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PREFACE
This book grew from notes first written in 2003 - 2004 from the students at the J J M
Medical College in Davangere.
There are many textbooks to choose from when preparing for the Anesthesiology
examination. The candidate suffers not from the lack of information but rather from
being inundated with it. The candidate then has the task of information sorting and
data compression to memorize and utilize all this information.
Graphic representation of data is an excellent form of data compression; figures or
drawings are frequently asked about at the viva examination, particularly since the
candidates understanding of a problem comes across most clearly when drawing a
figure or a using a picture. Figures are also a good way of approaching a topic.
I constructed parts of Dr Azams Notes in Anesthesiology for Postgraduate
students when preparing for the Anesthesiology examination and later when
preparing for tutorials.
Dr Azams Notes is aimed primarily at trainees in Anesthesia though more
experienced practitioners may find it useful as a refresher in recent concepts and
advances
Dr Azams Notes is not a substitute for the major anesthesiology text books but
concentrates on principles of management of the most challenging anesthetic cases.
The format is designed to provide easy access to information presented in a concise
manner. I have tried to eliminate all superfluous material. Selected important or
controversial references are presented as well as suggestions for further reading.
Some relate more to basic principles, physiology, pharmacology, etc. bookwork.
Others are more practical in nature, discussing the principles of anesthetic techniques
for certain high-risk situations.
Dr Azams Notes have been created keeping the Postgraduate needs while preparing
for the exams, and also help in his day to day practice. I am sure that Dr Azams Notes
will not only help him to secure highest marks but also help him to gain knowledge to
its full.
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NOTICE
Anesthesiology is an ever-changing field. Standard safety precautions must be
followed, but as new research and clinical experience broaden our knowledge, changes
in treatment and drug therapy may become necessary or appropriate. Readers are
advised to check the most current product information provided by the manufacturer
of each drug to be administered to verify the recommended dose, the method and
duration of administration, and contraindications.
However, in view of the possibility of human error or changes in medical sciences,
neither the author nor the publisher nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained
herein is in every respect accurate or complete, and they disclaim all responsibility for
any errors or omissions or for the results obtained from use of the information
contained in this work. Readers are encouraged to confirm the information contained
herein with other sources. It is the responsibility of the licensed prescriber, relying on
experience and knowledge of the patient, to determine dosages and the best treatment
for each individual patient. Neither the publisher nor the editor assumes any liability
for any injury and/or damage to persons or property arising from this publication.
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DEDICATION
To Mohammed Shafiulla, my father, my oxygen,
companion, and best friend; for being my major pillar of
support and making this vision a reality. Thank you for your
continual sacrifices with boundless love and limitless
gratitude, for the sake of your children. I owe you a debt I
can never repay.
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Contributions
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Table of Contents
PREFACE .......................................................................................................................................................... 3
NOTICE ............................................................................................................................................................... 4
DEDICATION .................................................................................................................................................... 5
CHAPTER 1 - MANAGEMENT OF UROENDOSCOPIC ........................................................................................ 11
PROCEDURES IN GERIATRICS ......................................................................................................................... 11
CHRONOLOGICALLY, GERIATRIC PATIENTS CAN BE CLASSIFIED AS FOLLOWS: ....................................................................... 12
PHYSIOLOGY OF AGEING IS DETERMINED BY: .................................................................................................. 12
PHYSIOLOGIC CHANGES ASSOCIATED WITH AGING ......................................................................................... 13
CARDIOVASCULAR SYSTEM ......................................................................................................................... 13
ANATOMICAL AND PHYSIOLOGICAL CHANGES IN RENAL SYSTEM. ..................................................................................... 25
PHARMACOKINETICS AND PHARMACODYNAMICS IN ELDERLY ....................................................................... 30
PREOPERATIVE EVALUATION ........................................................................................................................... 37
CHAPTER 2 - KIDNEY COCKTAIL ...................................................................................................................... 42
CHAPTER 3 - ACUTE RENAL FAILURE .............................................................................................................. 44
DEFINITION OF RENAL DYSFUNCTION AND ITS DIAGNOSIS .............................................................................................. 44
Urinary output ............................................................................................................................................. 44
CAUSES:.............................................................................................................................................................. 46
PRE RENAL........................................................................................................................................................... 46
PERIOPERATIVE CONSIDERATIONS............................................................................................................................. 47
PHYSICAL EXAMINATION AND PREPARATION FOR SURGERY ............................................................................................ 49
TABLE 5: TREATMENT OF HYPERKALEMIA................................................................................................................... 54
CHAPTER 4 - TURP.......................................................................................................................................... 57
DEFINITION ...................................................................................................................................................... 57
ANATOMY AND PATHOPHYSIOLOGY OF HYPERTROPHIC PROSTATE NERVE SUPPLY AND PAIN CONDUCTIVE PATHWAYS: .............. 57
Anesthetic problems:................................................................................................................................... 59
Preoperative evaluation. ............................................................................................................................. 60
Anesthesia ................................................................................................................................................... 62
Table 1: approximate doses of local anesthetic for regional block ............................................................. 63
TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) .............................................................................................. 66
Physiological changes during the lithotomy position. ................................................................................. 66
Non electrolyte solution: .......................................................................................................................... 67
COMPLICATIONS OF TURP: .................................................................................................................................... 68
POSTOPERATIVE COMPLICATIONS: ............................................................................................................................ 69
TURP SYNDROME: ................................................................................................................................................ 69
PATHOPHYSIOLOGY AND CLINICAL FEATURES OF TURP SYNDROME: ................................................................................ 71
SIGNS AND SYMPTOMS OF HYPONATREMIA ................................................................................................................ 73
TREATMENT OF TURP SYNDROME: .......................................................................................................................... 74
CHAPTER 5 - GUIDELINES FOR PREOPERATIVE INVESTIGATIONS AND LABORATORY TEST ABNORMALITIES. . 86
COMPLETE BLOOD COUNT....................................................................................................................................... 86
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Variability in the rate at which organ system function changes with increasing age
explains the presentation of patients as physiologically Young or old.
