. Persistent pain after
breast cancer treatment: A critical review of risk
factors & strategies for prevention. J Pain. 2011;
12:725-46.
6. Van Gulik L, Jansen L, Ahlers SJ, Bruins P,
Driessen AH, et al. Risk factors for thoracic
pain after cardiac surgery sternotomy. Eur J
Cradiothoracic Surg. 2011; 40:1309-13.
7. Argoff CE. Recent Management Advances in
Acute Postoperative Pain. Pain Pract. 2013 Aug
15. doi: 10.1111/papr.12108.
8. Coleman SA, Booker-Milburn J. Audit of
postoperative pain control: Influence of a
dedicated acute pain nurse. Anaesthesia. 1996;
51:1093-6.
9. Harmer M, Davies KA. The effect of education,
assessment and a standardised prescription on
postoperative pain management. The value of
clinical audit in the establishment of acute pain
services. Anaesthesia. 1998;53:424-30.
10. Rose DK, Cohen MM, Yee DA. Changing the
practice of pain management. Anesth Analg.
1997;84:764-72.
11. White CL. Changing pain management practice
and impacting on patient outcomes. Clin Nurse
Spec. 1999;13:166-72.
12. Briggs M, Dean KL. A qualitative analysis of the
nursing documentation of postoperative pain
management. J Clin Nurs. 1998;7:155-63.

13. Camp LD, OSullivan PS. Comparison of medical,
surgical and oncology patients descriptions
of pain and nurses documentation of pain
assessments. J Adv Nurs. 1987;12:593-8.

14. Clarke EB, French B, Bilodeau ML, Capasso
VC, Edwards A, Empoliti J. Pain management
knowledge, attitudes and clinical practice: The
impact of nurses characteristics and education.
J Pain Symptom Manage. 1996;11:18-31.
15. Davis BD, Billings JR, Ryland RK. Evaluation of
nursing process documentation. J Adv Nurs.
1994;19:960-8.

16. Ehnfors M, Smedby B. Nursing care as
documented in patient records. Scand J Caring
Sci. 1993;7:209-20.
17. Idvall E, Ehrenberg A. Nursing documentation
of postoperative pain management. J Clin Nurs.
2002;11:734-42.
18. Salanter S, Lauri S, Salmi TT, Aantaa R. Nursing
activities and outcomes of care in the assessment,
management, and documentation of childrens
pain. J Pediatr Nurs. 1999;14:408-15.
19 . Bardiau FM, Taviaux NF, Albert A, Boogaerts
JG, Stadler M. An intervention study to enhance
postoperative pain management. Anesth Analg.
2003;96:179-85.
20. Gould TH, Crosby DL, Harmer M, Lloyd SM,
Lunn JN, Rees GA, Roberts DE, Webster JA.
Policy for controlling pain after surgery. Effect of
sequential changes in management. BMJ. 1992;
305:1187-93.

21. Mackintosh C, Bowles S. Evaluation of a
nurse-led acute pain service. Can clinical nurse
specialists make a difference? J Adv Nurs. 1997;
25:30-7.

22. Miaskowski C, Crews J, Ready LB, Paul SM,
Ginsberg B. Anesthesia-based pain services
improve the quality of postoperative pain
management. Pain. 1999; 80:23-9.
23. Pesut B, Johnson J. Evaluation of an acute pain
service. Can J Nurs Adm.1997; 10:86-107.
24. Sartain JB, Barry JJ. The impact of an acute pain
service on postoperative pain management.
Anaesth Intensive Care.1999;27:375-80.
25. Stacey BR, Rudy TE, Nelhaus D. Management of
patient controlled analgesia: A comparison of
primary surgeons and a dedicated pain service.
Anesth Analg. 1997;85:130-4.

26. Stadler M, Schlander M, Braeckman M,
Nguyen T, Boogaerts JG. A cost-utility and costeffectiveness analysis of an acute pain service. J
Clin Anesth.2004;16:159-67.
41
27. Tighe SQ, Bie JA, Nelson RA, Skues MA. The
acute pain service: Effective or expensive care?
Anaesthesia.1998; 53:397-403.
28. Furdon SA, Eastman M, Benjamin K, Horgan
MJ. Outcome measures after standardized pain
management strategies in postoperative patients
in the neonatal intensive care unit. J Perinat
Neonatal Nurs. 1998;12:58-69.

29. Anderson EA. Preoperative preparation for
cardiac surgery facilitates recovery, reduces
psychological distress, and reduces the incidence
of acute postoperative hypertension. J Consult
Clin Psychol. 1987;55:513-20.
30. Daltroy LH, Morlino CI, Eaton HM, Poss R, Liang
MH. Preoperative education for total hip and
knee replacement patients. Arthritis Care Res.
1998;11:469-78.
31. Egbert LD, Battit GE, Welch CE, Bartlett
MK. Reduction of postoperative pain by
encouragement and instruction of patients. N
Engl J Med. 1964;270:825-7.
32. Elsass P, Eikard B, Junge J, Lykke J, Staun P, FeldtRasmussen M. Psychological effect of detailed
preanesthetic information. Acta Anaesth Scand.
1987;31:579-83.
33. Griffin MJ, Brennan L, McShane AJ. Preoperative
education and outcome of patient controlled
analgesia. Can J Anaesth. 1998;45:943-8.
34. Knoerl DV, Faut-Callahan M, Paice J, Shott S.
Preoperative PCA teaching program to manage
postoperative pain. Medsurg Nurs. 1999;8:25-33.
35. Lam KK, Chan MT, Chen PP, Ngan Kee WD.
Structured preoperative patient education for
patient-controlled analgesia. J Clin Anesth. 2001;
13:465-9.
36. Lilja Y, Rydn S, Fridlund B. Effects of extended
preoperative information on perioperative stress:
An anaesthetic nurse intervention for patients
with breast cancer and total hip replacement.
Intensive Crit Care Nurs. 1998;14:276-82.
37. Banning AM, Schmidt JF, Chraemmer-Jrgensen
B, Risbo A. Comparison of oral controlled
release morphine and epidural morphine in
the management of postoperative pain. Anesth
Analg. 1986;65:385-8.
38. Fitzpatrick GJ, Moriarty DC. Intrathecal
morphine in the management of pain following
cardiac surgery. A comparison with morphine IV.
Br J Anaesth. 1988;60:639-44.

39. Boldt J, Thaler E, Lehmann A, Papsdorf M,
Isgro F. Pain management in cardiac surgery
patients: Comparison between standard therapy
42
and patient-controlled analgesia regimen. J

Cardiothorac Vasc Anesth. 1998;12:654-8.
40. Murphy DF, Graziotti P, Chalkiadis G, McKenna M.
Patient controlled analgesia: A comparison with
nurse-controlled intravenous opioid infusions.
Anaesth Intensive Care. 1994;22:589-92.
41. Eng J, Sabanathan S. Continuous extrapleural
intercostals nerve block and post-thoracotomy
pulmonary complications. Scand J Thorac
Cardiovasc Surg 1992; 26:219 23.
42. Rademaker BM, Sih IL, Kalkman CJ, Henny CP,
Filedt Kok JC, Endert E, Zuurmond WW. Effects
of interpleurally administered bupivacaine 0.5%
on opioid analgesic requirements and endocrine
response during and after cholecystectomy: A
randomized double-blind controlled study. Acta
Anaesth Scand. 1991;35:108-12.
43. Carney J, McDonnell JG, Ochana A, et al. The
transversus abdominis plane block provides
effective postoperative analgesia in patients
undergoing total abdominal hysterectomy.
Anesth Analg. 2008;107:2056-60.
44. Michelet P, Guervilly C, Hlaine A, Avaro
JP, Blayac D, Gaillat F, Dantin T, Thomas P,
Kerbaul F. Adding ketamine to morphine for
patient-controlled analgesia after thoracic
surgery: Influence on morphine consumption,
respiratory function, and nocturnal desaturation.
Br J Anaesth. 2007; 99:396-403.

45. Reeves M, Lindholm DE, Myles PS, Fletcher
H, Hunt JO. Adding ketamine to morphine
for patient-controlled analgesia after major
abdominal surgery: A double blinded,
randomized controlled trial. Anesth Analg. 2001;
93:116-20.
46. Sveticic G, Farzanegan F, Zmoos P, Zmoos S,
Eichenberger U, Curatolo M. Is the combination
of morphine with ketamine better than
morphine alone for postoperative intravenous
patient-controlled analgesia? Anesth Analg.
2008;106:287-93.
47. Schmid RL, Sandler AN, Katz J. Use and efficacy
of low-dose ketamine in the management of
acute postoperative pain: a review of current
techniques and outcomes. Pain. 1999;82:111-25.
48. Subramaniam K, Subramaniam B, Steinbrook
RA. Ketamine as adjuvant analgesic to opioids:
a quantitative and qualitative systemic review.
Anesth Analg. 2004;99:482-95.
49. Aubrun F, Gaillat C, Rosenthal D. et al. Effect
of a low dose ketamine regimen on pain,
mood, cognitive function and memory after
major gynaecological surgery: a randomized,
double blind, placebo-controlled trial. Eur J

Anaesthesiol. 2008; 25:97-105.

50. Engelhardt T, Zaarour C, Naser B. et al.
Intraoperative low-dose ketamine does not
prevent a remifentanil induced increase in
morphine requirement after pediatric scoliosis
surgery. Anesth Analg. 2008;107:1170-75.
51. Asantila R, Eklund P, Rosenberg PH. Continuous
epidural infusion of bupivacaine and morphine
for postoperative analgesia after hysterectomy.
Acta Anaesth Scand. 1991;35:513-7.
52. Crews JC, Hord AH, Denson DD, Schatzman
C. A comparison of the analgesic efficacy of
0.25% levobupivacaine combined with 0.005%
morphine, 0.25% levobupivacaine alone, or
0.005% morphine alone for the management
of postoperative pain in patients undergoing
major abdominal surgery. Anesth Analg. 1999;
89:1504-9.
53. Tramer MR, Schneider J, Marti R-A, Rifat K.
Role of magnesium sulphate in postoperative
analgesia. Anaesthesiology. 1996;84:340-47.
54. Koinig H, Wallner T, Marhofer P, et al. Magnesium
sulphate reduces intra- and postoperative
analgesic requirements. Anesth Analg. 1998;
87:206-10.
55. Huang YM, Wang CM, Wang CT, Lin WP,
Horng LC, Jiang CC. Perioperative celecoxib
administration for pain management after total
knee arthroplasty: A randomized, controlled
study. BMC Musculoskelet Disord. 2008;9:77.
56. Plummer JL, Owen H, Ilsley AH, Tordoff K.
Sustained release ibuprofen as an adjunct to
morphine patient-controlled analgesia. Anesth
Analg. 1996;83:92-6.
57. Serpell MG, Thomson MF. Comparison of
piroxicam with placebo in the management of
pain after total hip replacement. Br J Anaesth.
1989;63:354-6.
58. Schug SA, Sidebotham DA, McGuinnety M,
Thomas J, Fox L. Acetaminophen as an adjunct
to morphine by patient-controlled analgesia in
the management of acute postoperative pain.
Anesth Analg. 1998;87:368-72.
59. Andrieu G, Roth B, Ousmane L, et al. The
efficacy of intrathecal morphine with or without
clonidine for postoperative analgesia after
radical prostatectomy. Anesth Analg. 2009;
108:1954-57.

60. Lavandhomme PM, Roelants F, Waterloos
H, et al. An evaluation of the postoperative
antihyperalgesic and analgesic effects of
intrathecal clonidine administered during

elective caesarean delivery. Anesth Analg. 2008;
107:948-55.
61. Farmery AD, Wilson-MacDonald J. The analgesic
effect of epidural clonidine after spinal surgery:
a randomized placebo-controlled trial. Anesth
Analg. 2009;108:631-34.
62. Lin TF, Yeh YC, Lin FS, et al. Effect of combining
dexmedetomidine and morphine for intravenous
patient-controlled analgesia. Br J Anaesth. 2009;
102:117-22.

63. Tufanogullari B, White PF, Peixto MP, et al.
Dexmedetomidine infusion during laproscopic
bariatric surgery: the effect on recovery outcome
variables. Anesth Analg. 2008;106:1741-8.
64. Mathiesen O, Jacobsen LS, Holm HE, et al.
Pregabalin and dexamethasone for postoperative
pain control: a randomized controlled study in
hip arthroplasty. Br J Anaesth. 2008;101:535-41.
65. Mathiesen O, Rasmussen ML, Dierking G, et al.
Pregabalin and dexamethasone in combination
with paracetamol for postoperative pain control
after abdominal hysterectomy. A randomized
clinical trial. Acta Anaesthesiol Scand. 2009;
53:227-35.
66. Jokela R, Ahonen J, Tallgren M, et al. A randomized
clinical trial of perioperative administration
of pregabalin for pain after laparoscopic
hysterectomy. Pain. 2008; 134:106-12.
67. Agarwal A, Gautam S, Gupta D, Agarwal S,
Singh PK, Singh U. Evaluation of a single
preoperative dose of pregabalin for attenuation
of postoperative pain after laparoscopic
cholecystectomy. Br J Anaesth. 2008;101:700-4.
68. Gilron I. Gabapentin and pregabalin for chronic
neuropathic and early postsurgical pain: current
evidence and future directions. Curr Opin
Anaesthesiol. 2007;20:456-72.
69. Moodie JE, Brown CR, Bisley EJ, et al. The safety
and efficacy of intranasal ketorolac in patients
with postoperative pain. Anesth Analg. 2008;
107:2025-31.
70. Kardash KJ, Sarrazin F, Tessler MJ, Velly AM.
Single dose dexamethasone reduces dynamic
pain after total hip arthroplasty. Anesth Analg.
2008;106:1253-57.
71. Pergolizzi JV, Raffa RB, Tallarida R, Tylor R. et
al. Continuous multimechanistic postoperative
analgesia: a rationale for transitioning from
intravenous acetaminophen and opioids to oral
formulations. Pain Practice. 2012;12(2):159-73.

72. Raffa R, Pergolizzi JV, Tallarida R. The
determination and application of fixed dose
analgesic combinations for treating multimodal
pain. J Pain. 2010;11:701-9.
43
73. Derry S, Barden J, McQuay H, Moore R. Single

dose celecoxib for postoperative pain. Cochrane
Database Syst Rev. 2008;4:CD004233.
74. Rajpal S, Gordon D, Pellino T, et al. Comparison
of oral multimodal analgesia versus IV. PCA
for spine sugery. J Spinal Disord Tech. 2010;
23:139-45.
75. Toms I, McQuay H, Derry S, Moore R. Single
dose oral paracetamol (acetaminophen) for
postoperative pain in adults. Cochrane Database
Syst Rev. 2008;4:CD004602.
76. Sawaddiruk P, Paiboonworachar S, Janthawichai
K. Comparison of efficacy and effectiveness
between ultracet and tramadol/ acetaminophen
in acute postoperative pain after upper extremity
surgery. J Med Assoc Thai. 2010;93:812-7.

77. Macario A, Royal M. A literature review of
randomized clinical trials of intravenous
acetaminophen (paracetamol) for acute
postoperative pain. Pain Pract. 2011;11:290-6.

78. Dhillon S. Tramadol/ paracetamol fixeddose combination: a review of its use in the
management of moderate to severe pain. Clin
Drug Investig. 2010;30:711-38.
79. Anand KJ. Pain plasticity and premature birth:
a prescription for premature suffering? Nature
Med. 2000; 6:971-3.
80. Grunau RE, et al. Neonatal procedural pain and
preterm infant cortisol response to novelty at 8
months. Pediatrics. 2004;114:e77-e84.

81. Schechter NL, Berde CB, Yaster M. Pain in
infants, children and adolescents: an overview
2nd edn. Philadelphia, PA: Lippincott; 2003:3.
82. Academy of Pediatrics; Task Force on Pain in
Infants, Children, and Adolescents, American
Pain Society. The assessment and management of
acute pain in infants, children, and adolescents.
Pediatrics. 2001;108(3):793-7.
83. Kokki H. Non-steroidal anti-inflammatory drugs
for postoperative pain: a focus on children.
Pediatric Drugs. 2003;5:103-23.
84. Dalens B. Complications in pediatric regional
anesthesia. In: Proceedings of the 4th
European Congress of Pediatric Anesthesia,
Paris,1997.

85. Kawaraguchi Y, Otomo T, Ota C, et al. A
prospective, double blind randomized trial
of caudal block using ropivacaine 0.2% with
or without fentanyl 1 g/kg in children. Br J
Anaesth. 2006; 97(6):858-61.
86. Puchalski Ritchie LM, Howie SRC, Nijai PC.
Development of a pain management protocol for
a pediatric ward in the Gambia, West Africa. Int J
Pediatrics. 2010;2010:975313.
44

87. Bosenberg AT, Raw R, Boezaart AP. Surface
mapping of peripheral nerves in children with
a nerve stimulator. Paediatr Anaesth. 2002;
12:396-403.

88. Bergh I, Sjstrm B, Odn A, Steen B. An
application of pain rating scales in geriatric
patients. Aging (Milano). 2000;12(5):380-7.
89. Sandra MG Zwakhalen, Jan PH Hamers, Huda
Huijer Abu-Saad, et al. Pain in elderly people
with severe dementia: A systematic review
of behavioural pain assessment tools. BMC

Geriatrics. 2006;6:3.
90. Kuczkowski KM, Chandra S. Maternal satisfaction
with single dose spinal analgesia fir labour pain
in Indonesia: a landmark study. J Anesth. 2008;
22:55-8.
91. International Association for the Study of Pain.
Declaration of Montreal. Available at http://
www.iasp-pain.org/painsummit/declaration.
Accessed June 5, 2011.
CHAPTER
Monitoring Standards
in Anesthesia
Gundappa Parameswara
Introduction
There have been concerns regarding safety
standards for safe surgery including anesthesia
all over the world. The WHO safety check list of
Safe Surgery Saves Lives has been introduced
to promote better outcome, reduce morbidity
and mortality associated with surgery.
Anesthesia may cause adverse outcome in
terms of morbidity as well as mortality. The
essential of monitoring, basically in the form
of clinical monitoring during anesthesia for
Oxygenation, Ventilation and Circulation has
been found to be inadequate and sometimes
unsatisfactory. Need for additional monitoring
devices to supplement the clinical monitoring,
was found necessary. Fortunately, technolgical
explosion and innovations have made
monitoring equipment available practically
for all parameters that may change during
anesthesia. More and more monitors are being
added every year in this competitive field of
medicine including anesthesia.
Recognizing the fact that monitoring of vital
parameters plays an important role in reducing
morbidity and mortality related to anesthesia,
the American Society of Anesthesiologists in
1986 under Dr H Ketcham Morrel took first step in
codifying minimum monitoring standards for
anesthesia. Subsequently, the World Federation
of Societies of Anesthesiology constituted and

International Task Force in 1989 to (a) guide
and assist anesthesia providers, professional
societies, hospital administrators, and the
governments in improving the quality and
safety of anesthesia (b) update and improvise
minimum mandatory monitory standards as
applicable to each country, depending on the
medicolegal, cultural norms and customs,
racial, endemic and environmental factors.
The recommendations of ITF were accepted
by WFSA in 1992. Subsequently most countries
have formulated and adapted their own version
of monitoring standards modifying suitability to
the requirements and available resources of their
country. The Indian Society of Anesthesiologists
mostly adapted and formulated guidelines on
monitoring in 1996 based on recommendations
of WFSA, and subsequently in 2008 minimum
monitoring standards were codified by this
author.
It is a well recognized fact that monitors
themselves do not reduce or prevent an adverse
outcome. They provide warning of impending
deterioration in the patient condition. It is the
man behind the machine an alert and trained
anesthesiologists who should interpret these
numbers and changes, act and take appropriate
action to prevent any untoward effect. It is also
recognized that monitors may also malfunction,
46
which should be recognized immediately and

replaced. Unfortunately human error may also
creep in preventing and recognition of problem.
This aspect can be only reduced by properly
trained professional and by continuous update
of the literature. Not all monitors are essential
in reducing morbidity or mortality during
anesthesia. Availability of more monitors,
and more information is unlikely to reduce
untoward effect, if effective treatment is not
available. Hence a set of minimum or core
monitors which have proved their reliability
improved the safety of anesthesia constitutes
the minimum standard of monitoring.
Technological revolution and availability
and affordability of monitors have made
necessary the review of these guidelines. Most
countries have recently revised their guidelines
in keeping with the requirements, resources,
safety of patients and legal requirements.
The WFSA revised the guidelines in 2010,
incorporates and elaborate upon the core
components of the Safe Anaesthesia part of
the 2008 World Health Organizations World
Alliance for Patient Safety Safe Surgery Saves
Lives global initiative. The Indian College of
Anesthesiologists on behalf of Indian Society of
Anesthesiologists has reviewed the guidelines
on the monitoring standards in anesthesia
following the WFSA recommendations. These
standards are intended to provide guidance
and assistance to anesthesia professionals,
their professional societies, hospital and
administrators, and governments for improving
and maintaining the quality and safety of
anesthesia care.
WFSA has adapted standardized WHO
terminology, which other countries may have
modified to their convenience. As per WFSA, (1)
a minimum set of monitors which are necessary
to be used in ALL anesthetic procedures to
maintain a minimum standard of anesthesia
is termed Highly Recommended in bold letters.
This is equivalent to Mandatory Standards
to be adapted for any anesthetic procedures
irrespective of level of infrastructure, resources,

training or organization. These Highly
Recommended Or Mandatory standards are
applicable for health care organization with
Level1 or Basic Infrastructure, such as Small
hospitals or health-care centers with sparsely
equipped operating rooms, where general
or regional anesthetics are administered for
simple and uncomplicated cases. They are not
applicable if only a superficial procedure under
local anesthesia is performed. (2) The Level-2 or
Intermediate Infrastructure hospitals or healthcare facilities such as district or bigger hospitals,
where
adequately
equipped
operation
theaters may perform many major surgeries,
which may not require intensive care should
have a monitoring standard of Anesthesia as
classified as Highly Recommended (Mandatory
Standards) and certain additional monitors
regarded as Recommended standards. (3) The
Level-3 or hospitals or Optimal Infrastructure
constitutes healthcare facilities such as
medical college hospitals, corporate or other
referral centers with facilities to perform
complicated and have intensive care facilities.
These healthcare facilities may perform all
complicated surgeries, even requiring intensive
care facilities. The monitoring standards in these
hospitals should have Highly Recommended
(Mandatory Standards) + Recommended
and certain additional monitors regarded as
Suggested standards. It should be recognized
here that depending upon the facilities and
resources, WFSA recommends different grades
and difficulties of anesthetic procedures being
performed. Correspondingly, the level of
monitoring should appropriately increase.
For precise understanding, the Indian
College of Anesthesiologists has used slightly
different nomenclature. The word Mandatory
is used instead of Highly Recommended.
The following table summarizes the practice
standards and infrastructure facilities and
nomenclature used by Indian College of
Anesthesiologists.
Monitoring Standards in Anesthesia
47
Level
Infrastructure
Type of Healthcare Facility
Type of Surgery
Performed
Anesthesia
Standards
ICA Nomenclature
Level 1
Basic
Small Hospitals
with sparsely
equipped
operating rooms
Uncomplicated
Simple
surgeries,
Emergency
management
of Trauma and
Obstetrics (but
no LSCS)
Highly
Recommended
Standards
Minimum
Mandatory
Standards
Level 2
Intermediate
Bigger, District
level hospitals,
with well
equipped
operation rooms.
May be without
Intensive Care
Facility
All types of
surgeries
not needing
intensive care.
management
of trauma and
obstetrics
including LSCS
Highly
Mandatory +
Recommended + Recommended
Recommended
Level 3
Optimal
Medical College
Hospitals,
Corporate
hospitals and
referral hospitals
with intensive
care facility
All types of
complicated
surgeries,
trauma,
obstetrics, and
superspecialty
surgeries
Mandatory +
Highly
Recommended + Recommended +
Recommended + Suggested
Suggested
Section 1: Professional
Standards
Anesthesiologist
a. The Anesthesiologists providing anesthesia
service to any surgical procedure should be
a qualified and certified having undergone
appropriate training and accredited with
a diploma (DA) or degree (MD or DNB) in
Anesthesiology. It is Recommended that
anesthesia be given only by qualified and
accredited anesthesiologists.
b.
Paramedical or nonmedical persons
(Nurses) cannot provide anesthesia unless,
they are appropriately trained and certified
to have undergone sufficient training in
anesthetic procedure. They may provide
anesthesia only as an assistant and under
supervision of qualified Anesthesiologists.
c. It is Recommended that anesthesiologist
may be assisted by another person, who
may be a trainee anesthesiologist or nurse

anestheiologist or anesthesia technician.
d. A qualified anesthesiologist or his assistant
should be present throughout the conduct
of anesthetic procedure. At the end of
the procedure, he or his assistant should
accompany the patient to recovery or
postoperative ward, and handover the
patient to designated incharge of the ward.
The anesthesiologists is responsible for
overall care of the patient, and should be
available for any consultation as required.
The anesthesiologists should provide same
care whether the patient is subjected to
General Anesthesia, Regional Anesthesia or
Monitored Anesthesia Care.
e. It is recognized that under certain
circumstances,
the
anesthesiologists
in charge, may require brief temporary
absence. In such situation, a responsible
assistant or another anesthesiologists should
48
be given hand over the charge of the patient.

In case an anesthesiologists working alone,
an emergency life saving situation calls for
absence of anesthesiologists attending on a
patient, the surgeon should stop operating
and assume responsibility of the patient and
monitor the patient till the anesthesiologists
returns.
f. It is Mandatory to record all the core data
of the patient in the anesthesia record. The
preoperative evaluation, intraoperative core
data and post operative vital parameters
should be properly recorded. The
intraoperative vital parameters like heart
rate, blood pressure, oxygen saturation
should be recorded at intervals not longer
than ten minutes, and earlier, if the clinical
condition is unstable.
g. It is Recommended that individuals or
departments collect cumulative data to
facilitate the progressive enhancement of
the safety, efficiency, effectiveness, and
appropriateness of anesthesia care.
The Institutional Standards

a. It is the responsibility of the management
of the Institution or hospital to procure
appropriate monitors and facilities, in
adequate numbers and in proper working
condition, before any anesthetic procedures
are undertaken. Appropriate additional
recommended monitors must be provided
before providing anesthesia for high-risk
patients.
b. The management should ensure that
these monitors and facilities are serviced
at regular intervals and ensure working
condition before providing anesthesia.
c. It is Suggested that institutes peer review the
collective data and develop protocols. It is
Suggested to institute confidential incident
reporting, to promote discussion and
analyzed and suggest remedies.
d. It is Suggested that the institutes should
encourage attendance at conferences,
Continued Medical Education Programme,
etc. so as to update the knowledge of

practice of anesthesia.
Professional Organisation Standards

a. It is Recommended that anesthesiologists
should enroll as member of their
professional body, locally, regional or at
national levels.
b. The professional should set standards
of
practice,
continuing
professional
development and certify and accredite
such programme. These organizations
should form links with appropriate groups
within the region and/or country and
internationally.
c. These organization may collect data
nationally and encourage formation of
protocols for safe practice of anesthesia.
Section II: Monitoring the

Anesthetic Equipment
1. It is the institutional responsibility to provide
appropriate anesthetic machines and
equipment, and maintenance, calibration
and renewal of equipment should be done
and recorded periodically as recommended
by the manufacturers.
2. The concerned anesthesiologists shall be
familiar with the set-up, proper use and
trouble shooting of the equipments. For more
complex equipment, the anesthesiologist
should be appropriately trained regarding
its usage before equipment or monitor is to
be used.
3. The anesthesiologist should check all the
anesthetic equipment and monitors before
connecting them on the patient. Alarm
setting should be appropriately set for upper
and lower limits and ensured that they are
working properly before commencing
anesthesia.
a. In children and other uncooperative
patients, who may not allow monitors
to be placed before anesthesia, patients
may be induced anesthesia and
monitors connected as soon as possible.

Till then, clinical monitoring of pulse
and auscultation shall be carried out.
4. All anesthetic equipment should have a low
and high parameter audible alarms set at
appropriate values and should always be
activated and loud enough to be heard.
Section III: Perioperative

Care and Monitoring
Preoperative Care
a.
The patient should be evaluated
preoperatively by the anaesthesiologists
or his competent assistant. All relevant
investigations should be checked and an
appropriate anaesthesia plan should be
formulated. It is Recommended to follow
Protocols and check list, if available, before
conduct of anaesthesia.
b. Anaesthesiologists should check availability
and working condition of all the equipments
and monitors needed before conduct of
anaesthesia.
c. It is Mandatory to fill the relevant
components of the World Health
Organization Safe Surgery Checklist.
Intraoperative Monitoring
It is Mandatory to monitor (a) Oxygenation
(b) Airway and Ventilation and (c) Circulation of
a patient before administration of anaesthesia.
Oxygenation
i. For every patient undergoing anesthesia,
it is Mandatory to give supplemental
oxygenation of at least 30% during
anesthesia and monitor for oxygenation
ii. It is Mandatory for all patients to receive
an assured inspired oxygen concentration
of at least 25%. This may be ensured by
appropriate anesthetic machine, which has
Oxygen or hypoxic guard set to minimum of
25% of Oxygen. These anesthetic machine
should also be fitted with oxygen failure
device and oxygen failure alarm.
49
iii. If anesthetic machine does not have a

hypoxic guard, then an Oxygen analyzer
fitted with low oxygen alarm set at
appropriate level should be connected to
the inspired limb of the patient circuit.
iv. Oxygenation of the patient should be
monitored clinically by observation of pink
color of the skin and mucous membrane
and absence of cyanosis. There must be
adequate, illumination of the patient for
proper observation of color.
v. It is Mandatory to monitor oxygenation
of patient with pulse oximeter which
displays both the saturation and heart rate.
The pulse oximetry should have variable
pitch pulse tone and low oxygen alarm
which is audible clearly. Display of pulse
plethysmography by the pulse oximeter is
strongly Recommended.
Airway and Ventilation

i. For every patient undergoing anesthesia, it
is Mandatory to monitor for ventilation.
ii. The ventilation should be monitored by
clinical monitoring of chest excursion which
should be synchronous thoracoabdominal
movement, observation of the rebreathing
bag (if breathing spontaneously) and
ausculatation of chest for breath sounds.
Quantitative measurement of expired
volume is strongly Suggested.
iii. When the ventilation is controlled by a
mechanical ventilator, it is Mandatory
to have a low pressure or low volume
alarm fitted to the ventilator to detect
disconnection or leak in the patients circuit.
The alarm should give a clear audible signal.
iv. It is Highly Recommended to monitor
ventilation by continuous monitoring of
end-tidal CO2 by capnography, both for
spontaneous and controlled ventilation.
The capnograph should be provided
with adjustable appropriate high and low
pressure alarm levels to detect both under
and over ventilation of the patient.
v. Whenever an endotracheal intubation or
laryngeal mask or I-gel is inserted, It is Highly
50
Recommended to confirm the position of the

tube, LMA or I-gel by monitoring end-tidal
CO2 measurement by capnography. When
capnography is used, its use should be
continued till the endotracheal tube, LMA
or I-gel is removed.
vi. It is Mandatory to monitor ventilation
in Level 2 and Level 3 hospitals, where
complicated and high-risk patients are
subjected for anesthesia.
vii.
During regional anesthesia (with no
sedation) or local anesthesia (with no
sedation), the adequacy of ventilation shall
be evaluated by Clinical observation of
qualitative clinical signs. During moderate
or deep sedation the adequacy of ventilation
shall be evaluated by continual clinical
observation of qualitative respiratory
clinical signs. It is strongly Recommended
to monitor end-tidal CO2, unless precluded
or invalidated by the nature of the patient,
procedure.
Circulation
i. For every patient under anesthesia, it is
Mandatory for Circulatory Functions to be
monitored.
ii. It is Mandatory for every patient subjected
to anesthesia, shall be monitored by
continuous tracing of Electrocardiogram.
The ECG monitoring should be continued
into the postoperative or recovery ward till
he is discharged to the ward.
iii. It is Mandatory to have a defibrillator
available in the operation theater, kept
charged and ready for use in case of cardiac
arrest.
iv. It is Mandatory for every patient to
be monitored for circulatory function
continually evaluated by at least one of the
following: palpation of a pulse, auscultation
of heart sounds, monitoring of a tracing of
intra-arterial pressure, or pulse oximetry.
The pulse rate may be recorded from
palpation or from ECG or pulse oximeter
monitors.
v. It is Mandatory for every patient undergoing

anesthesia to be monitored for blood
pressure. It shall be mandatory for blood
pressure to be monitored with a noninvasive
blood pressure monitor. They shall be
recorded frequently not longer than five
minutes.
vi. It is Mandatory for every patients at highrisk for anesthesia (ASA Grade III and
above) patients, who are hemodynamically
unstable, those requiring inotropic support,
and for surgeries with expected blood loss
more than 20% of the body weight, shall
have blood pressure monitored by an
continuous intra-arterial pressure tracing.
vii. For patients undergoing surgery in the
above category, it is strongly Recommended
to monitor central venous pressure by any
appropriate method.
Additional Monitoring
Certain Additional monitoring may be needed
for neonatal, prolonged or complex procedures.
Temperature
a. It is Recommended that facility to
monitor temperature of the patient either
intermittently or continuously should be
available or should be monitored frequently.
b. The temperature should be monitored
continuously in neonatal, young patient,
Geriatric patients and in patients
undergoing complex or prolonged surgery.
c. Measures to maintain body temperature by
body warming devices or Recommended.
Neuromuscular Monitor
a. It is Suggested that when neuromuscular
blocking drugs are used, a peripheral nerve
stimulator should be available and used as
necessary.
b. It is Recommended that whenever
patients with neuromuscular diseases,
receiving neuromuscular blocking muscle
relaxants, shall be monitored for degree of

neuromuscular block by a peripheral nerve
stimulator
Depth of Anaesthesia
a. Every patient undergoing general anesthesia
should be monitored regularly for depth of
anesthesia clinically.
b. It is Suggested to monitor inspired and
expired gas concentration of volatile
anesthesthetic agent.
c. The use of brain function monitors is
controversial and is not universally
recommended. However use of Brain
function Monitor is Suggested in patients
who may have high-risk of awareness under
anesthesia.
Section V: Monitoring during

Regional Anesthesia,
Anesthesia outside the
operation Rooms and
Monitored Anesthesia Care
1. It is Recommended that the standards of
monitoring should be same as patient
undergoing general or regional anesthesia
or anesthesia outside the operating rooms
should be similar to patient undergoing
surgery inside the operating rooms.
2. It is Mandatory for all patients should be
monitored by:
a. Electrocardiography
b. Pulse oximetry
c. Noninvasive blood pressure
Section VI: Monitoring

During Transportation
1. All patients who have received anesthesia
shall be monitored continuously till he
recovers from anesthesia and all reflexes are
active.
2.
Patients, while transferring to the
postoperative
recovery
area
shall
be accompanied by the responsible
51
Anesthesiologists, or his assistance with

adequate knowledge and experience, till
the patient is handed over to a responsible
person in the recovery room, and a brief
summary of case and proper instructions is
explained to the person in charge.
3. Patient should be shifted only when his
hemodynamic status is stable.
4. Patient should be continued to be monitored
with ECG, pulse oximeter and NIBP or
invasive arterial monitoring as needed.
5. If a patient requires mechanical ventilation
during transport, it is Recommended that
ventilation should be monitored with a
capnograph for end-tidal CO2 monitors, and
disconnection alarm for ventilator such as
airway pressure monitoring.
6. Should the patient require transfer to
another part of the hospital or outside, the
standard of monitoring should be same as
detailed above applicable for postoperative
recovery ward area.
Section VII: Monitoring in the

Postoperative Ward
1. Every patient undergoing anesthesia shall
be transported to a postoperative recovery
ward, and monitored by a competent and
responsible and dedicated qualified person,
till the patient recovers his vital reflexes.
2. Every patient shall be monitored in the postoperative recovery area with continuous
monitoring of ECG, pulse oximeter and
NIBP. Additional monitors like continuous
monitoring by direct arterial pressure
monitoring, CVP, etc. shall be monitored as
Suggested above.
3. Pain relief: It is Mandatory to employ
appropriate medication and modalities to
prevent and alleviate postoperative pain.
4. A postoperative recovery chart shall be
maintained by recovery ward staff detailing
level of consciousness, hemodynamic
status, and respiration. They shall be charted
at least every 15 minutes and earlier, if any
changes are noted towards deteriorating
condition of the patient.
52
5. Patient shall be transferred out of recovery

or postoperative ward, only when the patient
has completely recovered from the effect of
all anesthetic drugs, and all his reflexes are
intact and clinical condition of the patient is
stable.
6. If the clinical condition of the patient is
not stable, he should be transferred to
appropriate intensive care units further
management.
bibliography
1. Checking Anaesthetic Equipment. Association
of Anaesthetists of Great Britain and Ireland,
London, 2004.

2.
Immediate
Post
Anaesthetic
Recovery.
Association of Anaesthetists of Great Britain and
Ireland, London, 2002.
3. International Standards for a Safe Practice of
Anaesthesia 2010; World Federation of Societies
of Anaesthesiologists. e-Newsletter 2010.
4. Kotur PF. Monitoring the Anesthesiologists.

Editorial I.: Indian J Anaesth. 2002;46(4):244-245.
5. Practice Advisory for Intraoperative Awareness
and Brain Function Monitoring. Task Force
Report. Anaesthesiology. 2006:104;847-64.
6. Recommendations for Standards of Monitoring
during Anaesthesia and Recovery 4th edn: The
Ireland, March. 2007.
7. Recommendations for the Safe Transfer of
Patients with Brain Injury. Neuroanaesthesia
Society of Great Britain and Ireland & Association
of Anaesthetists of Great Britain and Ireland,
London, 2006.
8. Standards for Basic Anesthetic Monitoring
Approved by the ASAHouse of Delegates on
October 21, 1986, and last amended on October
25, 2005. Anesthesiology: Standards Guidelines
and Statements: Park Ridge, IL.,USA 1998.
9. Standards of Basic Anesthetic Monitoring.
American Society of Anesthesiologists 2010.

