Manage a Patient Under

Anesthesia

Andi Salahuddin
SMF/Bag.Anestesiologi, Perawatan
Intensif dan Pengelolaan Nyeri FK-
UNHAS/ RSWS Makassar
23 Pebruari 2011

Components of Anesthesia
( Trias Anesthesia )
Muscle Relaxation
Unconsciousness
Analgesia
REASON
1. Anesthetics have potent CNS, CV &
RESPIRATORY depressant in therapeutic
dose.
2. Severe depression is life threatening.

EMERGENCY STATE
MONITORING
Monitoring in the Past
Visual monitoring of
respiration and
overall clinical
appearance
Finger on pulse
Blood pressure
(sometimes)
Monitoring in the Present
Standardized basic monitoring requirements
(guidelines) from the ASA (American Society of
Anesthesiologists), CAS (Canadian
Anesthesiologists Society) and other national
societies
Many integrated monitors available
Many special purpose monitors available
Many problems with existing monitors (e.g., cost,
complexity, reliability, artifacts)
ASA Monitoring Guidelines
STANDARD I

Qualified anesthesia personnel shall be
present in the room throughout the
conduct of all general anesthetics,
regional anesthetics and monitored
anesthesia care.
http://www.asahq.org/publicationsAndServices/standards/02.pdf


ASA Monitoring Guidelines
STANDARD II

During all anesthetics, the patients
oxygenation, ventilation, circulation and
temperature shall be continually
evaluated.

http://www.asahq.org/publicationsAndServices/standards/02.pdf
The only indispensable monitor is the presence, at all
times, of a physician or an anesthesia assistant, under
the immediate supervision of an anesthesiologist, with
appropriate training and experience. Mechanical and
electronic monitors are, at best, aids to vigilance. Such
devices assist the anesthesiologist to ensure the
integrity of the vital organs and, in particular, the
adequacy of tissue perfusion and oxygenation.
CAS Monitoring Guidelines
The following are required:
Pulse oximeter
Apparatus to measure blood pressure, either
directly or noninvasively
Electrocardiography
Capnography, when endotracheal tubes or
laryngeal masks are inserted.
Agent-specific anesthetic gas monitor, when
inhalation anesthetic agents are used.
CAS Monitoring Guidelines
The following shall be exclusively
available for each patient:
Apparatus to measure temperature
Peripheral nerve stimulator, when
neuromuscular blocking drugs are used
Stethoscope either precordial, esophageal
or paratracheal
Appropriate lighting to visualize an exposed
portion of the patient.
CAS Monitoring Guidelines

The following shall be immediately
available:

Spirometer for measurement of tidal volume.
CAS Monitoring Guidelines
Detecting Mishaps Using Monitors
1. Disconnection
2. Hypoventilation
3. Esophageal intubation
4. Bronchial intubation
5. Circuit hypoxia
6. Halocarbon overdose
7. Hypovolemia
8. Pneumothorax
9. Air Embolism
10. Hyperthermia
11. Aspiration
12. Acid-base imbalance
13. Cardiac dysrhythmias
14. IV drug overdose

Source: Barash Handbook
These mishaps
Basic Monitoring
Cardiac: Blood Pressure, Heart Rate, ECG
ECG: Rate, ST Segment (ischemia), Rhythm
Respiratory: Airway Pressure, Capnogram, Pulse Oximeter,
Spirometry, Visual Cues
Temperature [pharyngeal, axillary, esophageal, etc.]
Urine output (if Foley catheter has been placed)
Nerve stimulator [face, forearm] (if relaxants used)
ETT cuff pressure (keep < 20 cm H
2
O)
Auscultation (esophageal or precordial stethoscope)
Visual surveillance of the anesthesia workspace and some
exposed portion of the patient
Visual Surveillance
Anesthesia machine / workspace checkout
Patient monitor numbers and waveforms
Bleeding/coagulation (e.g., are the surgeons using a lot
of suction or sponges? )
Diaphoresis / movements / grimaces
Line quality (is my IV reliable?)
Positioning safety review
Respiratory pattern (e.g. tracheal tug, accessory muscle
use etc.)
High Tech Patient Monitoring
Examples of Multiparameter Patient Monitors
High Tech Patient Monitoring
Some Specialized Patient Monitors
Depth of Anesthesia Monitor
Evoked Potential Monitor
Transesophageal
Echocardiography
Special Monitoring
Pulmonary artery lines (Swan Ganz)
Transesophageal echocardiography
Intracranial pressure (ICP) monitoring
Electrophysiological CNS monitoring
Renal function monitoring (indices)
Coagulation monitoring (e.g. ACT)
Acid-base monitoring (ABGs)
Monitoring depth of anesthesia
PROCEDURES
Review the principles of monitoring and
maintenance
Review the components, clinical signs,
and depth of anesthesia
Apply the principles of monitoring and
maintenance (Circle of Awareness)
Review the Principles of
Monitoring and Maintenance