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Renal
Renal blood flow
Glomerular filtration rate
Gastrointestinal
Hepatic blood flow
Hepatic mass
Musculoskeletal
Muscle mass
Total body water
Bone density
Body fat
Incidence of osteoarthritis
Neurologic
Cortical neurons
Cerebral blood flow except
with disease then
= decreased = no change
CARDIOVASCULAR SYSTEM
Cardiovascular changes that occur with ageing are more important to the
anesthesiologist than any of the age related physiological changes, as most of the
intravenous and inhalational anesthetic agents to some extent are CVS depressants.
Various changes seem are:
1. Decreased Beta receptor responsiveness.
2. Stiffening of connective tissue in the arteries, veins and heart.
3. Increase in the activity tissue in the arteries, veins and heart.
4. Gradual myocyte death without replacement.
5. Decreased responsiveness to atropine.
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Functional correction
Stiffening of chest wall (decreased TV)
Decreased electromygraphic (EMG)
activity by 50% in skeletal muscles.
Decreased MBC.
Poor cough.
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Various changes seen in lung volumes are as shown in the diagram below
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1) Changes in brain.
Neurons are postmitotis cell therefore they are not replaced when they get injured or
die. Total brain weight declines by 10-30% by the age of 80 years mainly there is
decline in grey matter. Cerebral metabolism and O2 demand is reduced mainly because
of decreased neuronal tissues mass.
Cerebral blood flow is reduced by modest degree but its auto regulation is well
maintained. Regional cerebral blood flow mainly depends on local metabolic and
neuronal activity and it remains unchanged. But diseases that alter cortical function
may uncouple local brain blood flow form metabolic requirement of the tissues they
perfuse. Cerebral glucose utilization is also decreased.
Reductions in neuronal density and declining neuro transmitter synthesis reduce
requirements for specific hemispheric global (CBF) and regional grey matter (CBF)
brain blood flow. Hemispheric cerebral metabolic requirements for oxygen (CMRo2
ml/100gm/min) will decline nonlinearly.
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diminished Eg: Short term memory, Visual and auditory reaction time, immediate
processing of information.
5) Sleep and plasticity.
Total average time in bed increases but there are arousal periods during the sleep. Early
awakening in the morning is seen. Rapid eye movement (REM) sleep is well maintained
but deeper stage III and slow wave sleep pattern are compromised.
Upper airway obstruction, apnoea and hypoventilation are common during sleep
leading to hypoxia induced disturbances in CVS and CNS metabolism. Nocturnal
ventilator response to CO2 remains unchanged. Circadian rhythm of adrenocortical
steroid release related sleep pattern does not change much.
6) Autonomic nervous system
The autonomic reflex responses are gradually impaired in the elderly. The speed
and magnitude of the response are low and they find it difficult to maintain homeostasis
under stress. They respond poorly to sudden changes in posture, hypovolemia and do
not increase their heart rate in response to stress as readily as a young adult. The
mechanism for this is a decrease in the number of receptors as well affinity of receptors
to the agonists.
7) Thermoregulation
Elderly are more prone for perioperative hypothermia because of:
- Frail constitution
- Reduced metabolic rate
- Reduced subcutaneous fat layer
- Major and long operations.
- Impaired thermoregulation i.e.
- Delayed and less vigorous compensatory mechanisms:
Eg: cutaneous vasoconstriction, shivering etc
Adverse effects of hypothermia:
- CNS depression
- Depression of ventilator drive which may extend postoperatively to produce
postoperative somnolence and hypoxia
- Prolonged drug action.