10. Thompson JP Mahajan RP. Monitoring the
monitorsbeyond risk management. British
Journal of Anaesthesia. 2006;97:1-3.
CHAPTER
Head Injury: Assessment and

Early Management
Girija Prasad Rath, Bikash Ranjan Ray
Head injury is a major public health and socioeconomic problem throughout the world. It is a
major cause of death, especially among young
adults,1 and life-long disability is common
in those who survive. Although high-quality
prevalence data are scarce, it is estimated that
in the USA, 5.3 million people are living with
a head injury-related disability,2 and in the
European Union approximately 7.7 million
people who have experienced head injury have
disabilities.3 Mortality following head injury
has been reported in the range of 39 to 51%.4,5
The role of specialized and trained trauma care
team supervised by emergency physicians have
been highlighted for improvement in functional
neurological outcome.6,7 This chapter focuses
on the initial assessment and management of
head injury in the prehospital and emergency
department (ED), and to provide a practical
approach for management of these patients.
Most of the literature is according to the
recommendations proposed in the Brain
Trauma Foundation (BTF)8 and Advanced
Trauma Life Support (ATLS) by American
College of Surgeons.9
Definition and Classification

of Head Injury
The broad definition used for head injury
includes patients with a history of a blow to
the head or the presence of a scalp wound or

those with evidence of altered consciousness
after a relevant injury.10 However, the term
head injury has been replaced with traumatic
brain injury (TBI) as this new term captures
the importance of the brain in these injuries.
The WHO Task Force defined TBI to be any
confusion and disorientation state at the time of
accident.11 The severity of head injury is based
on the Glasgow Coma Scale (GCS) (Table 6.1).
The treatment of head injured patients requires
TABLE 6.1
Glasgow Coma Scale (GCS) Score
Behavior
Response
Score
Eye opening
Spontaneous
To speech
To pain
None
4
3
2
1
Best verbal
response
Oriented
Confused
Words (Inappropriate)
Sounds (Incomprehensible)
None
5
4
3
2
1
Best motor
response
Obeys command
Localize pain
Flexion to painNormal
(Withdrawal)
Flexion to painAbnormal
Extension to pain
None
6
5
4
3
2
1
54
the rapid assessment of injuries and institution

of life-saving measures (Table 6.2).
The prehospital phase: It is the most important
period in the management of TBI as most of
the outcomes are related to the presence of a
high incidence of prehospital secondary brain
insults.12,13 The Brain Trauma Foundation (BTF)
proposed recommendations for prehospital
management of TBI with a standard protocolized
approach which were later revised in 2008.
Most of these recommendations were aimed to
minimize the effects of secondary brain injury
following primary insult. The contributory
factors to the secondary injury have been
the presence of hypoxemia, hypotension,
hypercarbia, hypoglycemia, hyperglycemia,
hyperthermia, and seizures.
Initial evaluation and management: All
patients with TBI should be assessed in the
prehospital setting for hypoxemia (saturation
< 90%) and hypotension (systolic BP < 90 mm
Hg). The GCS score which is a quick reproducible
scoring system to classify head injury should be
used for assessment. It is composed of three
components: eye opening, verbal response
and the best motor response. It should be
used repeatedly to determine improvement or
deterioration over the time. The GCS score can,
however, be affected by various pretrauma and
post-trauma factors. Reversible conditions like
alcohol intoxication, narcotic overdose and
hypoglycemia should be ruled out. The GCS
should only be evaluated after airway, breathing
and circulation are assessed and stabilized.
Airway management: Most of the evidence
supports the need of aggressive airway
management in prehospital settings in patients
with hypoxemia or GCS score less than 8 either
by endotracheal intubation or with bag mask
TABLE 6.2
Classification of severity of head

injury based on glasgow coma
scale (GCS) score
Severity of head injury
GCS Score
Mild
Moderate
Severe
1315
912
8 and less
ventilation. The debate of whether prehospital

intubation in severe TBI is beneficial remains
to be controversial; with specific focus on (a)
who should do itparamedics or emergency
physicians14 and (b) whether rapid sequence
induction (RSI) improves the outcome.15
Recent studies suggest that prehospital
intubation of TBI patient should not be done
if oxygen saturation is more than 90%.16 RSI
and intubation should be carried out in the
prehospital settings by trained personnel. A
higher rate of mortality and a lower incidence
of good neurologic outcome reported in the RSI
group.14 Hyperventilation was implicated for the
possible reason behind increase in mortality in
the RSI group. Because of these contradictory
evidences, no firm recommendation is available
at present for prehospital intubation.
The goal of prehospital fluid resuscitation is
to optimize cerebral hemodyanamics. Isotonica
fluids are most commonly used. Hypertonic fluid
resuscitation is recommended for severe TBI
(GCS < 8). However, in a recent study, Bulger et
al did not find any improvement in the 6 month
outcome with the use of hypertonic saline.17 The
end point of fluid therapy and the ideal fluid for
TBI patients is yet to be determined.
Ventilation strategy:The intubated patients
should be ventilated so as to maintain
normocarbia (PaCO2 3540 mm Hg).
Prophylactic hyperventilation (PaCO2 < 35 mm
Hg) should be avoided and used only if there
is clinical evidence of cerebral herniation or
acute neurological deterioration. The clinical
signs of cerebral herniation include dilated
and unreactive pupils, asymmetry in pupils,
extensor posturing or no motor response.
Targeted ventilation (PaCO2 3039 mm Hg) at the
emergency department was found to decrease
mortality (21.2% vs. 3.7%) in comparison with
ventilation achieved outside the target range.18
Hypothermia has been observed as a
management strategy in TBI, but the results
are still remaining inconclusive. Fox and
colleagues carried out a quantitative systemic
review and analyzed 12 studies involving 1327
patients.19 Early induction of mild to moderate
hypothermia was found to decrease mortality
Head Injury: Assessment and Early Management
and improve neurologic outcome in TBI patients

with maximal benefit in long-term advocation
of hypothermia. The National Acute Brain
Injury Study: Hypothermia II (NABIS: H II) was
a multicenter randomized trial of patients with
severe TBI who received either early cooling to
33C maintained for 48 hours or treatment at
normothermia.20 Patients were enrolled either
during transport to the hospital or in the ED.
The investigators did not find any differences
in outcome between the groups. Bukur and
colleagues21 reported higher mortality due
to prehospital hypothermia in moderate to
severe brain injured patients. The inconclusive
evidence regarding the role of hypothermia is
due to differences in the study methodology.
Transportation: Patients with severe TBI
should be transported directly to a center
where facilities for CT scan, operating room,
neurosurgical care, and the ability to monitor
and manage intracranial hypertension are
available. Prehospital team should be trained
to transport these patients so that they could be
operated during Golden Hour. The transport
method, duration and presence of physician in
the transport team have been found to affect the
outcome.22,23
55
In the absence of any of these risk factors,

the patient should be observed, and to be
transferred to the hospital if the symptoms
worsen or any of these risk factors appears. If
there is no one to supervize the patients then
also the patients should be transferred to the
hospital for observation.
Management children with TBI: The children
cannot be considered as small adults, and
mechanisms and outcome after TBI in them
may differ. The basic concept of treatment
does not differ from adult patients during the
prehospital phase. Whether the endotracheal
intubation in pediatric TBI patients during
this period is beneficial is under investigation.
Gerritse et al showed that on-scene emergency
tracheal intubation was performed effectively
by a physician-based system as compared to
paramedics.24 All other management strategies
such as normocapnia, avoidance of hypoxia
and hypotension, osmotherapy, and avoidance
of hyperthermia are similar to established
recommendations for adults.25
Assessment at the ED: As the timing is crucial,

the approach for a TBI patient should be
systematic, rapid and accurate. This approach is
termed as the initial assessment and includes:
Criteria to refer a patient to ED of a hospital: Preparation
Patients who have sustained head injury should Triage
be transferred to the ED of a hospital if they have Primary survey (ABCDEs)
any of the following risk factors:8,9
Resuscitation
Lack of full consciousness or unconsci Adjuncts to primary survey and resuscitation
-ousness
Consideration of the need for patient transfer
Any focal neurological deficit after the injury Secondary survey (Head-to-toe evaluation
Suspicion of skull fracture or penetrating
and patient history)
injury
Adjuncts to the secondary survey
History suggestive of high energy head injury Continued post-resuscitation monitoring
Convulsion after the injury
and re-evaluation
Amnesia for events, before or after the injury Definitive care.
Persistent headache after the injury
Preparation: All necessary personnel and
Any episode of vomiting after the injury
History of previous cranial neurosurgical resources should be present in the ED at the
time of the patients arrival. Proper functioning
intervention
of airway equipment (e.g. laryngoscopes and
History of coagulation disorder
tubes) should be organized and placed where it
Current anticoagulation therapy
is immediately accessible. Warmed intravenous
Current drug or alcohol intoxication
(IV) crystalloid solutions and appropriate
56
monitoring devices should be available. All

emergency medical personnel should be aware
of a guided protocol for acquiring additional
medical assistance when required. Standard
precaution equipment as per Occupational
Safety and Health Administration (OSHA) and
American College of Surgeons Committee
on Trauma (ACS COT) recommendations
including face masks, gloves, head gear and
water impervious gown should be available to
all personnel during handling of the patients.
Triage: Triage involves the sorting of patients
based on their needs for treatment and the
resources available to provide that treatment.
Treatment is rendered based on the ABC
priorities (Airway with cervical spine protection,
Breathing, and Circulation with hemorrhage
control). Other factors that may affect triage
and treatment priority include injury severity,
salvageability, and available resources.
Primary survey and resuscitation: Brain injury
often is adversely affected by secondary insults.
The mortality rate for patients with severe brain
injury who have hypotension on admission is
more than double that of patients who do not
have hypotension. The presence of hypoxia
in addition to hypotension is associated with
an increase in the relative risk of mortality
by 75%. The primary goals in the emergency
management of TBI include prevention of
hypoxemia, maintenance of blood pressure
and reduction in ICP. Therefore, it is imperative
that cardiopulmonary stabilization be achieved
rapidly in patients with severe brain injury.
It includes 5 steps in a particular sequence:
1. Airway maintenance with cervical spine
protection
2. Breathing and ventilation
3. Circulation with hemorrhage control
4. Disability: Neurologic status
5. Exposure/Environmental control: Completely
undress the patient, but prevent hypothermia.
Stabilization of the airway, breathing and
circulation (ABC) are the priority of all EDs
before attending other injuries. Patients with
the following conditions require immediate
tracheal intubation and mechanical ventilation:
GCS 8 or less.
Loss of protective laryngeal reflex
Inadequate ventilation (hypoxemia or
hypercarbia)
Spontaneous hyperventilation (PCO2 < 30
mm Hg )
Irregular respiration.
However, the risks associated with intubation
should also be assessed. Hypoxia, ICH, full
stomach, and co-existent injuries including
cervical spine instability and maxillofacial
injuries may be present. Careful preparation
and pre-oxygenation are mandatory. Airway
devices and adjuncts such as laryngeal mask
airway, Airtraq, or Glidescope may be
useful, and alternative means of oxygenation
and ventilation must be available.26 In some
cases, cricothyrotomy may be required.
Before administering anesthetic drugs the
hemodynamic status of the patient should
be assessed. The primary goal would to
prevent decreases in CPP with maintenance
of hemodynamic stability. Anesthetic agents
should allow rapid control of the airway while
attenuating increases in ICP and providing
hemodynamic stability. Usually thiopentone
and propofol are the preferred agents but
should be avoided in presence of hypotension.
Etomidate (0.20.4 mg/kg) may be used as
an alternative as it effective in reducing ICP
simultaneously maintaining a hemodynamic
stability. For rapid sequence intubation,
succinylcholine or rocuronium may be used.
Although succinylcholine is known to produce
a small increase in ICP, this is not clinically
significant and should be used particularly if
difficult airway is anticipated. Moreover, the
use of other anesthetic agents will also help to
obtund the effects of succinycholine on ICP.
According to BTF recommendations, the aim
is to maintain a PaO2 more than 60 mm Hg and
PaCO2 in between 35 and 40 mm Hg. Aggressive
hyperventilation should be tried if clinical
or radiological evidence of increased ICP is
present. Maintenance of blood pressure and
CPP is of paramount importance in TBI. The
most common cause of hypotension in these
patients is due to hemorrhage, hypovolemia,
and aggressive diuresis with mannitol. Hence,

aggressive fluid resuscitation with fluids should
be instituted. Isotonic crystalloid solutions are
preferred. The controversy continues regarding
the use of colloids versus crystalloids in TBI.
A post hoc analysis of 460 TBI patients from
the SAFE trial27 found that the patients of TBI
resuscitated with 4% albumin had a significantly
higher mortality at 2 years of injury as compared
to the patients resuscitated with 0.9% saline.
The CHEST (crystalloid versus hydroxyethyl
starch) trial on 7000 intensive care patients
included a very small number of TBI patients
and no reliable conclusions could be made in
these patients.28 Use of vasopressors has been
recommended if hemodynamic stability is not
achieved with fluids. As per the BTF guidelines,
the target end-point of resuscitation is to
maintain a systolic BP of more than 90 mm Hg.
Neurologic evaluation: As soon as the patients
cardiopulmonary status is managed, a rapid and
focused neurologic examination is performed.
It consists primarily of determining the GCS
score, pupillary light response, and focal
neurological deficit. The presence of drugs,
alcohol, intoxicants, and other injuries should
also be ruled out before assessment. The GCS
should be determined before administering
sedatives or paralytic agents.
Secondary survey: It is instituted once primary
survey is completed and resuscitation and
normalization of vitals is in process. It includes
history and head to toe survey of patient
including repeated neurologic evaluation,
complete
laboratory
and
radiological
evaluation.
Imaging: The investigation of choice for
detecting clinically important head injury is
CT scan of head. Although magnetic resonance
imaging (MRI) provides additional information
regarding the injury, it should not be used
as a primary imaging modality due to safety,
logistic and resources reasons. For adults who
have sustained a head injury and have any of
the following risk factors, perform a CT head
scan within one hour of the identification of
following risk factors:29
57
GCS less than 13 on initial assessment in the

ED.
Indication in mild head injury:
High risk
GCS less than 15 at 2 hours after the injury
on assessment in the ED.
Suspected open or depressed skull
fracture.
Any sign of basal skull fracture
[hemotympanum, panda eyes, CSF
leakage from the ear or nose (Battles
sign)].
Vomiting more than 2 episodes.
Age more than 65 years.
Medium risk
Amnesia before impact more than 30
minutes.

Dangerous
mechanism
of
injury
(pedestrian struck by vehicle, occupant
ejected from vehicle, fall from elevation
more than 3 feet.
For patients who have sustained a head injury
with no other indications for a CT head scan and
who are having warfarin treatment, a CT head
scan should be performed within 8 hours of the
injury. A provisional written radiology report
should be made available within 1 hour of the
scan being performed.
Investigating injuries to the cervical spine: For
cervical
spine
scanning,
multiplaner
reformatting CT imaging facility should be
available. MRI should be done if there are
presence of neurological signs and symptoms
with suspected cervical spine or vascular injury.
For adults who have sustained a head injury and
have any of the following risk factors, perform
a CT scan of cervical spine within 1 hour of the
risk factor being identified:
GCS less than 13 on initial assessment
The patient has been intubated
Plain x-rays are technically inadequate (e.g.:
desired view is unavailable)
Plain x-rays are suspicious or definitely
abnormal
A definitive diagnosis of cervical spine injury
is needed urgently
The patient is having other body areas scanned
for head injury or multi-region trauma.
58
The patient is alert and stable; there is clinical

suspicion of cervical spine injury and any of the
following apply:
Age 65 years or older
Dangerous mechanism of injury (fall from
height of more than 1 meter or 5 stairs; axial
load to the head; high-speed motor vehicle
collision; ejection from a motor vehicle;
accident; bicycle collision)
Focal peripheral neurological deficit
Paresthesia in the upper or lower limbs.
A provisional written radiology report should
be made available within 1 hour of the scan
being performed. Adults, who have sustained a
head injury and have neck pain or tenderness
but no indications for a CT cervical spine scan,
perform 3- view cervical spine X-rays within
1 hour if either of these risk factors are identified:
It is not considered safe to assess the range of
movement in the neck.
Safe assessment of range of neck movement
shows that the patient cannot actively rotate
their neck to 45 to the left and right.
X-rays should be reviewed by clinicians
trained in their interpretation, within 1 hour.
Transfer from hospital to a neuroscience
unit: Neurosurgeon should be involved in
care of all the patients who have significant
abnormalities on imaging in order to decide
the surgically significant patients and further
management.9 Regardless of imaging, other
reasons for discussing a patients care plan
with a neurosurgeon and admission into a
neurosciences center include:
Persistent coma (GCS 8 or less) after initial
resuscitation
Unexplained confusion, which persists for
more than 4 hours
Deterioration in GCS score after admission.
Progressive focal neurological signs
A seizure without full recovery
Penetrating head injury
Cerebrospinal fluid leak
Absence of CT scan facilities
No reliable companion at home
Presence of significant injuries, intoxication,
skull fracture.
Discharge and Follow-up:Patients admitted

to the hospital following head injury may be
discharged after resolution of all the significant
sign and symptoms, provided the patients can
be observed at the home.9 Verbal and written
advice should be given to the patient and the
family, which should include:
Sign and symptoms requiring return to the
ED
Details about recovery process
Contact details of hospital services
Information regarding return to day-to-day
activities.
All patients should be informed about the
need for follow-up and rehabilitation, if
required.
CONCLUSION
The early assessment and management
of TBI patients is complex and requires a
coordinated and stepwise approach beginning
from the scene of the accident to transfer
of patient to neurosciences care center,
involving paramedics, emergency physicians,
neurointensivists, and neurosurgeons. Further
research is needed to devise protocols for early
management to prevent the onset and mitigate
the effects of secondary brain injury. Training
programmes particularly for the paramedics
should be planned and implemented to step
down the present burden of TBI.
REFERENCES
1. Maas AI, Stocchetti N, Bullock R. Moderate and
severe traumatic brain injury in adults. Lancet
Neurol. 2008;7:728-41.
2. Langlois JA, Sattin RW. Traumatic brain injury
in the United States: research and programs of
the Centers for Disease Control and Prevention
(CDC). J Head Trauma Rehabil. 2005;20:187-8.
3. Tagliaferri F, Compagnone C, Korsic M, et al. A
systematic review of brain injury epidemiology in
Europe. Acta Neurochir (Wien). 2006;148:255-68.
4. Lannoo E, Van Rietvelde F, Colardyn F, et al.
Early predictors of mortality and morbidity
after severe closed head injury. J Neurotrauma.
2000;17:403-14.

5. Bulger EM, Nathens AB, Rivara FP. Brain Trauma
Foundation: Management of severe head injury:
Institutional variations in care and effect on
outcome. Crit Care Med. 2002;30:1870-6.
6. Myburgh JA, Cooper DJ, Finfer SR, et al.
Epidemiology and 12 month outcomes from
traumatic brain injury in Australia and New
Zealand. J Trauma. 2008;64:854-62.
7. Klemen P, Grmec S. Effect of pre-hospital
advanced life support with rapid sequence
intubation on outcome of severe traumatic brain
injury. Acta Anaesthesiol Scand. 2006;50:1250-4.

8.
Brain
Trauma
Foundation;
American
Association of Neurological Surgeons; Congress
of Neurological Surgeons; Joint Section on
Neurotrauma and Critical Care, AANS/CNS:
Guidelines for the management of severe head
injury. J Neurotrauma. 2007;24(Suppl):S1-106.
9. Advanced trauma life support (ATLS): the
ninth edition. ATLS Subcommittee; American
College of Surgeons Committee on Trauma;
International ATLS working group. J Trauma
Acute Care Surg. 2013;74:1363-6.
10. Jennett B. Epidemiology of head injury. Arch Dis
Childhood. 1998;78:403-6.

11. Carroll LJ, Cassidy JD, Holm L, et al.
Methodological
issues
and
research
recommendations for mild traumatic brain
injury: the WHO Collaborating Centre Task Force
on Mild Traumatic Brain Injury. J Rehabil Med.
2004;43:113-25.
12. Wu X, Hu J, Zhuo L, et al. Epidemiology of traumatic
brain injury in eastern China, 2004: A prospective
large case study. J Trauma. 2008;64:1313-9.
13. Pearson WS, Ovalle F Jr, Faul M, et al. A review
of traumatic brain injury trauma center visits
meeting physiologic criteria from The American
College of Surgeons Committee on Trauma/
Centers for Disease Control and Prevention
Field Triage Guidelines. Prehosp Emerg Care.
2012;16:323-8.
14. Davis DP, Koprowicz KM, Newgard CD, et al.
The relationship between out-of-hospital airway
management and outcome among trauma
patients with Glasgow Coma Scale Scores of 8 or
less. Prehosp Emerg Care. 2011; 15:184-92.

15. Bernard SA, Nguyen V, Cameron P, et al.
Prehospital rapid sequence intubation improves
functional outcome for patients with severe
traumatic brain injury: a randomized controlled
trial. Ann Surg. 2010;252:959-65.

16. Badjatia N, Carney N, Crocco TJ, et al.
Brain Trauma Foundation; BTF Center for
Guidelines Management. Prehosp Emerg Care.
2008;12(Suppl 1):S1-52.
59
17. Bulger EM, May S, Brasel KJ, et al. Out-of-hospital

hypertonic resuscitation following severe
traumatic brain injury: A randomized controlled
trial. JAMA. 2010;304:1455-64.

18. Caulfield EV, Dutton RP, Floccare DJ, et al.
Prehospital hypocapnia and poor outcome
after severe traumatic brain injury. J Trauma.
2009;66:1577-82.

19. Fox JL, Vu EN, Doyle-Waters M, et al.
Prophylactic hypothermia for traumatic brain
injury: A quantitative systematic review. CJEM.
2010;12:355-64.
20. Clifton GL, Valadka A, Zygun D, et al. Very early
hypothermia induction in patients with severe
brain injury (the National Acute Brain Injury
Study: Hypothermia II): a randomised trial.
Lancet Neurol. 2011;10:131-9.
21. Bukur M, Kurtovic S, Berry C, et al. Pre-hospital
hypothermia is not associated with increased
survival after traumatic brain injury. J Surg Res.
2012;175:24-9.
22. Bulger EM, Guffey D, Guyette FX, et al. Impact of
prehospital mode of transport after severe injury:
A multicenter evaluation from the Resuscitation
Outcomes Consortium. J Trauma Acute Care
Surg. 2012;72:567-7.

23. Franschman G, Verburg N, Brens-Heldens V,
et al. Effects of physician based emergency
medical service dispatch in severe traumatic
brain injury on prehospital run time. Injury.
2012;43:1838-42.
24. Gerritse BM, Draaisma JM, Schalkwijk A, et al.
Should EMS-paramedics perform paediatric
tracheal intubation in the field? Resuscitation.
2008;79:225-9.
25. Zebrack M, Dandoy C, Hansen K, et al. Early
resuscitation of children with moderate-tosevere traumatic brain injury. Pediatrics.
2009;124:56-64.

26. Rozet I, Domino KB. Care of the acutely
unstable patient. In: Cotrell JE, Young WL
(Eds.) Neuroanesthesia. 5th edn. Philadelphia,
PA:Mosby. 2010. p.165
27. Myburgh J, Cooper DJ, Finfer S, et al. Saline
or albumin for fluid resuscitation in patients
with traumatic brain injury. N Eng J Med.
2007;357:874-84.

28. Myburgh JA, Finfer S, Bellomo R, et al.
Hydroxyethyl starch or saline for fluid
resuscitation in intensive care. N Engl J Med.
2012;367:1901-11.
29. Stiell IG, Wells GA, Vandemheen K, et al. The
Canadian CT Head Rule for patients with minor
head injury. Lancet. 2001;357(9266):1391-6.
CHAPTER
Guidelines to Quality
Assurance in Anesthesia
Jayashree Sood
Quality is described in terms of degree of

excellence for a specific purpose. Quality
assurance in anesthesia practice is administering
anesthesia of the highest order which can be
expected in that setting and is a focus on patient
safety Patient safety is a fundamental objective
of anesthesia care because anesthesia by itself
has no therapeutic value. Quality assurance
in anesthesia care improve patient safety and
satisfaction.
Quality of care, which determines quality
assurance, is usually measured in terms of three
indicatorsstructure, process and outcome as
described by Donabedian.
Structure refers to the setting in which
care was provided, that is the personnel and
facilities used to provide healthcare services
and the manner in which they are organized.
The structure must be adequate to perform its
mission.
Process of care includes the sequence and
coordination of patient care activities indicating
what is actually done. The process must be
workable and efficient.
Outcome of care refers to changes in health
status of the patient following the delivery of
medical care.
Proactive guidelines are systematically
developed statements to assist the anesthesia
practitioner in specific clinical circumstances.
A quality improvement (QI) program in

anesthesia focuses on measuring and improving
the above components of care.
Quality Assurance Cycle
Quality assurance in anesthetic practice may be

broadly divided into:
1. Practice guidelines, policies or protocols
2. Anesthesia record
3. Risk management
4. Adverse incident reporting
5. Critical incident analysis
6. Peer review
7. Audit
8. Cost effectiveness
Guidelines to Quality Assurance in Anesthesia
9. Regulation and licensing of anesthesia

personnel.
Provision of Anesthesia
Services
Qualification of the Anesthesiologist
It is important to understand that anesthesia
services are being provided under different
settings in India. They are being provided in
major hospitals where are all anesthesiologists
are qualified.
They are also being provided in the rural
settings where the qualification of the concerned
anesthesiologist may be questionable. It is
essential that any clinician administering
anesthesia should be qualified, either a diploma
or a masters degree. No clinician without these
qualifications should be allowed to administer
anesthesia. In the private setting, qualified
anesthesiologists are practicing either as
free standing or a group practice and should
understand the legal implications of group
practice.
Operating Room Services

The operating room where anesthesia services
are to be provided should conform to the
standards being provided by other major
hospitals. The operating room should be safe
against electric and fire hazards. All necessary
clearances should be obtained before surgeries
are begun.
Major hospitals should have a medical gas
pipeline system which should be certified
by the concerned authorities. If however,
in smaller hospitals, pipeline system is not
available, there is should be free availability
of gas cylinders. In rural set-ups, oxygen
concentrators should be in place. Before
beginning the first case of the morning, the
preanethetic check list for gas pipeline and
anesthesia machine should be done and
documented. The breathing circuit, routine
equipment, vacurim suction and drugs should
be checked. The anesthesia machine should
61
have an annual maintenance contract. An

oxygen analyzer along with other alarms should
be in place. A suction machine, preferably
electrical, is essential. A defibrillator is
mandatory in all places providing anesthesia.
A laryngoscope and endotracheal tubes should
be present. Equipment required to maintain a
difficult airway including stylet, bougie and an
LMA is recommended. All equipment must be
examined regularly by an authorized body and
replaced when required. Specific monitoring
required for the concerned surgeries should
be available, e.g. temperature monitoring for
long surgeries, CVP and other noninvasive
cardiac output monitoring in major surgical
procedures. All the concerned parameters
should be recorded at regular intervals in the
anesthesia chart.
Sterilization of Equipment
The protocol for infection control prepared
by the hospital authorities should be strictly
adhered to. The color coded bags for hospital
waste disposal should be used. All syringes and
needles should be destroyed and disposed off in
color coded bags.
Equipment which needs to be sterilized
should be done according to hospital protocol.
Monitoring Equipment
Mandatory monitoring should be available
which includes heart rate, blood pressure
and oxygen saturation. So a monitor which
includes all three should be kept. A capnogram
is mandatory for all intubated patients and
laparoscopic surgeries.
Drugs
Those drugs which are required for providing
general and regional anesthesia should be
freely available. A regular supply of thiopentone
sodium, neuromuscular blocking drugs
including suxamethonium and nondepolarizing
drugs, analgesic, atropine and the reversal drugs
is mandatory.
62
Drugs including lignocaine and bupivacaine

which are necessary for regional anethesia
procedures should be present. Emergency
drugs should be kept ready in a dedicated slot
so that they are immediately available when
required. Drugs which have exceeded their shelf
lives should be replaced with new ones.
Preoperative Examination
All patients posted for surgery should have a
preanesthetic evaluation by the anesthesiologist.
There should be a preanesthetic evaluation
form which should be filled for all patients so
that this form can be consulted when anesthesia

is being administered to them.
All comorbidities should be optimized
preoperatively.
Investigations should be done according to
guidelines set by the respective organizations
(our PAC Diag Guidelines). Hemoglobin
estimation and routine urine examination
should be done for all cases since anemia is
a common finding in our country and some
patients may be reporting to the hospital for
the first time. Routine urine examination is
a very simple test which reveals involvement
of several organs, e.g. kidney and endocrines.
Fasting instructions are very essential to be

followed.
Although international guidelines allow clear
fluids 2 hours before surgery, they may not be so
rigidly followed by patients in our country since
many individuals do not realize the importance
of fasting, therefore fasting instructions should
be given very clearly.
Before elective surgery the minimum
duration of fasting should be 8 hours after a
normal heavy meal and 6 hours after a light
meal or infant formula.
Premedication with an oral anxiolytic should
be given according to hospital protocol, unless
there is a contraindication.
The plan of anesthesia should be explained
to the patient. Plan of postoperative analgesia
should be discussed with the patient. Informed
consent should be taken.
Preoperative Checklist
A preoperative safety checklist adapted from
the WHO, must be followed. It may be modified
according to the institution where it is being
used. Our hospital safety checklist as given:
Patient identification, surgical procedure
and side of operation must be documented and
verified by the anesthesiologist, surgeon and
technician.
The Intraoperative Period

The anesthesia machine, equipment drugs and
suction should be checked before each case.
All syringes filled with drugs should be labeled.
An intravenous access should be obtained
even for minor procedures under LA. The
anesthesiologist or his assistant must remain
with the patient throughout the intraoperative
period whether it is general, regional or
monitored anesthesia care.
The anesthesiologist is responsible for the
perioperative anesthetic care of the patient.
Simultaneous administration of general or
regional anesthesia by one anesthesiologist an
more than one patient is not allowed.
63
Whenever an obstetric delivery is being

done, the anesthesiologist is responsible only
for the mother, while a neonatologist must be
present for neonatal resuscitation.
An anesthesia chart should be maintained
for all patients. Documentation of all events in
the perioperative period are mandatory.
Records
Maintaining records is of the utmost
importance. All changes in the intraoperative
period should be documented. All variables
including heart rate and blood pressure should
be recorded regularly according to the clinical
situation. Oxygen saturation must be monitored
continuously and recorded at regular
intervals. End-tidal CO2 should be monitored
continuously if the trachea is intubated and if
it is a laparoscopic surgical procedure. Alarms
should not be disabled.
The intraoperative documentation should
also include the details of drugs administered,
their time of administration route and dose.
The volume and type of fluids administered
should be written in the perioperative period.
Urine output, if the patient catheterized should
be measured and recorded.
Post-anesthesia Care Unit

Recovery room facility should be available
wherever anesthesia services are being
provided.
The recovery room should be equipped with
essential monitoring equipment.
The anesthesiologist should accompany the
patient to the recovery room.
The vital signs of all patients brought to the
recovery room should be monitoredoxygen
saturation, blood pressure and heart rate.
An accurate record of the immediate recovery
period should be maintained.
Supplemental oxygen and suction machine
in working condition are mandatory. Emergency
drugs and defibrillator should be immediately
available.
64
Discharge from the PACU is the responsibility

of the anesthesiologist. There should be a check
list to decide whether the patients are ready to
be shifted to the room.
Discharge Criteria after

Daycare Surgery
If a hospital has a day care centre, there should
be a vital signs monitoring chart which is
documented for all patients. Discharge Criteria

should be followed. The anesthesiologist must
have the authority to discharge these patients.
Guidelines for Obstetric Analgesia

Obstetric analgesia services should only
be extended to those facilities who have an
experienced anesthesiologist with adequate
training in obstetric anesthesia.
A hospital planning to introduce obstetric

analgesia services needs proper infrastructure
with well trained nurses and adequate
monitoring facilities in the labor suite.
All emergency equipment should be
available in case a complication occurs during
any procedure.
Informed consent should be taken before
initiating the regional anesthesia.
An intravenous access should be obtained in all
these parturients. Hospital protocols made for the
initial dose of local anesthetic and the subsequent
top ups should be followed. Monitoring of vital
signs should be done and documented.
The anesthesiologist should remain with
the patient till adequate pain relief is obtained.
Subsequently should be immediately available
if required. Top up doses to be given only by a
qualified anesthesiologist. Clear fluids may be
allowed in established labor.
65
Guidelines for Acute Pain

Management
Protocols for pain management in the
postoperative period should be made and
followed by the pain physicians.
VAS score and other vital signs should
be documented. The back and the epidural
catheter dressing should be examined daily.
An anesthesiologist should be available
immediately in case of an adverse event.
Anesthesia Outside the Box

A qualified anesthesiologist should provide
anesthesia care in these remote locations.
Appropriate anesthesia equipment with
oxygen, routine and emergency drugs and
suction machine should be available.
Fasting status should be checked before
inducing anesthesia.
66
Adverse Incident Reporting

All adverse events including life-threatening or
unusual complications, adverse drug reactions
should be reported.
Critical incidents are events that cause, or
had the potential to cause, patient injury if not
noticed and corrected in a timely manner.
Audit
All data should be audited.
Criteria based audit evaluates performance
according to predetermined criteria.
The audit should be reviewed regularly to
ensure that remedial steps are taken whenever
required.
Quality Assurance in ICU

Quality of care in ICU can be assessed by
1. Measurement of patient satisfaction
2. Analyzing frequency of delivery of care
3. Monitoring of complications
4. Duration of hospitalization
5. Analysis of mortality data.
Development of protocols, guidelines and
programm enhance the quality of care.
Further Reading
1. Benn J, Arnold G, Wei I, Riley C, Aleva F. Using
quality indicators in anaesthesia: Feeding back
data to improve care. Br J Anaesth. 2012;109:80-91.
2. Archer JC. State of the science in health
professional education: Effective feedback. Med
Educ. 2010;44:101-8.
3. Hetimiller ES, Martinez EA, Pronovost PJ. Quality
improvement. In: Miller RD, editor.Millers
Anesthesia. 7th ed. Philadelphia: Churchill
Livingstone; 2010. pp. 81-92.
4. Haller G, Stoelwinder J, Myles PS, McNeil J. Quality
and safety indicators in anesthesia: A systematic
review. Anesthesiology. 2009;110:1158-75.
5. van der Veer SN, de Keizer NF, Ravelli AC,
Tenkink S, Jager KJ. Improving quality of care.
A systematic review on how medical registries
provide information feedback to health care
providers. Int J Med Inform. 2010;79:305-23.
CHAPTER
Preanesthetic Evaluation
and Investigation
JP Sharma, Nidhi Kumar
INTRODUCTION
Preanesthetic evaluation is mandatory for
safe anesthesia practice and if properly done,
reduces perioperative complications and
also helps to decrease postsurgical morbidity
and mortality, which depends not only on
the surgical procedure itself, but also on
the patients preoperative physical status.
Subsequent preoperative optimization of the
patients condition reduces operative and
anesthesia-related risks.
Patients often have comorbidities that
require careful assessment and coordination.
There are several models available for the
preoperative anesthetic assessment clinic, most
of which rely both on anesthetists and specialist
nurses.1 All hospitals should aim to provide
appropriately staffed clinics. The visit to the
pre-operative clinic also gives the patients an
opportunity to discuss the choices of anesthetic
technique, methods for pain relief and the
risks, in a calmer atmosphere than immediately
before the operation. It also helps in making
good rapport with the patients. By having
appropriate discussion and counseling gaining
patients confidence also helps in reducing
requirements of premedication by assuring and
reassuring the patients. Bedside PAC should
be considered in those who are unable to visit
PAC rooms like orthopedic patients and sick
patients. It is advisable to evaluate the patient

again in the night before surgery, which helps
in diagnosing and managing any new sign,
symptoms.2
Even emergency cases associated with
higher mortality and morbidity, require a more
abbreviated evaluation. Short relevant history,
fasting status and quick assessment of airway
and review of relevant investigations available
with the patients help reducing perioperative
complications in emergency cases.
Preanesthetic check-up is a team approach
involving an anesthetist, surgeon and
physician/super specialist to optimize patients
general condition to make him suitable so he
can tolerate anesthetic and surgical stress.
Perioperative care of the patient as well as
efficiency in the OT is always enhanced by close
communication with all.3
Preferably preanesthetic check-up should
be done by anesthesiologist responsible for
providing anesthesia to that patient.
Preoperative evaluation services should be
such that every patient is fully informed about
their proposed procedure/alternatives and the
interventions that will need to be undertaken,
estimate the level of risk for every patient, ensure
every patient understands their own individual
risk so that they can make an informed decision
about whether to proceed to surgery, identify
co-existing medical illnesses and optimally
68
prepare patients whilst taking into account the

urgency of the operation and identify patients
with a high-risk of complications in the perioperative period and define the appropriate
postoperative level of care (day stay, inpatient,
ward).4,5
Preanesthetic Evaluation
Review of hospital charts and prior anesthesia
records, if any available with the patient, helps
in detecting the presence of a difficult airways,
individual response to surgical stress and
specific anesthetics, any drug interactions,
increased nausea vomiting or delayed recovery,
respiratory assistance in postanesthetic care
and history of malignant hyperpyrexia.6,7
The history should include the duration and
the course of his illness; any pre-existing disease
and chronic medications. History of smoking
and alcohol intake and artificial devices if
any like hearing aids, false eyes, pacemaker,
dentures should be asked.7 Patient having
history of chronic smoking should be advised to
quit smoking since it causes increased sputum
production, decreased ciliary function of the
respiratory epithelium and increased airway
sensitivity which lead to difficulty during and
after anesthesia.8,9
History of chest pain, palpitations,
breathlessness, orthopnea, syncope, ankle
swelling have to be ruled out. If the history of
chest pain is present then further investigations
and possible treatment should be taken in close
cooperation with the cardiologist. Functional
evaluation of cardiovascular risk is done by
observing vigor and stamina in walking.10,11
Adults with prior myocardial infarction (MI)
almost always have coronary artery disease.
The risk assessment for noncardiac surgery
is based on the time interval between MI and
surgery, and if it is less than 30 days than the
patients are at high-risk. If the patient has a
pacemaker, determine the type and model,
date of implantation and when the battery
life and performance were last interrogated.
If prior cardiac catheterizations or coronary
revascularizations have been performed, obtain
the reports. The waiting period for surgery after

bare metal stent placement is generally 3 to 4
weeks, while for drug eluting stents it is for 6 to
12 months. The anesthesiologist must weigh the
risk of regional versus general anesthesia when
these patients are taking antiplatelet drugs.12,13
Any recent episode of fever, cough, cold or flu
is enquired as it can increase the postoperative
pulmonary complications. History of dyspnea,
wheeze, stridor, snoring, sleep apnea and any
pre-existing lung disease is obtained. Patients
with obstructive and restrictive lung disease
should be assessed by bedside lung function
tests. FEV1/FVC ratio is greatly decreased in
obstructive lung disease and is nearly normal in
restrictive lung disease.
Asthma is an important co-existing disease
encountered by the anesthesiologist. Frequent
use of bronchodilators, hospitalization and
requirement of systemic steroids indicate
severity of disease.14
Any significant history regarding jaundice,
ascites, malaena, vomiting of altered blood
and altered sensorial should be taken. Such a
history increases the potential of dehydration,
electrolyte disturbances, and anemia in the
patients. Patients with liver disease have altered
protein binding, volume of distribution of drugs
as well as coagulation abnormality.15 They show
prolonged effect of sedative drugs and some are
resistant to muscle relaxants due to increased
volume of distribution. Patients with history
of heartburn, acid reflux may require antacid
prophylaxis and rapid sequence induction.
Renal disease have to be ruled out though
history and if present determine the stage and
whether the patient has ever required dialysis.
Renal insufficiency increases risk because it
producesanemia, electrolyte disturbances,
peripheral neuropathy, abnormalities in drug
metabolism and excretion, contribute to
bleeding because of a functional platelet deficit
associated with renal impairment.16
Among the endocrine disease, diabetes,
thyroid, parathyroid disease, pituitary and
adrenal disease can increase the perioperative
risk substantially. History to rule out such
diseases include frequently waking up at night
Preanesthetic Evaluation and Investigation
to urinate, sweating much more than others

every now and then, chronic deep seated
headaches, facial flushing even when not
exercising, consistently feeling warmer or colder
than others, history of weight gain, depression,
steroid intake, history of muscle cramps in legs,
etc.
Majority of diabetics develop secondary
disease in one or more organ system, which
must be identified preoperatively so that
an appropriate plan can be developed for
perioperative management. Signs of autonomic
dysfunction should be assessed which may
predispose to hemodynamic instability during
anesthesia and increases risk of pulmonary
aspiration due to gastroparesis. Positioning
injuries during surgery are more common in
these patients. Long standing diabetes causes
glycosylation of proteins which significantly
affects temporomandibular, atlantooccipital,
and cervical spine resulting in difficulty
in intubation. Diabetic patients should be
scheduled for surgery as the first case of the
day to prevent prolonged fasting. An attempt
should be made to control blood sugar within
a range of 100 to 200 mg/dL.17 Type 2 diabetics
not receiving insulin and undergoing minor
surgery usually can be managed satisfactorily
without insulin.18 However, diabetic patients
scheduled for major surgery, who are receiving
hypoglycemic medication or who have poor
glycemic control, should be established on
insulin therapy preoperatively. Continuous
intravenous infusion of insulin is a better
option than intermittent subcutaneous bolus
regimens19 and, at least in perioperative cardiac
surgical patients, may be associated with
improved outcome.20 Although intermittent
intravenous bolus regimens are still used, this
approach is difficult to recommend.21,22
Patients having thyroid swelling, preoperative
assessment should focus on evaluation of
signs and symptoms of hyperthyroidism and
hypothyroidism. Hyperthyroid patients have
higher resting heart rates in comparison to
normal subjects. Thyroid storms due to high
overloads of thyroid hormones that accelerate
their heart rate to as high as 300 beats a minute,
69
is a very life-endangering condition and can

result in arrhythmia or heart attack. An EKG
is advised in such patients preoperatively. A
large thyroid mass can distort upper airways,
producing inspiratory stridor or wheeze. In such
cases X-ray chest should be done for evidence of
tracheal deviation and narrowing.23 If there are
any concerns regarding airway compromise, a
CT scan is performed to determine the extent
and location of tracheal narrowing or detect
tracheal invasion. Indirect laryngoscopy is
often performed preoperatively by ENT surgeon
to document vocal cord function. This is an
invaluable tool for the anesthetist to assess the
laryngeal inlet and any deviation from normal
anatomy.
In patients taking long-term steroid therapy,
one should have a high index of suspicion
of adrenal cortical suppression and cushing
syndrome. Determine when, how much, for
what reason, and for how long the patient took
a steroid. Steroid-induced adrenal suppression
may persist for up to a year after even relatively
short courses of corticosteroids in doses above
10 mg/d. If this has occurred, coverage with
stress doses of steroids starting just before
surgery and continuing for 48 to 72 hours is
advised.
Prolonged or unusual bleeding from cuts,
nosebleeds, minor bruises, tooth extractions,
or surgery should be sought and whether such
excessive bleeding required blood transfusion.
Any serious bleeding problem in any family
member or blood relative is considered
important. Use of any medications such as
aspirin, NSAIDs, anticoagulants known to
affect blood clotting must be asked. Antiplatelet
agents like, clopidogreal or ticlopidine, warfarin,
and nonsteroidal anti-inflammatory drugs, oral
contraceptives, estrogens should be considered
for stopping before surgery Clopidogreal
must be stopped seven days preoperatively.
However, low dose (75 mg) aspirin should be
continued whenever possible for most surgical
specialities.24-26
Neurological status is assessed by whether
the patient is well oriented to time and
place. If history of seizure, convulsion is
70
present consider increased resistance to

competitive neuromuscular blockers and avoid
exposure to epileptogenic drugs. History of
stroke or paralysis, tremor, migraine headaches,
nerve injury, or any other disorder of the
nervous system should be asked. Medications
like antidepressant, sedative, tranquilizing, or
antiseizure medications should be enquired.
In case of pediatric patients birth history
relating to mode of delivery, cry at birth,
jaundice, and history of apnea should be asked.
Weight especially in pediatric patient helps in
assessing the dose requirement of anesthetic
drugs. In patients with history of acute episode
of respiratory tract infection, rule out whether
it is viral or infective in pathology, auscultation
of chest must be done and an X-ray chest if
needed. Weigh the risk benefits of surgery
and anesthesia and if surgery is required then
standard guidelines should be followed. Patients
posted for cleft lip and cleft palate surgery, any
other congenital anomaly should be ruled out.
An observant anesthesiologist starts
assessing the patient as soon as the patient
enters the clinic. An outlook of the patient as
he enters the clinic gives us an idea of the built,
respiratory pattern, level of comfortness on
sitting, economic status of the patient. Noninvasive blood pressure monitor and pulse
oxymeter are important tools helping in quick
assessment of the patient. The general physical
examination of the patient includes palpation
of the pulse for rate, rhythm, character and
volume, arterial blood pressure in both arms,
and in at least one arm 2 minutes after the
patient assumes the upright position after lying
down. SpO2 monitor with plethysmography
usually available in preanesthetic clinics helps
assessing pulmonary status. Patient should be
examined for pallor, icterus, cyanosis, clubbing,
dehydration, edema and lymphadenopathy.
Signs of congestive heart failure can be assessed
by engorged neck veins, hepatomegaly, ascites,
ankle edema, basal crepitations.
Assessment of pattern of ventilation,
respiratory rate, ronchi and crepitation should
be done. Oxygen saturation on room air by pulse
oxymetry gives some clue regarding pulmonary
function of the patient. The basic algorithm of

inspection followed by palpation, percussion
and auscultation should be followed for all the
systems.
A basic concern of the anesthesiologist is
always the patients airways. Evaluation of
airways involves determination of thyromental
distance, ability to flex base of neck and
extend the head, and examination of oral
cavity, including dentition. The Mallampatti
classification has become the standard for
assessing the relationship of the tongue size
relative to the oral cavity.27 For neuraxial block
examine the spine to rule out infection of
the overlying skin, any scar mark, scoliosis,
kyphosis, etc.
INVESTIGATION
It is generally accepted that the clinical history
and physical examination represent the best
method of screening for the presence of disease.
Routine laboratory tests in patients who are
apparently healthy on clinical examination and
history are not beneficial or cost effective. If a
relevant investigation has been performed in
the preceding 4 months a repeat investigation
is not warranted, unless there is a significant
change in the patients condition.
Patients under the age of 40 years without
any co-existing disease do not require any
investigations preoperatively in western
set-up. But in India a complete hemogram
and urine microscopy is advised in pediatric
as well as adult patients. Hemoglobin helps
assessing the allowable blood loss for a patient
and also the need of any blood transfusion
intraoperatively.28-30 A pregnancy test should be
obtained for women of childbearing potential.
A preoperative electrocardiogram is required
for patients with cardiovascular or respiratory
diseases, male patients older than 40 to 45
years of age and women older than 50 years
of age, and patients with multiple risk factors
undergoing high-risk cardiovascular surgeries.
Clinical characteristics that may necessitate
a preoperative chest X-ray include smoking,
recent upper respiratory infection, chronic
Preanesthetic Evaluation and Investigation
obstructive pulmonary disease, and cardiac

disease.31 Preoperative spirometry may be
appropriate in patients with existing chronic
pulmonary disease or asthma.31
Further cardiac or pulmonary testing like
echocardiography and pulmonary function test
should be guided by the findings of the basic
preoperative evaluation.
Assessments of nutritional and fluid and
electrolyte status is an essential component
of preoperative evaluation. Malnourished
patients are at increased risk for surgical
morbidity and mortality. Assessing serum
albumin level provides information about the
patients nutritional condition. Serum urea
and electrolytes is advised in patients with
clinical evidence of renal disease, symptomatic
cardiovascular disease, diabetes, patients on
drugs like diuretics, digoxin, steroids, others
causing electrolyte disturbances. Serum
potassium and magnesium should be carefully
monitored and corrected in patients taking
diuretics because these abnormalities can
predispose to perioperative arrhythmias.
Similarly, it is important to monitor serum
glucose during the perioperative period,
especially in diabetics or patients taking
steroids.28,29,32,33 Coagulation profile is indicated
in patients with clinical evidence of liver disease
including a history of hepatitis, bleeding
disorder, anticoagulants.34
These recommendations must be used
with the clinical information obtained from an
accurate history and examination. If, for any
reason, there is doubt regarding these tests
then advice should be sought. This encourages
communication between the surgeon and the
anesthetist which is essential for the well-being
of the patient.
Conclusion
By improving the planned admission process,
one may enhance the patient experience and
the clinical process, as well as the efficiency
and productivity of the institution. Preoperative
assessment and planning should form a natural
part of the process for all planned surgery. The
71
only goal is to match the intensity of the process

to the patients level of fitness and complexity of
the procedure.
References
1. Van Klei WA, Hennis PJ, Moen J, et al. The
accuracy of trained nurses in preoperative
health assessment: results of the OPEN study.
Anesthesia. 2004;59:971-8.
2. Greenberg CC, Regenbogen SE, Studdert DM,
et al. Patterns of communication breakdowns
resulting in injury to surgical patients. Journal
of the American College of Surgeons. 2007;204:
533-40.
3. Rushforth H, Burge D, Mullee M, et al. Nurse-led
paediatric pre-operative assessment: an
equivalence study. Paediatric Nursing. 2006;18:
23-9.
4. Rai M, Pandit J. Day of surgery cancellations after
nurse-led pre-assessment in an elective surgical
centre: the first 2 years. Anesthesia. 2003;58:
685-7.
5. Kinley H, Czoski-Murray C, George S, et al.
Effectiveness of appropriately trained nurses
in pre-operative assessment: randomised
controlled equivalence/non-inferiority trial.
British Medical Journal. 2002; 325: 1323.
6. Gibby GL, Gravenstein JS, Layon AJ, et al. How
often does the preoperative interview change
anesthetic management? Anaesthesiology. 1992;
77:1134.
7. Roizen MF, Kaplan EB, Schreider BD, et al:
The relative roles of the history and physical
examination, and laboratory testing in
preoperative evaluation for outpatient surgery:
The Starling curve in preoperative laboratory
testing. Anaesthesiol Clin North Am. 1987;5:15.
8. Theadom A, Cropley M. Effects of preoperative
smoking cessation on the incidence and risk of
intraoperative and postoperative complications
in adult smokers: a systematic review. Tob
Control. 2006;15:352-8.
9. Thomsen T, Tnnesen H, Mller AM. Effect of
preoperative smoking cessation interventions
on postoperative complication and smoking
cessation. Br J Surg. 2009;96:451-61.
10. Eagle KA, Berger PB, Calkins H, et al. ACC/
AHA Guideline Update for Perioperative
Cardiovascular Evaluation for Noncardiac
SurgeryExecutive Summary. A report of the
American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
72
(Committee to Update the 1996 Guidelines

on Perioperative Cardiovascular Evaluation
for Noncardiac Surgery). Anesth Analg. 2002;
94:1052-64.
11. Chassot PG, Delabays A, Spahn DR. Preoperative
evaluation of patients with, or at risk of, coronary
artery disease undergoing non-cardiac surgery.
Br J Anaesth. 2002;89:747-59.