Monitoring
Tasks
Level of Anesthesia
A
B
C
Monitoring
Level of Anesthesia
Unresponsive to pain stimuli
Eyes fixed and pupils constricted
Muscles relaxed
Monitoring
Airway
Must maintain positive control over the
patients airway (to include the tongue)
Monitor the airway at all time while the patient
is under general anesthesia.
Monitoring
Airway
Oxygenation

pre-oxygenate for Intubation
100% O2 - 6 L/min
resuscitation 100% O2 - 15+ L/min
Ventilation
Monitoring
Breathing
The lungs and breathing must be
continuously monitored.
Rate and depth of respirations
Dry versus wet lungs? ( humidifier )
Monitoring
Breathing
I Inspection
A Auscultation
P Palpation
P Percussion
Monitoring
Circulation
Heart rate, character, and rhythm = 68
strong and regular
Tissue perfusion
Body temperature
Renal Function

Output = >25 to 50cc/hr

Components of General
Anesthesia
Muscle Relaxation

Amount of skeletal muscle relaxation
requirements depend on the type of
operation.

Components of General
Anesthesia
Analgesia/ Areflexia

Pain reflexes are subdued.

Components of General
Anesthesia
Unconsciousness/Hypnosis

The patient is oblivious to all sensation
but pain reflexes can occur.
Depth of Anesthesia
Stages and Planes of Ether Anesthesia
Stage I Amnesia
Stage II Excitement
Stage III Surgical Anesthesia
Plane 1
Plane 2 The Surgical Plane
- Plane 3
Plane 4
Stage IV Impending Death
Stages and Planes of Ether
Anesthesia
STAGE I Amnesia

From the onset of drowsiness to the loss of
the eyelash reflex.
Stages and Planes of Ether
Anesthesia
STAGE II Excitatory Stage

Agitation, delirium, irregular respiration and
breath holding .
Pupils dilate, eyes diverge.
Stages and Planes of Ether
Anesthesia
STAGE III Surgical Anesthesia

Plane 1
From the return of regular respirations to the
cessation of REM.

Stages and Planes of Ether
Anesthesia
STAGE III

Plane 2 The Surgical Plane
From the cessation of REM to the onset of
paresis of the intercostal muscles.
Stages and Planes of Ether
Anesthesia
STAGE III

- Plane 3
From the onset to the complete paralysis of
the intercostal muscles.
Stages and Planes of Ether
Anesthesia
STAGE III

Plane 4
From the paralysis of the intercostal muscles
to the paralysis of the diaphragm - at the end
of this plane the patient will be apneic.
Stages and Planes of Ether
Anesthesia
STAGE IV Impending Death

From the onset of apnea to circulatory failure.
Why we need monitors?
1. Our sense is limited.
2. Free up the anesthetist hand.
3. Monitor many parameters simultaneously
The Circle of Awareness is the
anesthetist monitoring
management tool.
The circle helps the anesthetist
to monitor and manage:
Vital signs
Stage of general anesthesia
Airway, respiratory and cardiac systems
Input and output of all fluids and drugs
Time
Recording
Communications
The circle of awareness should
begin a few moments after the
patient is placed on anesthesia
maintenance.
PATIENT
Patient should be unresponsive to painful stimuli
Eyes should be: Fixed, pupils constricted (dilated =
caprine specific) and non-reactive to light
Mandible and tongue: Relaxed
Limbs: Relaxed, non-withdrawal to pain
If being assisted by personnel within the OR,
request a temperature and blood pressure be taken
at this time
AIRWAY
Inspect Oxygen Tubing: From the wall to the
patient
Inspect Endotracheal Tube: Secured, bulb
inflated, bite block present, and suction PRN
Inspect Patients Respiratory Effort: Note rate
and rhythm, one deep ventilation
BREATHING
Inspect Trachea: Look for Tracheal deviation
or jugular vein distention (JVD)
Inspect Chest: Rise and fall
Auscultate Chest: Clear breath sounds, note
rate and rhythm (again)
CIRCULATION
Auscultate Heart: Note rate and rhythm
Inspect All IVs : Read labels and check fluid
levels, check drip rate, inspect tubing to
catheter, inspect IV site for infiltration
RECORD
Record on the SF 517: Time, drug input,
suction, oxygenation, ventilation, level of
consciousness, vitals signs, fluid input/output,
all complications throughout surgery in other
remarks
REPORT
Communicate: Communication the patients
status and vitals to surgical team.
Insure you receive a response from the
surgeon
At this point, make improvements,
adjustments and corrections to any
deficiencies that you discovered during the
circle
SUMMARY OF
PROCEDURES
Review the principles of monitoring and
maintenance
Review the components, clinical signs,
and depth of anesthesia
Apply the principles of monitoring and
maintenance (Circle of Awareness)