- Precipitates negative post operative nitrogen balance and accelerates protein
catabolism.
- This compromises wound healing and surgical recovery.
- Impairment in coagulation.
- Immune dysfunction.
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Prevention by using:
Warm IV Fluids, heating blankets, warmed water mattresses and forced air warming.
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Both volume of urine produced and the fraction of total daily creatinine excreted
during sleep is increased. This effect combined with age related reduction in
urinary bladder capacity predisposes to nocturia.
In conclusion, loss of renal tissues mass and reduced GFR due to the decline of
nephron functional reserve, unaltered osmorecetpor/ACP responsiveness, are
probably responsible for the age related impairment of water homeostasis.
Hence, fluid restricted elderly surgical patients are at increased risk of
dehydration and hypernatremia.
SUMMARY OF MAJOR AGE-RELATED CHANGES IN RENAL AND HEMATOLOGICAL
STRUCTURE AND FUNCTION
Kidney
Modest by variable loss of renal tissue mass, especially in cortices
Marked decline in renal blood flow and glomerular filtration rate
Slight increase in filtration fraction
Glomerulotubular balance well maintained
Reduced tubular responsiveness to hormones that conserve salt and water
Decreased acid excretion
Blood
Normal erythrocyte, platelet, and leukocyte indices
Reduced erythropoietic functional reserve
Normal coagulation and haemostasis
Decreased fibroinolytic reserve, predisposition to infection and autoimmune
phenomena
Pharmacokinetics
Decreased renal clearance of hydrophilic drugs and metabolites
Slightly reduced plasma protein binding of xenobiotics
Increased apparent drug potency and high plasma drug concentrations due to
delayed redistribution of parenteral drugs from plasma
Haematological changes:
Volume of bone marrow is reduced, but the functional remains normal when there is
adequate supply of iron, folic acid and Vit. B12. Flexibility of RBC is decreased,
compromising small vessel perfusion especially in patients in shock or with
polycythemia and with conditions of acute hemoconcentration. RBC fragility is
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Body composition
Decreasing skeletal muscle mass throughout adulthood (especially in sedentary
men)
Loss of metabolically active organ (e.g., liver, kidney) lean tissue mass and blood
flow.
Decreased intracellular water
Maintained circulating blood volume (aerobically active, normotensive older
adults)
Tissue functions
Little qualitative changes in metabolic activity
Atrophy and fibrocalcification of elastic and mechanically specialized tissues (skin,
eye, large arteries)
Altered tissue receptor/agonist interactions for neurotransmitters and trophic
hormones
Pharmacokinetics
Increased alpha-phase drug concentrations
Delayed redistribution of drugs from plasma to affect compartments in the
biophase
Reduced elimination clearance for drugs undergoing hepatic or renal biotransformation
Increased steady-state distribution volumes for lipophilic drugs
Prolonged elimination half-times
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PHARMACODYNAMICS
IN
Drug dose
Absorption
Distribution
Binding
Metabolism
Excretion
Plasma
Concentratio
n
Distribution
Diffusion
Binding
Physiological state
Pathological changes
Other drugs
Tissue
concentratio
n
Drug
response
Pharmac
o
Kinetic
factors
Pharmac
o
Dynamic
factors
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Volume of distribution affected by total body water, protein content and body fat
content.
Elderly people have increased body fat decreased serum protein levels and total
body water. This will increase the volume of distribution for lipid soluble drugs,
decreasing their plasma concentration. Conversely, water soluble agents have less
volume of distribution, hence higher plasma concentration. Because of increased
volume of distribution of lipid soluble agents, they have longer duration of action, hence
delayed recovery and also they have to be used in smaller doses. Clearance for
intravenous agents depends on the efficiency of hepatic metabolism and renal
elimination and for inhalational agents it depends on the efficiency of cardiopulmonary
system function.
Renal and hepatic function decline with age, so the drugs which depend upon
their clearance on the function of these two organs may show prolonged duration of
action. Increased elimination half life make them susceptible for cumulative drug
effects, Age related decline in CNS function make elderly more sensitive to drugs is also
reduce. Altered plasma protein binding also effects distribution and elimination of a
drug. Ageing causes decrease in serum albumin level and increase in acid glycoprotein
(which binds to basic drugs). Protein bound drugs cannot interact with end organ
receptors and are unavailable for metabolism or excretion.
Anesthetic implications of various physiological changes:
It is difficult to elicit proper history because of decreased visual auditory acuity
as well as impaired memory. These changes can also contribute for post operative
confusion. Elderly may present with nutritional anaemia (which increase perioperative
CNS mortality and morbidity by increasing demand for increased cardiac output).
Anaemia will be less responsive to iron therapy. Decreased lean tissue mass and fat
reduces their body weight. They are shorter and may be kyphotic because of reduced
intervertebral spaces. Poor dentition poses problems during airway management.