12. Dupuis JY, Labinaz M. Noncardiac surgery
in patients with coronary artery stents: what
should the anesthesiologist know? Can J Anesth.
2005;52:356.
13. Riddell JW, Chiche L, Plaud B, et al. Coronary
stents and noncardiac surgery. Circulation. 2007;
116:378.

14. Kabalin CS, Yarnold PR, Grammer LC. Low
complication rate of corticosteroid treated
asthmatics undergoing surgical procedures.
Arch Intern Med. 1995;155:1379.
15. Strunin L. Preoperative assessment of the patient
with liver dysfunction. Br J Anaesth. 1978;50:
25-34.

16. Kheterpal S, Tremper KK, Heung M, et al.
Development and validation of an acute kidney
injury risk index for patients undergoing
general surgery: results from a national data set.
Anesthesiology. 2009;110:505-15.
17. Coursin DB. Perioperative management of the
diabetic patient. 55th ASA Annual Refresher
Course Lectures, 2004, 210.

18. Thompson J, Husband DJ, Thai AC, et al.
Metabolic changes in the non-insulindependent diabetic undergoing minor surgery:
effect of glucoseinsulinpotassium infusion. Br
J Surg.1986;73:301-4.
19. Christiansen CL, Schurizek BA, Malling B, et
al. Insulin treatment of the insulindependent
diabetic patient undergoing minor surgery.
Continuous intravenous infusion compared with
subcutaneous administration. Anesthesia.1988;
43: 533-77.
20. Furnary AP, Zerr KJ, Grunkemeier GL, et al.
Continuous intravenous insulin infusion reduces
the incidence of deep sternal wound infection
in diabetic patients after cardiac surgical

procedures. Ann Thorac Surg. 1999;67:352-60.

21. Hall GM. Insulin administration in diabetic
patients: return of the bolus? Br J Anaesth. 1994:
72:1-2.
22. Hirsch IB, McGill JB, Cryer PE, et al. Perioperative
management of surgical patients with diabetes
mellitus. Anesthesiology. 1991;74:346-59.

23.
Franklyn
JA.
The
management
of
hyperthyroidism. N Engl J Med. 1994;330:1731-9
24. Kearon C, Hirsh J. Perioperative Management
of Patients Receiving Oral Anticoagulants. Arch
Intern Med. 2003;163:2532-3.
25. Eckman MH. Bridging On the River Kwai: The
Perioperative Management of Anticoagulation
Therapy. Med Decis Making. 2005;25:370-3.

26.
Dunn AS, Wisnivesky J. Perioperative
Management of Patients on Oral Anticoagulants:
A Decision Analysis. Med Decis Making. 2005;
25:387-97.

27. Mallampati SR, Gatt SP, Gugino LD, et al.
A clinical sign to predict difficult tracheal
intubation: A prospective study. Canadian
Anesthetists Society journal 1985;32(4):429-34.
28. Kaplan EB, Sheiner LB, Boeckmann AJ, et al. The
usefulness of preoperative laboratory screening.
JAMA. 1985;253:3576-81.

29. McKee RF, Scott ME. The value of routine
preoperative investigations. Ann R Coll Surg
Engl. 1987;69:160-2.
30. Lunn JN, Elwood PC. Anaemia and surgery. Br
Med. 1970;3:71-3.
31. Archer C, Levy AR, McGregor M. Value of routine
preoperative chest X-rays: A meta analysis. Can J
Anaesth. 1993;40:1022.
32. Campbell IT, Gosling P. Preoperative biochemical
screening. Br Med J. 1988;297:803-4.
33. Catchlove BR, Wilson Macl R, Spring S, et al.
Routine investigations in elective surgical
patients. Med Jf Aust. 1979;107-10.
34. Rohrer MJ, Michelotti MC, Nahrwold DL.
A prospective evaluation of the efficacy of
preoperative coagulation testing. Ann Surg.
1988;208:554-7.
CHAPTER
Perioperative Fluid
Management in Children
LD Mishra, P Ranjan
Fluid management in children needs a special

knowledge and skill more so in neonates
Over transfusion in this age group may lead
to pulmonary edema and other associated
respiratory complications, due to ill developed
kidney functions
The variability in fluid requirement is due to
the differences in the rate of caloric expenditure
and growth, the ratio of body surface area to
body weight, degree of renal function maturity
and the amount of total body water (TBW)
at different ages. In comparison to grown up
children and adult, infants have greater fluid
needs because of high BMR and growth; surface
area-to-weight ratio is about three times greater,
hence higher insensible fluid loss; and greater
urinary excretion of solutes combined with
lower tubular concentrating ability.
Following four major components are
mainly used to determine the hourly rates of
intraoperative fluid volume administration in
children.
1. Maintenance fluid is mainly based on
caloric expenditure at different ages.
2. Estimated volume deficit incurred during
preoperative fasting or by other fluid
deficits; one-third of such deficits may be
replaced during the first hour of surgery
while the remaining volume may be infused
over the complete duration of the surgery.
3. Severity of surgical and nonsurgical trauma.

This may comprise the largest volume of
fluid loss or fluid redistribution, which
derives largely from the ECF compartment.
4. Blood loss and fluid deficit must be
adequately replaced to support systemic
blood pressure. In this regard, following
possibilities should always be kept in
mind before calculating the required fluid
replacement.
The main aim of perioperative fluid
management is to maintain an adequate
intravascular volume without the development
of hyponatremia. Children are at risk of
developing hyponatremia in the perioperative
period, mainly due to following factors:
Prehydration with hypotonic fluid.
Nausea, pain and stress associated with
surgery that may lead to stimulation of ADH
release during and after surgery.1
The limited ability of children to excrete a
large water load.
Acute hyponatremia results in increased
water content in neurons (Brain edema)
without a change in solute content. This may
cause symptoms such as headache, nausea,
and vomiting or muscle weakness in children.
Younger children are more susceptible to more
severe hyponatremic encephalopathy due
to a large brain-to-skull ratio.2 Isotonic fluid
74
infusion is mostly recommended during the

perioperative period. Ringer lactate solution
contains all the essential components and
is nearly isonatremic (Na+=130 mEq/L), and
isotonic but also contains K+(4 mEq/L), Ca++(0.9
mmol/L), Cl(109 mEq/L) and lactate (27.7
mmol/L). It is widely acceptable and most
suitable fluid in children during perioperative
period. High energy supply is especially
important in preventing hypoglycemia in
children who have greater energy requirements
(e.g. premature but full-term neonates). It may
sometimes lead to hyperglycemia (in 0.52% of
pediatric patients). This disorder is less common
in children receiving regional anesthesia, which
reduces the hyperglycemic effects of surgery.
It has been suggested that a solution of Ringer
lactate with 1% Dextrose is sufficient to prevent
both hypo- and hyperglycemia in most children
excluding premature and term neonates.3
However, in pediatric neurosurgical
patients, perioperative fluid management
becomes more challenging due to blood loss
which is difficult to measure and possibilities of
cerebral edema. Inadequate fluid replacement
leads to cardiovascular instability, and over
hydration with hypo-osmotic solutions may
cause cerebral edema. It is worth mentioning
that diuretics, used to reduce brain bulk cause
intravascular volume shifts with electrolyte
disturbances specially in smaller children.
Colloid containing solutions often have
been used during neurosurgery because
albumin is excluded from the extracellular fluid
of the brain. Ringer lactate increases brain water
content and may raise the intracranial pressure
(ICP), hence may lead to cerebral edema, but
not with hydroxyethyl starch when used for fluid
replacement in neurosurgical children. These
are due to differences in osmolality, rather
than the colloidal osmotic pressure, of the two
solutions.4 Other studies have also proved the
superiority of colloids for plasma expansion in
children.
Dextrose containing solutions are harmful
and cause global and regional cerebral ischemia
that may cause neurological damage.
Acceptable isotonic fluids are Lactated

Ringers solution and normal saline.
Normal saline is probably the most
commonly used crystalloid administered
during craniotomies in children as it is slightly
hyperosmolar (308 mOsm/kg) compared with
serum osmolarity (285290 mOsm/L) and
therefore helps to prevent cerebral edema.
Caution: (1) Large quantities of Normal saline
produce a hyperchloremic metabolic acidosis
and hypernatremia in children.5 (2) Lactated
Ringer (273 mOsm/L) is slightly hypo-osmolar
and large quantities of its infusion can increase
chances of cerebral edema formation.
Fluid in children
with burn injury
Children often sustain burn injuries while
playing with the crackers or during freak
fire accidents. The most appropriate fluid
necessary to resuscitate a burn shock in child
is still debatable. Adequacy of volume of fluid
and replacement of extracellular salt into the
burned tissue are the most reliable predictors
of successful resuscitation.6 In such patients
Crystalloid (Lactated Ringers solution) is the
most popular currently used resuscitation fluid.
However hypertonic saline may be beneficial
in modulating the inflammatory cascade
and restoring hemodynamic parameters
and microcirculatory flow. Rate of fluid
administration should be titrated to maintain a
urine output of 1mL/kg/hr.
Central venous pressure (CVP) monitoring
is very useful in guiding fluid therapy. It is the
true reflection of right heart filling pressure,
provided the tip of the catheter is properly placed
in the central circulation. Once resuscitation
is complete fluid infusion can be decreased to
a maintenance rate that depends on the size
of burn and expected extra evaporative losses.
Various formulas have been suggested as a guide
to initiate and maintain fluid resuscitation in
children who sustain burn injury, but the actual
rate of fluid administration must be dictated by
patient response (i.e. urine output).
Perioperative Fluid Management in Children
Trauma
When a child who has sustained multiple
injuries presents for surgical intervention,
the fluid status must be quickly assessed
before induction of anesthesia by physical
examination, and the fluid resuscitation must
be continued in case of ongoing blood loss or
third space fluid losses.
The aim of fluid resuscitation should be
to maintain normovolemia and osmolar to
oncotic pressures in the intravascular space.
Crystalloids (Ringer lactate) solution or normal
saline are most commonly used in the initial
stages of resuscitation. Hypertonic saline
solution (3%) has also been used as it increases
serum osmolality and thereby maintains
intravascular volume for longer periods and
with small volume administered than isotonic
solutions.7
The decision to administer glucose
containing solutions must be based on
blood glucose level. The issue of glucose
administration is of greater importance in head
trauma victims because elevated blood glucose
levels have been found to correlate significantly
with indicators of the severity of brain injury
and poor neurological outcomes.
Colloid solutions such as 5% albumin
and hydroxyethyl starch have also been used
for fluid resuscitation. Benefits of colloid
solutions include their ability to increase colloid
75
oncotic pressure, prolonged maintenance

of intravascular volume and smaller volume
required compared with crystalloid solutions.
For these reasons, colloids may also be
beneficial in children with head trauma because
the smaller volume of fluids administered may
reduce the likelihood of cerebral edema.
References
1. Robertson G, Antidiuretic hormone. Normal and
disordered functions. Endocrinol Metab Clin
North Am. 2001; 30: 671-94.
2. Moritz M, Ayus JC. Disorders of water metabolism
in children: Hyponatremia and hypernatremia.
Pediatr Rev. 2002;23:371-80.
3. Berleur MP, Dahon A, Murat I, et al. Perioperative
infusions in paediatric patients: Rationale for
using Ringer lactate solution with low dextrose
concentration. J Clin Pharm Ther. 2003;28:31-40.
4. Steurer MA, Berger TM. Infusion therapy for
neonates, infants and children. Anaesthesist
2011;60(1):10-22.
5. Peterson B, Khanna S, Fisher B. Prolonged
hypernatremia controls elevated intracranial
pressure in head injured paediatric patients. Crit
Care Med. 2000;28:1136-43.
6. Neelya A, Nathen P, Highsmith R. Plasma
proteolytic activity following burns. J Trauma
1988;28:362.
7. Bailey AG, McNaull PP, Jooste E, et al. Perioperative
crystalloid and colloid fluid management in
children: where are we and how did we get here?
Anesth Analg 2010;110(2):375-90.
CHAPTER
10
Central Venous Catheter

Management Guidelines
Mahesh Kumar Arora, Dalim Kumar Baidya
Introduction
Central venous catheters (CVC) are routinely
used in emergency department (ED), operating
room (OR) and intensive care units (ICU)
for management of patients. This allows
measurement of central venous pressure
(CVP), infusion of vasoactive medications,
parenteral nutrition, etc. However, insertion
and maintenance of CVC may be associated
with several risks and various complications.
Injury to the surrounding structures (arterial
puncture, hematoma, pneumothorax, etc.)
and catheter related blood stream infections
(CRBSI) are among the major concerns. These
complications may be minimized by adherence
to proper guidelines and developing standard
operating procedures (SOP) of the particular
institute. The following guideline has been
developed based on available evidence in
literature and may be followed to improve
outcome. However, individual institutes are
encouraged to develop their SOPs depending
on local resource availability and feasibility.
Preparation of Resource and

Training of Staff
Healthcare personnel involved in the
insertion and maintenance of CVC and
professionals involved in the hospital
infection control should be properly trained

in indications of CVC, aseptic procedure to
be followed, catheter maintenance checklist
and appropriate infection control measures
of CRBSI.
Regular assessment should be done as to
the adherence to these guidelines.
Whenever feasible strict aseptic precautions
to be followed and standard equipment set
to be used for CV catheterization.
An assistant should be used whenever
possible and a SOP should be followed for
insertion and maintenance of CVC.
Selections of Insertion Site

and Type of Catheter
Benefits of inserting CVC at a particular
site should be weighed against the risk
of mechanical complication vs risk of
infectious complications.
Any
contaminated
or
potentially
contaminated site (e.g. adjacent to surgical
wound or tracheostomy site) should be
avoided.
Femoral site should be avoided.
Prefer subclavian vein over internal jugular
vein or femoral vein to minimize infectious
risk.
Subclavian site should be avoided in
patients with chronic kidney disease and in
Central Venous Catheter Management Guidelines
those on hemodialysis to avoid subclavian

vein stenosis.
Use a CVC with minimum number of ports
or lumens required.
If a catheter has been inserted in emergency
situation violating the sterile precautions
then it should be replaced within 48 hours.
Chlorhexidine-silver
sulfadiazine
impregnated or minocycline-rifampicin
impregnated catheters may be used when
intended duration of catheter stay is six days
or more. However, this should be considered
in an institute only after a comprehensive
strategy to reduce CRBSI has failed.
However, use of antibiotic coated CVCs
does not replace the adherence to strict
aseptic precautions.
Aseptic Precautions and

Infection Control Measures
Proper hand hygiene should be performed
with soap water or alcohol based hand rubs.
Maximal barrier precautions should be
obtained including cap, mask, sterile gown,
sterile gloves for insertion of CVC and
during guidewire exchange of CVC.
Skin insertion site should be prepared with
> 0.5% chlorhexidine preparations with
alcohol. If chlorhexidine is not available
or contraindicated 70% alcohol or iodine
preparations may be used as alternative.
Safety of chlorhexidine has not yet been
established in neonates.
Proper antiseptic skin preparation should
be followed during dressing change as well.
The antiseptic solution should be allowed to
dry.
After insertion of catheter sterile gauze
or sterile, transparent, semipermeable
dressing should be used to cover the
catheter site.
The transparent dressing should be changed
once in 5 to 7 days. The gauze dressing
should be changed once in two days. For
tunnelled CVC for long-term use, the
dressing should be changed not more than
77
once in 7 days. However, dressing should be

changed if it is soiled or become loose.
Local antibiotic ointment should not be
used at the catheter insertion site as it may
promote fungal infections.
Chlorhexidine
impregnated
sponge
dressing may be used if CRBSI rates remain
high in spite of proper adherence to aseptic
strategy.
Catheter site should be visually inspected
daily through the transparent dressing.
Systemic antibiotic prophylaxis should not
be used routinely for prevention of CRBSI.
However, this may be considered in immune
compromised hosts and high-risk neonates.
Prophylactic antibiotic lock solutions may
be used in patients with long-term catheters
with history of CRBSI.
Routine change of CVC to prevent CRBSI
should not be performed.
In case of fever due to suspected CRBSI,
guide-wire exchange of catheter should not
be performed.
Guide-wire exchange of catheter may be
performed for a malfunctioning catheter if
no evidence of infection is present.
If guide-wire exchange is performed, new
set of sterile gloves should be used after
removing the old catheter (i.e. before
handling the new catheter).
All components of the pressure monitoring
systems including transducer, calibration
kit, flush solution should be kept sterile.
The transducer along with the flush solution
and tubing should be changed at 96 hours
interval.
Continuous flush system should be used
to maintain the patency of the pressure
monitoring system. This will ensure
minimal manipulation of the system.
Parenteral nutrition or dextrose containing
solutions should not be used through the
pressure monitoring lines.
Fluid administration sets that are
continuously used should be replaced at
an interval of 96 hours or more but within
seven days.
78
Administration sets used for blood, blood

products, parenteral nutrition should be
replaced every 24 hours.
A CVC should be removed whenever
clinically deemed not necessary.
A CVC should be removed if infection of the
skin site is suspected and a new CVC should
be inserted at a different place if necessary.
CVC ports or lumens should be capped
when not in use. All the access ports should
be wiped with antiseptic solutions before
each use.
Precautions to Prevent
Mechanical Injury
The site of catheterization should be chosen
based on clinical skill and experience of the
person inserting the catheter and need of
the patient.
Access in the upper body (neck, chest)
should be preferred over lower body to
reduce the risk of thrombotic complications.
While inserting CVC in neck or chest
(internal
jugular
or
subclavian),
Trendelenuerg position should be used.
Real time ultrasound should be used for
internal jugular vein cannulation.
Real time ultrasound may be used for
subclavian or femoral vein cannulation.
In case of any uncertainty regarding guidewire placement, it should be checked
by using ultrasound or transesophageal
echocardiography or fluoroscopy or
continuous electrocardiography.
After placement of catheter it should
be confirmed by venous waveform and
pressure measurement.
Final position of the catheter tip should

be confirmed by chest radiography
or
fluoroscopy
or
continuous
electrocardiography.
Limitation
The existing international guidelines in
relation to use of CVC are based on literature
comprising data from western world and there
is paucity of data from the Indian subcontinent.
Consequently the recommendations in the
current guideline are largely influenced by
international societies like Center for Disease
Control and prevention (CDC), Infectious
Disease Society of America (IDSA), Society of
Critical Care Medicine (SCCM), etc. Although
basic recommendations regarding aseptic
precautions or prevention of mechanical
injuries may remain similar, those on infection
control measures should take into consideration
the local data on CRBSI. Therefore, the current
guideline may require further introspection and
modifications with increased publication of
related data from large centers of our country.
Further Reading
1. Mermel LA, et al. Clinical practice guidelines for
the diagnosis and management of intravascular
catheter related infection: 2009 update by
Infectious Disease Society of America. Clin
Infectious Disease. 2009;49:1-45.
2. OGrady N, et al. Guideline for the prevention
of intravascular catheter related infections. Clin
Infectious Disease. 2011;52:e1-e32.
3. Practice Guidelines for central venous access: A
report by American Society of Anesthesiologists
Task Force on Central venous access.
CHAPTER
11
Inadvertent Perioperative
Hypothermia
BB Mishra
Introduction
Inadvertent perioperative hypothermia (IPH) is
a recognized and common side effect occurring
during surgery. IPH is a recognized side-effect
of general and regional anesthesia when normal
thermoregulation is inhibited. Hypothermia
is defined as a core temperature less than
36C (96.8F). It is not unusual for patient core
temperatures to drop to less than 35C within
the first 30 to 40 minutes of surgery and if not
managed intraoperatively, many of these are
likely to be hypothermic on admission to the
recovery ward.1
Hypothermia is graded as:
Mild (core temperature 35.035.9C)
Moderate (34.0C34.9C)
Severe ( 33.9C).
Inadvertent perioperative hypothermia is a
common but preventable complication of perioperative procedures, which is associated with
poor outcomes for patients.
Hypothermia is defined as a patient core
temperature of below 36.0C. Adult surgical
patients are at risk of developing hypothermia
at any stage of the perioperative pathway.
Hypothermia may be found at any stage of
the perioperative period, from pre-induction
through to the postoperative recovery.2 Reasons
for hypothermia include the loss under
anesthesia, of the behavioral response to cold
and the impairment of thermoregulatory heat
preserving mechanisms.1
Further to this are:

Anesthetic-induced peripheral vasodila
tation (with associated heat loss) means that
patients can often get cold while waiting for
surgery.
Exposure of the body during preparation for
surgery.
Fluid deprivation as part of the fasting
regime before induction of general
anesthesia (large variations in current
practice from 2 hours to more than 12
hours), often resulting in patients being dry
and poorly perfused.
Impaired heat distribution which can be
further complicated by the lack of warming
of intravenous solutions.
During the first 30 to 40 minutes of
anesthesia, a patients temperature can drop
to below 35.0C. Reasons for this include
loss of the behavioral response to cold and
the impairment of thermoregulatory heatpreserving mechanisms under general or
regional
anesthesia,
anesthesia-induced
peripheral vasodilatation (with associated heat
loss), and the patient getting cold while waiting
for surgery on the ward or in the emergency
department.
It is important to prevent inadvertent
perioperative hypothermia.
The control of normal body temperature
is a well established, and changes to body
temperature have been discussed in this
80
narrative review. Whilst a normal range exists

forbody temperature, adult patients being
prepared for surgery can experience largely
downward trends within this normal range,
which is then compounded by induction of
anesthesia.
Typical patterns following induction
of anesthesia see a dramatic fall to core
temperature in the first hour of anesthesia, with
as much as 1.5C lost to core temperature, and
the bodys normal thermoregulatory response to
initiating heat gain impaired due to anesthesia.
Normal body temperature range for the
purpose of this guideline is 36.5C to 37.5C,
enabling all preventive measures (active
warming) to aim to restore patient core
temperature to at least 36.5C.
Risk Factors
Pharmacological agents:
Pre-medication: Alpha 2-adrenergic
antagonists, Clonidine
Benzodiazepines:
Midazolam
Benzodiazepine
antagonists,
Flumazenil
Anticholinergics:
Atropine,
Glycopyrrolate
Cholinesterase Inhibitors: Physostigmine
IV Induction Agents: Ketamine, Propofol
Inhalational
Agents:
Halothane,
Isoflurane, Xenon, Nitrous oxide
Opioids:
Pethidine,
Morphine,
Alfentanil, Remifentanil
Other Centrally acting analgesics:
Tramadol, Nefopam
Serotonin Antagonists: Ondansetron3,
Dolasetron and Granisetron
Alpha 2-adrenergic Antagonists

There is acceptable evidence comparing
clonidine with placebo given in the preoperative
phase, to show no significant effect on core
temperature 30 minutes after induction of
spinal anesthesia and weak evidence to show
a significantly lower temperature for clonidine
after 180 minutes.

clonidine with placebo given at induction of
anesthesia, to show that there is no significant
effect on core temperature at 60 minutes
intraoperatively, or 15 or 60 minutes after
extubation.
There is good evidence when comparing
clonidine to placebo given at the end of surgery,
to show that there is no significant effect of
clonidine on core temperature at 15, 20, 60 or
120 minutes after extubation.
Benzodiazepines
There is weak evidence comparing a higher
dose (50 g/kg IM) of midazolam with no
premedication given in the preoperative
phase, to show significantly lower patient core
temperatures preoperatively. The evidence
suggests a larger effect for increased doses.
midazolam with no premedication given in the
preoperative phase, to show significantly higher
patient core temperatures intraoperatively.
There is weak evidence comparing midazolam
with no treatment given at the end of anesthesia,
to show no significant difference in patient core
temperatures intraoperatively and up to 30
minutes postoperatively, but significantly lower
temperatures at 60 minutes postoperatively.
Flumenazil
There is good evidence comparing flumenazil
with no treatment given to patients as they
startto awake, showing significantly lower
patient core temperatures 20 to 60 minutes
postoperatively.
Anti-muscarinic Agents
There is weak evidence comparing atropine
with placebo given preoperatively, to show a
statistically significant increase in patient core
temperature at the end of the preoperative
period. There is weak evidence comparing
glycopyrronium to placebo given preoperatively,
to show no significant difference in patient core
temperature at the end of anesthesia.
Inadvertent Perioperative Hypothermia
Physostigmine
There is weak evidence comparing IV
physostigmine to placebo when given at the end
of anesthesia, to show no significant difference
in patient core temperature 15 minutes
postoperatively.4
Drugs for Induction of Anesthesia

There is weak evidence comparing ketamine
to placebo given at induction of anesthesia, to
show statistically significantly higher patient
core temperatures at 30 and 60 minutes
intraoperatively and acceptable evidence for
the end of surgery.
General Anesthesia Drugs

There is insufficient evidence to determine if
there is a difference in patient core temperature
intraoperatively between isoflurane and
propofol.
There is insufficient evidence to determine if
there is a difference in patient core temperature
intraoperatively between xenon or nitrous
oxide in addition to isoflurane, compared with
isoflurane alone. There is insufficient evidence
to determine if there is a difference in patient
core temperature intraoperatively between
0.5% and 1.0% halothane.
Analgesiaopioids
There is acceptable evidence when comparing
pethidine to placebo given just before spinal
anesthesia, to show there is no significant
difference in patient core temperature
intraoperatively.
There is good evidence comparing pethidine
to placebo given at the end of surgery, to show
there is no significant difference in patient core
temperature postoperatively.
81
preoperatively, to show there is no significant

difference in patient core temperature at the
end of anesthesia.
tramadol to placebo given just before regional
anesthesia, to show there is no significant
difference in patient core temperatures at 15
minutes intraoperatively, but significantly
lower temperatures at 30 to 90 minutes. There is
acceptable evidence comparing nefopam with
placebo given just before regional anesthesia,
to show there is no significant difference in
patient core temperatures at 15, 30 and 60
minutes intraoperatively, but significantly
lower temperatures at 90 minutes. There is good
evidence comparing tramadol to placebo given
at the beginning of wound closure, to show there
is no significant difference in the incidence of
IPH. When Granisetron was compared with
Placebo, Granisetron treated patients were
warmer.
Risk factors investigated by the cohort studies
(multivariate analyses) or RCTs
The following risk factors have been investigated:
Patient Characteristics
Age
Blood pressure (1 case control study)
BMI (no studies; but body fat, body weight, 1
body weight/surface area reported)
Gender
Height
Heart rate (1 case control study)
Length of preoperative starvation (no
studies)
Temperature in the preoperative phase
Temperature at first Anesthetic intervention
ASA grade
Score of acute physiologic system (SAPS II)
Pre-existing medical conditions (diabetes
mellitus, thyroid disease, corticosteroid
disease, cardiac disease).
Analgesiaother Centrally
Acting Analgesics
Anesthesia Factors
There is weak evidence comparing tramadol

to tramadol with glycopyrronium given
Duration of anesthesia
Type of anesthesia
82
Anesthesia: end expiratory pressure

Height of spinal block.
Surgery factors
Urgency of operation: urgent, emergency,
elective
Type of surgery
Magnitude of surgery (major, intermediate,
minor)
Laparoscopic/open surgery
Duration of surgery
Patient position intraoperatively.
Other Risk Factors

Irrigation fluids volume

IV fluids volume
Blood transfusion
Blood loss
Packed erythrocytes
Forced air warming
Temperature monitoring
Particular hospital.
Environmental Factors
Theater temperature.
Conclusion for Age as a Risk Factor

The evidence suggests that age is not an
important risk factor for the incidence of
hypothermia either intraoperatively or
postoperatively, although the data on core
temperature suggests that older people (over
60 years) have lower temperatures after 3 hours
of surgery and in PACU. There is evidence that
older patients take longer to rewarm to 36C
postoperatively.
Conclusion for Body Fat/Weight and

Height as a Risk Factor
Increased body weight may have a small
protective effect on the incidence of
perioperative hypothermia in ICU. The evidence
for body weight and body fat intraoperatively
is inconsistent. There is no significant effect of
height on IPH.
Conclusion for Diabetes

Diabetes without neuropathy is not a risk factor
for IPH, but patients with diabetic neuropathy
have significantly lower core temperatures than
diabetics without neuropathy after 3 hours of
surgery.
Preoperative Temperature
A low preoperative temperature is a significant
risk factor for IPH.
Effect of Type of Anesthesia

Meta-analysis of two studies (one very large)
showed the incidence of IPH in ICU or PACU
was significantly higher for combined general
and regional anesthesia compared with general
or regional anesthesia separately.
Some studies reported less incidence of IPH
with regional anesthesia. In patients undergoing
general (mainly) or combined or regional
anesthesia, an increase in theater temperature
is protective of patients becoming hypothermic,
both intraoperatively and in ICU.5
Duration of Anesthesia
No significant effect of gender is found on the

incidence of IPH.
In the studies that covered a wide range of

durations of anesthesia or surgery, there was
weak evidence to show a significant effect
of duration of surgery, above and below two
hours, on the incidence of IPH in ICU. There
may have been a dependence on the definition
of hypothermia.
ASA as Risk Factor
Height of Spinal Block
ASA Grade > 1 is a risk factor for IPH and the risk
increases with ASA Grade.
There is weak evidence to show a significant

effect of the height of spinal block in regional
Gender
anesthesia, with a high level of block giving

lower core temperatures.
Positive End Expiratory Pressure

There is insufficient evidence to determine if a
positive end expiratory pressure has an effecton
the incidence of hypothermia.
Surgery Risk Factors

1. Magnitude of surgery: There is good
evidence to show a significant effect of
magnitude of surgery on the incidence of
IPH intraoperatively or in ICU, with major
surgery and intermediate surgery both
increasing the incidence of IPH. Although
there is heterogeneity between studies, each
is significant separately.
2. Urgency of surgery: There is acceptable
evidence to show no significant effect of
urgency of surgery (elective/emergency) on
the incidence of IPH in ICU.
3. Type of surgical procedure: There
is acceptable evidence to show no
significant difference in core temperatures
intraoperatively between laparoscopic and
open procedures causing perioperative
hypothermia.
4. Patient position intraoperatively: There is
insufficient evidence to determine if there is
an effect of patient position intraoperatively
on the core temperature intraoperatively.
Other
1. Intravenous fluid infusion: There is
weak evidence that a higher volume of
intravenous fluid is a minor risk factor for
perioperative hypothermia in ICU, but a
lack of information on the warming of fluids
was alimitation.
2. Irrigation fluids: There is acceptable
evidence to show a large significant effect
of room temperature irrigation fluid volume
on the incidence of IPH in PACU. Lower
volumes of fluids (below 20 liters) resulted
in less hypothermia.
83
3. Blood transfusion: There is acceptable

evidence to show that transfusion of
unwarmed blood (4C) as an independent
risk factor increases the risk of IPH
intraoperatively.
Environmental risk factors

1. Theater temperature: There is good evidence
that an increase in theater temperature
is protective of patients becoming
hypothermic, both intraoperatively and in
ICU.
There is weak evidence to show
significantly higher core temperatures
intraoperatively for patients undergoing
surgery in a warmer theater (21 to 24C)
compared with a cooler theater (18 to 21C).
There is acceptable evidence to show
that the effect of theater temperature has
more effect for general anesthesia when
compared with regional anesthesia.
2. Theater humidity: There is weak evidence
that theater humidity is not an independent
risk factor for IPH.
CONSEQUENCES OF IPH
There is acceptable evidence to show a
significant dependence of the incidence of
surgical wound infection on the incidence of
IPH.
There is acceptable evidence to show a
significant dependence of the incidence of
morbid cardiac events, both on the incidence of
IPH, and on the absence of forced air warming
intraoperatively.
There is acceptable evidence to show
dependence approaching significance of the
incidence of mechanical ventilation on the
incidence of IPH.
Temperature Measurement/Monitoring
Core body temperaturenormal range:
36.8C37.9C
Oral temperature: 36.0C to 37.6C
Rectal temperature: 34.4 to 37.8C
84
Axilla temperature: 35.5 to 37.0C

Ear temperature: 35.6 to 37.4C
Forehead temperature: 36.1 to 37.3C
Methods of Recording Temperature

Examples of diverse methods of intermittent
temperature measurement within clinical
effectiveness reviews were:
Sublingual devices (Conahan 1987;
Goldberg 1992)
Tympanic membrane devices (Hynson
1992; Nelskyl 1999; Johansson 2003)
Nasopharyngeal devices (Stone 1981; Wills
2001; Champion 2006)
Esophageal devices (Tllfsrud 1984a;
Tllfsrud 1984b; Youngberg 1985;
Joachimsson 1987; Ouellette 1993; Mouton
1999; Saad 2000; Nguyen 2002; Farley 2004;
Hamza 2005)
Rectal devices (Eckerbom 1990)
Pulmonary artery devices (Bcklund 1998).
Emerging technology has recently (Smith
2000) seen a shift towards the use of
tympanic membrane thermometers.
Treatment of Hypothermia
Types of Intervention
The following interventions were to be
considered:
Active Warming Mechanisms

The following types of warming mechanisms
were considered under active warming:6
Forced air warming
Electric blanket
Water mattress
Radiant heating
Warmed blankets
Heating gel pad.
Warming of IV Fluids7
Reflective blanket.
Reflective clothing.
Results showed that the incidence of
adverse events like Myocardial infarction and
ventricular arrhythmias was lower significantly
in the warmed groups.
The incidence of shivering was lower in the
warmed groups.
Incidence of hypothermia was significantly
less in the forced air warmed Group.8
Complications of Warming Devices

The most common adverse effects were burns
and infection. Although many potential sources
of adverse effects can be identified, there does
not seem to be empirical support that indicates
that warming systems increase the risk of
infection if properly used.9
GUIDELINEs RECOMMENDATIONS
1.1 Perioperative Care

1.1.1 Patients should be informed that:

Staying warm before surgery will
lower the risk of postoperative
complications.

They should bring additional
clothing.
1.1.2
When using any temperature
recording or warming device,
healthcare professionals should:

Be trained in their use.

1.1.3 Healthcare professionals should:

Be aware of, and carry out,
any adjustments that need to
be made in order to obtain an
estimate of core temperature
from that recorded at the site of
measurement.
1.2 Preoperative Phase

Thermal Insulation Mechanisms

The following mechanisms were considered
under thermal insulation:
1.2.1 Patients should be managed as

higher risk if any two of the following
apply:
ASA grade II to V (the higher the
grade, the greater the risk).
Preoperative temperature below

36.0C.

Undergoing combined general
and regional anesthesia.

Undergoing
major
or
intermediate surgery.

At
risk
of
cardiovascular
complications.
1.2.2
Healthcare professionals should
ensure that patients are kept
comfortably warm while waiting for
surgery.

1.2.3 Special care should be taken to
keep patients comfortably warm
when they are given premedication
(for example, nefopam, tramadol,
midazolam or opioids).

1.2.4 The patients temperature should be
measured and documented in the
hour before they leave the ward or
emergency department.

1.2.5 If the patients temperature is below
36.0C:

Forced air warming should be
maintained
throughout
the
intraoperative phase.
1.2.6 The patients temperature should
be 36.0C or above before they
are transferred from the ward or
emergency department (unless there
is a need to expedite surgery because
of clinical urgency, for example
bleeding or critical limb ischemia).

1.2.7 On transfer to the theater suite:

The patient should be kept
comfortably warm

The
patient
should
be
encouraged to walk to theater
where appropriate.
1.3 Intraoperative Phase

The intraoperative phase is defined as total
anesthesia time, from the first anesthetic
intervention through to patient transfer to the
recovery area of the theater.
1.3.1 The patients temperature should be
measured and documented before
85
induction of anesthesia and then every

30 minutes until the end of surgery.
1.3.2 Standard critical incident reporting
should be considered for any patient
arriving at the theater suite with a
temperature below 36.0C.

1.3.3 Induction of anesthesia should not
begin unless the patients temperature
is 36.0C or above (unless there is a need
to expedite surgery because of clinical
urgency, for example bleeding or critical
limb ischemia).
1.3.4 In the theater suite:

The ambient temperature should
be at least 21C while the patient is
exposed.

Once forced air warming is
established, the ambient temperature
may be reduced to allow better
working conditions.

Using equipment to cool the surgical
team should also be considered.
1.3.5 The patient should be adequately
covered throughout the intraoperative
phase to conserve heat, and exposed
only during surgical preparation.
1.3.6 Intravenous fluids (500 mL or more)
and blood products should be warmed
to 37C using a fluid warming device.

1.3.7 Patients who are at higher risk of
inadvertent perioperative hypothermia
and who are having anesthesia for less
than 30 minutes should be warmed
intraoperatively from induction of
anesthesia using a forced air warming
device.
1.3.8 All patients who are having anesthesia
for longer than 30 minutes should be
warmed intraoperatively from induction
of anesthesia using a forced air warming
device.

1.3.9 The temperature setting on forced
air warming devices should be set
at maximum and then adjusted to
maintain a patient temperature of at
least 36.5C.
1.3.10 All irrigation fluids used intraoperatively
should be warmed in a thermostatically
86
controlled cabinet to a temperature of

38 to 40C.
1.4 Postoperative phase

The postoperative phase is defined as the 24
hours after the patient has entered the recovery
area in the theater suite.

1.4.1 The patients temperature should
be measured and documented on
admission to the recovery room and
then every 15 minutes.

Ward transfer should not be arranged
unless the patients temperature is
36.0C or above.

If the patients temperature is below
36.0C, they should be actively
warmed using forced air warming
until they are discharged from the
recovery room or until they are
comfortably warm.