Delayed gastric emptying and associated decreased airway reflexes make them prone
for aspiration. They arrive to the operating room with increased sympathetic activity
because of anxiety and pain. There may be difficulty in canulation and homeostasis
because of fragile veins. Careful handling during positioning is necessary. Elderly are
more dependent on increased sympathoadrenal activity for maintenance of their basal
activity than young adults. Hence GA/SA induced disintegration of Sympatho adrenal
activity may be dangerous in them especially if autonomic response is already
compromised by HTN/other CVS pathology.
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anesthesia induced modification of the lung, thorax and abdominal unit, but not by
increase in true shunt. Hence this hypoxia wont respond to increase in PEEP or
hyperventilation/use of large tidal volume/intermittent sigh/by increasing
concentration of delivered O2. N2O can disrupt neurological function within the cerebral
cortex causing cognitive disorder.
With regional epidural anesthesia, lesser dose of local anesthetic is required.
Greater cephalad spread is seen, maximum plasma concentration is attained sooner and
recession of block is more rapid. This is because of: Increase in rigidity of the space
(decreased spread through the intervertebral space) decreased local resistance to L.A
and more rapid vascular absorption. Duration of spinal anesthesia is slightly increased,
but spread of anesthesia is indistinguishable from that seen in young adults. Incidence
of cauda equine syndrome is high, PDPH incidence is decreased. More prone to
neurotoxic injury by lidocaine because of decreased CSF volume or spinal canal stenosis.
Bradycardia produced intraoperatively is less responsive to atropine.
Post operatively:
They are more prone for pulmonary atelectasis, sleep apnoea, obstruction of
airway and aspiration pneumonia because of diminished airway reflexes and increased
periodic breathing during sleep. They maintain O2 delivery by increasing O2 extraction
not by increasing cardiac output. Hypoxia can precipitate myocardial ischemia. Hence,
post operative O2 supplementation is must. They are more susceptible to acute
respiratory failure and their MBC is less. Hence, it will be difficult to wean them from
the ventilator. Good post operative analgesia should be provided to avoid pain and
anxiety induced precipitation of MI, stroke etc. High antibiotic coverage is must.
Adequate nutrition, fluid and electrolyte balance should be maintained.
Maximum residential depression of nervous system occurs during the second
day of GA in both young and elderly. Transient confusion and disorientation may persist
for a longer duration. Ultimate recovery of intact neurological function is more difficult
to re-establish promptly in the elderly surgical patient than in the young. Pre-existing
CVS and cerebrovascular diseases are also contributory factors for the post operative
neurological dysfunction along with anesthetic agents and techniques.
It should be remembered that:
There are no specific principles/guidelines to the perioperative management of the
geriatric patient that will guarantee rapid emergence or uncomplicated neurological
outcome
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the dosage of Midazolam is reduced to 30-60% if the patient is still anxious; Inj.
Midazolam is given in 1 mg IV increments.
For Biopsy/Diathermy/Incision:
1% lidocaine with adrenaline (1:200.000) is infiltrated into the area.
The advantage of this technique is that is more safe and has got high acceptancy.
Patient can be discharge within 1 hour after the procedure.
Spinal/Epidural anesthesia:
Bupivacaine, with or without narcotics are used in various concentrations. 0.25% is
found to be least toxic.
Advantages:
Minimal physiological disturbances. Provides adequate muscle relaxation of
pelvic floor, perineal and thigh muscles. Can diagnose over hydration, bladder
perforation, visual disturbances and change in consciousness early. More useful if Xrays are to be taken during cystoscopic examination. Since patients can be asked to
cooperate by holding their breath at the proper time.
Complications:
Hypotension, high or total spinal, headache, backache, meningitis etc are seen
with regional block PDPH is rare in elderly. Transient hearing loss not seen with
epidural anesthesia, because of transmission of decreased CSF pressure to the inner ear
through the cochlear duct
General Anesthesia:
Is indicated when:
Regional anesthesia fails.
Regional anesthesia is contraindicated.
Patient is unco-operative/anxious.
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Surgical stress
Immunological changes
No
significant No significant
difference
Difference
More
Decreased heat
Production.
Therefore
if
unwarmed
irrigating fluid is
used, heat loss
will be more.
No change in Cortisol levels seen in
both groups
Decreased
Smaller
lymphocyte and elevation
in
lymphocyte
glucose
responsiveness
Need
post Can give post
operative
pain operative
medication early analgesia with
and
very epidural
frequently
catheter insitu
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PREOPERATIVE EVALUATION
History:
In the workup of any patient, the history is of paramount importance. This is
particularly true in urology. History helps us to know whether the disease is acute or
chronic and directs towards that specific investigations to be done.
HISTORY OF PRESENTING ILLNESS
Various enquiries in particular to the patient with urological problems are:
History of:
Coexisting diseases Eg: IHD, HTN, Asthma, TB etc.
Previous hospitalization.
Other surgical procedures
Blood transfusions.
Cognitive dysfunction/malignancy/gait disturbances
Alcohol/smoking habits.
Bladder habits.
Family history of DM/HTN/IHD/TB etc.
Present/past medications with regard to indication, dosage, frequency duration
and any allergic drug reactions.
Drugs commonly prescribed for the elderly patients:
Drug
Adverse effect or drug interaction
Diuretics
Hypokalemia
Hypovolemia
Digitalis
Cardiac dysrhythmias
Cardiac conduction disturbances
Beta antagonists
Bradycardia
Congestive heart failure
Bronchospasm
Attenuation of autonomic nervous system activity
Centrally
acting Attenuation of autonomic nervous system activity
antihypertensive
Decreased MAC
Tricyclic antidepressants
Anticholinergic effects
Cardiac dysrrhythmias
Cardiac conduction disturbances
Increased MAC
Lithium
Cardiac dysrrhythmias
Prolongation of muscle relaxants
Antidysrrhythmic
Prolongation of muscle relaxants agents
Antibiotics
Prolongation of muscle relaxants
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PHYSICAL EXAMINATION
I. General physical examination.
Look
for
appearance,
behaviour,
gait,
speech,
presence
of
anxiety/depression/confusion. Presence/absence of pallor, cyanosis, clubbing,
lymphadenopathy, periorbital and pedal oedema, dehydration etc. Examine the spine
for any deformity. Check tone of anal sphincter. Elicit achillis tendon and
bulbocavernous reflexes. Assess-nutritional status, body mass index, skin fold thickness.
Assess Airway:
Check mouth opening, neck movements, buccal pad of fat
Look for dentition loose teeth,
Look if there is any vertebrobasilar insufficiency,
Grade airway by mallampatti scoring system.
II. SYSTEMIC EXAMINATION
Respiratory system
Cardiovascular system
C.N.S. with regard to intelligence and memory as well.
Detailed neurological survey has to be done to uncover sensory or motor
impairment that will account for residual urine or incontinence.
Per-abdomen:
Look for any organomegaly, free fluid, lymphnode enlargement especially,
hypogastric, external iliac, preaortic etc. Which can present as abdominal mass? Also
palpate left supraclavicular LN as testicular and prostatic malignancies metastasise
here.
INVESTIGATIONS:
History and physical examination directed testing, markedly improves the
effectiveness of preoperative preparation and assists in the formation of appropriate
anesthetic plan.
Various tests to be done on an elderly surgical patient should be primarily
determined by the surgical procedure and by the type and severity of pre-existing
disease and the extent of functional compromise.
Hb% TC, DC, ESR.
Complete haemogram, BT. CT
Peripheral blood smear: May show hypochromic anaemia in case of chronic
pyelonephritis, uremia and carcinoma.
Urine: Albumin, Sugar,Micriscopy, Culture, pH, specific gravity
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ECG
RBS
Renal function tests:
Blood urea, serum creatinine,
Creatinine clearance
Serum electrolytes.
Roentogenography examinations of urinary tract
USG, CT Scan, Radioisotopic studies and endoscopic examination depending on
the need.
RISK ASSESSMENT.
Risk factors for postoperative mortality in elderly surgical patients:
ASA Physical status
III & IV
Surgical procedures
Co-existing diseases
Functional status
Nutritional status
Place of residence
Ambulatory status
Bedridden.
PREOPERATIVE PREPARATION:
Elderly are associated with certain psychological stresses which make them
anxious or depressed and increases the risk of post operative delirium, confusion,
cognitive dysfunctions and dysfunctions and depression, thus delying the recovery.
These stresses include
Fear of loss of normal functioning.
Fear of long term hospitalization/death.
Fear of operative and anesthetic procedures.
Awareness of financial burden.
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CrCl (ml/min) =
(140-age) x weight
(kg)
72 x serum Cr (mg/dl)
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This equation is simply the ratio of the expected amount of muscle breakdown (taking
age and weight into account) to the breakdown product present in the serum multiplied
by a 'fudge factor' of 72. Women being smaller the resulting value is multiplied by 0.85
for females. However in acute renal failure with rapidly failing kidneys this formula may
overestimate creatinine clearance and a more accurate estimation is required. This may
be done by collecting urine over a period of time, usually 24 hours but in the ICU
situation even 2 hours has been shown to yield accurate results and may be more
practical ads well. The following equation is then used
Urine sodium and osmolality. When perfusion of the kidneys is reduced, sodium
reabsorption increases and excretion decreases and a urine sodium of less than 20
meqL-1 results (urine osmolality >400 mosmolkg-1). This may occur in hypovolemia due
to dehydration or haemorrhage, or from decreased forward flow as is seen in patients
with cardiac failure. Urinary sodium concentrations of less than 10 meqL -1 may be seen
in patients with hepatorenal syndrome or very severe hypo perfusion.