1.4.2 Patients should be kept comfortably
warm when back on the ward.

Their temperature should be
measured and documented on
arrival at the ward.
1.4.3 If the patients temperature falls below
36.0C while on the ward:

They should be warmed using
forced air warming until they are
comfortably warm

Their temperature should be
measured and documented at least
every 30 minutes during warming.
If these guidelines are followed,
incidence of IPH can be drastically
controlled.
References
1. Cochrane Handbook for Systematic Reviews of
Interventions 4.2.5 [updated May 2005] (2007)in:
Higgins J, Green S, (Eds) The Cochrane Library,
Issue 3, 2005. Chichester, UK:John Wiley & Sons,
Ltd.
2. Abelha FJ, Castro MA, Neves AM, et al.
Hypothermia in asurgical intensive care unit,
BMC Anesthesiology, 2005;5:7.
3. Powell RM, Buggy DJ. Ondansetron given before
induction of anesthesia reduces shivering after
general anesthesia. Anesthesia and Analgesia.
2000;90(6):1423-7.
4. Rohm KD, Riechmann J, Boldt J, et al.
Physostigmine for the prevention of post
Anesthetic
shivering
following
general
anesthesiaa placebocontrolled comparison
with nefopam. Anesthesia. 2005;60(5):433-8.
5. Berti M, Casati A, Torri G, et al. Active
warming, not passive heat retention, maintains
normothermia during combined epiduralgeneral anesthesia for hip and knee arthroplasty.
Journal of Clinical Anesthesia. 1997;9(6):482-6.
6. Camus Y, Delva E, Sessler DI, et al. Pre-induction
skin-surface warmingminimizes intraoperative
core hypothermia, Journal of Clinical Anesthesia.
1995;7(5):384-8.
7. Reynolds L, Beckmann J, Kurz A. Perioperative
complications of hypothermia. Best Pract Res
Clin Anaesthesiol. 2008;22(4):645-57.
8. Sessler DI. Temperature regulation and
monitoring. In: Miller RD, Eriksson LI, Fleisher
LA, Wiener-Kronish JP, editors. Millers
Anesthesia. 7th ed. Phidelphia: Churchill
Livingstone/Elsevier; 2010.pp.1533-6.
9. Moola S, Lockwood C. Effectiveness of
strategies for the management and/or
prevention of hypothermia within the adult
perioperative environment. Int J Evid Based
Health.2011;94:337-45.
CHAPTER
12
Practical Guidelines for

Ultrasound Guided Nerve Blocks
Mridula Pawar
Direct ultrasound visualization significantly

improves the outcome of most techniques in
regional anesthesia.1 Such direct visualization
can improve the quality of nerve blocks and
avoid complications. Apart from seeing the
targeted structures, it is possible to visualize
distribution of local anesthetic. In case of wrong
distribution, needle can be repositioned under
vision and block can be redone.
Review Basics of Ultrasound

Body parts like blood, fluid conduct sounds
poorly (echo lucent) and appear dark. Body
parts with low water like air and bone reflect
all the sound so appear light. Body parts in
between appear dark to light.
Ultrasound waves of lower frequencies
penetrate deeper than high frequency.
Hyperechoic reverberation artifact may be
seen with metallic foreign bodies like block
needle.
Local Anesthetic injected for regional block
is anechoic.
Nerves, muscles and tendons are sensitive to
transducer manipulation.
Know Your Equipment

Ultrasound transducer consists of array
of piezoelectric crystals that produce
high-frequency sound waves in response to

an electrical signal.
Most of regional blocks are performed with
linear transducershigh scan line density
produces the resolution necessary for nerve
imaging.
Small curved probes are used for
supraclavicular and infraclavicular nerve
blocks.
Ulnar aspect of operator s Hands must be
close to the skin of the patient to control the
transducer and needle.
Long axis images will be shown with proximal
side on the left and distal side on the right.
These views are useful for seeing distribution
of local anesthetic along the nerve path in
one image. It is easier to see nerve in short
axis and slide along the nerve path for its
identification.
Right handed operators prefer a right hand
screen bias so that they can see their hands
and display during the procedure.
Needle viewing:
Needle tip viewing is critical to the
safety and success of the block which
depends on Angle of insonation, needle
gauge, motion, echogenic modifications,
receiver gain.
Bevel of the needle should face the
transducer to improve needle tip visibility.
88
Bevel of the needle should be towards the

nerve so that it will not puncture it.
In-plane vs out-of-plane approach:
Out-of-plane has shorter needle path
but because of un-imaged needle
path, it may cross the plane of imaging
without recognition. In-plane approach
is direct visualization of needle tip and
injection. Needle tip is visualized before
advancement but has long needle path.
Needle may be moved slightly or inject
less than 1 mL test dose to improve tip
visibility.
Avoid rapid jabbing motion of the needle
which may cause puncture of vital
structures or paresthesia.
When angle of approach is more than
30 degrees, an echogenic needle (with
roughened surface) is useful.
Sonographic Signs of Successful

Injection of Local Anesthetic
Should clarify the nerve boarder- view nerve
in short axis to evaluate circumferential
distribution of drug.
Successful drug injection will track along
the nerve- (short axis sliding assessment) , it
should track along nerve divisions.
Successful injection should separate the
connected structures like blood vessel or
other peripheral nerves.
Before you inject local anesthetic, be sure
to see the needle tip and other anatomical
structures. If tissues do not move upon local
anesthetic injection, stop, needle tip may
be may be into a blood vessel. Frequent
aspirations, injection pressure, and patient
response are all important factors.
Ultrasound-guided Catheter
Placement for Peripheral
Nerve Blocks
In-plane and out-of-plane approach can be
used for catheter placement.
In-plane approach, needle bevel must be

turned so that the catheter slides along the
nerve but not around the nerve.
Long axis in-plane approach: It will allow
nerve, needle and catheter view at the same
time but it is difficult to keep all in the plane
of imaging by transducer manipulation
and because of long path taken by needle
in the tissue and catheter placement is like
tunneling.
Short axis in-plane approach: One may inject
local anesthetic or saline and withdraw
needle back a little before threading a
catheter.
Anatomical Structures
Precise identification of structures is paramount
to attain the goals of ultrasound guided regional
nerve block
Skin and subcutaneous tissue: Skin is
hyperechoic, subcutaneous tissues are
hypoechoic with septa parallel to skin.
Peripheral nerves: These have fascicular
or honey comb echo texture because of
hypoechoic (nerve tissue and hyperechoic
connective tissue.
Nerves that are surrounded by hyperechoic
fat are easier to visualize as the nerve boarders
are clearer, as compared to nerves which are
surrounded by hypoechoic muscles.
When scanning superficial nerves, apply
generous amount of acoustic coupling gel.2
How to Differentiate
Tendons from Nerves
Cross sectional area is constant along the
nerve path while change in cross sectional
are of tendon is substantial.
At high frequency of insonation > 10 MHz,
fascicular echotexture of nerve can be
distinguished from fibrillar echotexture of
tendon.
There is branching of nerves but not of
tendons.
Practical Guidelines for Ultrasound Guided Nerve Blocks
There are often adjacent vessels but

infrequent with tendons.
How to Differentiate
Artery from Vein
Visible pulsation from the artery are
observed when compression is applied with
transducer, or apply Doppler as almost every
peripheral nerve has a long running path
with accompanying artery or vein.
Arteries have thicker valves than vein and do
not have valves.
Veins are thin walled and easily compressed
with transducer.
Interscalene and
Supraclavicular Block
Anatomy
In brachial plexus is seen stacked between
anterior and middle scalene muscles, block
is referred as interscalene block. If brachial
plexus is seen as a compact group of nerves
lying superior and lateral to subclavian
artery, it is referred as supraclavicular
block. Ultrasound guided block burrs the
distinction between the two.
Monofascicular ventral rami of brachial
plexus is hypoechoic and may be difficult to
identify in between scalene muscles.
Best nerve visibility is near first rib in short
axis and imaging plane must face caudally at
the brachial plexus.
Supraclavicular region is more consistent
and can be used to trace the plexus back to
interscalene groove.
Perform the block where imaging is most
reliable.
The number of visualized components of
the brachial plexus (five ventral rami, three
trunks and six divisions) vary with the angle
of the transducer and its position in the neck.
Position
Semi sitting position with head of the
bed elevated to 45 to 60 degrees. Patient
89
is comfortable and arm is lowered by

gravity.
Patients head is turned to opposite side from
the block.
The operator stands either at the head of the
bed or at the side of the bed.
Equipment
A small curved or small linear (2025 mm
foot print, frequency 1014 MGz) transducer
is preferred.
A compact transducer is can be rocked back
to improve needle visibility.
Ulnar aspects of both hands of the operator
must be placed for the best control of needle
and transducer.
A short (50 mm), broad (21 Gauge) echogenic
needle is used for optimum control and
visibility.
Procedure
Multiple injection technique is used to
ensure complete plexus anesthesia.
Initial aim of the needle is deep (caudal
elements of the plexus) so that brachial
plexus rises closer to skin surface with
injection of local anesthetic. Subsequent
needle passes become easier.
A sterile transparent dressing can be used to
cover the transducer.
Approximately 15 to 20 mL of local anesthetic
is injected watching for the distribution of
the local anesthetic around the trunks of the
plexus. The local anesthetic is injected in 5
mL aliquots followed by aspiration for blood.
All local anesthetic has epinephrine added to
make a solution of 1: 400 000 that acts as an
intravascular marker as well as minimizing
systemic absorption.
If the distribution is inadequate, the needle
can be repositioned and the injection
continued.
A peripheral-nerve catheter can then be
threaded into the interscalene space, all the
time watching with the ultrasound where the
catheter passes in relationship to the nerve
trunks.
90
Final confirmation of catheter placement is

confirmed by injection through the catheter
of a few milliliters of local anesthetic (can
also use air/local anesthetic combination)
that again confirms proximity to the brachial
plexus with the ultrasound.
Sciatic Nerve Block

Used for regional anesthesia for lower extremity
surgery and usually combined with femoral
nerve block.
Anatomy
Sciatic nerve (L4-S3) is the largest nerve in
the body with transverse diameter of 17 mm,
hyperechoic seen as bright triangle, difficult
to visualize in gluteal region and thigh.
Short axis view with sliding of the transducer
is usually better than long axis view to confirm
nerve identity and distinguish it from the
adjacent tendons of semitendinosus-biceps
and semimembranosus.
Sciatic nerve lies between the greater
trochanter (lateral) and ischial tuberosity
(medial).
Equipment
A broad medium frequency linear probe,
5 cm foot print or larger will be required.
Initial depth setting of 40 to 60 mm.
Needle -20G, 90 mm in length.
Position
Prone, lateral or supine.
Prone position allows the most stable assess
for proximal sciatic nerve block. In plane
technique from lateral side is easy.
Patients who cannot lie prone, lateral
position with hip bump to provide stability is
another relatively easy alternative.
Operator stands on side of the patient.
Anterior approach to proximal sciatic nerve is
used in patients who are difficult to position
lateral or prone. It is deeper than other
approaches and is used in thin patients.
Procedure
Begin by scanning the subgluteal region near
posterior midline. If imaging is difficult, can
trace sciatic nerve proximally from popliteal
fossa.
When an accompanying artery is identified
on the lateral side of sciatic nerve, place the
needle tip in connective tissue between artery
and the nerve. This requires puncturing the
connective tissue and slowly injecting as the
needle is withdrawn to identify the correct
layer surrounding the nerve.
Fascia surrounding the sciatic nerve is very
thick, so it is important to get right needle
position and drug distribution.
Perforating arteries usually can be seen
crossing the anterior side of the nerve.
Supine approach:
Obtain a long axis view of the femur with
the transducer placed on the anterior
aspect of thigh. Bone is identified by bright
cortical surface and acoustic shadowing.
Now slide the transducer medially to get
a long axis view of the sciatic nerve at
approximately twice the depth of femur.
Sciatic nerve appears as an echogenic
linear, wide and straight structure lying
deep to adductor magnus muscle. If
femoral artery is visible, the transducer
has slide too medially.
Sciatic nerve will bow like a string as the
block needle approaches.
When the local anesthetic is in correct
tissue plane, the injection will track
along the proximal-distal course of the
nerve and on both anterior and posterior
side.
This block is performed 2 to 5 cm distal to
the lesser trochanter of the femur, external
rotation of the leg promotes access to the
sciatic nerve.3
Femoral Nerve Block

Femoral nerve is the largest branch of lumbar
plexus and innervates anterior thigh, the patella,
medial leg and foot.
Practical Guidelines for Ultrasound Guided Nerve Blocks
Anatomy
Femoral nerve is oval or triangular in cross
section, size of 3 mm anteroposterior and 10
mm mediolateral in inguinal region.
Lies lateral to femoral artery.
It is covered by echogenic subcutaneous
tissue and fascia.
Lies on hypoechoic iliopsoas muscle
interface of bright fascia and dark muscle,
nerve can be difficult to visualize.
Position
Supine position with leg slightly abducted with
the nerve in short axis view.
Equipment
High frequency linear probe of 38 to 50 mm
foot print. With initial depth setting of 25 to
30 mm.
Needle of 20G, 70 mm length.
Procedure
Both out-of-plane and in-plane approaches
have been used as it is not important to
position the needle tip adjacent to the nerve.
The best visibility is proximal to inguinal
crease.
The tilt of transducer strongly influences
femoral nerve visibility due to anisotropic
effect.4
Begin by scanning with the probe along the
inguinal crease. Slide proximally until the
common femoral artery and femoral nerve
are seen in short axis view. Best Femoral
Nerve imaging is usually 1 to 2 cm proximal
to the inguinal crease.
Approach short axis view of the femoral
nerve, in-plane from lateral side.
Place the needle tip through the facia iliaca
at the lateral corner of femoral nerve.
Inject underneath the femoral nerve between
nerve and iliopsoas muscle.
The needle tip should be placed in the layer
under the femoral nerve so that the injection
91
lifts the nerve towards the surface. This is

especially important when catheter is placed.
Successful injection not only surrounds the
femoral nerve but also tracks along its small
distal branches.
Out of plane approach has been found to be
very safe and effective.5
Complications
Although ultrasound may not completely
prevent complications, it can facilitate early
recognition of them.
Intravascular injection should be suspected
in the absence of visible local anesthetic
spread.
Intraneural injection can be recognized by
nerve expansion.6
In fact this expansion, rather than pain on
injection7 may be the most reliable indicator
of intraneural needle placement.
Paresthesia or pain is not a sensitive indicator
of intraneural puncture or injection. It is
inappropriate to assume that intraneural
injection is benign. Factors that may prevent
injury include the intraneural injection of
only a small volume of fluid and the use of a
short-beveled needle.8,9
References
1. Marhofer P, greher M, Kapral S, et al. Ultrasound
guidance in regional anesthesia. Br J Anesth
2005; 94:7-17.
2. Thain LM, Downey DB. Sonography of peripheral
nerves: technique, anatomy, and pathology.
Ultrasound. 2002;18:225-45.
3. Vloka JD, Hadzic A, April E. Anterior approach to
the sciatic nerve block: the effect of leg rotation.
Anesth Analg. 2001;92(2):460-2.
4. Soong J, Schafhalter-Zoppoth I, Gray AT. The
importance of transducer angle to ultrasound
visibility of the femoral nerve. Reg Anesth Pain
Med. 2005;30:505.
5. Sites BD, Spence BC, et al. Characterizing novice
behavior associated with learning ultrasound
guided peripheral regional anesthesia. Reg
Anesth Pain Med. 2007;32:107-15.
6. Bigeleisen PE. Nerve puncture and apparent
intraneural injection during ultrasound-guided
92
axillary block does not invariably result in

neurologic injury. Anesthesiology. 2006;
105:779-83.
7. Moore DC. Perineural space versus nerves
perineurium-beware the latter are potential
expressways to the spinal cord! Reg Anesth Pain
Med. 2007; 32:368.
8. Mitchell Fingermana, James G Benonisb,

Gavin Martinc. A practical guide to commonly
performed ultrasound-guided peripheral-nerve
blocks. Current Opinion in Anaesthesiology.
2009,22:600-7.
9. Ki Jinn Chin, Vincent Chan. Ultrasound-guided
peripheral nerve blockade. Current Opinion in
Anaesthesiology. 2008,21:624-31.
CHAPTER
13
Epidural Analgesia:
The Practice Guidelines
Mritunjay Varma
Introduction
Epidural analgesia is highly effective for
controlling acute pain after surgery or trauma
to the chest, abdomen, pelvis or lower limbs.
It has the potential to provide excellent pain
relief, minimal side-effects and high patient
satisfaction when compared with other methods
of analgesia. However, epidural analgesia can
cause serious, potentially life-threatening
complications; safe and effective management
requires a coordinated multidisciplinary
approach. All practitioners should be aware of
the complications associated with the use of
epidural analgesia. Some complications can be
fatal or result in permanent harm.
Complications
Frequent complications include:
Hypotension; respiratory depression (opioid
use); motor block
Urinary retention
Inadequate analgesia
Pruritus (opioid use).
Infrequent but well recognized complications
include:
Cardiovascular collapse
Respiratory arrest
Unexpected development of high block, e.g.
catheter migration, intrathecal, injection;
local anesthetic toxicity.
Postdural puncture headache syndrome

(including sub-dural hematoma).
Drug administration errors (especially wrong
route)
Pressure sores
Superficial infection around catheter
Epidural hematoma or abscess
Meningitis
Spinal cord ischaemia.
Permanent harm, e.g. paraplegia, nerve
injury.
Patient Selection and Consent

Patient selection for epidural analgesia should
be based on a careful risk/benefit analysis for
each patient.
Risk factors include: impairment of
coagulation (pathological or therapeutic);
infection; compromised immunity; duration
of epidural catheterization; cardiovascular
stability; and inadequate postoperative
monitoring capability.
Continuous epidural analgesia is a
significant procedure with specific and
potentially serious complications; therefore,
informed patient consent should be obtained.
The process of obtaining consent should
comply with national and local guidance.
There should be a discussion of the risks
and potential benefits of epidural analgesia,
including information.
94
on late complications that may occur after

discharge from hospital. A summary of this
discussion should be documented in the
patients notes. Consent should be facilitated by
written patient information.
Personnel, Staffing Levels and

Ward Environment
The Department of Anesthesia should ensure
that there are designated personnel and clear
protocols to support the safe and effective
use of epidural analgesia. This should be the
responsibility of a multidisciplinary acute pain
service including a consultant anesthetist and
clinical nurse specialist(s) with support from
pharmacy. The service should ensure that
appropriate documentation, administrative
routines and audit are in place. Ultimate
responsibility for the epidural in fusion remains
with the practitioner who instituted it (or
supervising consultant if inserted by a trainee).
However, immediate supervision of the patient
may be passed to the acute pain service and
properly trained ward staff. An agreed form of
communication should be used to facilitate this
transfer of supervision.
Trainee and Staff and Associate Specialist/
Specialty doctors must possess appropriate
competencies before performing epidural
injections and establishing infusions without
the direct supervision of a consultant or senior
colleague.
There must be adequate hand over of
information between on-call staff about patients
who are receiving epidural analgesia. Ideally, an
up-to-date list of ongoing epidurals should be
maintained and readily available.
Nurses with specific training and skills
in the supervision of epidural analgesia and
management of its complications must be
present on the ward and on every shift (i.e.
24-hour cover). Staffing levels and expertise
should be sufficient to enable adequate
monitoring and care to be given to all patients
receiving epidural analgesia.
These staff must be immediately available to

respond to adverse events. Oxygen and full
resuscitation equipment must be available.
Patients receiving epidural analgesia should
be situated close to the nurses station, thus
ensuring close supervision. If nursing in a
single room is being considered, a full risk
assessment with respect to the epidural should
be undertaken and staff should be sure that
appropriate monitoring and care can take place
in this environment.
Before the patient returns to the ward, the
responsible anesthetist should be assured
that the ward is sufficiently staffed to ensure
safe management of the epidural. A system
of communication should exist to inform the
anesthetist and theater staff if this is inadequate.
There should be 24-hour access to:
1. Medical staff, trained and competent in the
management of epidurals, immediately
available to attend patients;
2. Senior anesthetic advice and availability;
and
3. A resuscitation team with a resident doctor
with appropriate competencies.
Catheter insertion
Epidural catheter insertion must be performed
using an aseptic technique. This should include
hand washing, sterile gloves, sterile gown, hat,
mask, appropriate skin preparation and sterile
drapes around the injection site. The tip of
the epidural catheter should be positioned
at a spinal level appropriate for the surgery.
A catheter placed in a low position may be
associated with poor analgesia and need for
large volumes of infusion in adults.
The catheter should be secured in order to
minimize movement in or out of the epidural
space. It is advisable to tunnel the catheter if it
has to be kept in situ for 3 to 5 days. The dressing
should allow easy visibility of the insertion
site and catheter. Anesthetists inserting
epidural catheters should be aware of, and
adhere to, local infection guidelines (including
Epidural Analgesia: The Practice Guidelines
use of prophylactic antibiotics in special

circumstances).
Local guidelines should be in place with
respect to the insertion and removal of epidurals
in patients on anticoagulants or with impaired
coagulation. All staff should be aware of, and
adhere to, these guidelines.
Equipment
Ideally, equipment for epidural insertion and
infusion should be standardized throughout
the institution so that it is familiar to all staff
providing or supervising epidural analgesia.
Staff must be trained in the use of this
equipment.
Infusion pumps should be configured
specifically for epidural analgesia with pre-set
limits for maximum infusion rate and bolus size;
lock-out time should be standardized if used for
PCEA. Pumps should be designated for epidural
analgesia only and should be labeled as such.
There should be a documented maintenance
program.
The epidural infusion system between
the pump and patient must be considered as
closed; there should be no injection ports.
An antibacterial filter must be inserted at the
junction of epidural catheter and infusion line.
Effective management of epidural analgesia
may require the administration of a bolus
injection of solution into the system. This may be
performed using the syringe within the pump,
thus not breaching the system. If a separate
handheld syringe is used, the injection must
be performed using a strict aseptic technique.
Bolus injections must be performed by staff
with appropriate training and competencies
and more intensive monitoring of the patient is
required immediately after the injection.
Epidural infusion lines should be clearly
identified as such. The National Patient Safety
Association (NPSA), UK has recommended the
use of yellow tubing to differentiate epidural/
spinal lines from arterial (red), enteral (purple)
and regional (gray) in fusions.
In November 2009, the NPSA, UK
recommended that equipment should be
95
developed that will enable NHS institutions to

perform all epidural, intrathecal and regional
infusions and boluses with devices that will not
connect with intravenous Luer connectors or
intravenous infusion spikes.
Resuscitation equipment, oxygen and
appropriate drugs must be readily available
wherever epidural infusions are employed.
Drugs for Epidural Analgesia

There should be a limited number of solutions
approved and available for epidural infusions in
every hospital. They should be prepared under
strict sterile conditions in specifically designed
units. Many are available commercially. Any
variation from this should occur in exceptional
circumstances only and with the agreement of
the responsible consultant after a risk/benefit
analysis.
Epidural infusions should be labeled For
Epidural Use Only.
Epidural infusions should be stored in
separate cupboards or refrigerators from
those holding intravenous and other types of
infusions in order to reduce the risk of wrong
route administration.
The lowest possible effective concentration
of local anesthetic should be used in order to
preserve motor function as much as possible.
This improves patient satisfaction and aids
detection of neurological complications. If
higher concentrations are required, the infusion
rate should be reduced periodically to allow
assessment of motor block.
The use of drugs beyond licence should be
consistent with local hospital guidelines.
Patient monitoring
Patients must be monitored closely throughout
the period of epidural analgesia. It should
be performed by trained staff aware of its
significance and action required in response to
abnormal values.
Monitoring should include:
Heart rate and blood pressure
Respiratory rate
96
Sedation score
Temperature
Pain score
Degree of motor and sensory block.
In addition, requirements for monitoring will
be determined by the nature of the surgery, and
condition and age of the patient.
The frequency of observations should be
determined by normal clinical considerations.
With respect to the epidural, they should be
more frequent in the first 12 hours of the epidural
infusion, after top-up injections, changes of
infusion rate and in periods of cardiovascular or
respiratory instability.
Monitoring should follow clear written
protocols and compliance to these should be
audited.
Epidural blockade can cause hypotension.
However, when hypotension occurs after
surgery, other common causes should be
considered and excluded, e.g. bleeding,
myocardial insufficiency, sepsis, pulmonary
embolus, dehydration.
Pain scores (at rest and on movement or
deep breathing) and sedation scores will help
to identify inadequate or excessive epidural
drug administration. Monitoring protocols
should give clear guidance on actions required
if analgesia is inadequate.
Sedation is often the most sensitive
indication of opioid induced respiratory
depression. Monitoring of sensory and motor
block is essential for the early detection of
potentially serious complications. The Bromage
Scale is an accepted tool for the measurement
of motor block. An increasing degree of motor
weakness usually implies excessive epidural
drug administration. However, it can indicate
very serious complications including dural
penetration of the catheter, or the development
of an epidural hematoma or abscess. Therefore,
it is essential that protocols are in place to
manage the scenario of excessive motor block.
An epidural abscess or hematoma can
cause severe, permanent neurological damage
and must be detected and treated as soon as
possible. This diagnosis must be considered if
excessive motor block does not resolve rapidly
after stopping the epidural infusion. A clear

protocol should be in place describing the
actions required in this situation, including
informing senior anesthetic staff and immediate
availability of suitable imaging and surgical
expertise.
Records must be kept of the monitoring
described above as well as epidural infusion
rate, total amount used, inspection of epidural
insertion site, patency of intravenous access
and integrity of pressure areas.
Staff should be aware that increased or
breakthrough pain may indicate surgical
complications including the development of
compartment syndromes. Special care should
be taken when interpreting physical signs in
patients who may have sustained neurological
damage.
Epidural Analgesia in Children

All the recommendations in this guideline
apply also to neonates, infants and children but
methods of monitoring and assessment scores
must be appropriate for developmental age.
Dosing regimens for children must be
adapted for age and weight with maximum
dosage clearly defined to minimize the risk of
cumulative local anesthetic toxicity, especially
in neonates and infants < months of age.
Clear protocols for prescription, monitoring
and troubleshooting of pediatric epidural
infusions should be used. Infusion devices
should be programmed and double checked
with extreme care as there is an increased
risk of error when managing small infants
and neonates. Hourly assessments are
recommended, especially in the first 12 hours.
There should be regular review of the need to
continue the infusion, especially after 48 hours.
Motor block should be assessed and
documented formally using an age-appropriate
assessment. A clear action plan should be in
place if motor block persists or progresses.
Spread of local anesthetics in neonates
and infants is extensive and low catheters
can be used to provide an effective block for
thoracolumbar dermatomes without using
Epidural Analgesia: The Practice Guidelines
unacceptable doses of local anesthetic. Whilst

caudal catheters are effective, these can become
soiled unless carefully dressed or tunnelled
away from the insertion site.
Compartment syndrome is a particular
concern after very prolonged procedures, after
lower limb surgery and when the patient has
been positioned during surgery in other than
the standard supine position.

An
anesthetist
with
appropriate
competencies and training should be
immediately available to attend a child who is
receiving an epidural infusion.
Written and verbal advice should be
provided to patients and carers alerting them to
the signs and symptoms of an epidural abscess
and what to do if they occur. Many children are
discharged before the mean time of onset of
these signs and symptoms.
Documentation, Guidelines
and Protocols
Contemporaneous records must be kept of
events throughout the period of epidural
analgesia. This includes consent, insertion
and removal of the catheter, prescription of
the infusion, monitoring, additional doses
and notes about any complications or adverse
events.
Safety is enhanced by the use of standard
pre-printed prescription forms rather than
hand written prescriptions that might be
misinterpreted. Contact telephone and/or
bleep numbers for expert medical and nursing
personnel must be printed on documents that
are kept on the ward, and near to the patient.
Protocols and guidelines should include:
Over all management of patients with
epidural infusions
Instructions for the use of the pump
Description of the drug concentrations used
in the hospital
Description of infusion rates and how to
adjust them
Instructions for changing epidural solution
bags or syringes
97
Frequency of observations
Maintenance
of
intravenous
access
throughout the infusion period
Identification and management of early and
late complications
Management of inadequate analgesia;
Management of accidental catheter
dis-connection
Instructions for removal of the epidural
catheter and monitoring for complications
Insertion and removal of epidural catheters
in patients receiving anticoagulants
Pain management after cessation of the
epidural infusion
Management of opioid and local anesthetic
toxicity
Mobilisation after epidural removal, e.g.
during enhanced recovery programs.
Audit and critical incidents

There should be regular audits concerned
with epidural analgesia. These could include:
efficacy and patient satisfaction; incidence
of complications; adherence to management
protocols.
There should be clear procedures for the
reporting of, and response to, critical incidents
associated with the use of epidural analgesia.
Education
There should be formal, documented training
in place for doctors and nurses who are
responsible for supervising patients receiving
epidural analgesia.
Training
programs
should
include
induction and regular update sessions and be
commensurate with the responsibilities of the
staff involved.
Further Reading
1. Brauer M, George JE, Seif J, Farag E. Recent
advances in epidural analgesia. Anesthesiology
Research and Practice 2012;14.
2. Hawkins JL. Epidural analgesia for labour and
delivery. N Engl J Med 2010;362:1503-10.
98
3. Moriarty A. Pediatric epidural analgesia.

Pediatric Anesthesia 2012;22:51-5.
4. Richard B, Alan JR, Vincent WS Chan. Spinal,
Epidural, and Caudal Anesthesia. In: Miller RD,
editor. Millers Anesthesia. 8th edn. Philadelphia,
PA: Churchill Livingstone/Elsevier, 2015.p.
1684-720.
5. Silva M, Halpern SH. Epidural analgesia for
labour: current techniques. Local and Regional
Anaesthesia 2010;3:143-53.
6. Unic Stajanovic D, Babic S, Jovic M. Benefits,

risks and complications of perioperative use
of epidural anesthesia. Med Arch 2012;66:
340-3.
7. Freise H, Van Aken HK. Risks and benefits of
thoracic epidural anaesthesia. Br J Anaesth 2011;
107: 859-68.
8. Glieder L, Rebelo H, Oliviera R, Neves A. Regional
analgesia in intensive care. Rev Bras Anestesiol
2012;62:724-30.
CHAPTER
14

Parshotam Lal Gautam
Description or Definition of
Procedure/Service
Monitored anesthesia care (MAC) as words
define, refers to the patient care being monitored
by anesthesia personnel present during a
procedure and does not necessarily/implicitly
indicate the level of anesthesia needed. Often
it amounts to light sedation in addition to
monitoring vitals and well-being of patient.
However, MAC provider must be prepared, and
competent enough to rescue airway during
sedation, manage medical problems, and
qualified to switch over to general anesthesia
whenever necessary to accomplish procedure.
This requirement is either because of patient
characteristic or procedure based. Thus the
service mandates assessment of patient and
preparation of procedure suite like properly
equipped OR. To be more specific in definition,
ASA house of delegates updated MAC definition
on September 2, 2008.1 They defined MAC as
a specific anesthesia service for a diagnostic
or therapeutic procedure. Indications for
monitored anesthesia care include:
The nature of the procedure
The patients clinical condition and/or
The potential need to convert to a general or
regional anesthetic.
MAC includes all aspects of anesthesia
carea preprocedure visit, intraprocedure
care and postanesthesia care, thus care needs

adherence to same principles and standard
of care as for any other anesthetic procedure.
During MAC, the anesthesiologist provides
multiple specific services in addition to
monitoring such as diagnosis and treatment
of clinical problems, support of vital functions,
psychological support, administration of drugs
and anesthetic agents or other medications as
necessary for patient safety during procedure.2
If the patient loses consciousness and the ability
to respond purposefully, the anesthesia care is
a general anesthetic, irrespective of whether
airway instrumentation is required. MAC
should be subject to the same level of payment
as general or regional anesthesia.
Practice Guidelines: Broadly speaking practice
guidelines and standards are the same as
applicable to any general or regional anesthesia.
Preanesthetic
assessment,
preparation,
monitoring and perioperative care need to
executed in a similar way with same level of
alertness, spirits, precautions and standard of
care. MAC can be as easy and safe as any GA
procedure in ASA 1 or 2 undergoing simple
procedure or it can be as hard and difficult as
any major surgery in patient with ASA physical
status 5.
Preanesthetic
assessment:
An
essential
component of MAC is the assessment and
100
management of a patients actual or anticipated

physiological derangements or acute medical
problems that may occur during a procedure or
surgery.
General assessment:The anesthesiologist
need to perform a thorough review of
the patients medical history, tests and
examination as required for general
anesthesia.
Cognitive function:
Ability to verbally
communicate with the patient is important as
it helps in sedation monitoring, reassurance
and assessment of patients well-being.
Cardiorespiratory reserve and physical
fitness:
Poor cardiorespiratory reserves
are often the indication for MAC over
GA. Although American Society of
Anesthesiologists (ASA) physical status does
not contribute directly that patient should be
done under MAC or GA, but MAC provider
should assess ASA physical status class for
assessing a patient before surgery as highrisk patient may be considered more safe
under MAC.3
P1 A normal, healthy patient
P2
A patient with mild systemic
disease
P3
A patient with severe systemic
disease
P4
A patient with severe systemic
disease that is a constant threat to
life
P5
A moribund patient who is not
expected to survive without the
operation
P6
A declared brain-dead patient
whose organs are being harvested.
Airway
assessment:
The
Mallampati
score is considered a predictor of difficult
tracheal intubation and is routinely used
in preoperative anesthesia evaluation. The
score is obtained by having the patient extend
the neck, open the mouth, and extend the
tongue while in a seated position. Patients
are scored from Class 1-4 as follows:4
Class I - The tonsils, uvula and soft palate
are fully visible
Class 2 - The hard and soft palate, uvula

and upper portion of the tonsils
are visible
Class 3 - The hard and soft palate and the
uvula base are visible
Class 4 - Only the hard palate is visible.
Patients with Class 3 or 4 Mallampati
scores are considered to be at higher risk
of intubation difficulty. Anesthesiologists
should assess airway for feasibility of mask
ventilation.5,6 Obesity, unfavorable upper
lip bite test/mandibular protrusion test and
elderly age group are considered reliable
risk factor to predict difficult ventilation.
Considering other parameters such as
thyromental distance, receding mandible,
bucked teeth along with Mallampatis Class 3
and 4 increase overall predictability of these
airway assessment for difficult intubation
and ventilation.7 While the Mallampati score
and other predictors of difficult airway do not
determine a need for monitored anesthesia
care, it may be considered in determining
risk for airway obstruction. Obese patients
particularly with obstructive sleep apnea are
at risk of airway obstruction after sedation.
It may be difficult and challenging even for
an experienced anesthesiologist to secure
airway and ventilation. Moreover if MAC is
administered outside the operation theater
suite, preparation for difficult airway should
be stand by or easily accessible in high-risk
airway.
Procedure explanation, briefing and
consent: Patient should be explained
about anesthetic technique and procedure.
Monitored anesthesia care is considered a
matter of patient choice. In these settings,
physician should discuss the risks and
benefits of monitored anesthesia care and
general anesthesia. Shared decision-making
is recommended. Monitored anesthesia care
may be appropriate whenever specific risk
factors or significant medical conditions
are present and carries a potential risk for
sedation during procedure by a surgeon or
proceduralist. These conditions include:8
High risk of complications due to severe

comorbidity (ASA Physical status 3 or more)
Morbid obesity or obstructed sleep apnea or
difficult airway
Inability to follow simple commands
(cognitive dysfunction, intoxication, or
psychological impairment)
Spasticity
or
movement
disorder
complicating procedure.
History or anticipated intolerance or
addiction to standard sedatives, such as
i Chronic opioid use
ii. Chronic benzodiazepine use
Extremes of age, i.e., younger than 18
years or age 70 years or older
Patients who are pregnant
Acutely agitated, uncooperative patients
and anxious patient
Preoperative
instructions:Preoperative
instructions and prescription such as fasting,
anxiolytics, aspiration prophylaxis and
concurrent medications are the same as for
any routine general anesthetics.
MAC technique:An intravenous catheter is
secured through which anesthetic drugs can
be administered. Monitor vitals as done for
other general anesthetics (See below). MAC
provider has to be with patient all times to
monitor patients well-being, and adjust the
level of sedation as needed. During MAC, the
provider can adjust the level of sedation to a
desired level ensuring patient comfort and
safety to accomplish the procedure. Comforting
patient with reassurance, psychological
support and physical comfort plays key role
to accomplish procedure uneventfully. In
addition to the sedation, surgeon will often
use local anesthetics for pain relief if deemed
for surgery or procedure. After detailed
assessment, anesthetic workstation is prepared
as practised for any other anesthetic procedure.
The combination of drugs (analgesic, amnesic,
and hypnotics) should be used to have
minimum of side effects to facilitate recovery.
Titration of drugs is tricky. It is important to
know the onset, duration and context sensitive
half life of drugs. While context-sensitive
101
half-time is a reflection of plasma drug decay,

the effect-site concentration is the important
factor in determining wakefulness. Effectsite drug concentrations lag behind plasma
concentrations and may be further delayed due
to low cardiac output that will slow onset time.
Aged patient may be more sensitive to sedatives
and patients with chronic use of these drugs
may be tolerant. Practice guidelines for pain
management and discharge are the same as any
other postoperative care following anesthetic
exposure.
Commonly used drugs for MAC and their
concerns: Although under MAC patient may
require no sedation to deep sedation equivalent
full general anesthesia as defined by the latest
definition by ASA, but moderate sedation
is mostly used in outpatient settings. The
most commonly used agents for monitored
anesthesia care (MAC) are midazolam, fentanyl
and propofol. Each of these drugs, however,
causes respiratory depression.9-11 A frequently
used combination is an short acting opioid and
benzodiazepine (for example, fentanyl with
midazolam) at doses individualized to obtain
the desired sedation level. Other drugs and
drug combinations have also been utilized for
this purpose. It is ones individual choice and
comfort level with the drug depending upon
ones experience. While both benzodiazepines
and opioids can cause respiratory depression,
particularly when used in combination because
of synergic effects caused by knocking down
hypoxic and hypercapnic drives respectively.
Thus effective reversal agents should be
available. Propofol is another agent that has
been gained popularity over the last couple
of decades by virtue of its property of quick
onset and fast recovery with minimal or no
postoperative hang over and nausea, and
facilitating fast tracking. It is increasingly used
to provide sedation for procedures as an agent
of choice. Propofol has a short context-sensitive
half-time even after prolonged infusions, and a
short effect-site equilibration time making it a
suitable choice for sedation in hemodynamically
stable patient. However, there have been
102
concerns about potential side effects and

safety when used by non-anesthesiologists.10
Propofol does not reliably produce amnesia in
subhypnotic doses and may lead to hypotension
in sick patient. Rapid administration of propofol
has the potential to induce apnea, hypotension
and general anesthesia, and there is no
pharmacologic antagonist to reverse its action
making it unsafe by non-anesthesia personnel
without airway management training. ASA has
offered practice guidelines for the provision of
sedation by non-anesthesiologists, stating that
personnel must be prepared to respond to deep
sedation and loss of airway protection should
these complications inadvertently occur during
sedation.12-14 Midazolam even in low doses
produce reliable amnesia.
MAC provider should understand the
effect site equilibrium, context sensitive half
life and recovery characteristics of sedatives
to avoid over dosage and enhance recovery.
While the elimination half-time of midazolam
is relatively short, the context-sensitive halftime is roughly twice that of propofol, and
is associated with prolonged postoperative
sedation and psychomotor impairment.
Effect-site equilibration concept is very
relevant to titrate boluses of drugs. Thiopental,
propofol, and alfentanil have short values
while midazolam, sufentanil, and fentanyl
have long values respectively so one has to
be careful while administering these drugs.
Even using the shortest value for midazolam
(0.95.6 m), 2.7 minutes is required for 87.5%
effect-site equilibration of a bolus dose. Low
cardiac output is another factor that will slow
onset time.15 The Cpss50 of benzodiazepine
decreases significantly as a function of age,
so it has to be used cautiously in geriatric
patients. Elimination of fentanyl is shorter than
sufentanils, its context-sensitive half-time is
twice that of sufentanils at two hours and 8 to 10
times longer at five hours. There is no constant
relationship between elimination half-life and
context-sensitive half-time. Protective airway
reflexes are depressed by sedation, debilitation,
and advanced age. Complete recovery of the
swallowing reflex is expected approximately
15 minutes after the return of consciousness

from propofol anesthesia and two hours after
midazolam despite the return to a normal state
of consciousness.
Other relatively recent additions are
2 agonist dexmedetomidine. Its use is
progressively increasing with awareness of
physicians. Dexmedetomidine, because of its
analgesic properties with lack of respiratory
depression, makes it baseline effective, safe,
suitable for cooperative sedation in a broad
range of surgical procedures. Dexmedetomidine
results in better patient satisfaction, less opioid
requirements, and less respiratory depression. It
is gaining popularity with increasing experience
with drug.16-21
MAC and elderly patients: Population aging is
a worldwide phenomenon. Nearly more than
30% of population are above 65 years of age. It
has been estimated that elderly people require
surgery four times more often than the rest
of the population, and that this number will
increase by 25% by 2020.22 Those caring these
patients must consider the normal decline in
functional reserve in patients aged patients
and associated comorbid medical problems.
Some of procedures like cataract surgery,
dental treatment, endoscopies, radiological
procedures, carotid endartectomies, etc. are
common procedures which can be done
easily under MAC and regional block without
having problems of GA. Thus monitored
anesthesia care (MAC) is an attractive option
in these settings. MAC provider should be
aware of geriatric problems and issues which
one can face during preoperative evaluation,
intraoperative assessment and postoperative
discharge. Two core concepts are important
while assessing functional status of aged patient;
one functional loss reserves of organ systems
and secondly this loss varies from person
to person.23 Despite availability of various
instruments to evaluate functional status
and health associated quality of life, the best
practical tool is self reported walking ability.24-27
Most of geriatric population is frail and frailty
makes a person more vulnerable to disability
during and after stress.28 The components
of the frailty syndrome include mobility;

muscle weakness; poor exercise tolerance;
unstable balance; and factors related to body
composition such as weight loss, malnutrition,
and muscle wasting. Frailty is reliable predictor
of mortality and hospital admission.29,30 Elderly
patients have poor compensatory response
for the stress, hypovalemia, hypoxia and
hypercarbia associated with sedation and
hypothermia. Elderly patients have increased
sensitivity to all sedatives and opioids (doubled
by age 80 years, quadrupled by age 90 years
with benzodiazepines). Anesthetic dosing for
boluses should be in halved and infusions
reduced by as much as two-thirds. Pain is best
treated using smaller doses in a multimodal
regimen, the aim being to reduce adverse effects
while ensuring adequate pain relief.31 Low
dose intravenous ketamine may 0.5 to 1 mg/
kg helps to reduce dose of other drugs. Oral or
intravenous administered NSAIDs can be give as
pre-emptive analgesia. In elderly NSAIDs may
be reduced to 50% of adult dose. Hypovolemia
and dehydration, which are common in the
elderly, may aggravate the risk of acute renal
insufficiency following use of NSAIDs.32,33
Sedatives, especially propofol in association
with angiotensin-converting enzyme (ACE)
inhibitors may cause hypotension.34 Presence of
common metabolic disorder of aged population
diabetes mellitus and hypertension may also
add up to the problem.
Commonly performed procedures under MAC
and their concerns: Variety of procedures can
be performed under MAC. There are different
inherent problems, concerns and requirements
related to patient status, procedure and MAC.
MAC is often indicated, when procedures can
be done easily without general anesthesia
but surgeon or physician is uncomfortable
without anesthesiologists involvement. These
patients are either too sick to be considered
safe for sedation or general anesthesia for given
procedure. Or the procedure is too simple
where general anesthetics can be avoided to
fast track, and procedure can be done with
minimal postoperative problems and care. The
103
advantage of this type of anesthesia service, as

opposed to general anesthesia, is that there are
typically fewer anesthesia related side-effects
and quick recovery leading to less loss of working
days. Currently MAC is the first choice in 10 to
30% of all the surgical procedures.35 The use of
MAC has been increasing rapidly over the last
decade to patients with lower anesthetic risk.36,37
The proportion of gastrointestinal (GI) tract
procedures performed with anesthesia services
increased from approximately 14% in 2003 to
more than 30% in 2009, with wide geographic
variation in the use of these services. A complex
set of factors have been proposed that contribute
to this increased use of anesthesia services
including patient and physician preferences,
clinical need, regulatory requirements, and
financial
considerations.34,37
Commonly
performed procedures are under MAC are:
Endoscopies of the upper and lower GI tract
Bronchoscopy
Extracorporeal lithotripsy
Transvaginal ovum retreival
Radiotherapy and imaging for infants
Angiography, pace-maker, central venous
catheter, and venous filter placements
Ocular surgical procedures
Arthroscopy, carpal tunnel repairing, other
minor orthopedic procedures
Minor surgical procedures, hernia surgical
repair
Perineal minor surgical procedures,
hemorrhoid surgical repair
Diagnostic and therapeutic hysteroscopy
Bladder endoscopy, prostate transurethral
resection.
As these services are not necessarily be
limited to operation theater but other remote
areas of hospital also. It is difficult to create
ideal theater conditions to which most of us
are used to. Some of specific procedures have
particular concerns in MAC such as sharing of
airway in dental and facial plastic procedures.
As surgeon shares his field with anesthesiologist
and in these settings, while picking of sedatives
and analgesics one must consider specifically
preservation airway reflexes.
104
MONITORING DURING MAC