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amyloidosis) and obstructive causes (large dilated pelvis and ureters). It can also
estimate renal perfusion using Doppler ultrasound.
Nuclear scans are useful in case of suspected embolus or vascular compromise.
Causes:
Investigations to help differentiate pre renal and renal causes of renal failure
Investigation
Urinary sodium (meqL-1)
Fractional excretion of sodium (%)
Urine osmolality (mosmL-1)
Urine creatinine / plasma creatinine
Urine/plasma osmolality
Pre renal
<20
<1
>400
>40
>1.5
Renal
>40
>2
250 - 300
<20
<1.1
Pre renal
Hypoperfusion due to any cause makes the kidney concentrate urine, decreases the
urine output and causes the BUN and creatinine to rise. The BUN level usually, but not
always, rises out of proportion to the creatinine level and a ratio of 20:1 is achieved.
Therefore prerenal failure is most often not a failure at all but a normal response on the
part of the kidney to an inadequate perfusion. Common causes include hypovolemia,
congestive cardiac failure and extreme vasodilation. Treating the precipitating cause
may rapidly and completely reverse the rise in BUN and creatinine levels. Genuine renal
injury may only occur if there is a superimposed insult like exposure to a nephrotoxic
agent. Serum Potassium may be elevated
Renal or intra-renal failure classically falls into 3 categories: Tubular failure
(including acute tubular necrosis), interstitial nephritis and glomerulonephritis and
vasculitis. However, it is probably more helpful to classify intrarenal failure according to
the causes of renal damage as enumerated in Table.
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Renal
Hypoxia
From pre renal causes
Renal vein thrombosis
Nephrotoxins
Aminoglycosides
Amphotericin
Chemotherapeutic agents
NSAIDS
Contrast media (beware
in diabetes and multiple
myeloma)
Tissue injury
Haemoglobinuria
Myoglobinuria
Uric Acid (tumour lysis)
Inflammatory nephritides
Glomerulonephritis
Interstitial nephritis
Polyarteritis
Myeloma
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Post Renal
Bladder neck
obstruction
Blocked drainage
system
Pelvis surgery
Prostatic enlargement
Raised intra-abdominal
pressure
Renal or uretric
Calculi
Clots
Necrotic papillae
Post renal: This occurs when there is an obstruction to renal flow anywhere distal to
the pelvis. Obstruction is always the most likely diagnosis when there is anuria.
For this is to occur either ureters, or the urethra should be obstructed. It is commonly
seen in patients with retroperitoneal or pelvic pathology and abdominal ultrasound is a
good diagnostic tool. Do remember to check the patency of the Foleys catheter.
Perioperative considerations
It is important to understand the pathogenesis of renal failure. Though the kidneys
receive 25% of the cardiac output, they only get 10% of the total body oxygen uptake.
Renal auto regulation does take care of the GFR over a wide range of blood pressures
and glomerular ultra filtration is a balance between vasodilators and vasoconstrictors.
However, of the blood that the kidneys receive the glomeruli receive 90-95% while the
medulla only receives 5-10%. Oxygen extraction on the other hand is much greater in
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the medulla due to active water and salt reabsorption. Thus the medulla is more prone
to hypoxic damage.
The occurrence of perioperative renal failure depends upon the surgery, preoperative
and intraoperative haemodynamics and renal conditions (diabetic patients have a 10
fold greater risk of renal deterioration in the presence of hypovolemia). All intravenous
and volatile induction agents affect renal function by decreasing cardiac output and
blood pressure. Extradural block (or high spinal) up to the level of T4 reduces
sympathetic tone to the kidneys, resulting in a decrease in RBF and GFR. Mechanical
ventilation with positive pressure also decreases renal blood flow. Major surgery with
extensive third space losses can lead to hypovolemia and renal hypoperfusion.
Thus the progression of renal failure may take one of three paths as seen in Fig. 1,
Exclusion of pre renal and post renal causes make intrinsic renal failure the most likely
cause. This is often associated with an increased morbidity and mortality.
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Risk factors for developing renal failure. The successful prevention of perioperative ARF
depends on the identification of patients who are at risk for developing ARF as seen in
Table 3.
Table 3: Risk factors
Patient factors
Perioperative factors
Advanced age
Hemodynamic instability- hypotension
Major vascular surgery (AAA)
Hypovolemia(oliguria)
Atherosclerosis
Diuretic therapy
Coronary artery bypass and other
Surgical oedema
cardiac surgery
Preoperative starvation
Hypertension
Gastric aspiration/vomiting
Congestive cardiac failure
Peritonitis/ ileus/obstruction
Biliary surgery / jaundice
Diarrhoea/bowel preparation
Chronic renal disease
Prolonged tissue exposure
Cirrhosis liver
Blood loss
Diabetes mellitus
Hypoxia
Myeloma
Tissue damage and inflammation
Nephrotoxic drugs
Ischaemia and reperfusion
Pre-eclampsia /eclampsia Sepsis
Major burns
Polytrauma
Muscle breakdown
Pancreatitis
Massive blood transfusions and
Transfusion reactions
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Mechanism of action
Other complications of renal failure include severe metabolic acidosis which is dealt
with by dialysis
Dialysis
Dialysis may be emergent or elective. The indications for dialysis are volume overload,
hyperkalemia, severe acidosis, and uremia (with a change in mentation, pericarditis,
pleuritis or bleeding). Emergency dialysis is rarely required in hospitalized patients. In
the ICU set up BUN and creatinine clearance is assessed daily and dialysis is usually
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started when the BUN level exceeds 100 mgdl-1 or the creatinine clearance is less thanl5
mlmin-1. (these figures are arbitrary and vary from centre to centre).
There are four contemporary modes of dialysis:
Peritoneal Dialysis (PD, not usually considered in the post operative general surgical
patient with abdominal pathology or respiratory compromise).
Haemodialysis (HD, difficult to do especially in the hypotensive post operative or septic
patient, requiring vasopressor support).
Continuous Arterio Venous Haemofiltration (CAVH, relies on an adequate pressure
head, has no external apparatus to control flow or provide warning and requires the
insertion of a wide bore catheter into an artery which may result in bleeding, an
aneurysm, thrombosis and clot formation).
It has been largely replaced by Continuous Veno Venous Haemofiltration CVVH, is a
slow method of solute and fluid removal, results in a largely haemodynamically stable
milieu and can remove a large quantity of cytokines which may reduce the incidence or
progression of multi-organ failure. The newer machines have improved safety features
such as an air detector and a pressure monitor. They do however require one on one
nursing and frequent, 4-6 hourly, and potassium assessment. They are capable of
removing up to 10 litres of fluid at one sitting and are often helpful in weaning from
mechanical ventilation and shortening ICU stay.
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Chapter 4 - TURP
INTRODUCTION
The prostate is a secretary organ wrapped around the urethra between the urinary
bladder and pelvic floor. The common conditions affecting the prostate are benign
prostatic hypertrophy (BPH) and cancer. BPH is an aging process, due to excessive
cellular growth of both glandular and stromal elements of gland, which leads to bladder
out flow obstruction and complications include recurrent infections, stone formation,
Haematuria and impairment of renal function. BPH in patients with prostate gland
(size) weighing less than 40 50 gm.
DEFINITION
TURP, it is the modified cystoscopic technique in which hypertrophied lateral and
median lobe of the prostate gland is excised with an electrical cautery. Bleeding being
controlled with coagulation current, Continuous irrigation is needed for distending the
bladder and to wash away blood and dissected prostatic tissue.
Sympathetic Parasympathetic
Bladder
T11 L2
S2 - 4
T11 L2 (Dome)
S2 4 (neck)
Prostate
T11 L2
S2 - 4
T11 L2, S2 4
L1 - 2
S2 - 4
S2 4
Penis
Urethra
and
Parasympathetic fibers are the main motor supply to the bladder except trigone of
bladder. The afferents carrying, sensation of stretch and fullness of bladder are
parasympathetic, where as pain, touch and temperature sensations are carried by the
sympathetic nerves. Sympathetic fibers are predominantly alpha adrenergic in the
bladder base and the urethra, and beta adrenergic in the bladder dome and lateral wall.
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The prostate is a pear shaped gland consists of four closely integrated zones- the
anterior, peripheral, central and preprostatic zones. Each zone is made up of secretary,
smooth muscle, and fibrotic tissue. All zones are enclosed in one capsule. The gland is
rich in blood supply. Arteries and veins penetrate the prostatic capsule and branch
inside the gland. The venous sinuses adjacent to, the capsule are particularly large.
As early as the fourth decade of life, nodules begin to develop in the preprostatic zones,
forming one middle, two laterals, and one anterior and posterior lobe. The middle and
posterior lobes are most commonly associated with BPH and lateral lobe associated
with malignancy causing urinary tract obstruction.
Anesthetic problems:
Patients presenting for prostate surgery are elderly and have co-existing morbidities.
Cardiovascular and respiratory problems are common, and they are often on various
medications. Prostatic surgery carries a high risk of intraoperative bleeding, and so
ideally, all patients should have blood taken for cross matching. Anticoagulant drugs
such as aspirin and non-steroidal antiinflammatory drugs should be stopped 10 days
prior to surgery. Patients on warfarin must be considered on an individual basis in
conjunction with their physician. Those requiring continuous anticoagulation may need
to change to intravenous heparin, which can then be stopped for the duration of
surgery.