Communication
and
observation:
The
patients response to verbal command should
be continually evaluated for effective titration
of sedation. The patient should be observed
for adverse effects of sedation and procedural
stress: diaphoresis, pallor, shivering, cyanosis,
and acute changes in neurologic status.
Monitoring level of sedation: Level of sedation
is a continuum status. With the same drug and
dosage patient may have different response
and level of sedation. It is difficult to predict
particularly in some patients with history of
use/abuse and tolerance of drugs. According to
OAA/S scale, a score of 3 to 4 means a moderate
level of sedation-analgesia, while a score of 1
to 2 means unconsciousness; for obtaining a
MAC, a score higher than 3 is required, while for
scores less than this point the patient has to be
considered in general anesthesia (Box 14.1).38
Although sedation is a continuum process,
but ASA in 2004, defined different levels of
sedation to simplify the understanding of need
of rescue airway management.
Minimal sedation (anxiolysis) is a druginduced state during which patients should
be able to communicate and respond
normally to verbal commands without
any tactile stimulation. Although cognitive
function and coordination may be impaired,
ventilator and cardiovascular function are
unaffected. He is fully alert to protect his
airway.
Moderate sedation/analgesia (conscious
sedation) is a drug-induced depression
of consciousness during which patients
communicate and respond purposefully
to verbal commands, either alone or

accompanied by light tactile stimulation.
No interventions are required to maintain a
patent airway, and spontaneous ventilation
is adequate. Cardiovascular function is
usually maintained.
Deep sedation/analgesia is a drug-induced
depression of consciousness during which
patients cannot be communicated or easily
aroused but respond purposefully following
repeated or painful stimulation. The ability
to independently maintain ventilatory
function may be impaired. Patients may
require assistance in maintaining a patent
airway, and spontaneous ventilation may
be inadequate. Cardiovascular function is
usually maintained, but may deteriorate
secondary to airway and ventilation
impairment. This is a particular problem in
elderly and morbidly obese patients.
General anesthesia is a drug-induced
depression of consciousness during which
patients are unresponsive to even painful
stimulation. The ability to independently
maintain ventilator function is often
impaired. Patients often require assistance
in maintaining a patent airway, and positivepressure ventilation may be required because
of depressed spontaneous ventilation or
drug-induced depression of neuromuscular
function. Cardiovascular function may be
impaired.
Pulse Oximetry:In addition to sedations
potential hypoxic effects, other predisposing
factors include obesity, pre-existing upper
airway obstruction and respiratory disease, age
extremes, and the lithotomy position. The ASA
Committee on Professional Liability analysis of
Box 14.1: The Observer Assessment of Alertness/Sedation Scale (OAA/S scale)

Answering
Vocal expression
Facial expression
Eyes only to calling
Ready to calling
Normal
Normal
Normal
Slow to calling
Initial slowing
Medium relaxing
Medium relaxing
Slowing
Slowing
Marked
ptosis
Only to loud calling Incomprehensible words
Only to shakes
Incomprehensible words
closed claims revealed that respiratory events

constituted the single largest source of adverse
outcomes.
Capnography: Sidestream capnographs have
been adapted for use with face masks, nasal
airways, and nasal cannulae.
Cardiovascular
system:
The ECG must
continuously be displayed and NIBP measured
and recorded at least every five minutes. The
pulse should be monitored palpation, oximetry,
or auscultation. Precordial stethoscope is an
inexpensive, effective and essentially a risk-free
tool.
Temperature: There is still the opportunity for
inadvertent hypothermia, particularly during
regional and conscious sedation techniques
in the elderly. Malignant hyperthermia is rare
during MAC because the common triggering
agents are rarely used. Hyperthermia can still
occur as a result of thyroid storm or malignant
neuroleptic syndrome.
Preparedness to manage adverse effects of drugs
and procedure:
Adverse events/effects secondary to deep
sedation and procedure: Airway obstruction,
hypoventilation, hypotension, arrhythmias,
claustrophobia, excessive movement and
poor tolerance of procedure.
Local anesthetic over dosage/toxicity: It
is important particularly in patient with
compromised cardiovascular reserves. The
more acidic pH of an acute hypercapnic
state in sedated patient with hypoventilation
lead to a degree of intracellular ion trapping
and high intracellular concentration.
Low perfusion in compromised cardiac
output may slow elimination and delay
recovery from toxicity. Hypoxia and acidosis
potentiates cardiovascular toxicity.
PACU care and discharge after MAC:It is
important to see that there is someone to look
after these patients at home after discharge.
Particularly elderly patients because of delayed
recovery of cognitive function and age related
frailty, may have poor oral intake. Pain is major
issue which if severe can lead to readmission.
Good pain relief is very satisfying to the patient.
105
Postoperative pain management: Postoperative

pain after day surgery may last more than 3 days
and affect quality of life for more than 7 days.39
Organizative aspects such as clear instructions
at discharge, availability of analgesic drugs and
follow-up are key factors,40 especially in geriatric
day surgery. Acetaminophen has few side effects
and no anti-inflammatory action, and is widely
used due to its high safety profile including
patient with poor hepatic function. At the
recommended therapeutic doses of 1 g 6 hourly
is usually well tolerated. Multimodal analgesic
strategy does excellently in relieving pain with
negligible side effects in the elderly population.
Tramadol is well tolerated and effective and is
indicated in the case of moderate-to-severe
pain. Slowly titrating the dose is effective in
reducing PONV. Confusion is concern after use
of narcotics and semisynthetic narcotics in the
elderly. Three stages of recovery exist; early,
intermediate and late recovery. The early and
intermediate recovery stages occur in either
in OR or PACU, whereas late recovery refers to
the resumption of normal daily activities after
discharge from hospital. Early recovery is the
time interval during which patients emerge from
anesthesia, recover control of their protective
reflexes, and resume early motor activity.
During this phase of recovery vital signs and
oxygen saturation are carefully monitored and
supplemental oxygen, analgesics, or antiemetics
can be readily administered. The modified
Aldrete score or modified postanesthetic
discharge scoring (PADS) is commonly used to
assess the fitness of patients to be discharged.
During the intermediate recovery period,
patients are usually cared for in a reclining chair
and progressively begin to ambulate, drink
fluids, void, and prepare for discharge. The
late recovery period starts when the patient is
discharged home and continues until functional
recovery is achieved and the patient is able to
resume normal activities of daily living. The
anesthetics, analgesics, and antiemetics can
also have an effect on the patients recovery
during the postdischarge period. However, the
surgical procedure itself has the highest impact
on the patients full functional recovery.
106
Principles and policies for discharge are same as

that for GA: Postanesthetic discharge scoring
(PADS) system is a simple objective cumulative
index that measures the patients home
readiness; it is based on five major criteria:
(1) vital signs, including blood pressure, heart
rate, respiratory rate, and temperature; (2)
ambulation and mental status; (3) pain and
PONV; (4) surgical bleeding; and (5) fluid
intake/output. Patients who achieve a score
of 9 or greater and have an adult escort are
considered fit for discharge (or home ready).
The requirement for patients to drink and
void before discharge is no longer considered
mandatory. A modified postanesthetic
discharge scoring system was developed that
eliminated input and output as discharge
criteria and resulted in earlier discharge for up
to 20% of patients (Box 14.2).41
Complications of MAC:Anxiolytics, sedatives
and analgesics used during a MAC depress
the central nervous system (CNS) in a dosedependent way and synergistically. Age
related alteration in pharmacokinetics and
pharmacodynamics, and pathophysiological
changes associated with medical condition may
lead to difficulty in optimal titration of desired
level of sedation. The spectrum of sedation
level is continuum process, and this spectrum
is an unbroken line which goes from a minimal
state of sedation to a profound unconscious
state, going through the conscious sedation
required during a MAC. At times higher levels of
sedation may compromise airway, ventilation
and circulation. The other side effects are
PONV, prolonged sedation, dysphoria, agitaion,
etc. While patient agitation may be due to
pain and anxiety but it can also be caused by
serious issues which need immediate attention
such as hypoxia, hypercarbia, impending local
anesthetic toxicity, and cerebral hypoperfusion.
Other less severe causes are: bladder distention,
hypothermia, hyperthermia, pruritus, nausea,
positional discomfort, IV site infiltration,
prolonged tourniquet inflation, or a member
of the surgical team leaning on the patient.
Recovery ideally should be complete and rapid.
The patient should be awake or arousable during
the procedure, and be able to communicate.
Box 14.2: Modified postanesthesia discharge

scoring (PADS) system
Vital Signs
2
1
0
Ambulation
2
1
0
Nausea and Vomiting
2
1
0
Pain
2
1
0
Surgical Bleeding
2
1
0
Within 20% of the

preoperative value
2040% of the preoperative
value
40% of the preoperative value
Steady gait/no dizziness
With assistance
No ambulation/dizziness
Minimal
Moderate
Severe
Minimal
Moderate
Severe
Minimal
Moderate
Severe
From Chung F, Chan VW, Ong D. A post-anesthetic

discharge scoring system for home readiness after
ambulatory surgery. J Clin Anesth. 1995;7:500.
conclusion
MAC is an attractive option where so ever
feasible irrespective of ASA physical status. In
sick patient with ASA status 3 or more it results
in minimal physiological derangement while
in healthy patients with ASA status 1 and 2, it
leads to quick recovery and back to work early.
However general anesthesia may be required
to accomplish procedure in some cases. Patient
assessment including history, examination and
investigations should be like any other type
of anesthesia. Infrastructure preparation and
monitoring should be of similar to OT suite.
Verbal communication is important to titrate
sedation and calm down anxious patient to
facilitate surgery/procedure. Selection of patient
and then selection of drugs/ drug combination
is important for smooth, safe and quick recovery.
References
1. American Society of Anesthesiologists (ASA).
Position on Monitored Anesthesia Care.
Approved by the House of Delegates on October
21, 1986, amended on October 25, 2005 and last
updated on September 2, 2008. http://www.
asahq.org/For-Members/Standards-Guidelinesand-Statements.aspx accessed on 29-09-2013.

2.
American
Society
of
Anesthesiologists
(ASA). Statement on Granting Privileges to
Nonanesthesiologist Physicians for Personally
Administering or Supervising Deep Sedation.
Approved by the ASA House of Delegates on
October 18, 2006, and amended on October
17, 2012.http://www.asahq.org/For-Members/
Standards-Guidelines-and-Statements.aspx
accessed on 29-09-2013.
3. Bang YS, Park C, Lee SY, Kim M, Lee J, Lee T.
Comparison between monitored anesthesia
care with remifentanil under ilioinguinal
hypogastric nerve block and spinal anesthesia
for herniorrhaphy. Korean J Anesthesiol. 2013;
64(5): 414-19.
4. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical
sign to predict difficult tracheal intubation: A
prospective study. Canadian Anaesthetists
Society Journal.1985;32(4): 429-34.
5. El-Orbany M, Woehlck HJ. Difficult mask
ventilation. Anesth Analg. 2009;109(6):1870-80.
6. Gautam P, Kaul TK, Luthra N. Prediction of
difficult mask ventilation. Eur J Anaesthesiol.
2005;22(8):638-40.
7. Shiga T, Wajima Z, Inoue T, Sakamoto A.
Predicting difficult intubation in apparently
normal
patients:
a
meta-analysis
of
bedside
screening
test
performance.
Anesthesiology.2005;103(2):429-37.
8. Evidence Based Guideline Monitored Anesthesia
Care (MAC): the Blue Cross and Blue Shield
Association last reviewed 3/2013.
9. Bailey PL, Pace NL, Ashburn MA, et al. Frequent
hypoxemia and apnea after sedation with
midazolam and fentanyl. Anesthesiology.
1990;73:826-30.
10. ASA Task Force on Sedation and Analgesia by
Non-Anesthesiologists. Practice guidelines for
sedation and analgesia by non-anesthesiologists.
11. Bhananker SM, Posner KL, Cheney FW, et al.
Injury and liability associated with monitored
anesthesia care: a closed claims analysis. (A
2006 review of closed malpractice claims in the
107
American Society of Anesthesiologists Closed

Claim Database revealed oversedation leading
to respiratory depression played a pivotal role
in patient injuries during MAC). Anesthesiology.
2006;104:228-34.
12. Singh H, Poluha W, Cheung M, et al. Propofol
for sedation during colonoscopy. Cochrane
Database Syst Rev. 2008;(4):CD006268.
13. McQuaid KR, Laine L. A systematic review and
meta-analysis of randomized, controlled trials
of moderate sedation for routine endoscopic
procedures. Gastrointest Endosc. 2008;67(6):910.

14. Horiuchi A, Nakayama Y, Hidaka N, et al.
Low-dose propofol sedation for diagnostic
esophagogastroduodenoscopy: results in 10,662
adults. Am J Gastroenterol. 2009;104(7):1650-5.
15. Simon C. Hillier SC, Mazurek MS. Monitored
Anesthesia Care. In: Barash, Paul G; and Cullen,
Bruce F; Stoelting, Robert K. (Eds.). Clinical
Anesthesia, 5th Edition. Lippincott Williams &
Wilkins 2006.pp.1246-61.
16. Herr DL, Sum-Ping STJ, England M. ICU sedation
after coronary artery bypass graft surgery:
dexmedetomidine-based versus propofol-based
sedation regimens. J Cardiothorac Vasc Anesth.
2003;17:576-84.
17. Candiotti KA, Bergese SD, Bokesch PM,
et al. Monitored anesthesia care with
dexmedetomidine: a prospective, randomized,
double-blind,
multicenter
trial.
Anesth
Analg.2010;110(1):47-56.

18. Anand S, Bhatia A, Raj kumar, et al.
Dexmedetomidine for monitored anesthesia
care in patients undergoing liberation procedure
for multiple sclerosis: An observational study.
2012;6(4):358-62.
19. Arain SR, Ebert TJ. The efficacy, side effects, and
recovery characteristics of dexmedetomidine
versus propofol when used for intraoperative
sedation.Anesth Analg.2002;95:461-6.

20. Abdalla MIM, Mansouri FA, Bener A.
Dexmedetomidine during local anesthesia. J
Anesth.2006;20:54-6.

21. McCutcheon C, Orme R, Scott D, et al. A
comparison of dexmedetomidine versus
conventional therapy for sedation and
hemodynamic
control
during
carotid
endarterectomy performed under regional
anesthesia. Anesth Analg.2006;102:668-75.
22. Naughton C, Feneck RO. The impact of age on
six-month survival in patients with cardiovascular
risk factors undergoing elective noncardiac
surgery. Int J Clin Pract. 2007; 61:768-76.
108
23. Frederick E. Sieber, Ronald Pauldine. Geriatric

Anesthesia In: Miller RD, Cohen NH, Eriksson
L, Fleisher LA, Wiener-Kronish JP, Young WL,
editors. Millers Anesthesia. 8th edn. USA:
Churchill Livingstone Elsevier; 2015.pp.2407-22.

24. Gabriella Bettelli. Anesthesia for the elderly
outpatient: preoperative assessment and
evaluation,
anesthetic
technique
and
postoperative pain management. Current
Opinion in Anesthesiology. 2010; 23: 726-31.

25. Hardy SE, Gill TM. Factors associated with
recovery of independence among newly
disabled older persons. Arch Intern Med. 2005;
165:106-12.
26. Alexander NB, Guire KE, Thelen DG, et al. Selfreported walking ability predicts functional
mobility performance in frail older adults. J Am
Geriatr Soc. 2000;48:1408-13.
27. Guralnik JM, Simonsick EM, Ferrucci L, et al. A
short physical performance battery assessing
lower extremity function: Association with selfreported disability and prediction of mortality
and nursing home admission. J Gerontol. 1994;
49:M85-M94.

28. Ferrucci L, Guralnik JM, Studenski S, et al.
Designing randomized, controlled trials aimed
at preventing or delaying functional decline and
disability in frail, older persons: A consensus
report. J Am Geriatr Soc. 2004; 52:625-34.
29. Fried LP, Tangen CM, Walston J, et al. Frailty in
older adults: Evidence for a phenotype. J Gerontol
A Biol Sci Med Sci. 2001;56:M146-M156.

30. Fleisher LA, Pasternak LR, Herbert R, et al.
Inpatient hospital admission and death after
outpatient surgery in elderly patients: importance
of patient and system characteristics and location
of care. Arch Surg. 2004; 139(1):67-72.
31. Ekstein M, Gavish D, Ezri T, Weinbroum AA.

Monitored anesthesia care in the elderly:
guidelines and recommendations. Drugs
Aging.2008;25(6):477-500.
32. Jolobe OMP. Nephrotoxicity in the elderly due to
co-prescription of ACE inhibitors and NSAIDs. J
R Soc Med. 2001;94:657-8.

33. Stillman MJ, Stillman MT. Choosing non
selective NSAIDs and selective COX-2 inhibitors
in the elderly: a clinical use pathway. Geriatrics.
2007;62:26-34.
34. Gragasin FS, Bourque SL, Davidge ST. Propofol
increases vascular relaxation in aging rats
chronically treated with the angiotensinconverting enzyme inhibitor captopril. Anesth
Analg.2013;116(4):775-83.
35. Albertin A, Fanelli G. Monitored anesthesia care.
Torino; Ed. UTET; 2001.
36. Liu H, Waxman DA, Main R, et al. Utilization
of anesthesia services during outpatient
endoscopies
and
colonoscopies
and
associated spending in 2003-2009. JAMA. 2012;
307(11):1178-84.
37. Fleisher LA. Assessing the value of discretionary
clinical care: the case of anesthesia services for
endoscopy. JAMA. 2012;307(11):1200-1.
38. Ghisi D, Fanelli A, Tosi M, et al. Monitored
anesthesia
care
Minerva
Anestesiol.
2005;71:533-8.

39. Beauregard L, Pomp A, Chinire M. Severity
and impact of pain after day surgery. Can J
Anaesth.1998;45:304-11.
40. Solca M, Savoia G, Mattia C, et al. Pain control in
day surgery: SIAARTI Guidelines. Min Anestesiol.
2004;70:5-24.
41. Chung F, Chan VW, Ong D. A post-anesthetic
discharge scoring system for home readiness
after ambulatory surgery. J Clin Anesth.
1995;7:500.
CHAPTER
15
Management of Local
Anesthesia Toxicity
Raminder Sehgal
Local anesthetics are generally safe and

effective but have the potential to cause
adverse side effects. These effects vary from
allergic reactions commonly seen with esters,
methemoglobinemia produced by Prilocaine,
local muscle or nerve damage to severe central
nervous system (CNS) and/or cardiovascular
system (CVS) toxicity which can be lifethreatening. Local anesthetic systemic toxicity
or LAST occurs as a result of high plasma
levels of local anesthetics which may be due
to overdosing (concentration x volume), rapid
absorption from injection site, diminished
tolerance or unintentional intravascular
injection. The severity of LAST depends upon
the local anesthetic compound, patient risk
factors which alter its pharmacokinetics
(cardiac, hepatic and renal failure, extremes
of age, pregnancy), acid-base status, tissue
vascularity, rate of drug administration and
the location and technique of the block. The
CNS is more sensitive to local anesthetic than
the CVS. The relative CV/CNS ratio describes
the dose required to produce arrhythmias or
cardiovascular collapse versus that required to
produce seizures. Lower the ratio, more toxic
is the drug. The CV/CNS ratio for bupivacaine
is 2.0, for ropivacaine 2.2 and for lignocaine
7.1 indicating higher cardiotoxicity potential
of bupivacaine. These practice management
guidelines apply to the use of local anesthetic
in the operation theater, labor room or the

wards and are based on the currently available
literature and focus on prevention, timely
detection and stepwise treatment of LAST.
GENERAL GUIDELINES
Local anesthetics should be used by
physicians who are competent and have
the skill necessary to administer local
anesthetics and recognize the signs and
symptoms of toxicity. A physician competent
to provide resuscitation including CPR and
provide postanesthesia care should also be
available.
Resuscitation equipment including oxygen,
suction, equipment to manage the airway
(laryngoscope, endotracheal tubes, bougies,
supraglottic airway devices), equipment to
provide ventilation (selfinflating bag and
face mask), vital sign monitor, emergency
drugs required during cardiopulmonary
resuscitation (CPR) and 20% intralipid should
be available wherever local anesthetics are
used.
A thorough preanesthetic check-up
should be done for all patients to identify
comorbidities and drug intake likely to affect
the LAST.
Informed consent should be obtained before
embarking on the procedure.
110
An intravenous access should be ensured

before injecting local anesthetic and should
be kept in place till its effect has worn off.
PREVENTION
Choose the local anesthetic agent with
the best safety profile. The dose and
concentration should be the lowest one
which will achieve the desired clinical effect.
Dose reduction is particularly important in
patients at risk of LAST like those at extremes
of age (< 4 months and > 70 years), those with
ischemic heart disease or conduction defects
and hepatic or renal failure.
Consider the use of ultrasound during
peripheral nerve blocks for accurate
placement of local anesthetic around the
nerves thus reducing the dose required for
desired effect. Ultrasound guidance also
reduces the onset time, increases success
rate and reduces the chance of accidental
intravascular placement.
Consider the use of a benzodiazepine for
premedication as it can lower the probability
of seizures and make the patient comfortable.
Consider the use of test dose with a reliable
marker
of
intravascular
placement.
Adrenaline given in a concentration of 10 to
15 mcg/mL detects intravascular placement
if it produces increase in heart rate by 10
to 15 beats per minute or increase in systolic
blood pressure by 15 mm Hg. For children
adrenaline 5 mcg/kg produces a rise in
systolic blood pressure by 15 mm Hg. This test
dose is not reliable in the elderly, patients on
beta blockers and patients who are sedated
or anesthetized. Low cardiac output states
prolong drug circulation and may not show
hemodynamic alterations reliably. Caution
should be exercised as false negative result
are also reported. Fentanyl 100 mcg can also
be used as a test dose in laboring patients. It
produces drowsiness in case of intravascular
injection.
Administer local anesthetic slowly in small
increments of 3 to 5 mL with a pause of at
least one circulation time between each

increment.
Aspirate frequently between injections
(every 35 mL) to observe for blood.
Maintain constant verbal contact with
the patient and monitor for signs of LAST.
Clinical signs of toxicity may be delayed up
to 30 minutes.
DIAGNOSIS
Look for CNS and CVS signs and symptoms
of LAST which are biphasic, with initial
stimulation followed by depression.
The CNS manifestation includes:
Pre-excitation: Tinnitus, light headedness,
confusion,
circumoral
numbness,
paresthesia, diplopia.
Excitation: Agitation, shivering, tremors,
twitching, convulsions.
Depression: Unconsciousness, respiratory
depression, respiratory arrest.
Respiratory or metabolic acidosis increases
cerebral blood flow thus increasing drug delivery
to the brain, and in turn increases the CNS
toxicity. Acidosis also decreases intracellular
pH, causes ion trapping and decreases plasma
protein binding to increase free base. Thus
immediate control of airway, oxygenation and
controlling the seizures is of utmost importance.
The CVS manifestation includes:
Hyperdynamic
phase:
Tachycardia,
hypertension, arrhythmia.
Progressive hypotension due to peripheral
vasodilation.
Conduction block: Increased PR interval and
QRS duration, bradycardia or asystole.
Ventricular
arrhythmia:
Ventricular
tachycardia, ventricular fibrillation, Torsades
de Pointes.
Note that the CNS toxicity precedes CVS
toxicity but in case of direct intravascular
injection the CNS symptoms may be bypassed.
With more potent local anesthetics, the cardiac
toxicity may manifest simultaneously with
seizures or may even precede it.
Management of Local Anesthesia Toxicity
MANAGEMENT OF LAST

Immediate measures:
Stop injection of local anesthetic.
Call for help.
Maintain airway, use supraglottic airway
devices or endotracheal tube if required.
Ventilate lungs with 100% oxygen to
prevent hypoxia, hyperventilate to
prevent acidosis which potentiates the
severity of LAST.
Secure intravenous access if not already
in place.
Control seizures with:
i. Intravenous midazolam 2 to 5 mg (drug of
choice) or
ii. Thiopentone 50 to 100 mg in small
incremental doses or
iii. Propofol 1 mg/kg in small incremental
doses.
iv. If seizures persist, administer muscle
relaxant in small doses (succinylcholine 1
mg/kg).
Note: Use lowest effective dose of thiopentone
and propofol as it can cause hypotension and
severe myocardial depression.
Muscle relaxants also help by facilitating
controlled ventilation thus preventing hypoxia,
hypercarbia and acidosis which exacerbates
cardiotoxicity.
Evidence is emerging on the early use of
lipid emulsion to control seizures and prevent
cardiac toxicity.
Consider use of sodium bicarbonate to
prevent/treat acidosis.
Treat hemodynamic instability to maintain
coronary perfusion, cardiac output and
oxygenation:
Use vasopressors to treat hypotension
and atropine to treat bradycardia
Use amiodarone (150 mg) to treat
arrhythmias.
Do not use lignocaine to treat arrhythmia.
It may add to the cardiotoxicity.
Manage cardiac arrest and arrhythmias
using standard BLS and ACLS protocol with
following modifications:
Use small dose of adrenaline 10 ot
100 mcg boluses in an adult (It has
111
arrhythmogenic potential and is seen to

result in poorer outcome in bupivacaine
induced asystole).
Avoid vasopressin (Has poorer outcome).
Avoid calcium channel blockers and betaadrenergic receptor blockers.
Use amiodarone for arrhythmia.
Consider sodium bicarbonate to maintain
pH > 7.25.
Consider therapy with H1 and H2
blockers.
Consider transcutaneous or intravenous
pacemakers for bradyarrhythmia.
Consider cardiopulmonary bypass as
a bridging therapy till local anesthetic
levels decrease in the tissues.
Continue CPR for at least 60 minutes
as good neurologic recovery is possible
after prolonged cardiac arrest from local
anesthetics.
Observe patient for at least 12 hours after
the injection.
Start lipid emulsion therapy at the earliest
sign of LAST (prolonged seizures. arrhythmia,
rapid progression of toxicity), soon after the
airway management as follows:
Give initial bolus of 20% intralipid
emulsion 1.5 mL/kg lean body weight
over 1 minute.
Simultaneously start intravenous infusion
of 20% intralipid emulsion at the rate of 15
mL/kg/h (0.25 mL/kg/minute).
If cardiovascular stability is not achieved,
give a maximum of two repeat boluses
of 20% intralipid emulsion, keeping 5
minutes between each bolus.
Double the rate of infusion to 30 mL/kg/h
(0.5 mL/kg/minute) after 5 minutes if
cardiovascular stability is not achieved.

Continue 20% intralipid infusion
throughout resuscitation and till 10
minutes after the patient is stable and
adequate circulation is restored.
Caution: Do not exceed the maximum
cumulative dose of intralipid (12 mL/kg).
Do not use propofol as a substitute for lipid
emulsion. (Has low lipid content and causes
myocardial depression).
112
Prevention is the key to avoiding potentially

serious consequences of local anesthetic
toxicity. Selecting a safe local anesthetic in
correct dose, close monitoring for signs of LAST
and instituting early treatment will prevent
progression to more serious systemic toxicity.
Timing of lipid emulsion is controversial but
evidence is emerging which supports early
administration at the first sign of toxicity.
Bibliography
1. AAGBI Safety Guide. Management of severe local
anaesthetic toxicity. 2010. www.aagbi.org.
2. Adam VN, Markic A, Sakic K, et al.
Local Anaesthetic Toxicity. Period Biol.
2011;113(2):141-6.
3. Bern S, Weinberg G. Local Anesthesia toxicity
and lipid resuscitation in pregnancy. Current
Opinion in Anestheiology. 2011;24:262-7.
4. Cox B, Durieux ME, Marcus MAE. Toxicity of

local anaesthetics. Best Practice & Research
Clinical Anaesthesiology. 2003;17(1):111-36.
5. Dewaele S, Santos AC. Toxicity of local
anesthetics. NYSORA- The New York School of
Regional Anesthesia. www.nysora.com accessed.
24.9.13.
6. Neil JM, Bernards CM, Butterworth JF, et al.
ASRA Practice Advisory on Local Anesthetic
Systemic Toxicity. Reg Anesth Pain Med.
2010;35(2):152-61.www.rapm.org. accessed.

7. Perioperative ACLS. 2011; www.asahq.org.
accessed 24.9.13.
8. Rajan N. Management of severe local anaesthetic
toxicity. Update in Anaesthesia. www.
anaesthesiologists.org. accessed 24.9.13.

9.
Weinberg GL. Lipid infusion therapy:
Translation to clinical practice. Anesth Analg.
2008;106:1340-2.
CHAPTER
16
Interhospital Transfer
of Critically Ill Patients
Rashmi Datta
INTRODUCTION
Acutely-ill patients are routinely transferred
to alternate locations to obtain additional
technical, cognitive, or procedural care, that
is not available at the existing location, either
to a higher level of care or for a specialty
service. Although they may appear stable,
the physiological reserves of these patients
are limited. Even minor adverse physiologic
changes can cascade into life-threatening
complications.
Therefore,
transportation
may be considered to represents a period of
cardiopulmonary instability. This is why few
advocate considering performing diagnostic/
therapeutic procedures within the hospital or
the site of accident itself.1-3
Acutely ill patients are at increased risk of
morbidity and mortality during transport.3,4
Risk can be minimized and outcomes improved
with careful planning, the use of appropriately
qualified personnel, and selection and
availability of appropriate equipment.3-5
During transport, there can be no hiatus in the
monitoring or maintenance of a patients vital
functions.
The transportation may be either primary
transfer (or extra hospital transfer) when patients
are transported from the site of occurrence of
accident to the place where they first receive
medical aid or secondary transfer. The latter
is both within a given hospital (intrahospital

transfer) to undergo tests and procedures or
between hospitals (Interhospital transfer), as
patients may require transfer to other facilities
for specialized services. Critically ill patients in
particular commonly require such secondary
transfers and are at high-risk for complications
en route.
Interhospital transfers can also be either
Emergency transfer due to either lack of
diagnostic facilities, staff, clinical expertise
and/or facilities for safe and effective therapy
in the referring hospital or Semi-urgent interhospital transfer. Non-emergency inter-hospital
transfer is typified by the nonurgent, planned
transportation of patients, with a medical
need for transport, to and from a healthservice
provider and between health care providers.
This will encompass a wide range of vehicle
types and levels of care consistent with the
patients needs.3,6-8
TRANSPORT TRIANGLE
There are three essential participants during
an interhospital transfer, i.e. referring
doctors, Critical Care Transport Team (CCTT)
personnel and receiving doctors. The triangle
of these three is called transport triangle
(Figure 16.1).
114
members have to be informed about the risks

and benefits and consent obtained. Medical
and nursing records and the complementary
diagnostic exams should be sent with the
patient.3,8-10
For contacting the tertiary hospital, a
proposed checklist is given in Table 16.1.
Figure 16.1 Transport triangle
RESPONSIBILITIES OF THE
TRANSPORT TRIANGLE
Once the decision of transporting a patient is
taken, it should be done as soon as possible.
Responsibility of Referring Doctors

It is the responsibility of the referring doctors
to ensure that all the required resources for the
treatment are available at the choice place of
transfer before the transfer of the patient. Family
TABLE 16.1
Responsibility of Interhospital
CCTT Personnel
The CCTT vary widely in composition, training
and experience.11 The needs of the patient
are the deciding factor in the composition of
transfer team, the commonality being that they
should have experience in the unique transport
environment and should have the ability to
evaluate and initiate appropriate treatment
promptly in critical patients. It is mandatory
that they should be trained in basic life support,
advanced cardiac life support and advanced
trauma life support.4,8,10-13
Proposed checklist prior to interhospital transfer
Information to the Patients name and a detailed information of the medical situation and the predictable
receiving hospital
therapy procedures required by the patient
Names and contacts of the participants in the process of transfer should be recorded
Requestors name and hospital
Pickup location, if required
Mode of transportation required, e.g. wheelchair, stretcher
Time patient must be at destination
Whether the patients chart or other items will also be transported (e.g. whether an
IV or O2 is in place)
Whether any additional assistance or security is needed
Isolation precautions, if any
Stability of the
patient
Airway: Airway safe and secured by intubation, tracheal tube position confirmed
Ventilation: Paralyzed, sedated and ventilated, ventilation established on transport
ventilator, adequate gas exchange confirmed by arterial blood gas analysis
Circulation: Heart rate and blood pressure stable, any obvious blood loss controlled,
circulating blood volume restored, hemoglobin adequate, minimum two intravenous
access, arterial line and central venous pressure monitoring line appropriate
Disability: Seizures controlled, raised Intracranial pressure managed
Trauma: Cervical spine protected, pneumothorax drained, intrathoracic and intraabdominal bleeding controlled, and bones and pelvic fractures stabilized
Metabolic: Blood glucose controlled, potassium level checked, ionized calcium, and
acid-base status checked
Monitoring: ECG, noninvasive blood pressure, capnography, pulse oximetery and
temperature monitoring
Interhospital Transfer of Critically Ill Patients
The CCTT should consist of a doctor

(Intensivist, Anesthesiologist, Pulmonologists,
in that order as per the stability of the patient),
Critical care nurse and a respiratory therapist.
As with doctors, the training of nurses and
respiratory therapists assigned responsibility
for inter-hospital transport varies widely but it
is mandatory that they should have completed
a competency-based orientation and has met
previously described standards for critical care
nursing.8,10
The CCTT should ideally be a minimum
of two people or if there are multiple patients,
a formula of n+1 (n = number of critical care
patients) has been suggested. This team is to
prepare the patient for transport, accompany
the patient en-route, monitor and intervene if
required. This team does not routinely provide
primary stabilization and also does not replace
the medical team capabilities of the referring
and receiving hospitals.11,12 As with many critical
work situations, all members of the CCTT
should pass the IM SAFE test as for pilots
before being actively involved (Table 16.2).14
Since there will almost certainly be situations
when a specialized team is not available for
inter-hospital transport, each referring and
tertiary institution must develop contingency
plans using locally available resources for those
instances when the referring facility cannot
perform the transport.15
While transportation, special care should
be taken to secure patients fully with five point
harness care. All equipment should be fixed.
The vehicle speed of the ground transport
ambulances (GTAs) should be controlled.4,11,16
TABLE 16.2
115
Standard documentation should be done (see

later).
Responsibility of Receiving Physician

The receiving hospital cannot refuse to accept
the transfer of a patient who is unstable or
has an emergency medical condition if they
have the capability and ability to care for the
patient.2,17
TYPES OF INTERHOSPITAL
TRANSPORTATION TEAMS
A vehicle dispatched directly from the referring
hospital to the receiving hospital constitutes
a one-way transport. When the transport
and medical team is sent from the receiving
hospital it is called a two-way transport. When
a third party provides the vehicle and team
from a location other than the receiving or
referring hospital, it is described as a threelegged transport. CCTTs can also be of different
types. A Retrieval CCTT is one who is centrally
located at tertiary referral center. On receiving
a call, the hospital dispatches these teams. The
obvious problem is the time delay in arrival
at the site of the patient. A Regional CCTT is
affiliated to an individual critical care network.
On receiving a call, the nearest team proceeds to
the site of the patient and, depending upon the
condition of the patient, takes him/her to the
nearest affiliated hospital. Most hospitals have
a Hospital CCTT dispatched by the hospital on
receiving a call and which brings the patient
back to the same hospital.3,7,9,11,12,14,15,17,18
IM Safe test for critical care transport team
Illness?
Do I have any symptoms?
Medication?
Am I using any kind of prescription or drugs?
Stress?
Am I under psychological pressure from the job or home?

Have I any worries about financial, health or family problems?
Alcohol?
Have I been drinking within eight hours? Within 24 hours?
Fatigue?
Am I tired and not adequately rested?
Eating?
Have I been eating and drinking adequately?
116
Specialized transport teams characteristically receive consistent and high levels of

training and experience in the transportation
of critically ill patients, compared with teams
assembled ad hoc.
CHOICE OF VEHICLE
Choice of transport vehicle is influenced by
numerous factors. These include the nature of
illness, possible clinical impact of the transport
environment,
urgency
of
intervention,
location of patient, distances involved,
number of retrieval personnel and volume of
accompanying equipment, road transport times
and road conditions, range and speed of vehicle,
weather conditions and aviation restrictions for
airborne transport as well as aircraft landing
facilities.18-20
Evacuating the patient can be done by both
Ground Transport Ambulances (GTAs) and
Aero-Medical Transfer (AMT). Advantages of
GTAs include a door-to-door service with no
requirement of additional transport vehicles.
There is ease of personnel training with few
weather restrictions. Moreover, civilian family
members can accompany the patient (Table
16.3). Practical problems while using the
currently available GTAs for transfer of patients
are given in Table 16.4.
AMT use rotary or fixed wing aircrafts.
The latter may be either pressurized or
unpressurized. Helicopters typically cruise at
TABLE 16.3

500 to 2000 feet. Special rescue helicopters

can go upto 15,000 to 20,000 feet under the
right conditions and for > 30 minutes provided
additional oxygen is available for all the
occupants. Modern helicopters routinely used
in medical missions are capable of sustained
speed in excess of 150 mph. Moreover, vertical
take-off and landing capabilities permit
evacuation of patients from areas inaccessible
to other transport vehicles. Fixed wing aircraft
have the advantage of having a greater range
and being faster but this is somewhat offset
by the need for a secondary road transfer at
either end. There is reduced noise whilst in
flight compared to most helicopters and more
space to provide in flight quality intensive care.
Fixed wing aircraft are also capable of flying in
a greater range of weather conditions. Pistonpowered unpressurised aircrafts (PPUAs) have
low cruising altitudes of 8,000-11,000 feet.
These are often noisier and subject to more
turbulence at lower levels. There may be higher
route restriction due to weather or terrain. The
patients oxygen status needs more monitoring.
On the plus side, PPUAs need less runway for
take-off and landing and can be flown from
unpaved surface. These are ideal for small
hops during which there is less time to climb
to higher altitude. Pressurized transport aircraft
have a cruising altitude of 25,000 to 35,000 feet
with a cabin altitude maintained between 5,000
to 8,000 ft. The absolute lowest cabin altitude is
in Emivest SJ30 Business jet (12,000 ft) At 8,000
Advantages of ground transport ambulances
Readily available
Adequate operational safety
Capable of securely carrying at least one stretcher and intensive care equipment
Safe seating for full team, ideally with access to the head and side of the patient with enough access for
observations and simple procedures
Equipped with adequate oxygen/other gases for duration of transport
Fitted with medical power supply with appropriate voltage and current capacity
Appropriate speed (coupled with) comfortable ride, without undue exposure to accelerations in any axis
Acceptable noise and vibration levels
Adequate cabin lighting, ventilation and climate control
Fitted with overhead IV hooks and sharps/biohazard waste receptacles
Straightforward embarkation and disembarkation of patient and team
Fitted with appropriate radios and mobile communications

TABLE 16.4
117
Practical problems while using currently available ground transport ambulances
T here is limited patient access. The height of the stretcher on which the patient lies is very low and cannot
be adjusted. Also the space behind does not allow for optimum airway management if required.
GTAs are usually provided with a generator through which all the electromedical equipment and climate
control runs. Most ambulances do not have a vent for the generator leading to fume built-up in the cabin. In
case there is no generator, there is a need to carry additional batteries/AC converters
Monitoring may be compromised by vibration, motion artifacts and limited visibility
The motion of the vehicle makes any intervention difficult while the vehicle is moving because of
translational forces both on the patient and CCT.
Training of the Critical Care Paramedic needs periodic updates in training. Also, frequent moves may hamper
the familiarization of the personel with the equipment.
TABLE 16.5
Tentative list of drugs to accompany critically Ill patients during transfer
Adenosine
Adrenaline
Aminophylline
Amiodarone
Atropine / Glycopyrrolate
Sodium Bicarbonate
Dexamethasone / Methylprednisolone
Diazepam / Midazolam
Isosorbide Dinitrate
Dobutamine / Dopamine
Dopamine
Phenobarbital
Flumazenil
Furosemide
Calcium Gluconate
Fentanil / Morphine
Mannitol
Naloxone
Noradrenaline
Paracetamol
Nitroglycerin or Glyceryl Trinitrate
Metoprolol / Esmolol
Thiopental Sodium / Propofol
Succinylcholine / Vecuronium Bromide
2% Lignocaine (+gel and spray)
Ondensetron
ft, while the partial pressure of inspired oxygen

(FiO2) is around 108 mm Hg which is adequate
to maintain oxygen saturation (SpO2) of over
90% in a healthy individual, a critically ill patient
with respiratory compromise could suffer from
hypoxemia.7,18,19,21-23
In India, Air Ambulance Services is provided
by companies like EMSOS, Saras, Helping Point
and Vibha Life savers to name a few.
ACCOMPANYING MEDICATIONS
Basic
resuscitation
drugs,
including
epinephrine and anti-arrhythmic agents, are
transported with each patient in the event of
sudden cardiac arrest or arrhythmia. A more
complete array of pharmacologic agents either
accompanies the basic agents or is available

from supplies (Crash Carts) located along the
transport route and at the receiving location. An
ample supply of appropriate intravenous fluids
and continuous drip medications (regulated
by battery-operated infusion pumps) has
to be ensured. Supplemental medications,
such as sedatives and narcotic analgesics, are
considered in each specific case. A proposed list
is given in Table 16.5.
ACCOMPANYING EQUIPMENT
The equipment used during interhospital
transport vary widely. The principle is that
all critically ill patients undergoing transport
should receive the same level of basic physiologic
118
monitoring during transport as they had in the

ICU. This includes, at a minimum, continuous
ECG monitoring, continuous pulse oximetry
and periodic measurement of blood pressure,
pulse rate, and respiratory rate. Monitors should
be portable, light weight, battery powered. It
is desirable that these should be compatible at
destination unit. When available, a memorycapable monitor with the capacity for storing
and reproducing patient bedside data will allow
review of data collected during the procedure
and transport.
In ventilated patients, both monitoring of
inspired oxygen (FiO2) and end-tidal carbon
dioxide (ETCO2) monitoring is mandatory.
Polarographic oxygen analyzers are less
susceptible to electromechanical interference
and consume less power than paramagnetic
analyzers. However, these measure the partial
pressure of oxygen and derive the saturation
(SpO2). This has a special consideration for
aero-medical transfers as FiO2 is affected by
altitude. Therefore, either barometric pressure
compensation should be in-built, a correction
factor applied or a manual calibration may
be required with changing altitudes. While
ETCO2 monitoring is independent of altitude,
mainstream analyzers are preferred to sidestream ones; the former is heavy, while the
latter uses more power and is susceptible to
water condensation in the sampling tubes.19,21,24
Critical care patients often have multiple
drug infusions running. Infusions must be
rationalized before transferring patients by
either combining drugs or resorting to boluses
as required. Compact, lightweight syringe driver
type pumps can be utilized for low volume
infusions. It is particularly important that these
devices be compatible with all types of syringes.
Fluid pressure bags should be available to
maintain IV flow rates as only minimal elevation
of fluid bags is possible in most vehicles.17,25
An oxygen source with ample supply to
provide for projected needs plus a 30-min
reserve should be catered for. The amount of
oxygen in each cylinder should also be checked.
Failure in oxygen supply can have disastrous
consequences. In adults and children, a default
oxygen concentration of 100% generally is

used. However, oxygen concentration must be
precisely regulated for neonates and for those
patients with congenital heart disease who have
single ventricle physiology or are dependent on
a right-to-left shunt to maintain systemic blood
flow.2,5,15,22,23,25
Appropriately sized apparatus for each
patient for airway management which includes
laryngoscopes, masks, and endotracheal tubes
(ETT), has to be transported with each patient.
ETT position is noted and secured before
transport, and the adequacy of oxygenation and
ventilation is reconfirmed. For practical reasons,
bag-valve ventilation is most commonly
employed during short inter-hospital transfers.
Portable mechanical ventilators are more
appropriate gaining increasing popularity in
this arena, as they administer prescribed minute
ventilation and desired oxygen concentrations
more reliably. Ventilators must be small, light
and robust and economical on gas consumption
whilst being able to work independently of an
external power source. These must have alarms
to indicate disconnection and excessively high
airway pressures and must have a backup
battery power supply Volume preset ventilators
deliver less than set tidal volume (V T). Transport
ventilators are a compromise between
portability and features.1,3,14,15,23,25
For
AMT,
gas-driven
constant-flow
ventilators are less susceptible to altitude
changes but the V T and minute ventilation
may be affected. Increasing altitude can cause
an increase in V T in pneumatically controlled
ventilators, necessitating setting changes in
flight. Newer ventilators compensate for the
changes in gas density and viscosity in higher
altitudes. The extent of the other features
needed is determined by the level of care
required by the patient. Noninvasive ventilation
has a limited role in AMT as most systems
have extremely high gas consumption and are
impractical except for very short flights.24-26
It is important that all medical equipment
used for transfer replicate standards of a
hospital ICU while functioning in the transfer
environment without endangering patient or
vehicular safety. General characteristics of

equipment are given in Table 16.6.
In many hospitals, pediatric patients share
diagnostic and procedural facilities with
adult patients. Under these circumstances,
a complete set of pediatric resuscitation
equipment and medications will accompany
infants and children during transport and also
will be available in the diagnostic or procedure
area.
IEC 60601 Standards are accepted by the
Bureau of Indian Standards as the National
Standard with no National deviation for
supporting regulatory regulations and approvals.
As per these standards, aeromedical equipment
should pass the shock drop and topple tests,
operate correctly at 10,000 feet between
temperature ranges of 15 to +50C and at a
relative humidity of 95% and electro-magnetic
emissions should not interfere with flight deck
instruments. These tests are also required
to obtain the compulsory CE Conformit
Europenne/Communaut Europenne mark.
The drop test is for hand-held or hand-guided
devices and three samples are dropped from a
height of 1.22 m (4 feet) three times on a tilecovered concrete surface. The IEC 60601-1 drop
test is a modification in which only one sample
is dropped three times from a height of 1 m. The
ball-impact test is conducted on the top, sides
and front surfaces of the device under test with
an impact of 6.78N-m or 5 ft-lb.2,19, 22, 25,27
AEROMEDICAL CONSIDERATIONS
AMT is overwhelmingly dominated by few
issues, an increase in altitude and exposure to
forces of acceleration, noise, vibration (Table
TABLE 16.6
119
16.7). One also has to consider the effects of

low ambient pressure on critical equipment.
One has to remember that both the human
physiological processes and calibration of
all life support and monitoring equipment is
adapted for life at or near sea level and changes
in pressure with increasing altitude affect both.
An increase in altitude will result in a
reduction in partial pressure of oxygen in
accordance with Daltons law. Increasing
altitude will also increase gas volume or where
volume is restricted there will be a relative
increase in pressure in accordance with
Boyles law. The temperature also decreases by
approximately 2C for every 300 m of altitude
gained and the partial pressure of water also
falls reducing the humidity of the air. Whereas
hypoxia can be detected with pulse oximetry
and mitigated with supplemental oxygen and
positive end expiratory pressure (PEEP), the
consequences of gas expansion are difficult to
recognize and reverse aboard an aircraft.1,15,19,28
Gas expansion accounts for the majority
of contraindications to AMT. Contrary to
common belief, cabin pressurization does not
eliminate this concern. A change from sea level
to 8000 feet of altitude will expand the volume
of trapped gas (inside body cavities, or air in
splints or cuff of ETT by approximately 35%. In
vulnerable patients, this can provoke a tension
pneumothorax, dehiscence of surgical wounds,
intracranial hemorrhage and irreversible ocular
damage. Expansion of air in the cuff of ETTs at
altitude can provoke ischemic tracheal mucosal
necrosis and collapse of the cuff during descent
could cause a loss of V T as well as aspiration.
This problem can be circumvented by replacing
air with saline in the ETT cuff. Ventilators may
General characteristics of equipments used for interhospital transfer
R
uggedness
High reliability and validated
Sufficient internal power with additional capacity for unexpected delays. If battery life is limited, the batteries
should be replaceable with no interruption of the devices function
Should be capable of using multiple power supplies (vehicle supplies, invertors, external batteries)
The devices should be restrained appropriately with suitable lie-down systems, straps or clamps to override
vibrations or gravitational forces
Use of space-saving rucksacks
120
TABLE 16.7
Considerations in aeromedical evacuation
Environmental
conditions
H
ypoxia and its effects on hemodynamics (tachycardia and hypertension)
Swelling of limbs beneath plaster casts with resulting neurovascular compromise
Increased volume of air filled endotracheal tube cuffs and body cavities
(pneumothorax)
Nausea, vomiting because of motion sickness and/or abdominal distention with
possible aspiration in patients with impaired level of consciousness
In mechanically ventilated patients increased incidence of ventilator induced lung
injury and ventilator associated pneumonia following changes in the delivered tidal
volumes at low barometric pressures
Acceleration during take off and landing may cause blood pooling
Decreased humidity with altitude causes drying of mucous membranes, skin, eyes,
bronchopulmonary surfaces and leads to mucus plug formation in ventilated
patients
Vibration can cause loss of venous access, stress and fatigue on patient and staff,
fracture displacement, bleeding from wounds, effects on equipment, loosen
attachments
Noise causes crew and patient stress, interferes with vital signs and physical exam
Hypothermia-temperature drops with altitude, can aggravate acidosis and
coagulopathy
Third-space loss: Lower ambient pressure results in leakage of fluid from intra-vascular
to extravascular space results in edema, dehydration and hypovolemia
Problems in
monitoring
D
ifficulty in manual check of pulse rate and blood pressure due to noise/ vibration
Inaccurate reading of automatic noninvasive blood pressure (under reads systolic
and over reads diastolic)
Electromagnetic interference between aircraft avionics and electromedical
equipment, can result in equipment malfunction and can compromise flight safety
Difficulty in hearing audio alarms
Inaccurate delivery of tidal volume in mechanically ventilated patients
Miscellaneous
E xhaustion of oxygen and power supply

Difficulty in performing procedure (CPR, endotracheal intubation)
Disposal of patient body fluids and excreta
also deliver less than the set V T with ascent and

the reverse with descent leading to volutrauma
(see here) Therefore, V T delivered should be
checked with spirometer.2,8,19,22,23,26-29
Acceleration and deceleration is a vector
quantity, having both magnitude and direction.
For this reason, proper positioning of the
patient to limit stresses induced by sustained
acceleration should be accomplished. In a
supine patient, gravitational forces (G forces)
during acceleration as in take-off will act in
a horizontal axis and will result in pooling of
blood in the lower extremities if loaded head
first. Healthy humans will be able to mount a
compensatory sympathetic response. Patients
with labile hemodynamics and/or impaired
autonomic function could have a fall in cardiac
output and blood pressure. A patient with a

head injury could have raised intracranial
tension during take-off if positioned feet first.
The G forces will act in the opposite direction
while landing.21,22,26,28
The noise level in many of the currently
used transport aircraft including helicopters
approaches 90 dB which is approximately
2000 times louder than heart/breath sounds.30
The most basic of monitoring skills require
nothing more than a stethoscope and a
sphygmomanometer. In a flight environment,
noise significantly limits the ability of the
caregiver to use these simple tools to assess
blood pressure and heart/ breath sounds. Noise
also precludes appreciation of auditory alarms
of ventilators and monitors necessitating
continuous eye on the patient and equipment.

Noise and vibration apart from causing fatigue,
anxiety and contributing to motion sickness
and interfering with communication can
also seriously jeopardize monitoring of vital
parameters. Vibration can interfere with graphic
displays of ECG, pulse oximetry and curves and
loops of ventilatory parameters. Decreased
humidity causes respiratory secretions to dry up
resulting in atelectasis and blockage of tracheal
tubes.19,23,26
There are no absolute contraindications to
AMT; level of preparation has to match with
patient requirement. Relative contraindications
are listed in Table 16.8. Patient problems
during aeromedical evacuation generally defy
TABLE 16.8
Relative contraindications to
aeromedical evacuation
P
neumothorax, unless reduced by chest tube
with underwater seal drainage in place
Decompression sickness
Air embolism (arterial or venous)
Bowel obstruction from any source (commonly
postoperative)
Unreduced incarcerated hernia
Volvulus / Intussusception
Laparotomy or thoracotomy within previous 7
days
Eye surgery within previous 714 days
Gas gangrene
Hemorrhagic cerebrovascular accident within
previous 7 days
Severe uncorrected anemia (haemoglobin
< 7.0 g/dL)
Acute blood loss with hematocrit below 30%
Uncontrolled dysrhythmia
Irreversible myocardial infarction
Congestive heart failure with acute pulmonary
edema
Acute phase of chronic obstructive pulmonary
disease
Acute exacerbation of bronchial asthma
Acute psychosis
Spinal injury unless immobilized or traction in
place in Stryker frame
Pacemaker (must be prepared to adjust en route
with a magnet)
Beyond 34th week of pregnancy unless medically
necessary
121
resolution when patient preparation (Tables

16.9 and 16.10) has been inadequate.
LEGAL ISSUES1,16,30,31
Majority of the doctors were worried in
transporting the accident victims for fear of
the legal process. But in the strictest sense,
the law requires the accident victims to
be transported even by the non-medical
public and if not, it amounts to negligence.
(Negligence is the omission to do something
which a reasonable man would do, or do
something which a prudent and reasonable
man would not do. Alderson B in Blyth v
Birmingham Co (1856)11. Exch (781-784).
The transport could be accomplished with
medicos or even with paramedical people.
Even if the patient dies during transport, the
law just requires the matter to be informed to
the police personnel.
In Supreme Court criminal writ petition
no 270 of 1988 it is held that It is the duty
of the medical men to render all the help to
the patient which he could and also see that
the person reaches the proper expert as early
as possible. So it is the duty of the doctor
to render all possible help first and then
transfer the patient.
Before the initiation of any type of transport,
the patient or his/her legal representative
should be informed of the fact and an
explanation of the situation, reason for
transport, name of referral hospital should
be given and when necessary his/her
agreement. A summary of risks and benefits
may be given to the patient or his next-of-kin.
In writ petition no 796 of 1992 the Supreme
Court held that before transfer, three
obligations are imposed:
Screening the patient
Stabilizing the patients condition
Transfer or discharge of the patient for
better treatment.
Hospitals cannot transfer the patient unless
the transfer is appropriate. The patient
consents to transfer after being informed
of the risks of transfer and the referring
122
TABLE 16.9
Goals and checklist of patient preparation
Head injuries
Avoid intracranial hypertension

Position head end of patient towards nose end of aircraft to avoid accelerationinduced rise in intracranial pressure
Altitude restriction should be considered if raised intracranial pressure as low
partial pressure of oxygen can increase intracranial pressure.
Prevention of secondary brain injury by avoiding
Hypoxia (keep SpO2 > 9294%)
Shock (keep MAP > 70 mm Hg; CVP > 5 mm Hg)
PaCO2 around 3540 mm Hg in first 24 hours of flight)
Blood glucose <150 mg/dL
Serum osmolarity 280 and 320 mOsm
Serum sodium between 130 and 150 mEq/L
Avoid hypothermia, anemia, coagulopathy
Patients with a Glasgow Coma Scale 12 should be intubated and sedated with
continuous infusion of propofol before air evacuation
Antiepileptic medication should be administered
Fascio-maxillary
injuries
I f patient has wired jaws keep a wire cutters ready

In a patient with eye injuries, altitude restriction is recommended
Premedicate with antiemetics before boarding especially if prone to motion
sickness
Chest injuries
M
onitor chest lift and SpO2
Maintain adequate oxygenation and ventilation (FiO2 ~ 40% with tidal volumes
68 mL/kg)
Be prepared for needle thoracostomy and/or chest tube placement
Keep ICD open and functional throughout the flight
Tracheotomy tubes should be changed before flight and an extra tube should be
sent with the patient
Abdominal injuries
C
heck for occult and frank hemorrhage
Avoid hypothermia, acidosis, coagulopathy, sepsis
Monitor for abdominal compartment syndrome (urinary output, bladder pressures
and peak airway pressures)
Patients prone to paralytic ileus from any cause should have nasogastric tube in
place. Patient with colostomy, an extra colostomy bag should accompany these
patients as drainage is more profuse because of gas expansion
Neurological injuries
N
asogastric tube should be inserted in patient with quadriplegia, paraplegia and
left to gravity drain
Free swinging weights for traction are unacceptable for flight, cervical traction via a
Collins traction device should be applied
Orthopedic injuries
E nsure optimal stability of the fracture segments

Watch for hemorrhage
Monitor for fat embolism, compartment syndrome, neurovascular injuries,
rhabdomyolysis
Consider deep vein prophylaxis
Avoid use of pneumatic splints as during hypobaria in splint-pressure will increase
Hemorrhagic shock
E nsure minimum hemoglobin of 7.0 g/dL

Patients with shock are likely to have increased intravenous fluid requirements in
flight; so keep pressure bags rapid for rapid infusion
(Contd...)
123
(Contd...)
Burn injuries
Ensure escharotomies for full thickness circumferential burns before emplaning
Airway management
U
se saline for filling cuff of endotracheal / tracheostomy tube
Use tube fixator for better fixing of endotracheal tube
Give supplemental oxygen to maintain oxygen saturation(SpO2) > 90%
Cardiac Patients
E vacuation should be undertaken 10 days post MI or 5 days pain free period and
should receive supplemental oxygen en-route
General points
P
atient should be stable enough to tolerate a trip of 68 hours with a high
probability of not developing any complications en-route
Use of eye pads / ointment / artificial tears in unconscious patient
Ensure all drainage tubes are unclamped and left to gravity drain
TABLE 16.10 Sample preflight checklist

C
onfirm there are no contraindications to air
evacuation
Complete trauma survey
Perform chest radiography to rule out
pneumothorax
Perform radiography or CT of facial or skull
trauma
Check all medical equipment is present and
functioning
Check battery status of ventilator, monitors and
oxygen requirement including reserves
Secure all lines, tubes and drains
Remove or deflate air splints
Deflate air balloons, ETT cuff and fill with saline
Confirm ground ambulance for departure and
destination airfields
Carry all medical records, lab reports and imaging
reports
Liaison with the air-crew for:
Requirement of cabin altitude restriction
(CAR) if any, as per clinical condition of patient
Weather en-route
Time to diversionary airfields
Contingency plans, including diversion
options
physician certifies that the medical benefits

expected from the transfer outweigh the
risks. Appropriate transfers must meet the
following criteria:
The transferring hospital must provide
care and stabilization within its ability.
Copies of medical records and imaging
studies must accompany the patient.
The receiving facility must have available

space and qualified personnel and agree
to accept the transfer.
The inter-facility transport must be made
by qualified personnel with the necessary
equipment.
State Commission of Kerala No. 19 of 1990
and West Bengal No. 101/0/1997 held that
transfer in a car is not negligent if all possible
assistance were given to the patient while
transportation.
A receiving hospital cannot refuse to accept
the transfer of a patient who is unstable or
has an emergency medical condition if they
have the capability and ability to care for the
patient.
A standard documentation should be
developed across the network and be used
for both intrahospital and interhospital
transport. This should include a core data
set for audit purposed and CCT should able
to retain a duplicate for such purposes.
Document should include transfer details,
a medical summary, a nursing summary of
the patient during transfer and audit data
including reasons for transfer, urgency of
transfer, time taken from time of requesting
for the ambulance to completion, any
adverse events/critical incidents en-route.
Precise,
complete
and
detailed
documentation is essential not only for good
patient care but also adequate legal defense
if charges arise later. If documentation is
appropriate, the burden of establishing
124
negligence rests on plaintiff. To prove

negligence, the plaintiff has to prove both
a breach of duty on the part of the doctor
which resulted in damage to the patient.
However, if the documentation is
incomplete/lost, spoliation comes into
play. Spoliation means lost for a reason. In
this case, the plaintiff no longer required to
prove negligence. The onus of responsibility
rests on the defendant to prove that the
documentation was inadvertently lost and
not misplaced as a means of concealing his
true actions.
While recording the Accident Register,
utmost care has to be exercised, as it would
be the valid legal document in the court of
law. The conscious status of the patient is to
be mentioned in an undoubted way as the
court decides the reliability of the statement
only on that score. The person from whom
the history is elicited is to be very clearly
stated as the version from the person other
than the patient is a statement whereas from
the dying patient it is the Dying declaration.
As per the Dec 2013 Supreme Court (SLP
No(C) No.25237/2010) ruling, GTAs can use
red lights of the blinker type with a purple
glass. The ruling has upheld the use of multitoned horns as per rule 119(3) of the 1989
Motor Acts Rules though one should use the
siren only if the patient is instable.
In trauma cases, postmortem is Compulsory.
The state commission of Gujarat (No. 77
of 1993) held that It is the duty of the
medical officers to prove or rule out the
cause of death for which they are allegedly
responsible. Only avenue open to them
was postmortem. It is no valid excuse to
say that the relatives declined postmortem
or they signed their unwillingness.
In petition No. 84 of 1991 National
Commission observed, when the cause
of death is not in doubt there was no
occasion for the hospital authorities to
suggest autopsy.
It may be noted that according to Indian
Cultural beliefs and cremation practices, people
are sentimentally exposed to a dead body being

cut up. In fact generally autopsy is resisted.
In the US, there is a statute called Emergency
Medical Treatment and Active Labor Act
(EMTALA) which was enacted by introducing it
in 1986 into the Consolidated Omnibus Budget
Reconciliation Act, 1985 (COBRA). This Act is
also known as the Patient Anti-Dumping Act.
The basic principles include:
Hospitals have to provide a medical screening
examination for all patients seeking medical
attention in order to determine if a medical
emergency situation exists.
A patient may not be transferred to another
facility if they are at risk to deteriorate from
or during transfer with the caveat that Unless
the current hospital cannot meet the needs of
the patient.
The patient may not be transferred if he/she
is unstable and remain at risk of deterioration
unless the sending physician certifies in
writing that the benefits to be obtained at the
receiving hospital justify the risks of transfer.
The patient must be accepted by the
receiving hospital prior to transfer.
The receiving hospital must accept the
patient if it has the space and the skills
necessary to care for the patient.
The patient or a legally responsible person
must request the transfer after being advised
of the risks and benefits of transfer.
The sending hospital must provide whatever
treatment is within its capabilities to ensure
that the patient is stabilized prior to transfer.
CONCLUSION
Choice of aircraft or ground ambulance depends
upon patient care issues. The Commission on
Accreditation of Medical Transport Systems
(CAMTS), recently published Accreditation
Standards states that Any in-service aircraft/
ambulance can be configured in such a way
that the medical transport personnel can
provide patient care consistent with the mission
statement and scope of care of the Medical
Transport Service.
GTAs are generally used. Advancements

in the field of aviation (tilt-rotor aircraft)
and medical technology (user friendly,
sophisticated, miniature monitoring and life
support equipment, point of care testing)
can create an ICU in the sky which can offer
state-of-the-art critical care to critically-ill
patients right from the place of injury to tertiary
care centers. However these technological
advancements need to be backed with properly
trained medical teams who are well versed
with important aspects unique to aero-medical
evacuation including the effects of flight
physiology on medical conditions, oxygen
limitations, and distinctive medication and
equipment requirements.
REFERENCES
1. Ira J Blumen, Frank Thomas, David Williams.
Transportation of the critically ill patients. In:
Jesse B Hall, Gregory A Schmidt, Lawrence DH
Wood (Eds). Principles of critical care. 3rd edn.
McGraw-Hill Medical Publishing Division. 2005.
pp.79-91.
2. Papson JP, Russell KL, Taylor DM. Unexpected
events during the intrahospital transport
of critically ill patients. Acad Emerg Med.
2007;14(6):574-7.
3. Warren J, Fromm RE Jr, Orr RA, et al. Guidelines for
the inter- and intrahospital transport of critically
ill patients. Crit Care Med. 2004;32(1):256-62.
4. Koppenberg J, Taeger K. Interhospital transport:
transport of critically ill patients. Curr Opin
Anaesthesiol. 2002;15(2):211-5.
5. SIAARTI Study Group for Safety in Anesthesia
and Intensive Care. Recommendations on
the transport of critically ill patient. Minerva
Anestesiol. 2006;72(10):XXXVII-LVII.
6. Berlac PA, Wammen S, Giebner M, et al.
Ambulance transportation Guidelines. Ugeskr
Laeger. 2010;26;172(17):1300-3.
7. Sethi D, Subramanian S. When place and
time matter: How to conduct safe interhospital transfer of patients. Saudi J Anaesth.
2014;8(1):104-13.
8. Blakeman TC, Branson RD. Inter- and intrahospital transport of the critically ill. Respir Care.
2013;58(6):1008-23.
9. Rice DH, Kotti G, Beninati W. Clinical review:
critical care transport and austere critical care.
Crit Care. 2008;12(2):207-11.
125

10. Brub M, Bernard F, Marion H, et al.
Impact of a preventive programme on the
occurrence of incidents during the transport of
critically ill patients. Intensive Crit Care Nurs.
2013;29(1):9-19.
11. Droogh JM, Smit M, Hut J, et al. Inter-hospital
transport of critically ill patients; expect
surprises. Crit Care. 2012;16(1):R26.

12. Grisson TE, Farmer JC. The provision of
sophisticated critical care beyond the hospital.
Lessons from physiology and military
experiences that apply to civil disaster medical
response. Crit Care Med. 2005;33:S13-S21.
13. Kupas DF, Wang HE. Critical care paramedics
-a missing component for safe interfacility
transport in the United States. Ann Emerg Med.
2014;64(1):17-8.
14. US. Federal Aviation Administration-H-8083-25.
The Pilots Handbook of Aeronautical
Knowledge CFR Part 91 Sec. 91.103 - Preflight
Action page 16-6.
15. Ramnarayan P. Measuring the performance of an
inter-hospital transport service. Arch Dis Child.
2009;94(6):414-6.
16. Pontecorvo C, Minerva M, Vitali F, et al. Interhospital transport of the critical patient. Minerva
Anestesiol. 1991;57(12):1819-20.
17. Kumari S, Kumar S. Patient safety and prevention
of unexpected events occurring during the intrahospital transport of critically ill ICU patients.
Indian J Crit Care Med. 2014;18(9):636.

18. Grisson TE, Farmer JC. The provision of
sophisticated critical care beyond the hospital.
Lessons from physiology and military
experiences that apply to civil disaster medical
response. Crit Care Med. 2005;33:S13-S21.

19. Milligan JE, Jones N, Helm DR. et al. The
principles of aeromedical retrieval of the
critically ill. Trends in Anaesthesia and Critical
Care. 2011;1:22-6.
20. Calland V. Extrication of the seriously injured
road crash victim. Emerg Med J. 2005;22:817-21.
21. Thomas SH, Brown KM, Oliver ZJ, et al. An
Evidence-based Guideline for the air medical
transportation of prehospital trauma patients.
Prehosp Emerg Care. 2014;18 (Suppl 1):35-44.
22. Liu X, Liu Y, Zhang L, et al. Mass aeromedical
evacuation of patients in an emergency:
experience following the 2010 Yushu earthquake.
J Emerg Med. 2013;45(6):865-71.

23. Cornelius M. Care in the air: bringing the
wounded closer to home. Plast Surg Nurs.
2009;29(3):165-8.
126
24. Helm M, Schuster R, Hauke J, et al. Tight control of

prehospital ventilation by capnography in major
trauma victims. Br J Anaesth. 2003;90(3):327-32.

25. McGuire NM. Monitoring in the field. Br J
Anaesth. 2006;97(1):46-56.
26. Blakeman T, Britton T, Rodriquez D Jr, et al.
Performance of portable ventilators at altitude.
J Trauma Acute Care Surg. 2014;77 (3 Suppl
2):S151-5.
27. Stevenson A, Fiddler C, Craig M, et al. Emergency
department organization of critical care transfers
in the UK. Emerg Med J. 2005;22(11):795-8.
28. Gaazkowski R. New possibilities in emergency
medical transportation and emergency services
of Polish Medical Air Rescue. Anestezjol Intens

Ter. 2010;42(3):174-8.

29. Lubillo S, Burillo-Putze G, Alonso E, et al.
Helicopter emergency medical service in Canary
Islands, Spain. Eur J Emerg Med. 2000;7(1):55-9.

30. Meenakshi Sundaram AL, HonJustice S
Nagamuthu. Medico Legal Aspects in Trauma
Anesthesia. Ind J Trauma. Anaesth Crit Care.
2007; 8 (2): 627-31.

31. Law Commission of India 201st Report on
Medical Treatment after Accidents and During
Emergency Medical Condition and Women in
Labour.; F.No. 6(3)125/2006-LC(LS) 31st August,
2006.
CHAPTER
17
Practice Guidelines for

Management of the Difficult Airway
SK Malhotra
The guidelines for difficult airway management

are recommendations that can be changed
and altered as per the resources and clinical
requirement of an institute. Guidelines may not
take place of a hospital protocol and therefore
should not be called absolute standards that
can bring definite results. From time to time,
the guidelines undergo amendments as the
medical skills and know-how develops. The
suggestions given in guidelines are based on
existing literature and data which has clinical
practicability and skill in the field. Task Force
on Difficult Airway Management has given the
guidelines that have been accepted by ASA.
Definitions
An ideal definition to describe difficult airway is
not there in the scientific literature. However, it
can be defined as a clinical situation in which
a conventionally trained anesthesiologist
experiences difficulty with facemask ventilation
of the upper airway, difficulty with tracheal
intubation, or both.1 Various factors affecting
this situation are condition of the patient,
resources available and experience of the
anesthesiologist. The Task Force recommends
that anesthesiologists should employ clear
descriptions of the difficult airway. Some of the
descriptions advocated are as follows:
When it is difficult to ventilate using

facemask or supraglottic device. It may
be due to leak or resistance in the circuit
and may be detected as inadequate chest
inflation, decreased breath sounds, signs of
obstruction, desaturation as well as features
due to hypoxia or hypercarbia such as
rhythm disturbances.
There is problem in insertion of supraglottic
device owing to anatomical abnormality.
Routine laryngoscopy does not allow
visualization of larynx, partially or completely
in spite of several attempts.
Difficulty in intubation of trachea due to
anatomical or pathological causes.
Not possible to intubate trachea at all,
despite numerous attempts.
Goal of the airway guidelines is to accomplish
the security of airway and to decrease the
complications such as trauma to teeth and
airway, need for surgery to achieve airway,
cerebral hypoxia and even cardiac or respiratory
arrest. The major aim of guidelines is to secure
airway during anesthesia under the control of
an anesthesiologist at different locations and in
all age groups.
The guidelines were first prepared in 2002 by
Task Force comprising of ten anesthesiologists
appointed by ASA. They reviewed and evaluated
the difficult airway literature from indexed
128
journals. From all the material, a consensus

was made and guidelines finalized. In 2011, the
guidelines were evaluated again after reviewing
the literature and various recommendations
were made.
Assessment of Airway
The past medical records and history must be
evaluated for a difficult airway before taking the
patient for anesthesia. This helps in identifying
anesthetic and medical aspects that may
influence the airway. Various factors affecting
airway management include age, obesity,
obstructive sleep apnea, history of difficult
laryngoscopy or intubation.2,3
A thorough physical examination may help
in detecting anatomical abnormalities in the
upper airway.4-6 Various features to assess
airway are recognized (Table 17.1).
Preparation of Airway Management

The availability of difficult airway devices in
the form of Airway management cart must
be assured. The patient with difficult airway
should be explained beforehand about the
risks and complications involved. An assistant
should be ready in case difficult airway has to
be handled. The role of preoxygenation is vital
to buy precious time as well as supplementing
TABLE 17.1
oxygen throughout the procedure to avoid

hypoxia.7 The facemask, nasal cannulae,
supraglottic device or simple insufflation
may be employed for this purpose. The
pediatric patients may not cooperate during
preoxygenation.
The presence of Difficult airway
management cart is of great value and should
contain the essential items (Table 17.2).
Plan for Difficult Airway Intubation

The strategy to manage difficult airway
may be guided by ASA algorithm for airway
management (Fig. 17.1). The plan depends on
the kind of surgery, patients condition and the
choice of anesthetist.
Following points must be considered to plan
a difficult airway:
Patients consent is vital and so is his will to
cooperate. One may find it hard to ventilate
by mask. The insertion of supraglottic device
may be difficult. Successful laryngoscopy
and intubation as well as surgical airway may
be difficult.
Anesthesiologist should consider various
choices, such as, (a) consideration of GA
versus awake technique for intubation.8,9
(b) Percutaneous or surgical access
for
airway.
(c)
Intubation
while
maintaining spontaneous ventilation.
(d) Use of videolaryngoscope as primary
approach.10,11
Features of airway assessment
1.
Any protruding teeth
2.
Mouth opening ( < 3 cm)
3.
Uvulaits visibility (Mallampati class > 2)
4.
Length/thickness of neck
5.
Thyromental distance ( < 6 cm)
6.
TABLE 17.2
Difficult airway management cart
1.
Various kinds and sizes of laryngoscopic blades
2.
Tracheal tubes-appropriate size
3.
Fiberoptic bronchoscope
Neck extension/flexion
4.
Videolaryngoscope
7.
Jaw protrusion (Relationship of maxillary and

mandibular incisors)
5.
Stylets, light wands
6.
Bougie, tube changer
8.
Upper lip biting test
7.
Supraglottic devices (LMA/Intubating LMA)
9.
Shape of palate (high arched palate)
8.
Devices to secure emergency surgical airway
Practice Guidelines for Management of the Difficult Airway
Figure 17.1 Difficult Airway Algorithm (Courtesy: American Society of Anesthesiologists).
129
130
Assess whether the patient can be ventilated

or there is a critical cannot ventilate, cannot
intubate situation.12
In case initial approach to ventilate is not

successful, some alternative plans may be
considered. Among these, awake intubation
is commonly considered. Other approaches
may be blind intubation,15 use of bougie/
light wand,16 changing laryngoscope blade,
videolaryngoscope or fiberoptic intubation.17
Documentation
should
include
the
following:
The details of the difficulties faced during
mask ventilation as well as intubation.
The mention of various devices and
techniques used to secure airway.
The role and advantages of the devices used
in the process.
The patient should be apprised of the airway
difficulty involved and how the intubation
was secured. This would help in appropriate
management in future. A detailed report about
airway management must be written in the
patient record. The concerned surgeon or
caregiver should also be informed. The aftercare
of the expected complications following difficult
airway is a must, such as, laryngeal edema,20
damage to trachea, pulmonary aspiration21
and pneumothorax.22 If any features of these
complications appear, like pain in the throat,
swelling or tenderness of the face and neck,
problem in swallowing or pain in the chest must
be communicated immediately.
Plan for Extubation
Key Points
There should be an appropriate plan for

extubation keeping in mind the kind of surgery
and clinical aspects of the patient.18
The effect of extubation on ventilation must
be considered.
A strategy should be thought regarding steps
to be taken if patient cannot maintain proper
ventilation after extubation.
Stylet may be left in the trachea that would
help in case reintubation is required.
Similarly, LMA or intubating LMA may be left
in place to ensure satisfactory re-intubation.
Always carry out a thorough and detailed

airway assessment during preanesthesia
check-up.
If indicated by evaluation, anticipate the
probability of encountering a difficult airway.
If severe difficulty expected, try to secure
airway using awake technique.
In case the initial plan fails, have backup
plan(s) to secure the airway successfully.
Alternative Approaches for

Difficult Ventilation
If ventilation with facemask fails, other devices
that may be employed are, supraglottic airway,
oral/nasal airway, rigid bronchoscope, two
person ventilation with mask or transtracheal
invasive ventilation.13,14
Alternative Approaches for

Difficult Intubation
Postoperative Care and

Documentation
A proper documentation should be made
about the difficulties encountered in securing
airway.19 This will help in undertaking proper
management in the future.
REFERENCES
1. Apfelbaum JL, Hagberg CA, Caplan RA, et al.
Practice guidelines for management of the
difficult airway: An updated report by the
American Society of Anesthesiologists Task
Force on Management of the Difficult Airway.
2. Ezri T, Medalion B, Weisenberg M, et al. Increased
body mass index per se is not a predictor of
difficult laryngoscopy. Can J Anaesth. 2003;
50:179-83.
Practice Guidelines for Management of the Difficult Airway

3. Heinrich S, Birkholz T, Ihmsen H, et al. Incidence
and predictors of difficult laryngoscopy in
11,219 pediatric anesthesia procedures. Paediatr
Anaesth. 2012; 22:729-36.
4. Rose DK, Cohen MM. The airway: Problems and
predictions in 18,500 patients. Can J Anaesth.
1994;41(5 Pt 1):372-83.
5. Tremblay MH, Williams S, Robitaille A, et al.
Poor visualization during direct laryngoscopy
and high upper lip bite test score are predictors
of difficult intubation with the GlideScope
videolaryngoscope. Anesth Analg. 2008;
106:1495-500.
6. Wilson ME, Spiegelhalter D, Robertson JA, et
al. Predicting difficult intubation. Br J Anaesth.
1988;61:211-6.
7. Xue FS, Tong SY, Wang XL, et al. Study of the
optimal duration of preoxygenation in children.
J Clin Anesth. 1995;7:93-6.
8. Dimitriou VK, Zogogiannis ID, Liotiri DG.
Awake tracheal intubation using the Airtraq
laryngoscope: A case series. Acta Anaesthesiol
Scand. 2009;53:964-7.
9. Suzuki A, Toyama Y, Iwasaki H, et al. Airtraq for
awake tracheal intubation. Anaesthesia. 2007;
62:746-7.
10. Koh JC, Lee JS, Lee YW, et al. Comparison of the
laryngeal view during intubation using Airtraq
and Macintosh laryngoscopes in patients with
cervical spine immobilization and mouth opening
limitation. Korean J Anesthesiol. 2010; 59:314-8.
11. Aziz MF, Healy D, Kheterpal S, et al. Routine
clinical practice effectiveness of the Glidescope
in difficult airway management: An analysis of
2,004 Glidescope intubations, complications, and
failures from two institutions. Anesthesiology.
2011;114:34-41.
131
12. Das B, Nasreen F, Haleem S, et al. A cannot

ventilate, cannot intubate situation in a patient
posted for emergency surgery for acute intestinal
obstruction. Anesth Essays Res. 2013;7:140-1.
13. Cook T, Howes B. Supraglottic airway devices:
recent advances Contin Educ Anaesth Crit Care
Pain. 2011;11(2):56-61.
14. Davidovic L, LaCovey D, Pitetti RD. Comparison
of 1- versus 2-person bag-valve-mask techniques
for manikin ventilation of infants and children.
Ann Emerg Med. 2005;46(1):37-42.
15. Holzapfel L. Nasal vs oral intubation. Minerva
Anesthesiol. 2003;69(5):348-52.
16. Kim JH, Kim KW, Park J, et al. Use of light wand
as an adjunct during intubation of patient with
large epiglottic cyst. Korean J Anesthesiol.
2013;65(6 Suppl):S21-2.
17. Collins SR, Blank RS. Fiberoptic intubation:
an overview and update. Respir Care. 2014;
59(6):865-78.
18. Cavallone LF, Vannucci A. Extubation of the
difficult airway and extubation failure. Anesth
Analg. 2013;116(2):368-83.
19. Haigh FP, Swinton FW, Dalgleish DJ.
Documentation and communication of the
difficult airway. Anaesthesia 2006;61(8):817.
20. Divatia J, Bhowmick KV. Complications of
endotracheal intubation and other airway
management procedures. Indian J Anaesth.
2005;49(4):308-18.
21. Cook TM, MacDougall-Davis SR. Complications
and failure of airway management. Br J Anaesth
2012;109:(suppl 1): i68-i85.
22. Rashid AM, Williams C, Noble J, et al.
Pneumothorax,
an
underappreciated
complication with an airway exchange catheter.
J Thorac Dis. 2012; 4(6):659-68.
CHAPTER
18
Practice Guidelines in
Obstetric Anesthesia
Sunanda Gupta, Seema Partani
These guidelines are recommendations to

enhance the quality of obstetric anesthesia,
reduce the incidence and severity of
complications and help in the provision of
safe and adequate anesthesia. These are not
standard or absolute requirements but can be
modified according to local or individual needs
and constraints.
Preanesthetic Requirements
History and Physical Examination
The antepartum screening in all high-risk
parturients referred for anesthesia consultation
should include a complete maternal medical,
obstetric and anesthetic history, baseline vitals,
height and weight, head and neck, airway,
heart, lung and back examination along with
categorization into ASA physical status (I-V).
Recognition of any anesthetic or obstetric risk
factors should encourage a communication
between the anesthesiologist, obstetrician and/
or members of the multidisciplinary team.
Laboratory Investigations
For a normal healthy parturient undergoing
cesarean section (CS) or postpartum tubal
ligation (PPTL), a hematocrit and Complete
Blood Count will suffice. A routine platelet
count is not necessary in the healthy parturient.

It should be individualized and based on a
patients history, physical examination and
clinical signs. Similarly a blood type and
screen or cross match should only be done, on
anticipation of hemorrhagic complications.
Specific investigations like recent blood glucose
in diabetics on insulin, recent CBC in sickle cell
disease, platelets, PT, PTT, fibrinogen in HELLP
and Intrauterine fetal demise of unknown
etiology will be required.
Perianesthetic Recording of
Fetal Heart Rate
Fetal heart rate should be monitored before
and after initiation of neuraxial analgesia
for labor. There is no need of continuous
electronic monitoring of fetal heart rate in the
perianesthetic period.
Informed Consent
It should be taken by the anesthesiologist before
any procedure according to the hospital or
institution protocol.
Ideal Requirements
Obstetric operating theaters, both in the
delivery suite and main operation theaters
Practice Guidelines in Obstetric Anesthesia
should have comparable basic monitoring

facilities which include ECG, noninvasive blood
pressure, pulse oximeter and ETCO2 monitor
along with support personnel. Resources for the
treatment of potential complications (e.g., failed
intubation, inadequate analgesia, hypotension,
respiratory depression, pruritus, vomiting)
should be available in the operating suites.
Recovery room should have monitoring for
noninvasive blood pressure, ECG and oxygen
saturation. A high dependency unit should be
available for high-risk parturients in the vicinity
of the obstetric unit along with access to the ICU
if need arises.
Aspiration prophylaxis
Oral intake of clear liquids, in small quantities,
like water, fruit juices without pulp, carbonated
beverages, clear tea and black coffee, should be
encouraged in normal parturients, up to 2 hours
before induction of anesthesia, as it increases
maternal satisfaction. However, oral intake
should be further restricted on an individual
basis, in patients who are at risk of aspiration
(morbidly obese, diabetes, difficult airway)
or who are at risk for cesarean delivery due to
nonreassuring fetal heart rate pattern. A fasting
period for solids (especially fatty food) of 6 to 8
hours should be followed in all patients posted
for elective surgery (CS-Cesarean section or
PPTL-postpartum tubal ligation). Solid food
should be avoided during labor. Non-particulate
antacids, H2 receptor antagonists and/or
Metoclopramide should be given timely before
anesthetic induction in elective surgery.
Guidelines for regional

anesthesia in Obstetrics
Absolute Contraindication for
Regional Anesthesia
Uncorrected maternal hypovolemia
Documented coagulopathy (PT>1.5 times
normal)
Sepsis at local site
Patient refusal or inability to cooperate.
133
For Labor Epidural

Every parturient does not require anesthetic
care during pain relief for labor and delivery.
There are many options, with neuraxial
analgesia as one of the available techniques. If
there is adequate trained staff and resources,
neuraxial analgesia should be offered based
on the anesthetic and obstetric risk factors,
patient preferences and progress of labor. All
these patients should have a patent intravenous
line, along with resources to treat complications
like hypotension, systemic toxicity, high spinal
and opioid related side effects like respiratory
depression, pruritus, nausea, etc. No preloading
with fluids is required before initiation of
neuraxial analgesia. Basic monitoring facilities
should include ECG, noninvasive blood
pressure monitoring, heart rate and oxygen
saturation.
Neuraxial analgesia should not be withheld
till an arbitrary cervical dilatation is achieved.
Early initiation of neuraxial analgesia does not
affect the maternal or neonatal outcome, nor
does it increase the incidence of CS. In patients,
attempting vaginal birth after a previous CS, an
early epidural catheter placement can be used
for labor analgesia or for subsequent operative
delivery. Similarly in the high-risk parturient,
an early placement of the catheter (even before
labor starts) can help in avoiding GA in an
emergency.
Regional analgesia should only be initiated
and maintained in locations where appropriate
resuscitation equipment and drugs are
immediately available. Informed consent
should be obtained and documented in the
medical record. Intravenous access must be
established before initiating regional analgesia.
The intravenous access should be maintained
as long as regional analgesia is administered.
The anesthesiologist should be immediately
available until analgesia is established and the
patients vital signs are stable.
Single Injection Spinal Opioids with or

without Local Anesthetics
Single spinal injection of opioids with or
without local anesthetics may be used to
134
provide effective, although time-limited

analgesia for spontaneous vaginal delivery. If
labor is expected to last longer or if operative
delivery is expected then a catheter technique
instead of a single shot technique should be
used. To improve the quality and duration of
analgesia, local anesthetics should be added
to the intrathecal opioids. The single injection
spinal technique for labor analgesia are more
advantageous in cases where rapid onset of
analgesia is required, e.g. in advanced labor.
Continuous Infusion Epidural Analgesia

Opioids when added to local anesthetics in
CIE has the added advantage of reducing the
dose of local anesthetics, improve the quality of
analgesia and minimize motor block. Adequate
analgesia for labor should aim at producing
minimal motor block with lowest possible
concentration of local anesthetics which
provides adequate analgesia as well as maternal
satisfaction. In most patients a dilution of
0.125% of local anesthetics is adequate to
provide analgesia.
Patientcontrolled Epidural Analgesia

For maintenance of epidural analgesia, PCEA
provides a flexible and effective approach.
Comparison with fixed-rate CIE has proved
that PCEA with a background infusion, requires
fewer doses of local anesthetics, improves
analgesia and also reduces frequency of
anesthetist interventions.
Combined Spinal Epidural Analgesia

Combined Spinal Epidural (CSE) with local
anesthetics and opioids provides effective and
rapid analgesia as compared to epidural local
anesthetics and opioids, with better patient
satisfaction.
Anesthesia for
Cesarean delivery
Various techniques are available to provide
anesthesia for operative delivery, which
includes epidural, spinal combined spinal

epidural and general anesthesia. Choice of
technique depends on anesthetic, obstetric or
fetal risk factors (e.g., elective vs emergency),
the preferences of the patient, and judgment
of anesthesiologist. Neuraxial anesthesia is
the preferred technique for operative delivery
in majority of the cases. Onset of anesthesia
through an indwelling epidural catheter or
initiation of spinal anesthesia, are considered
equivalent, for urgent caesarean delivery.
General anesthesia may be an ideal choice
in specific situations like profound fetal
bradycardia, ruptured uterus, massive obstetric
hemorrhage with hemodynamic disturbances,
or severe placental abruption. Irrespective of
the anesthetic technique used, a left uterine
displacement should be maintained until the
delivery of the fetus.
Type of Spinal Needles

To minimize the risk of postdural puncture
headache the pencil point needles should
be used rather than the cutting bevel spinal
needles.
Intravenous Fluid Preloading

It may be used to reduce the incidence of
hypotension following spinal anesthesia for
caesarean delivery. However, initiation of spinal
anesthesia should not be delayed to infuse a
fixed volume of fluids.
Requirement of Vasopressors
Intravenous ephedrine and phenylephrine
are both acceptable drugs to treat maternal
hypotension. In the absence of maternal
bradycardia, phenylephrine may be preferable
as it improves fetal acid-base status in
uncomplicated pregnancies.
For Postoperative Analgesia

For postoperative analgesia, after neuraxial
anesthesia following cesarean delivery,
neuraxial opioids are a preferred choice
as compared to parentral opioids as they

improve analgesia and maternal satisfaction.
Nonsteroidal anti-inflammatory drugs like
Dicofenac and analgesics like Paracetamol can
be used per rectal/IV/oral in the postoperative
period, if there are no known contraindications.
Removal of Retained Placenta

Anesthetic Technique
There is no preferred technique for the removal
of retained placenta. If there is an existing
epidural catheter in place and the patient
is hemodynamically stable then epidural
anesthesia is preferable. If the patient is not
hemodynamically stable and if there is major
maternal hemorrhage, then general anesthesia
with endotracheal tube should be the preferred
option as compared to regional anesthesia.
Before initiating neuraxial or general anesthesia,
hemodynamic status should be assessed and
aspiration prophylaxis should be initiated.
Uterine Relaxation
General
endotracheal
anesthesia
with
halogenated agents or terbutaline sulfate or
Nitroglycerine can be used for uterine relaxation
during removal of the retained placental tissue.
Nitroglycerine can be used as incremental doses
intravenously or as a metered dose sublingually,
which relaxes the uterus sufficiently to remove
the placental pieces, with less complications
like hypotension.
Postpartum Tubal Ligation

For Post partum tubal ligation (PPTL), fasting
guidelines and aspiration prophylaxis should
be strictly adhered to as for caesarean delivery.
Anesthesiologists should be aware that gastric
emptying will be delayed in patients receiving
opioids during labor, and that epidural
catheters are more likely to fail with longer
postdelivery time intervals. The choice of
anesthetic technique should preferably be
neuraxial anesthesia. However, decision for
neuraxial vs general anesthesia should be based
135
on patient preferences, anesthetic and obstetric

risk factors.
Management of Obstetric and

Anesthetic emergencies
Resources for Management of
Hemorrhagic Emergencies
All resources required for management of
massive obstetric hemorrhage like: equipment
for rapid blood and fluid infusion, fluid warmer,
warming blanket or forced air warmer and
large bore iv catheter should be available.
Blood should be sent for blood grouping/
cross matching, complete blood count and
coagulation studies. In an emergency, type
specific or group O RhD negative blood can
be administered. A minimum of 6 whole units
of blood should be ordered. Once surgical
hemostasis is achieved, continued oozing
should be managed with blood products. In
cases where banked blood is not available, or
the patient refuses banked blood, intraoperative
cell salvage should be considered. A pressure
bag system for rapid fluid infusion is mandatory
as also a high flow warming blanket to keep the
patient warm and reduce coagulation problems.
Consider early use of CVP monitoring and
direct arterial pressure monitoring. Decision to
transfer to a high dependency unit or intensive
care unit, should be taken according to the
criticality of the patient.
Central Invasive Hemodynamic

Monitoring
The decision to perform invasive monitoring
should be individualized as per the patients
clinical condition and cardiovascular risk
factors.
For Management of
Airway Emergencies
All obstetric units should have trained
personnel and basic airway management
equipment available in the labor and delivery
units. In the operation theaters and labor
136
TABLE 18.1
Difficult airway management equipment
Basic intubation equipmentBasic airway equipment should be readily available at each anesthesia machine
or cart and includes:
Masks (varying sizes)
Oral airways (710 cm) +/- nasal airways
Laryngoscopes straight and curved blades (#3, 4), regular and short handles +/- McCoy blade
Tracheal tubes (varying sizes)
Stylets
Gum elastic bougie
Lubricating jelly
Magill forceps
Laryngeal mask airway (LMA) appropriate size
Standard monitoring equipment (ECG, noninvasive blood pressure, carbon dioxide [CO2] analyzer, oxygen [O2]
monitor, pulse oximeter)
Suction device
Self-inflating Ambu bag and mask for positive-pressure ventilation
Medications for blood pressure support, muscle relaxation and hypnosis
TABLE 18.2
Difficult intubation equipment
Equipment for difficult intubation is specialized and should be kept in one location and checked regularly:
Flexible fiberoptic bronchoscope
Videolaryngoscope (e.g. Glidescope, C-Mac)
At least one device suitable for emergency nonsurgical airway ventilation, including but not limited to:
lightwand, jet ventilator, Combitube, Intubating LMA, ProSeal LMA (PLMA)
Jet ventilation apparatus
Cricothyrotomy kit
Retrograde intubation equipment
Ventilating tube exchangers
Topical anesthetics and vasoconstrictors
wards, the basic intubation kit (Table 18.1)

along with specific difficult airway equipment
(Table 18.2) should be available as a portable
unit, which should be accessible to both the
labor and delivery areas as well as the operation
theater. All units should have indigenously
developed protocols for stepwise management
of the difficult airway in parturients. When
tracheal intubation fails, ventilation should be
maintained with a mask and cricoid pressure,
an LMA or supraglottic device like Combitube,
intubating LMA (fastrach) should be considered
till delivery of the fetus, rather than repeatedly
trying to intubate the patient. If ventilation is
not possible, then a surgical airway should be
created.
Cardiopulmonary
Resuscitation in
obstetric patients
Basic and advanced life support equipment
should be available in the delivery as well as
operative areas. In the event of a cardiac arrest
during pregnancy, a left uterine displacement
should be ensured, apart from other standard
resuscitative measures, since patient position
is the most important factor in enhancing the
quality of CPR. This can be achieved initially
by manual left uterine displacement in the
supine position using either two-handed or
one-handed technique from the patients
right side or left side respectively. If a wedge
is available, then a left lateral tilt of 27 to 30

degrees, can be given, using a firm wedge
to support the pelvis. If resuscitation fails to
produce an effective cardiac output, a timely
decision for operative delivery should be taken
within 4 minutes to save the mother and fetus.
Bibliography
1. Blood transfusion and the anaesthetist. Manage
ment of massive haemorrhage. London: AAGBI,
2010.
137
2. Guidelines to the Practice of anesthesia. Revised

edition 2013. Can J Anesth. 2013;60(1):60-84.
3. Nice Clinical Guidelines 132. Caesarean Section
2011. http://www.guidance.nice.org.uk.

4.
Obstetric anaesthesia services. Obstetric
Anaesthesia Association UK 2012.
5. Practice Guidelines for Obstetric anaesthesia: An
updated report by the ASA task force on obstetric
anaesthesia. Anesthesiology. 2007;106:843-63.
www.anesthesiology.org
6. Sabai BM. Acute Management of Obstetric
Emergencies. Pub. Elsevier Health Sciences.
2011.
CHAPTER
19
Checking Anesthesia Equipment

Susheela Taxak
Introduction
The anesthetist has a primary responsibility
to understand the function of the anesthetic
equipment and to check it prior to use.
Anesthetist must not use equipment unless they
have been trained to use it and are competent to
do so. Failure to check the anesthesia equipment
is a major contributor in many anesthetic
misadventures. These guidelines are framed so
as to assist practitioners and health facilities to
minimize equipment-related risks.
Principles
Responsibilities: Each facility is required to
designate an individual to be responsible
for servicing and maintaining equipment
and ensuring that relevant personnel
are trained in the checking and use of
anesthesia equipment.
Servicing of anesthesia equipment
should be performed regularly, at
specified intervals in accordance with
the manufacturers documented service
requirements and recorded in detail.
Confirmation that a secondary means
of oxygenation and positive pressure
ventilation is immediately available.
Anesthesia Delivery
System Checks
The following checks should be carried out
at the beginning of each operating theater
session. In addition, specific checks should be
carried out before each new patient during a
session or when there is alteration or addition
to the breathing system, monitoring or
ancillary equipment. It is the responsibility of
an anesthetist to make sure that a these checks
have been performed and have been carried
out correctly. It is essential that anesthetists
have full training and formal induction for any
machines they may use.
Section A:
Checks self-inflating bag and
presence of alternate oxygen supply source:
Verify auxiliary oxygen cylinder and
self-inflating manual ventilation device are
available and functioninga safety measure
often overlooked. Because equipment failure
with resulting inability to ventilate the patient
can occur at any time, a self-inflating manual
ventilation device (e.g. Ambu bag) should be
present at every anesthetizing location for every
case and should be checked for proper function.
In addition, a source of oxygen separate from
the anesthesia machine and pipeline supply,
specifically an oxygen cylinder with regulator
and a means to open the cylinder valve, should
be immediately available and checked. The

early use of alternative means of ventilation may
be life saving.
Section B:
perform the manufacturers
machine check:
Power supply: Turn on anesthesia delivery
system and confirm that AC power and
back-up battery power is available. Visual
indicators of the power source showing
the presence of both AC and battery power
should be checked and connection of
the power cord to a functional AC power
source should be confirmed. Verify that
anesthetic machine is directly connected
to the mains electrical supply. Multisocket
extensions leads must not be plugged into
the anesthetic machine outlets or used
to connect the anesthetic machine to the
mains supply. Electrical power supply
for desflurane vaporizers should also be
checked. Switch on the gas supply master
switch (if one is available).
Gas supply: Anesthesia delivery systems rely
on a supply of oxygen for various machine
functions. At a minimum, the oxygen supply
is used to provide oxygen to the patient.
Pneumatically-powered ventilators also
rely on a gas supply. Identify and take note
of the gases that are being supplied by
pipeline, confirming with a tug test that
each pipeline is correctly inserted into the
appropriate gas supply terminal. Check
that anesthetic apparatus is connected to a
supply of oxygen and adequate supplies of
other gases intended for use are available.
Verify that all pressure gauges for pipelines
connected to the anesthetic machine
indicate 400 to 500 kPa.
Verify that cylinders mounted on
machine are filled and have acceptable
minimum pressure. Typically, an oxygen
cylinder will be used if the central oxygen
supply fails. If the cylinder is intended to be
the primary source of oxygen (e.g. remote
site anesthesia), then a cylinder supply
sufficient to last for the entire anesthetic
is required. The oxygen cylinder valve
139
should be closed after it has been verified

that adequate pressure is present, unless
the cylinder is to be the primary source of
oxygen (i.e. piped oxygen is not available).
Other gas supply cylinders (e.g. air, N2O)
need to be checked only if that gas is
required to provide anesthetic care.
Check the operation of flowmeters,
where these are present, ensuring that each
control valve operates smoothly and bobbin
moves freely throughout its range without
sticking. Confirm anti-hypoxia device is
working by turning on the nitrous oxide flow
and ensuring that 25% oxygen also flows and
on turning off oxygen flow, nitrous oxide flow
also stops. Operate the emergency oxygen
bypass control and ensure that flow occurs
from the gas outlet without significant
decrease in the pipeline supply pressure.
Ensure that the emergency oxygen bypass
control ceases to operate when released.
Turn on oxygen flow and check that oxygen
analyzer display approaches 100%. Turn off
all flow control valves.
Oxygen monitor: Calibrate, or verify
calibration of, the oxygen monitor and check
the low oxygen alarm. The oxygen monitor
is essential for detecting adulteration of
the oxygen supply. Most oxygen monitors
require calibration once daily, although
some are self-calibrating. For selfcalibrating oxygen monitors, they should be
verified to read 21% when sampling room
air. The low oxygen concentration alarm
should also be checked.
Suction: Safe anesthetic care requires the
immediate availability of suction to clear
the airway if needed. Verify availability of
high vacuum tracheal suction with backup
means of suction.
Breathing system: Verify the whole system
is patent and there is no leak between
common gas outlet (CGO) and flowmeter
by performing two bag test. The breathing
system pressure and leak test should
be performed with the correct circuit
configuration to be used during anesthetic
140
delivery. If any components of the circuit

are changed after this test is completed,
the test should be performed again. Ensure
that there are no leaks or obstructions in
the reservoir bags or breathing system and
they are not obstructed by foreign material.
Perform a pressure leak test (between
20 and 60 cm of water) on the breathing
system by occluding the patient end and
compressing the reservoir bag. Verify that
gas flows properly through the breathing
circuit during both inspiration and
exhalation. Proper testing will demonstrate
that pressure can be developed in the
breathing system during both manual and
mechanical ventilation and that pressure
can be relieved during manual ventilation
by opening the APL valve.
Vaporizer: Ensure that vaporizer(s) for the
required volatile agent(s) are fitted correctly
to the anesthetic machine. Check that the
locking mechanism is fully engaged and
that the control knobs rotate fully through
the range(s). Ensure that the vaporizer is
not tilted. Tilting a vaporizer may result in
delivery of dangerously high concentrations
of anesthetic. Turn off the vaporizer. Verify
that vaporizers are adequately filled and not
overfilled, if applicable, that the filler ports
are tightly closed. High and low anesthetic
agent alarms are useful to help prevent
over- or under-dosage of anaesthetic vapor.
If anesthetic vapor delivery is planned,
an adequate supply is essential to reduce
the risk of light anesthesia or recall. This
is especially true if an anesthetic agent
monitor with a low agent alarm is not being
used.
Ventilator: Check that the ventilator is
working and configured correctly. Confirm
ventilator settings and evaluate readiness to
deliver anesthesia care. When a ventilator
is being used, we should check for low
pressure or disconnect alarm. Ensure that
the ventilator tubing is securely attached.
Check that the pressure relief valve functions
correctly at the set pressure.
Carbon dioxide absorber: Inspect the

contents and connections and ensure
there is adequate supply of carbon dioxide
absorbent. Check the color of absorbent to
ensure that it is not exhausted.
Alternative breathing system: Ensure the
presence of alternative breathing circuit
(Bains, T-piece). Perform an occlusion test
on the inner tube and check the adjustable
pressure limiting (APL) valve, where fitted,
can be opened and closed.
Correct gas outlet: Ensure that there is no
misconnection or miselection of an auxiliary
common gas outlet (ACGO). Whenever a
breathing system is changed, either during
a case or a list, its integrity and correct
configuration must be confirmed.
Scavenging: Verify correct connections
between the scavenging system and the
anesthesia delivery system. Ensure vacuum
level is adequate.
Monitors: Verify availability of required
monitors and check alarms. The first step
is to visually verify that the appropriate
monitoring supplies (BP cuffs, oximetry
probes, etc.) are available. All monitors
should be turned on and proper completion
of power-up self tests confirmed. Verifying
proper function of pulse oximetry and
capnography. Ensure proper functioning
of visual and audible alarms. Check the gas
Sampling lines are properly attached and
free from obstruction or kinks. Be aware of
the default alarm settings if using these.
Airway equipment: Ensure the presence of
full range of airway equipment, including
tracheal tubes, laryngeal mask airway,
appropriate laryngoscope, oropharyngeal
airway, bacterial filter and catheter
mount. Check that all these equipment are
functioning properly. Equipment for the
management of anticipated or unexpected
difficult airway must be available and
checked regularly in accordance with
departmental policies.
An Arrest Cart containing emergency
resuscitation equipment including a manual
resuscitator, defibrillator, appropriate

medications and intravenous equipment
must be immediately available.
Facilities that care for children should
have specialized pediatric equipment.
Wherever obstetric anesthesia is performed,
a separate area for newborn assessment and
resuscitation, including designated oxygen,
suction apparatus, electrical outlets, source
of radiation heat, equipment for neonatal
airway management and resuscitation, shall
be provided.
Personal protection devices, including N95
masks, facemasks, means of disposal of
hazardous and infectious wastes and sharps
should be provided.
The equipment, supplies and appropriate
assistance necessary for the safe
performance of invasive procedures should
be provided. Diagnostic equipment, such
as nerve stimulator, ultrasound, image
intensifier and X-ray should be available to
anesthesiologist as required.
Section C: Check final status of machine:
Vaporizers off
Bag/Vent switch to bag mode
APL open
Zero flows on flowmeters
Suction adequate
Breathing system ready
Monitors functional
Capnogram present
Equipment and drugs
Section D: Record keeping:
Document completion of checkout procedures.
Each individual responsible for checkout
procedures should document completion of
these procedures. Documentation gives credit
for completing the job and can be helpful if an
adverse event should occur.
Section E: Do not forget:
Availability of self-inflating bag should be
confirmed. Check presence of a resuscitation
trolley and defibrillator. Check system for total
intravenous anesthesia like infusion site, and
clear labeling of lines and drugs.
141
Section F: Timing:
Perform the entire check list daily and document
it daily on log book or patient record.
Section G: Checks before each case:
Verify patient suction is adequate to clear
the airway
Verify availability of required monitors,
including alarms
Verify that vaporizers are adequately filled
and if applicable that the filler ports are
tightly closed
Verify carbon dioxide absorbent is not
exhausted
Breathing system pressure and leak testing
Verify that gas flows properly through the
breathing circuit during both inspiration
and exhalation
Document completion of checkout
procedures
Confirm ventilator settings and evaluate
readiness to deliver anesthesia care.
(Anesthesia time out).
Section H: Minimum test under life-threatening
conditions:
High pressure test of the breathing circuit
ensures there are no leaks distal to common
gas outlet
Check patient suction
Observe and/or palpate breathing bag
during preoxygenation. This ensures:
Adequate flow of oxygen
Good mask fit (very important)
The patient is breathing
The circuit is unobstructed
The Bag/Vent switch is on Bag not
Vent (older machines).
Conclusion
A checkout procedure for ansesthesia machine
is intended to determine that the equipment is
present, functioning properly and ready for use.
Failure to check equipment properly is a factor
in many critical incidents. Properly checking
equipment can reduce equipment related
mortality and morbidity, improves preventive
142
maintenance, and educates the anesthesia

provider about equipment.
Bibliography
1. American
Society
of
Anesthesiologists
Recommendations for Pre-Anesthesia Checkout
Procedures. Sub-Committee of ASA Committee
on Equipment and Facilities (2008). http://
w w w . a s a h q . o r g / Fo r- Me m b e r s / C l i n i c a l Information/2008-ASARecommendationsfor-PreAnesthesia-Check out.aspx (accessed 18
02 2012).
2. Australian and New Zealand College of
Anaesthetists. Minimum Safety Requirements
for Anaesthetic Machines for Clinical Practice
(2011).
http://www.anzca.edu.au/resources/
professionaldocuments/documents/technical/
pdffiles/T3.pdf (accessed 18 02 2012).
3. Hartle A, Anderson V, Bythell V, et al. Checking

anaesthetic equipment: AAGBI 2012 guidelines.
Anaesthesia. 2012;67:660-8.
4. International Electrotechnical Commission. IEC
60601-2-13. Medical electrical equipment. Part
2-13: Particular requirements for the safety and
essential performance of anaesthetic systems.
http://webstore.iec.ch/preview/info_iec60601213%7Bed3.1%Den.pdf (accessed 18/02/2012).
5. International
Standards
Organization.
ISO860601-2-13:2011.
Medical
electrical
equipment. Part 2-13: Particular requirements
for basic safety and essential performance of
an anaesthetic workstation. http://ww.iso.org/
iso/catalogue_detail.htm?csnumber=51285
(accessed 18/02/2012).
6. Merchant R, Chartrand D, Dain S, et al.Guidelines
to the practice of anaesthesia revised edition
2013. Can J Anaesth. 2013;60:60-84.
CHAPTER
20
Perioperative Blood Transfusion

T Prabhakar, RK Tripathi
To raise new questions, new possibilities, to regard old problems from a new angles, require creative
imagination and marks real advance in science.
Albert Einstein
Blood being a precious and scarce resource,
every attempt should be made to transfuse
blood and blood products only when essential.
Low Hemoglobin (Hb), blood loss and
hypovolemia are main indicators for perioperative blood transfusion. Blood transfusions,
transfusion medicine continues to be dogged by
controversies and a lack of conclusive evidence.
That leaves us wondering when and to whom
to give blood perioperatively. Platelet and fresh
frozen plasma (FFP) transfusion trigger point are
also not very clear. Hence in this article we have
tried to elucidate certain important practical
guidelines of transfusion medicine as related to
our perioperative transfusion practice.
Adverse events associated with blood
transfusions,
including
infections
and
transfusion reactions, also have been
recognized. Recent publications1-2 have
demonstrated
an
association
between
transfusions and increased morbidity and
mortality.
Purpose
of
blood
transfusion: Blood
transfusions are given basically to increase
the intravascular volume and oxygen carrying
capacity. The goals should be to restore
intravascular volume, cardiac output and organ
perfusion to sustain normal levels. The rationale

for blood transfusion is rooted in the physiology
of oxygen delivery (DO2) which depends upon
the concentration of hemoglobin (Hb), the
percent saturation of O2 in that hemoglobin
(SaO2), and the cardiac output (CO):
DO2 = Hb %SaO2 CO
Because oxygen requirement by tissues
are increased during acute surgical stresses
perioperatively, it is mandatory to maintain
adequate oxygen levels for better outcome.
Manipulation
of
hemoglobin,
oxygen
saturation and/or cardiac output increases
oxygen delivery. However, hemoglobin is
normally almost fully saturated with oxygen,
and increasing cardiac output in the face
of adequate filling pressures requires the
use of ionotropic agents. Thus, augmenting
hemoglobin level is a beneficial strategy to
increase oxygen delivery.3
Transfusion trigger:
Transfusion trigger is
hemoglobin/hematocrit at which the risks
of decreased O2 carrying capacity exceed the
risks of transfusion. In 1942, minimum 10 g/
dL hemoglobin and 30% hematocrit levels, has
been accepted over the years as the appropriate
transfusion trigger but recent guidelines
144
state that when a patients hemoglobin level

falls below six or seven grams per deciliter, a
patient will benefit from a transfusion, and
that if the levels are above 10, a patient does
not need a transfusion. But when blood levels
are in-between 7 and 10, there has been little
consensus about what to do.4
Risks of Blood Transfusion

Blood transfusion, which introduces a foreign
substance transplant into the body, initiates
a series of complex immune reactions. Patients
often develop antibodies to transfused red
blood cells making it more difficult to find
a match if future transfusions are needed.
Transfused blood also has a suppressive effect
on the immune system, which increases the
risk of infections, including pneumonia and
sepsis.5
Cancer Recurrence
A study published in the Oct. 18, 2003, issue
of The Lancet about cancer progression in
advanced squamous cell carcinoma of the
oropharynx, who had initial hemoglobin levels
less than 12 g/dL. When transfusions were given
to reach a target hemoglobin of 14 g/dL found
a 62% increased risk of recurrence and survival
was also adversely affected. In colorectal cancer
a similar recurrence was also observed by
Amato et al in 2011.6
HOW MUCH HEMOGLOBIN

IS ENOUGH?
Various studies have been done in this field
which illustrates that low levels of Hb are
tolerated by healthy subjects. Carson et al7
observed that surgery was safely performed
in patients with Hb levels as low as 6 g/dL,
providing blood loss was less than 500 mL. In a
study Hebert et al8 compared liberal transfusion
strategy (Hb1012 g/dL) with a restrictive
transfusion strategy (Hb 79 g/dL) and found
mortality was significantly lower in the
restrictive strategy group, although the 30 days
mortality rate was not significantly different.

Therefore a restrictive strategy is superior, in
some patients, to a more liberal transfusion
strategy. Although in one study Herbert et al
also found that a postoperative hematocrit of
< 28% was significantly associated with
increased myocardial ischemia and morbid
cardiac events. This was particularly apparent in
the setting of tachycardia. Koch et al9 concluded
that giving erythrocytes (packed red cells) older
than 14 days was associated with an increased
risk of postoperative complications along with
reduced short-term and long-term survival in
patients undergoing coronary artery bypass
surgery. This concluded that to the extent
possible, newer blood might be used in clinical
situations that seem to call for it.10
In 2006, the American Society of
Anesthesiologists (ASA) advised that blood
is rarely indicated when the hemoglobin
concentration is greater than 10 g/dL and is
almost always indicated when it is less than
6 g/dL, especially when the anemia is acute. The
transfusion of autologous RBCs may be more
liberal than those for allogeneic RBCs because
of lesser risks.11
BLOOD COMPONENT THERAPY

In 2005 The Association of Anesthetists of
Great Britain and Ireland recommended that,
Assessment of hemostasis in the pre-operative
period can reduce perioperative blood loss
and as red cell concentrates do not contain
coagulation factors or platelets, so the use of
blood components [fresh frozen plasma (FFP)
and platelets] needs to be considered early in
managing a patient with massive hemorrhage.
Thawed FFP can be stored at 4C and can be
used safely within 24 hours. Platelet transfusion
in the bleeding patient, or a patient requiring
urgent surgery, is indicated at a platelet count
< 50000/L but in stable nonbleeding patients
in intensive care, a trigger of 10,000/L is
acceptable. Vitamin K +/- prothrombin complex
concentrate (PCC) is recommended to reverse
warfarin. FFP is indicated when there is severe
bleeding or when PCC is unavailable.
Evidence Based Guidelines for

Blood Transfusion (Cochrane)
In 2012 in an article Carson JL, et al. Transfusion
thresholds and other strategies for guiding
allogeneic red blood cell transfusion studied
Nineteen trials involving a total of 6264 patients
found that restrictive transfusion strategies
reduced the risk of receiving a RBC transfusion
by 39%. This equates to an average absolute risk
reduction (ARR) of 34%. The volume of RBCs
transfused was reduced on average by 1.19
units. However, heterogeneity between trials
was statistically significant for these outcomes.
Restrictive transfusion strategies did not appear
to impact the rate of adverse events compared
to liberal transfusion strategies (i.e. mortality,
cardiac events, myocardial infarction, stroke,
pneumonia and thromboembolism). Restrictive
transfusion strategies were associated with a
statistically significant reduction in hospital
mortality, but not 30 days mortality. The use of
restrictive transfusion strategies did not reduce
functional recovery, hospital or intensive care
length of stay. There are no trials in patients
with acute coronary syndrome.11,12
Other Strategies to Reduce

Cell Salvage
Cell salvage or auto-transfusion involves
the collection of a patients own blood from
surgical sites which can be transfused back
into the same person during or after surgery, as
required. There are significant reduction in both
the incidence and volume of allogeneic blood
transfusion compared with the control.
145
until bleeding is controlled. However, while

maintaining blood pressure may prevent
shock, it may worsen bleeding. Oxygen carrying
capacity of transfused blood will take time
anything between 6 and 24 hours depending
upon the age of the blood, temperature and 2,3
DPG level.
Platelet-rich Plasmapheresis
Platelet-rich plasmapheresis is a technique
that involves a patients own blood (autologous
whole blood) being withdrawn via an
intravenous catheter into a device that separates
the blood by centrifugation into red blood cells,
plasma, and a highly concentrated platelet
solution. This concentrated autologous platelet
solution is returned to the patient at the end of
the operation to optimize blood clotting and
minimize bleeding.
A WORKABLE GUIDELINE
Indications for Red Blood Cells
Hb < 7 g%; although lower thresholds
may be acceptable in patients without
symptoms and where specific therapy
(eg iron) is available. Hb < 7 g% during
surgery associated with major blood loss or
if evidence of impaired oxygen transport,
Hb < 8 g% for otherwise healthy patients
for cesarean section in emergency and for
elective Iron and Folic acid supplementation
should be given to achieve 10 g%, on a
chronic transfusion regimen or during
marrow suppressive therapy, however Hb
< 10 % to 12 g% recommended only for very
select populations, e.g. Neonates and cardiac
surgeries.
Fluid Administration
Timing and Volume
Indication for Platelet Transfusion
Treatment of hemorrhagic shock involves

maintaining blood pressure and tissue
perfusion until bleeding is controlled. Different
resuscitation strategies have been used to
maintain the blood pressure in trauma patients
Platelets transfusion if risk factors like

fever, antibiotics, hemostatic failure, risk of
intracranial hemorrhage are present. Surgery/
invasive procedure platelets < 50000/L.
However, higher counts may be needed
146
in surgery with high-risk of bleeding, e.g.

neurosurgery or Transfuse if there is bleeding
or high-risk of bleeding, regardless of actual
platelet count. In cases of bleeding/massive
transfusion maintain platelets > 50000/L if
thrombocytopenia likely to be a contributing
factor for bleeding. Maintain platelets > 100000/
L in the presence of DIC or CNS trauma.
Indications for Fresh Frozen Plasma

Warfarin effect- life-threatening bleeding in
addition to the use of vitamin K and vitamin
K dependent clotting factor concentrates for
bleeding with abnormal coagulation
Liver disease, if bleeding with abnormal
coagulation
Acute DIC when there is bleeding and
abnormal coagulation
Following massive transfusion or cardiac
bypass for bleeding in the presence of
abnormal coagulation.
Cryoprecipitate may be indicated in Fibrinogen
deficiency, in the setting of clinical bleeding, an
invasive procedure, trauma or DIC.
Management of Transfusion
1.
A formal checking process prior to
commencement of transfusion
2. The use of correct equipment (filters, pump,
consideration of blood warmer)
3. Correct transfusion documentation including
patient observations, start and finish times.
Complications During Transfusion

The most common immediate adverse
reactions to transfusion are fever, chills and
urticaria. The most potentially significant
reactions include acute hemolytic transfusion
reactions, bacterial contamination of blood
products and transfusion related acute lung
injury. All suspected transfusion reactions
must be reported to the issuing blood bank
immediately.
CONCLUSION
Patient blood management encompasses
an evidence-based medical and surgical
approach that is multidisciplinary including
transfusion medicine specialists, surgeons,
anesthesiologists, and critical care specialists
and multiprofessional including physicians,
nurses,
perfusionists
and
pharmacists.
Awareness of risks and understanding of the
normal and pathological physiology must
remain the guiding principle for perioperative
blood transfusion management. The data
available suggests that most patients can
tolerate hemoglobin levels in the 7 to 9 g/dL
range without suffering adverse consequences
related to the anemia while patients with acute
cardiac disease may require higher hemoglobin
levels.
Remember that, when used correctly, blood can
be life-saving. Inappropriate use can endanger
life and may cause a shortage of blood for
other patients who require it. World Health
Organization.13
REFERENCES
1. Hebert P, Wells G, Blajchman MA, et al.
Transfusion Requirements in Critical Care
Investigators, Canadian Critical Care Trials
Group, N Engl J Med. 1999;340:409-17.
2. Wu WC, Rathore SS, Wang Y, Radford MJ,
Krumholz. Blood transfusion in elderly patients
with acute myocardial infarction. N Engl J Med.
2001;345:1230-6.

3. Miller RD. Patient blood management:
Transfusion therapy. In: Miller RD, editor.
Millers Anesthesia. 8th ed. Philadelphia,
PA: Churchill Livingstone/Elsevier, 2015.
p.1830-67.
4. Marshall JC. Transfusion trigger: when to
transfuse? Crit Care. 2004;8:S31-3.
5. Rao SV, Jollis JG, Harrington RA, et al. Relationship
of blood transfusion and clinical outcomes in
patients with acute coronary syndromes. JAMA.
2004;292:1555-62.
6. Amato A, Pescatori M. Cochrane SummariesPublished online Feb 16, 2011.

7. Carson JL, Hill S, Carless P, et al. Transfusion
triggers: a systematic review of the literature.
Transfusion Med Rev. 2002;16:187-99.
8. Hbert PC, Wells G, Marshall J, et al. Transfusion
requirements in critical careA pilot study.
JAMA. 1995; 273:1439 for the Canadian Critical
Care Trials Group.
9. Koch CG, Li L, Sessler DI, et al. Duration of
red-cell storage and complications after cardiac
surgery. N Engl J Med. 2008; 358:1229-39.
10. Adamson JW. New blood, old blood, or no blood?
N Engl J Med. 2008; 358:1295-6.
147

11.
ASA Guideline for preoperative blood
transfusion-2002.

12. Carless PA, Henry DA, Carson JL, et al.
Transfusion thresholds and other strategies for
guiding allogeneic red blood cell transfusions.
Cochrane Database Syst Rev. 2010.
13. Carson JL, Carless PA, Hebert PC. Cochrane
Database Syst Rev. 2012 Apr 18;4:CD002042. doi:
10.1002/14651858.CD002042.pub3 -Transfusion
thresholds and other strategies for guiding
allogeneic red blood cell transfusion.
CHAPTER
21
Infrastructure Requirements
for Operation Theater
Naresh Dua, VP Kumra
Introduction
The functioning and infrastructure of operation
theaters has pivot role in any hospitals esteem.
Nowadays, large number of surgical patients
are getting admitted for different surgeries.
The surgical speciality and super-speciality
branches are advancing tremendously with
good results.
Safer anesthetic techniques, complete aseptic
environment, sophisticated equipment and
skills make the surgical outcome successful. For
all these requirements, operation theater (OT)
needs specialized planning and execution which
is not a simple civil engineering work. A civilmechanical-electrical-electronic-biomedical
combo effort driven in harmony with medical,
surgical team requirements form an ideal OT.
Anesthesiologists, by virtue of their knowledge
of the intricacies of physiology, physics and
biomedical aspects of medicine and constant
proximity to the operation theater should
preferably be involved from the early stages of
planning of operating theaters.1
Definition
Operation theater is that specialized facility of
the hospital where life saving or life improving
procedures are carried out under strict aseptic
conditions on the human body by invasive
methods in a controlled environment by
specially trained personnel to promote healing

and cure with maximum safety, comfort and
economy.2
Utilization of
operation theater
Operation theater complexes are designed
and built to carry out investigative, diagnostic,
therapeutic and palliative procedures of varying
degrees of invasiveness. Many operation theater
set-ups are customized to the requirements
according to a particular speciality.
Infrastructure of
operation theater
Infrastructure starts with proper planning,
designing along with all the parameters and
ancillary units required for smooth running of
operation theater.
Aim of Planning
The main objectives of planning include
promotion of high standard of asepsis,
maximum safety and proper utilization of OT
and its staff. The working conditions should
be optimized for patient and staff comfort to
facilitate good coordinated services. There
should be planning with the aim to ensure
Infrastructure Requirements for Operation Theater
functional separation of spaces and minimal

maintenance requirement.
Requirements for designing

Operation theaters require specialized planning
because surgical facilities represent a central
life saving activity, they make or break the
reputation of the hospital. The functional
efficiency of the OT governs the revenue
generation as it is a major cost consuming
center in the establishment of the hospital. It
is responsible for an appreciable quantum of
revenue in private sector. As no one plan suits
all hospitals, a scientific and detailed planning
is required while designing an OT in order
to ensure its smooth functioning, efficiency
and effective utilization. To design the OT,
the basic fundamental asepsis environment
has to be maintained by keeping the outside
contaminate out by separation of clean area
from contaminated area within OT complex.3
Basic architecture of the OT

The OT complex should be located at a low
transaction area of hospital. The OT complex
should be located away from the inpatient area,
often in a blind wing or on the top or bottom
floor. It is a scientifically planned barrier system,
such that it keeps the flow of traffic from the
clean area to dirty ones and never vice verse.
Four zones can be described in an
OT complex, based on varying degrees of
cleanliness, in which the bacteriological count
progressively diminishes from the outer to the
inner zones (operating area) and is maintained
by a differential decreasing positive pressure
ventilation gradient from the inner zone to the
outer zone.4
1. Protective zone: It includes:
Changing rooms for all medical and
paramedical staff with conveniences
Transfer bay for patient, material and
equipment
Rooms for administrative staff
Stores and records
Pre- and postoperative rooms
149
Intensive care unit (ICU) and post

anesthesia care unit (PACU).
Sterile stores
2. Clean zone: Connects protective zone to
aseptic zone and has other areas also like:
Stores and cleaner room
Equipment store room
Maintenance workshop
Kitchenette (pantry)
Firefighting device room
Emergency exits
Service room for staff
Close circuit TV control area
3. Aseptic zone: Includes operation rooms
(sterile)
4. Disposal zone: Disposal areas from each OR
and corridor lead to disposal zone.
Accessory Working Areas

Changing room: This is important with
respect to maintaining privacy, for changing
from street clothes to gown and to provide
lockers and lavatories for the staff.
Preanesthetic checkup (PAC) room:This
area is planned for patients preoperative
evaluation and to take care of their special
needs.
Holding area: This area is planned for IV
line insertion, preparation, catheter/gastric
tube insertion, connection of monitors, and
shall have O2 and suction lines. Facility for
CPR should be available in this area.
Induction room (anesthetic room):It
should have all facilities as in OT, but
depends on hospital policy and space
availability. The anesthetic room will
provide a more tranquil atmosphere to the
patient than the OT. It should provide space
for anesthetic trolleys and equipment and
should be located with direct access to
circulation corridors and ready access
to the operating room. It will also allow
cleaning, testing and storing of anes
thesia equipment. It should contain work
benches, sinks. It should have sufficient
power outlets and medical gas panels for
testing of equipment.
150
Postanesthetic recovery room: It should

bepreferably adjacent to the recovery room.
These should contain a medication station,
hand washing station, nurse station, storage
space for stretchers, supplies and monitors/
equipment and gas, suction outlets and
ventilator. Additionally 80 sq ft (7.43 sq m)
for each patient bed, clearance of 5 ft (1.5
m) between beds and 4 ft (1.22 m) between
patient bed sides and adjacent walls should
be planned.
The anesthesia gas/cylinder manifold room
and storage area: A definite area for this
should be designated. It should be in a cool,
clean room that is constructed of fire resistant
materials. Conductive flooring must be laid
but is not required if noninflammable gases
are stored. Adequate ventilation should be
allowed for leaking gases to escape. Safety
labels should be put on each cylinder and
separate space for empty and full cylinders
should be allocated.
Offices for staff nurse and OT staff: The office
should allow access to both unrestricted
and semi-restricted areas as frequent
communication with public is needed.
Rest rooms: Pleasant and quiet rest for staff
should be arranged either as one large room
for all grades of staff or as separate rooms;
both have merits. Comfortable chairs,
one writing table, a book case, etc. may be
arranged.
Seminar room: Since the OT staff cannot
leave the complex easily, it is better to have a
seminar room within the OT complex. Intradepartmental discus
sions, teaching and
training sessions for staff (with audio-visual
aids) may be conducted here.
Store room: This is designed to store large
but less frequently used equipment of the
OT. There should be storage space for special
equipment after cleaning.
Theater sterile supply unit (TSSU): Within
this area, following are desirable:
Temperature between 18 and 22C,
humidity of 40 to 50% is the aim.
Air conditioning with 10 to 12 air

exchanges per hour
Storage of sterile drapes, sponges, gloves,
gowns and other items ready to use.
Option to store in the goods from one side
and remove from other side of the room is
highly preferable.
Proper inventory to prevent running out
of stock.
Scrub room: This is planned to be built
within the restricted area. Elbow operated or
infrared sensor operated taps / water source
is ideal. It is essential to have nonslippery
flooring in this area.
Principles to be Taken into Consideration

while Planning an OT (Physical/Architecture):
Location: Low rise buildings limited to two
or three storeys high are preferred because
of maximum advantage of natural light
and ventilation. The OT should be separate
from general traffic and air movement
of rest of the hospital. OT, surgical wards,
ICU, accident and emergency department,
Radiological department should be closely
related and access is also required to
sterilizing and disinfecting unit (SDU) and
laboratory facilities. The location of the
operation complex in a multi-storey building
is planned either on the top floors or in the
basement to avoid traffic.5
Zone wise distribution of the area should be
done to avoid crisscross movements of men
and machines.
Adequate and appropriate space should be
allotted as per utility of the area.
Provision for emergency exit must be kept in
accessible area.
Provision for ventilation and temperature
control, laminar flow, HEPA filter air
conditioner should be installed to minimize
infection.
Operation rooms: The number and size can
be as per the requirement of the hospital but
recommended size of OT is 6.5 m 6.5 m
3.5 m. Glass windows can be planned on one

side only.
Doors: Main door to the OT complex has to
be of adequate width (1.21.5 m). The doors
of each OT should be spring loaded flap
type, but sliding doors are preferred as no
air currents are generated. All fittings in OT
should be flush type and made of steel.
The surface/flooring must be slip resistant,
strong and impervious with minimum joints
(e.g. mosaic with copper plates for antistatic
effect) or jointless conductive tiles/ terrazzo,
linoleum, etc. The recommended minimum
conductivity is 1 m Ohm and maximum
10 m Ohms. Presently the need for antistatic
flooring has dimin
ished as flammable
anesthetic agents are no longer in use.2
Walls: Laminated polyester or smooth paint
provides seamless wall; tiles can break and
epoxy paint can chip out. Collusion corners
to be covered with steel or aluminum plates
or can be made round, color of paint should
allow reflection of light and yet soothing
to eyes. Light color (light blue or green)
washable paint will be ideal. A semi-matt
wall surface reflects less light than a highly
gloss finish and is less tiring to the eyes of OT
team.
Operation table: One operation table per OT
should be the norm.
Electric point: Adequate electric points on
the wall (at < 1.5 m height from the floor)
should be present in OT.
X-ray illuminators: There should be X-ray
film illuminators preferably recessed into the
wall.
Scrub area: It should be planned for atleast
for 2 to 3 persons in each OT.
There has to be a preparation room in clean
zone.
The width of corridors should not be less
than 2.85 m width for easy movement of staff,
stretcher and machines.
Separate corridors be should be planned for
uses other than going into OT.
Gas and suction (control, supply and
emergency stock) should be planned for all
151
OTs and areas where patients are retained.

Oxygen, gas and suction pipe to be connected
with central facility and standby local facility
should also be available.
Provision for adequate and continuous water
supply: Besides normal supply of available
water at the rate of 400 liters per bed per day,
a separate reserve emergency over head tank
should be provided for operation theater.
Elbow taps have to be installed 10 cm above
wash basins.
Planning of proper drainage system with
provision of easy repair work have to be in
place.
Preoperative area with reception with
separate des
ignated area for pediatric
patients is desirable.
The safety in working place is essential, and
fire ex
tinguishers have to be planned in
appropriate zone.
Provision for expansion of the OT complex
should be borne in mind during planning
stages itself. So that in future if need arises,
much OTs can be formulated.
Ventilation
Central air conditioning should ensure
temperature range of 18 to 24C with 50
to 60% humidity levels. A minimum of 20
air changes/hour should be ensured. It is
preferred to have 100% fresh air. Theater to
maintain positive pressure and controlling of
pressure is adhered to by providing pressure
release dampers at the time of opening
and closing of the door. The minimum
bacteriological requirements are that the air
should not contain detectable Clostridium
spores of coagulase positive Staphylococcus.
During surgical operations the concentration
of
bacterially-contaminated
airborne
particles in the operating theater averaged
over any 5 minute period should not exceed
180 per m3 (5 per ft3), and special types
of surgical operation, e.g. orthopedic and
transplantation procedures, higher standards
of air cleanliness must be ensured.2
152
Pendant Services
Two ceiling pendants for pipeline services
should be designed; one for surgical team and
one for anesthesiologist. Anesthetic pendant
should be retractable and have limited lateral
movement and provide a shelf for monitoring
equipment. It should have oxygen, nitrous
oxide, 4 bar pressure medical compressed air,
medical vacuum, scavenging terminal outlets
and at least four electric sockets.
Piped Gases in the OT

1. Automatic/semi-automatic fail safe manifold
room to be designed.
2. Two outlets for O2 and suction and one for
N2O are a minimum in each OT.
3. Pipeline supply system should be able to
cut off from mainline if the problem occurs
anywhere along the delivery hosing / tubing.
Scavenging
The method of scavenging should be decided
during planning stage of OT. International
standards are available for scavenging but it is
ideal to plan the type of system (active/passive),
number and location of scav
enging outlets
beforehand.
ELECTRICAL
All electrical equipment in the OT need proper
grounding. In the past, isolated power systems
were preferred when explosive agents were
being used. They have the advantage of a
transformer using grounded electricity and
there is no risk to the patient or machines if a
machine gets faulty.
The grounded systems as used at homes
offer protection from macro shock but devices
may lose power without warning. Life support
systems, if in use could be disturbed.
Following criteria are ideal with respect to
electrical functioning in OT complex:6
Use of circuit breakers/interrupters is
desirable if there is an overload or ground
fault.
Power line of 220 Volts should be maintained

without much fluctuation.
Suspended
ceiling
outlets
should
have locking plugs to avoid accidental
disconnection.
Insulation around ceiling electrical power
sources should withstand frequent bendings
and flexings. They should not develop cracks
and should not damage wires. Wires inside
rigid or retractable ceiling service column
can help to some extent.
Wall outlets to be installed 1.5 m above
ground.
Use of explosion proof plugs is desirable.
Multiple outlets from different electrical line
sources should be available.
Electrical load calculation should be
based on equipment likely to be used and
appropriate current carrying capacity cords
to be used.
Emergency power: OT electrical networks
need to be connected to the emergency
generators with au
tomatic two way
changeover facility.
Lighting
General illumination is furnished by ceiling
lights. Lighting should be evenly distributed
throughout the room. Around 300 lux light is
sufficient light for anesthesiologist to adequately
evaluate the patients skin color. Electrical wiring
should be in concealed conduit lighting both
natural and artificial should be of appropriate
illumination.
Isolated power systems help prevent sparks
from igniting flammables anesthetics and also
help to protect patients and personnel from
shock. Ground fault circuit interrupters (GFCIs)
may be utilized which are designed to shut off
the electric power within a few milliseconds
of the occurrence of a ground fault, thereby
preventing serious electric shock.
To minimize eye fatigue, the ratio of intensity
of general room lighting to that at the surgical
site should not exceed 1:5, preferably 1:3. This
contrast should be maintained in corridors
and scrub areas, as well as in the room itself,
so that the surgon becomes accustomed to

the light before entering the sterile field. Color
and hue of the lights also should be consistent.
The overhead operating light must have the
following feature.2,4
An intense light, within a range of 27,000
to 127,000 lux is required into the incision
site. It must be without glare on the surface.
The light may be equipped with an intensity
control.
Provide a diameter light pattern and focus
appropriate for size of the incision. Fixture
should provide focused depth by retracting
light to illuminate both the body cavity and
the general operating field.
Light should be shadowless. Multiple light
sources and/or reflectors decrease shadows.
The goal should be to produce the bluewhite color of daylight.
It should enable easy cleaning.
The installation of lights should be
aerodynamically designed to facilitate
airflow.
Light must produce a minimum of heat.
Halogen bulbs generate less heat than other
types.
Anesthesia Equipment and

Monitoring Needs
At least one anesthesiologist should be in the
team involved in planning an OT. It is imperative
that certain mandatory considerations with
respect to the anesthetic equipment and
monitors be planned during the planning and
design stage itself. Personal, practice and cost
preferences may influence the plans.1
Communications
Telephones, intercom and code warning signals
are desirable inside the OT. One phone per
OT and one exclusively for use of anesthesia
personnel is desirable. Inter
com to connect
to control desk, pathology and other OTs as
well as use of paging receivers (bleeps) is also
ideal. A code signal, when activated, signals an
153
emergency state such as cardiac arrest or need

for immediate assistance.
Catering
Basic services such as preparation of beverages
and some snacks, use of vending machines may
be planned, augmented by provision of hot and
cold meals from main hospital kitchen.
Cleaning
The construction materials selected for the OT
complex should aim to minimize maintenance
and cleaning costs. The corners have to be
minimum in number and it should be rounded
to minimize dirt collection.
Data Management
Customized network connections should be put
in place or a conduit should be planned. A well
designed system such as hospital information
system (HIS) can provide automated records,
materials management, quality improvement
and assessment, laboratory tracking, etc. The
Software for OT management are costly and
hospitals are generally slow to adopt to changes.
Customized OT software can be designed for
individual hospital needs.7
Operating Theater Satellite Pharmacy

The pharmacy should be accessible from OT
areas. It should have a laminar flow hood,
a refrigerator, space for drug storage locked
containers for controlled substances computer,
desk area for paper work and pharmaceutical
literature. Special kits for specific surgeries may
also be arranged. The pharmacy may open for
1 to 24 hours based on need but it is desirable
that an after hour system is planned.
Statutory Regulations
The design and planning of an OT complex will
need compliance with mandatory regulations
154
related to local administration such as

Municipal Corporation, Government, Pollution
Control Board, Fire Safety Department, Water
supply and Drainage department, etc.
Regulatory Authority
The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) standards
can be used to formulate the basic infrastructure
plans of OT.
Conclusion
The operation theater is an aseptic zone
with controlled climatic environment for the
operation and perioperative care of patients
undergoing diagnostic and surgical procedures
under anesthesia. The robotic surgeries and
other superspeciality branches has necessitated
the modernization of operation theater. The
design of an operating theater offers a challenge
to the planning team to optimize efficiency by
creating safer practice in anesthesia, asepetic
and controlled climatic conditions, realistic
functional traffic flow and flexibility for future
expansion.
Model operation theater specification
varies from hospital to hospital as per
surgeon-anesthesiologists
demand
for
different diagnostic, therapeutic and surgical

interventions.
References
1. Dorsch JA, Dorsch SE. Operating room design
and equipment selection, Understanding
Anaesthesia Equipment, 4th Edn; Williams and
Wilkin; 1999.pp.1015-16.
2. Gupta SK, Kant S, Chandrashekhar R.
Operating unit planning essentials and design
considerations. Journal of the Academy of
Hospital Vol. 17 (2):(2005-012005-12).
3. Harsoor SS, Bhaskar SB. Designing an ideal
operating room complex. Indian Journal of
Anaesthesia. 2007;51:193-199.
4. Bridgen RJ. Ch1. The operating department 2.
Organization and management 3. Electricity and
electromedical equipment 4. Static electricity:
operating theratre technique, 5th edn: Churchill
Livingstone 1988; 09,10,13,16-21,27-31, 41,
43-45,109.
5. Sehulster LM, Chinn RYW, Arduino MJ, et al.
Guidelines for environmental refection control in
health care facilities. Recommendations from CDC
and the Healthcare infection Control Practices
Advisory Committee (HICPAC) November 2003.
6. National Fire Protection Association (NFPA).
Standard for Health Care Facilities. NFPA, 2002.
An update version of NFPA 99 standards.
7. Miller Rd. Operating room information systems.
Millers anesthesia, 6th Edn; Elsevier Churchill
Livingstone; 2005.pp.3131-32.
CHAPTER
22
Preoperative Fasting Guidelines

Vinod Kalla
Introduction
Fasting protocols for elective surgery aim to
provide a balance between safety and comfort
for the patients. Prolonged fasting time causes
patient discomfort along with physiological
alterations consequent upon fluid deprivation
and caloric restriction. The full stomach patient
on the other hand makes for a poor candidate
for an elective surgical procedure because
of risk of pulmonary aspiration of gastric
contents necessitating delay or postponement
of such cases. Publications appear in literature
since 1950s on trials of fasting protocols
before elective surgery.1,2 There has been a
convergence of views over the intervening
decades towards shorter fasting times. Current
practices aim to minimize fluid deprivation
and physiological changes in the immediate
preoperative period.
Certain groups of patients like the obese,
pregnant women not in labor, diabetics and
those suffering from gastroesophageal reflux are
considered to have delayed gastric emptying.
However, the current evidence suggests that
they can also follow the same guidelines as
healthy adults.
The purpose of these guidelines is to:
Increase patient satisfaction
Avoid delays and cancellations of planned
surgeries
Decrease the risk of dehydration and

hypoglycemia
Minimize perioperative morbidity.
Fasting Protocol for Adults

undergoing Elective Surgery
Fluids: Adults can be allowed to drink clear
fluids including water, pulp-free juice, black
tea or coffee, carbonated drinks, coconut
water, etc. up to 2 hours before elective
surgery. This has been seen to increase
gastric pH and reduce the gastric volume.3
Clear carbohydrate rich drinks (ORS) can
be safely given up to 2 hours preoperatively.
These fluids change the metabolism from
overnight fasted state to that of a fed state and
also reduce postoperative insulin resistance
without any evidence of increase in gastric
volume.4,5
Solid food: A fasting period of less than 4 hours
after a light breakfast has been reported to
have equivocal finding with regard to gastric
volume and pH. Despite this, preoperative
fasting of 6 hours is recommended after
consumption of solids. Additional fasting
time of 8 hours or more is recommended
after ingestion of fried or fatty food and meat.
Chewing gum and sucking of boiled sweets
can be allowed up to the time of induction of
anesthesia.
156
Women in labor should be encouraged to

ingest clear fluids. Ingesting of solid food
should be discouraged.
Pregnant women scheduled for cesarean
section can drink clear fluids up to 2 hours
before surgery.6,7
Fating Guidelines for

Infants and Children
Fluids: Clear fluids can be given to infants
and children up to 2 hours preoperatively.8
Breast milk can be given up to 4 hours before
surgery.9
Infant formula, cow milk and solids should
be withheld 6 hours preoperatively.9
Fasting time exceeding 8 hours may result in
hypoglycemia in children.
Pharmacological Prophylaxis
Against Pulmonary Aspiration
Routine preoperative use of prokinetic
(metoclopramide), H2 receptor antagonist
(ranitidine),
antacids
(magnesium
trisilicate, sodium citrate) and antiemetics
(ondansetron) to reduce the risk of
pulmonary aspiration in patients who do not
have increased risk for pulmonary aspiration
is not recommended.
Parturients scheduled for elective cesarean
section should be administered oral H2
receptor antagonist (ranitidine 150 mg) or
proton pump inhibitor (omeprazole 40 mg)
along with prokinetic (metoclopramide 10
mg) at bed time and again 60 to 90 minutes
before induction of anesthesia.
In case of emergency cesarean section,
intravenous H2 antagonist (ranitidine 50
mg) and prokinetic (metoclopramide 10 mg)
should be administered at the time decision
for surgery is taken.
References
1. Murray FA, Erskine JP, Fielding J. Gastric
secretion in pregnancy. J Obstet Gynaecol Br
Empire. 1957; 64:373-81.
2. MW. Lincoln, Aspiration of Gastric Contents

under Anaesthtesia: a review & Clinical Study,
Western journal of medicine. 1957;87(6): 403-7.
3. Hutchinson A, Maltby JR, Reid CR. Gastric fluid
volume and pH in elective inpatients. Par I:
Coffee or orange juice versus overnight fast. Can
J Anaesth. 1988; 35;12-5.
4. Taniguchi H, Sasaki T, Fujita H, et al. Preoperative
fluid and electrolyte management with oral
rehydration therapy. J Anesth. 2009; 23:222-9.
5. Kaska M, Grosmanova T. Havel E, et al. The impact
and safety of preoperative oral or intravenous
carbohydrate administration versus fasting in
colorectal surgery: a randomized controlled trial.
Wien Klin Wochenschr. 2010;122:23-30.
6. Porter JS, Bonellon E, Reynolds F. The influence
of epidural administration of fentanyl infusion
on gastric emptying in labour. Anaesthesia. 1997;
52:1151-6.
7. Wong CA, Loffredi M, Ganchiff JN, et al.
Gastric emptying of water in term pregnancy.
8. Shime N, Ono A, Chihara E, Tanaka Y. Current
practice of preoperative fasting: a nationwide
survey in Japanese anesthesia-teaching
hospitals. J Anesth. 2005;19:187-92.
9. American Society of Anesthesiologist Task Force
on Preoperative Fasting. Practice guidelines for
preoperative fasting and the use of pharmacologic
agents to reduce the risk of pulmonary aspiration:
application to healthy patients undergoing elective
procedures Anesthesiology. 1999;90:896-905.
Recommended Reading
1. Smith I, Kranke P, Smith A, OSullivan G, Soreide
E, Spies C, Veld BI. Perioperative fasting in adults
and children: guidelines from the European
Society of Anaesthesiology. Eur J Anaesthesiol.
2011;28:556-69.
2. Apfelbaum JL, Caplan RA, Connis RT, Epstein
BS, Nickinovich DG, warner MA. Practice
guidelines for preoperative fasting and the use
of pharmacologic agents to reduce the risk of
pulmonary aspiration: Application to healthy
patients undergoing elective procedures.
Anesthesiology. 2011;114(3):495-511.
3. Merchant R, Chartrand D, Dain S, Dobson G,
Kurrek MM, Lagac A, Stacey S, Thiessen B.
Guidelines to the Practice of Anesthesia-Revised
Edition 2014. Can J Anaesth. 2014;61(1):46-59.
CHAPTER
23
Anesthetic Care for MRI

Sarla Hooda, Prashant Kumar
There is a need for an efficient and effective

method of sedation/anaesthesia in the MRI.
The continuous presence of a strong magnetic
field, small bore of magnet and restricted
access to the patient make it a difficult place.
Children and adults with movement and
learning disorders or claustrophobia who are
unable to lie still during the long period of
scan necessitate the requirement of sedation
or general anesthesia. Even patients requiring
general anesthesia are often difficult to manage,
e.g. rare pediatric syndromes and critical care
patients. Performing anesthesia at a MRI suite is
a process where things have to be well planned
with well trained staff to guarantee maximum
safety to patient and all.1,2
Basic Physics
MR imaging is a non-invasive and radiation free
diagnostic procedure. Atomic nuclei containing
a positive charge (due to their protons) spin
on their own axis like the earth. MRI scanner,
generally use hydrogen nuclei (i.e. protons) to
generate images. When protons are exposed to
a static magnetic field, the orientation of their
spinning axis will be aligned with that of the
static field. If a transient magnetic field is applied
perpendicular to the static field it will cause the
nuclei to flip orientation and rotate. This process
consumes energy. This energy will be released
when nuclei resume their original alignment at

cessation of second magnetic field.3 Magnetic
field is generated by large electromagnets. The
field strength of such electromagnets in routine
clinical use is 1.5 Tesla to 7.0 Tesla (1 T=10000
Gauss). One can understand the magnitude
of such field by knowing the fact that earthss
magnetic field is approx. 0.5 Gauss. The coils
wires are made superconductor by bathing wire
(copper embedded with a niobium/titanium
alloy) in liquid helium at 4.22 K (i.e. -269 C).
In this situation wires resistance becomes
negligible and current generated in the coil
continues to flow indefinitely with no energy
input. It is important to note that electromagnet
created by this super conductor is always on,
regardless of whether we use it for scan or not.
Magnet can be turned off by allowing helium to
evaporate the process called quench. To restart
such magnet will involve many days with loss of
lacs of rupees as cost of liquid helium.3
Different tissues in the body have different
relaxation rates. T refers to relaxation time
constant, and images may be T1 weighted
(generated a few milliseconds after the
electromagnetic field is removed) or T2
weighted (generated later then T1) depending
on the characteristics of the tissue you wish
to look at. Nuclei in hydrogen take a long time
to decay to their original position, so fluid will
appear dark (minimal signal) in a T1 weighted
158
image but white in the later T2 image as the

signal appear. MRI machine is contained within
a radiofrequency shield called Faraday Cage.
Specific Issues
Remote locations, special patient needs, limited
access to patient in tunnel, high magnetic field,
ferromagnetic objects and their projectile effect,
ferromagnetic implants, specific equipment
and monitoring issues, high level acoustic
noise (reaching up to 95 decible), scavenging,
quenching and its associated hypoxia, contrast,
cold environment are the major concerns for
anesthesiologist at MRI suite. A field of more
than 30 Gauss is capable of erasing magnetic
strip data which are stored on computer disks
and credit cards.
procedure, have an important role wherever

available.
Guidelines for Preparation of Patient

Remain the Same as for General
Anesthesia
Written informed consent informing the
risk involved, adequate fasting (request of
anesthesia assistance after failed attempt of
conscious sedation cannot be accepted if patient
is not fasting), intravenous access, standard
monitoring, ready availability of emergency
equipment and presence of anesthesiologist
experienced in working in specific environment
and equipment are required. Preoperative
assessment should include a history of
implanted devices4,5 (Table 23.1).
Preparation and Techniques
Monitoring Equipment
Distraction can be a powerful tool for reducing

anxiety and increasing patient compliance.
Techniques such as audiovisual aids are useful
during the scan when patients are required to lie
still in the bore. Having a point of interest (such
as a parent/relative or video screen) is helpful in
maintaining the patient in one position.
Educational play therapists can use a range
of resources to assist children to comply with
the procedure without sedation or anesthesia
by using brochures, MRI toys, story books,
discussions and most importantly Mock MRI
All equipment to be used within scanning room

must be nonferromagnetic and should be MR
safe (i.e. present no safety hazard to patient or
personnel when taken into MR room provided
instructions concerning its use are followed,
however it does not guarantee its normal
function and interference with imaging) or
MR compatible (i.e. MR safe which function
normally in MR environment)6 (Table 23.2)
MRI compatible monitors are commercially
available. These may include a master monitor
and a slave monitor. The master monitor stays
TABLE 23.1
Implanted devices to be verified for compatibility with MRI
Device
Reason
Metallic make-up and tattoos
Can distort image or heat-up to cause burn
Cardiac pacemaker/ ICDs
Switch malfunction
Metal eye splinters
Can cause injury/blindness
Vascular clips, intrauterine contraceptive devices
If, ferromagnetic, could move in the magnetic field, with

potentially disastrous consequences.
Most modern ones are non-ferromagnetic and are safe in
MRI
Interventional radiological device (coil/stents)
Orthopedic devices (prosthetic joints, wire plates) Titanium or chromium/cobalt implants are compatible
Cochlear implants
Contain a magnet which may move and cause injury

TABLE 23.2
159
Compatibility of other anaesthetic equipments5,7
Laryngoscopes
Standard batteries are highly magnetic; plastic scopes and paper- or aluminum
covered lithium cells are available
Stylet
Copper stylets
Endotracheal tube
Spring within valve cuff may distort image; nonmagnetic valve. Reinforced
tubes and metal connectors be avoided
Laryngeal mask airway
Spring within valve cuff may distort image this can be minimized by taping it as
far as possible from the area to be scanned; nonmagnetic valve available
Anesthesia machine
Nonmagnetic machines are available; aluminum cylinders are required
Ventilator
Compatible ventilators are available
Infusion pump
Used at 30 gauss line, but extensions are recommended to minimize the field
effect on motor function; the need for long extension lines may exclude patients
requiring high dose inotropes
Suction
Wall mounted with long tubing
Defibrillators
Cathode ray tube and batteries will malfunction within the 30 gauss line;
resuscitation be preferably be carried out outside the magnetic field
Standard patient trolleys

and IV poles
contain iron, so are unsuitable
Intravenous cannula
needles
These are made from stainless steel and are safe
in the MRI suite and the slave monitor sit in

the MRI control room and receive information
wirelessly from the master monitor3.
The electrocardiogram introduces problems
with both image degradation from wire leads
(ensure to avoid any loop) and inability
of ECG monitor to discern ECG from
background static magnetic field waves.
High impedance graphite electrode with
specially insulated leads placed at V5, V6
maximizes QRS and minimize artifacts are
clinically important
Pulse oximetry is essentially to be used on
all anesthesiologist-administered sedation
or general anesthesia. Use of nonferrous
pulse oximeter with probe placed on a distal
extremity as far from the scan site as possible
is required.
Special note has to be taken as chest
excursions may not be observed easily and
saturation might fall late after cessation of
breathing, especially when oxygen is being
insufflated. Thus making end tidal CO2
monitoring indispensible in RI procedure.

Long tubings needed in MRI suits may
also be a contributory factor for waveform
showing a prolonged upslope. It is more
important to follow trends then to look for
absolute values. Use of special respiratory
belt which provide respiratory measurement
in MRI scanner is a better alternative.
Blood pressure monitoring can be
accomplished using the oscillometric
method. Invasive pressures can be monitored
using high pressure low compliance tubings
with transducer placed beyond 50 Gauss
line.
Temperature monitoring needs to be
done with temperature probes that use
radiofrequency filters or with nonferrous
skin temperature probe.
Anesthesiologists expertise is required in
pediatric airway management as in event of
hypoventilation, the scan has to be stopped, the
table pulled out and airway managed in odd
environment.
160
Drugs for Sedation

The ideal sedation agent for this type of setting
would have a rapid onset, rapid recovery, be
easily titrated for varying levels of sedation, be
safe for both pediatric and adult patients, allow
patients to remain hemodynamically stable, and
have a low cost, A variety of drugs are available
for sedation.8
Chloral hydrate is a sedative and hypnotic
drug with barbiturate like effect. In
therapeutic doses i.e. 25 to 100 mg kg-1 it has
onset in 15 to 30 minutes with duration of
60 to 120 minutes. It has only a slight effect
on respiration and blood pressure. Nausea,
vomiting and long recovery time along with
high failure rates of successful MRI scan
has to be considered about this drug as cost
effective and time saving sedation option.9
Midazolam is not a comfortable drug for
sedation in MRI when used alone. This is due
to its short duration of action, it is needed
to be given repeatedly or in continuous
infusion. However in combination with
fentanyl or pentobarbital or ketamine can be
used effectively. Associated risk of respiratory
depression has to be taken care of.
Propofol is a near perfect drug due to its
effectiveness, short recovery time and easy
titrability to the required sedation level.
Doses of 2 to 5 mg kg-1 hr-1 are sufficient
to maintain sedation. Propofol has been
associated with short ready to scan and
discharge time. When administering
propofol in the MRI suite, the patients EKG,
heart rate, oxygen saturation, respirations
and blood pressure should all be monitored
Propofol is also compatible via a Y-site with
Gadolinium, the contrast agent used in
MRI. Dosing of propofol needs to be closely
controlled and possibly titrated for effect, an
electronic infusion pump is recommended
for administration. Placement of syringe
pump beyond 30 Gauss line with fixation to
a base is essential safety measure.8
Ketamine in doses of 1 to 1.5 mg kg-1 when
used iv or 4 to 5 mg kg-1 as intramuscular has
onset time of 1 to 5 minutes with duration
of 15 to 30 minutes. Analgesic component

of ketamine is usually not required for MRI
procedure.
Generally
coadministarion
of anticholinergics or benzodiazepines
is required. Ketamine is also associated
with hypertonicity, hypertension and
re-emergence.9
Dexmedetomidine as selective alpha2 agonist.
It has minimal respiratory effects. A loading
dose of 2 to 3 kg-1 over 10 minutes followed
by a continuous infusion @ 1 to 2 kg-1 hr-1
is sufficient to provide adequate sedation
maintenance. However hemodynamic side
effects of low blood pressure and heart rate
may be observed. Compatibility of infusion
pump has to be taken care of as it may
malfunction near the field.
Anesthesia for MRI

Where potential complications of deep sedation
like hypoventilation, CO2 retention in head
injury patients, apnea, airway obstruction,
laryngospasm,
and
cardiopulmonary
impairment are concern, general anesthesia is
often preferred for the diagnostic procedures
rather than sedation.10 Managing general
anesthesia for MRI procedures has advantages
including; being independent of childs
cooperation, being more predictable, better scan
quality because the child is immobilized and
scan interruptions due to sedation side-effects
are minimized. In addition, it is possible to
perform breath-holding maneuvers for images
that need complete immobilization. In principle
all types of general anesthesia techniques can be
used in MRI. If the ventilator is equipped with
a vaporizer, maintenance of anesthesia using
inhalation agents is still standard in pediatric
anesthesia. New short acting inhalation
anesthetics such as sevoflurane and desflurane
have acquired widespread acceptance in
pediatric anesthesia because of their rapid
uptake and elimination. Sevoflurane is an ideal
inhalation agent routinely used for children.
Use of N2O in 50% Oxygen help in reducing
inhalational concentration reduction.10 On
the other hand, propofol can be used for total

intravenous anesthesia. Laryngeal masks and
tracheal tubes can be used in the MRI setting.
The decision should depend on comorbidities,
anatomy and fasting status in the individual
case.
Widely accepted technique with airway
managed with a supraglottic device is a safe,
predictive and controlled method. Availability
of anesthesia machine with a vaporizer in
preparation room along with all monitoring
equipment is of great help. The child can be
made to sleep in parents lap using inhalational
anesthetic with sevoflurane. As soon as child
goes to sleep iv access is secured. Airway be
secured with a appropriate size supraglottic
device like LMA, igel or Ambu LMA. The child
can then be allowed spontaneous respiration
through circuit using inhalational anesthetics.
While wheeled inside the suite the spontaneous
respiration can be maintained with 1 MAC
of inhalational. Addition of N2O is another
option to reduce high concentration of O2
and gases. Spontaneous technique allows for
predictable smooth spontaneous recovery.10
Use neuromuscular blockers whenever needed
(such as in situations of controlled ventilation
and respiratory maneuvers).
General anesthesia with endotracheal
intubation may sometimes be necessary during
MR imaging. Patients with head trauma, requiring
control of their EtCO2, children from PICU who
are intubated due to underlying pathology and
infants with history of apnea and bradycardia
are few of the examples of indications for
endotracheal intubation. In lack of clear medical
reason for tracheal intubation most instances
spontaneous ventilation is preferred.11
Planning and safety

Framework for anesthesia in the MRI
environment is quite different from that
found in the operating room. Involvement of
experienced anesthesiologist in planning is
important as anaesthesia management for
MRI does not just involve simply duplicating
comparable operating room requirements.
161
In addition to the separate areas for patient

preparation and recovery, the design of the
transport path to the MRI must be barrier-free.
Placement of workstation along with fixation of
monitors and syringe pumps be designed with
consideration of 50 gauss line. The nominated
consultant anesthesiologist should ensure that
anesthetic staff is familiar with the anesthetic
machine and monitoring equipment which are
often of a nonstandard configuration. All staff
should be familiarized with local rules of the
MR department which are appropriate to their
individual role.6
Conclusion
The decision of sedation or anesthesia has to
be made on a case-by-case basis, taking into
account all characteristics of the individual. A
fully equipped anesthesia workstation is strictly
required for both sedation and anesthesia.
Airway management and resuscitation
equipment have to be prepared and directly
available. Adequate training in pediatric airway
and emergency management in this setting with
a restricted view of and access to the patient is
essential for anesthesiologists working in this
environment.
References
1. Uentrop LS, Goepfert MS. Anaesthesia or
sedation for MRI in children. Current Opinion in
Anaesthesiology. 2010;23:513-7.
2. The Association of Anaesthetists of Great Britain
and Ireland. Provision of anaesthetic services
in magnetic resonance units. London UK: The
Ireland ;May 2002
3. Olive D. Dont Get Sucked in: Anaesthesia for
Magnetic Resonance Imaging in Keneally J
(Ed) Australian and New Zealand college of
Anesthetists: Melbourne; 2005. pp.85-96.
4. Teissl C, Kremser C, Hochmair ES, HochmairDesoyer IJ. Magnetic resonance imaging and
cochlear implants: compatibility and safety
aspects. J Magn Reson Imaging. 1999;9:26-38.
5. Bresland MK, Thomas ML, Roy WL. Anesthesia
for offsite procedures. In: Healy TEJ, Knight PR
(Eds). Wylie and Churchill- Davidsons A Practice
162
of Anesthesia 7th edn. Arnold Publishers:

London; 2003.
6. The Association of Anaesthetists of Great Britain
and Ireland. Provision of anaesthetic services
in magnetic resonance units. London UK: The
Ireland;May 2002.
7. Peden CJ, Menon DK, Hall AS, Sargentoni
J, Whitwam JG. Magnetic resonance for the
anaesthetist. Part II: Anaesthesia and monitoring
in MR units. Anaesthesia. 1992;47:508-17.
8. Kress JP, OConnor MF, Pohlman AS, et
al. Sedation of critically ill patients during
mechanical ventilation. A comparison of

propofol and midazolam. American Journal of
Respiratory and Critical Care Medicine.
9. Krauss B, Green SM. Procedural sedation and
analgesia in children. Lancet. 2006;367:766-80.
10. Orhan Me, Bilgin F, Kilickaya O, Atim A, Kurt E.
Nitrous oxide anesthesia in children for MRI: a
comparison with isoflurane and halothane. Turk
J Med Sci. 2011;41:387-96.
11. Committee on Drugs: Guidelines for Monitoring
and management of pediatric patients during
and after sedation for diagnostic and therapeutic
procedures. Pediatrics. 1992;89:1110-5.
Index
Page numbers followed by f refer to figure, t refer to table and b refer to box
A
Adrenaline 26, 110
for anaphylaxis
management 26
in children 27t
Aero medical transfer 116
Airway management,
preparation of 128
Airway
assessment 128
features of 128t
difficult
algorithm 129f
definition 127
intubation 128
Aldrete score 105
Alpha 2-adrenergic
antagonists 80
Ambulances ground transport
advantages of 116t
practical problems 117t
Ambulatory surgery 17
general anesthesia 19
intraoperative care 18
intravenous regional
anesthesia 19
perioperative care 18
peripheral nerve block 19
postoperative recovery 20
preoperative preparation 18
regional anesthesia 19
Ambulatory surgical unit 13
AMT see also aero medical
transfer
Analgesia
epidural 93, 97
audit and critical
incidents 97
catheter insertion 94
complications 93
drugs for 95
equipment used 95
in children 96
patient monitoring 95
patient selection and
consent 93
protocols and guidelines
97
risk factors 93
Anaphylactic reactions 23, 26t
anesthetic technique 29
associated etiologies 26t
grading of severity of 25t
non-immunogenic 24
Anaphylaxis 23
allergic 23
definition 23
non-allergic 23, 24
perioperative 24
clinical features 24
differential diagnosis 25
etiology of 23
investigation 27
management guidelines
26t, 26
management in
children 27t
risk factors for 25t
Anesthesia equipment
anesthesia delivery system
checks 138
airway equipment 140
alternate oxygen supply
source 138
alternative breathing
system 140
breathing system 139
carbon dioxide
absorber 140
correct gas outlet 140
gas supply 139
monitors 140
oxygen monitor 139
power supply 139
scavenging 140
self-inflating bag 138
suction 139
vaporizer 140
ventilator 140
Anesthesia
depth of 51
for MRI 160
general 104
intraoperative monitoring 49
airway and ventilation 49
circulation 50
neuromuscular monitor 50
oxygenation 49
temperature 50
local
CNS manifestation 110
diagnosis 110
prevention 110
monitoring 48
monitoring standards in 45
perioperative care and
monitoring 49
quality assurance 60, 66
acute pain management 65
adverse events
reporting 66
drugs 61
guidelines for obstetric
analgesia 64
in ICU 66
in operating room
services 61
intraoperative period 63
monitoring equipment 61
post-anesthesia
care unit 63
preoperative checklist 63
preoperative
examination 62
records maintinance 63
sterilization of
equipment 61
regional 4
Anesthesiologist 47
qualification of 61
164
Anesthetic, local, systemic

toxicity 109
Anxiolysis 104
Apnea, postanesthetic 15
Atracurium 23
Atropine 61
B
Benzodiazepines 80
Blood transfusion
complications 146
evidence based guidelines
for 145
management of 146
perioperative, strategies to
reduce 145
purpose of 143
risks of 144
cancer recurrence 144
Brachial plexus 89
Bupivacaine 62
C
Catheter related blood stream
infections/CRBSI 76, 77
CCTT 115
Central venous catheters /CVC
infection control
measures 77
limitation 78
precautions to prevent
mechanical injury 78
selections of insertion site 76
Central venous pressure/
CVP 76
Cerebral edema 74
Cerebral herniation 54
Chloral hydrate 160
Cisatracurium 24
Compartment syndrome 97
CRBSI See also catheter
related blood stream
infections
Cricothyrotomy 56
Critical care transport team 113
Im safe test 115, 115t
Croup, postintubation 15
CVC see also central venous
catheters
D
Dexmedetomidine 102, 160
E
Epidural abscess 96
Etomidate 56
F
Fasting guidelines
for adults 155
for infants and children 156
Femoral nerve 91
Fentanyl 101, 102
FFP see also fresh frozen
plasma
Flumenazil 80
Fresh frozen plasma
transfusion 143
indications for 146
G
Glasgow coma scale/GCS
score 53, 53t
Glucagon, for anaphylaxis in
children 27t
H
Head injury
classification 53
definition 53
as per WHO task force 53
severity as per glasgow coma
scale/GCS score 54t
Histamine levels 28
Hypersensitivity reactions, type
4 delayed 24
Hypertension management; in
post anesthesia care
units 9
Hyponatremia, in children,
perioperative
period 73
Hyponatremic
encephalopathy 73
Hypotension management; in
post anesthesia care
units 8
Hypothermia
consequences of 83
definition 79
environmental risk
factors 83
grades 79
risk factors 80
treatment of 84
active warming
mechanisms 84
thermal insulation
mechanisms 84
I
IgE assay, anaphylactic
reaction 28
Inadvertent perioperative
hypothermia /IPH 79
effect of anesthesia
duration 82
effect of anesthesia type 82
management
intraoperative phase 85
perioperative care 84
postoperative phase 86
preoperative phase 84
risk factors 82
surgery risk factors 82, 83
Interhospital transfer
aeromedical
considerations 119
aero-medical transfer 116, 121
patient preparation 122t
relative
contraindications 121t
sample preflight
checklist 123t
checklist 114t
drugs to accompany
critically ill
patients 117t
emergency transfer 113
equipment required 117
general characteristics
of 119t
ground transport
ambulances/GTAs 116
legal issues 121
medications required 117
primary 113
secondary 113
transport triangle 113, 114f
Index
Interhospital transportation
teams, types of 115
Intradermal tests/IDT, for
anaphylactic
reaction 28
Intravenous colloids 24
IPH see also Inadvertent
perioperative
hypothermia
K
Ketamine 160
Ketorolac, in post operative
pain 11
Kounis syndrome 24
L
LAST see also local anesthetic
systemic toxicity
Lignocaine 62
CV/CNS ratio 109
Local anesthetic systemic
toxicity 109
management of 111
M
MAC see also Monitored
Anesthesia Care
Magnesium trisilicate 156
Metoclopramide 156
Midazolam 80, 101, 160
Mivacurium 23
Modified aldrete score 3
Modified postanesthetic
discharge scoring/
PADS 105
for ambulatory surgery 20t
Monitored anesthesia care/
MAC 99
ASA definitions 99
commonly performed
procedures 103
commonly used drugs for
101
complications of 106
in elderly patients 102
monitoring 104
adverse events/effects
secondary to deep
sedation and
procedure 105
capnography 105
cardiovascular
system 105
communication and
observation 104
level of sedation 104
local anesthetic over
dosage/toxicity 105
PACU care and
discharge 105
pulse oximetry 104
temperature 105
practice guidelines 99
preanesthetic assessment 99
airway assessment 100
cardiorespiratory reserve
and physical
fitness 100
cognitive function 100
general assessment 100
preoperative
instructions 101
procedure explanation,
briefing and
consent 100
Morphine, in post operative
pain 10
MRI 157
compatibility of anaesthetic
equipments 159t
compatibility of implanted
devices 158t
N
Narcotics, for post operative
pain 11
Nerve block
femoral 90
equipment 91
position during 91
procedure 91
for post operative pain 11
interscalene and
supraclavicular 89
equipment 89
position during 89
procedure 89
sciatic
equipment used 90
position during 90
165
procedure 90
usage 90
ultrasound guided 87
complications 91
Neuromuscular blocking
agents/NMBA 23
NMBA see also Neuromuscular
Blocking Agents
Nonsteroidal anti-inflammatory
drugs/NSAIDs, in post
operative pain 10
O
OAA/S scale 104
Observer assessment of
alertness/sedation
scale (OAA/S scale)
104b
Obstetric anesthesia 132
aspiration prophylaxis 133
cardiopulmonary
resuscitation 136
combined spinal epidural
analgesia 134
continuous infusion epidural
analgesia 134
emergency management
airway emergencies 135
anesthetic
emergencies 135
for cesarean delivery 134
for labor 133
informed consent 132
laboratory investigations 132
neuraxial analgesia 133
patientcontrolled epidural
analgesia 134
regional 133
spinal opioids 133
Omeprazole 156
Operation theater
basic architecture of 149
catering 153
cleaning 153
data management 153
definition 148
infrastructure of 148
operating theater satellite
pharmacy 153
piped gases in 152
166

regulatory authority 154

requirements for
designing 149
scavenging methods 152
statutory regulations 153
utilization of 148
ventilation 151
P
PACU bypass SCORE 4t
PACUs see also post-anesthesia
care units
PADS 106
Pain management
in childbirth 39
in critically ill and cognitively
impaired patients 39
in geriatric patients 38
multimodal approach for 36
multimodal approach
techniques, types
of 37
pediatric patients 38
perioperative
evaluation 34
preparation 35
techniques 35
Pain
acute, definition 32
ASA task Forces
recommendations
for 34
postoperative 10
management 10
risk factors 10
Pancuronium 24
Perioperative fluid
management, in
children 73
Perioperative fluid monitoring
in children
central venous pressure/
CVP monitoring 74
with burn injury 74
with trauma 75
Physostigmine 81
Piston-powered unpressurised
aircrafts/PPUA) 116
Platelet infusion 143
indication for 145
Platelet-rich
plasmapheresis 145
Post-anesthesia care units 1
Complications 6
airway obstruction 6
atelectasis 7
cardiogenic shock 8
circulatory
complications 8
diffusion hypoxemia 7
dysrhythmias 9
emergence delirium 15
hypertension 9
hypotension 8
hypothermia 12
hypoventilation 8
hypovolemic shock 8
hypoxemia 6
nausea and vomiting 11
pneumothorax 7
postoperative pain 10
pulmonary edema 7
pulmonary embolism 7
respiratory
complications 6
septic shock 8
factors influencing stay in 4
pediatric 14
standards 4
Postanesthesia discharge score
system 13t
Postanesthesia discharge
scoring/PADS system,
modified 106b
Postanesthesia recovery score 3
Postpartum tubal ligation 135
Preanesthetic evaluation 68
asthma 68
diabetes 68, 69
evaluation of cardiovascular
risk 68
hyperthyroidism 69
hypothyroidism 69
investigation 70
chest X-ray 70
coagulation profile 71
echocardiography 71
electrocardiogram 70
nutritional and fluid and
electrolyte status 71
pulmonary function
test 71
serum albumin level 71
serum glucose 71
serum urea and
electrolytes 71
jaundice 68
long-term steroid therapy 69
malignant hyperpyrexia 68
neurological status
assessment 69
parathyroid disease 68
renal disease 68
unusual bleeding 69
Prilocaine, side effects 109
Propofol 101, 160
side effects 102
Propofol-alfentanil-nitrous
oxide 12
R
Ranitidine 156
RAPBC see also regional
anesthesia PACU
bypass criteria
Red blood cells, transfusion
indications for 145
Regional Anesthesia PACU
bypass criteria 3
Retained Placenta removal 135
Ringer lactate 74
Rocuronium 56
Ropivacaine, CV/CNS ratio 109
S
Salbutamol , for anaphylaxis in
children 27t
Sedation
ASA suggested levels 104
deep 104
minimal 104
moderate 104
Skin Tests, for anaphylactic
reaction 28
Society for ambulatory
anesthesia/SAMBA 17
Sodium citrate 156
Spinal Needles 134
Succinylcholine 23, 56
Index
Surgical patient safety
checklist 62
Suxamethonium 61
T
TBI see also traumatic brain
injury
Temperature
methods of recording 84
esophageal devices 84
nasopharyngeal
devices 84
pulmonary artery
devices 84
rectal devices 84
sublingual devices 84
tympanic membrane
devices 84
Thiopentone 24
Thiopentone sodium 61
Transversus abdominis plane
block /TAP 36
Traumatic brain injury/TBI 53
ABC 56
criteria to refer a patient to
ED 55
assessment at the ED 55
imaging 57
CT scan 57
magnetic resonance
imaging/MRI 57
management in children 55
neurologic evaluation 57
prehospital management
airway management 54
167
brain trauma foundation/

BTF 54
transportation 55
primary survey and
resuscitation 56
ventilation strategy 54
Tryptase 27
V
Vecuronium 24
W
Warming devices, complications
of 84
White and song scoring
system 13

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PRACTICE GUIDELINES

Editorial Board Members

VP Kumra MD DAc FICA

B Radhakrishnan MD MPhil FICA

SM Basu MD DA (London) FICA

Indian College of Anaesthesiologists

Indian Society of Anaesthesiologists

The Health Sciences Publisher

Jaypee Brothers Medical Publishers (P) Ltd.

Jaypee-Highlights Medical Publishers Inc.

Jaypee Medical Inc.

Jaypee Brothers Medical Publishers (P) Ltd.

Jaypee Brothers Medical Publishers (P) Ltd.

Practice Guidelines in Anesthesia

Bikash Ranjan Ray MD

Anil Agarwal MD MNAMS FICA

Anjan Trikha MD FICA

Ashok Kumar Saxena MD FAMS FICA

Dalim Kumar Baidya MD

Girija Prasad Rath MD DM

Gundappa Parameswara MD FICA

Jayashree Sood MD FFARCS PGDHHM FICA

Practice Guidelines in Anesthesia

Professor and Head

LD Mishra MD PhD FICA

Parshotam Lal Gautam MD

Professor and Head

Prashant Kumar MD PDFNA

Mahesh Kumar Arora MD

Mritunjay Varma MD FRCA

Professor and Head

Raminder Sehgal MD FICA

Rashmi Datta MD DNB

T Prabhakar VSM MD PDCCC (Neuroanesth), FICA

Sunanda Gupta MD PhD FAMS FICA

VP Kumra MD DAc FICA

VP Kumra MD DAc FICA

Abdul Qayoom Dar

2. Perioperative Care of Ambulatory Anesthesia

Anil Agarwal, Kamal Kishore

3. Anaphylactic Reactions During Anesthesia

4. Acute Pain Management Guidelines and Protocols: Evidencebased

Ashok Kumar Saxena

5. Monitoring Standards in Anesthesia

6. Head Injury: Assessment and Early Management

Girija Prasad Rath, Bikash Ranjan Ray

7. Guidelines to Quality Assurance in Anesthesia

Practice Guidelines in Anesthesia

8. Preanesthetic Evaluation and Investigation

JP Sharma, Nidhi Kumar

9. Perioperative Fluid Management in Children

10. Central Venous Catheter Management Guidelines

Mahesh Kumar Arora, Dalim Kumar Baidya

11. Inadvertent Perioperative Hypothermia

12. Practical Guidelines for Ultrasound Guided Nerve Blocks

13. Epidural Analgesia: The Practice Guidelines

14. Monitored Anesthesia Care

Parshotam Lal Gautam

15. Management of Local Anesthesia Toxicity

16. Interhospital Transfer of Critically Ill Patients

Accompanying Medications 117; Accompanying Equipment 117

17. Practice Guidelines for Management of the Difficult Airway

18. Practice Guidelines in Obstetric Anesthesia