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Preoperative evaluation.
Preoperative evaluation is to know their general -condition, functional capabilities of
specific disease and drug intake, which enable to make judgment for the acceptance of
surgery, permits treatment of pre-existing disease, allow appropriate lab testing
to
be performed to access the expected perioperative and intraoperative problem and
their management.
Incidence of systemic medical disorders in TURP patients.
Disorder
Incidence %
Cardiac disease
67
Cardiovascular
50
Abnormal ECG
77
COPD
29
Diabetes mellitus
8
Routine history, including alcohol intake, smoking and drug history.
Physical examination: Pallor, cyanosis, clubbing, icterus, lymphadenopathy,
oedema, pulse rate respiratory rate and blood pressure.
Examination of all organ systems (cardiovascular system, Respiratory system
and CNS).
Airway assessment: Mallampatti grading, Dentition- loose tooth, denture. Loss of
buccal pad of fat- difficult in approach to induction or maintenance by mask.
Risk factors:
Obesity, Smoking, Malnutrition, Recent/Chronic infections, Alcoholism, DM, Malignancy
and Drugs
Investigations:
i. Urine for albumin, sugar and microscopy including culture and sensitivity.
ii. Haemogram, blood sugar.
iii. Renal function tests: blood urea and serum Creatinine
iv. ECG.
v. X-ray of Chest and kindneys.
vi. Serum electrolytes.
vii. USG of kidney, bladder and prostate.
viii.
Prostatic specific antigen (PSA).
ix. 2D Echo-abnormal ECG with relevant history of angina and IHD.
x. Pulmonary function tests.
xi. Liver function tests. In selected cases.
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Pulse oximetry
2.
ECG
3.
4.
Temperature.
5.
6.
7.
Intravenous fluids: Normal saline is the appropriate choice for TURP, to decrease any
effects of dilutional hyponatremia. Fluids should be given cautiously, because these
patients are at risk of fluid overload. Remember impaired renal function and during
surgery, the irrigating fluid will be absorbed.
Blood loss is a complication of radical prostatectomy or for very large prostates.
Isovolemic haemodilution may be used to reduce the use of allogenic blood. Prostatic
tissue contains many,a receptors, and so a-adrenergic agonists (e.g. methoxamine) may
be used to decrease blood loss.
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Anesthesia
Regional anesthesia is used for prostatic surgery. A surgical block to the level of T10 is
required, and the caudal, subarachnoid (spinal) or epidural routes may be used. The
addition of short-acting opiates (e.g. Fentanyl) will reduce the dose of local anesthetic
needed to provide an adequate block. Epidural or combined spinal and epidural
anesthesia with an epidural catheter is the preferred regional method and can be used
postoperatively for pain relief.
Spinal anesthesia: Block should be up to Tl0
Provides adequate anesthesia for the patient and good relaxation of the pelvis
floor and the perineum.
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Epidural
anesthesia
Caudal
anesthesia
15 ml
100 cg
20 ml
100 cg
20 ml
100 cg
General anesthesia:
Necessary in patients who require ventilatory or Haemodynamic support.
In patients with uncontrolled Hypertension and IHD
When there is contraindication to regional anesthesia.
Patient's refusal for regional anesthesia.
- Pre oxygenation with 100% of oxygen for at least 5 min.
- Injected slowly to avoid circulatory depression.
- Slow onset of anesthesia due to sluggish circulation.
- Delayed elimination due to retarded metabolism.
- Titrate, the dose required.
- Signs of effect should be observed rather than giving preselected standard dose.
Inducing agents: Common inducing agents are, Thiopentone, Midazolam, Propofol, and
Etomidate. Propofol may be close to an ideal induction agent because of its rapid
elimination.
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Difficult intubation.
Cervical arthritis/ rheumatoid arthritis.
Difficult in visualization of glottic opening during direct Laryngoscopy.
3.
4.
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Osmolality (mosm/g)
175
220
165
275
139
167
178
Of these, Cytal and Glycine are the two most commonly used solutions. To maintain the
transparency, these solutions are purposely prepared moderately hypotonic. (Normal
serum Osmolality is 280 to 300 mosm/Lit)
Non-electrolyte solution prevents dissipation of diathermy current during resection.
Complications are very much reduced but CNS symptoms, over hydration caused by
circulatory overload and decreased plasma osmolality remain as complication.
Properties of commonly used irrigating solutions for transurethral resection
procedures:
Osmolality
Solution
Advantages
Disadvantages
(MOSM/L)
Distilled water
0.0
Improved visibility
Hemolysis,
Hemoglobinemia,
Hemoglobinuria
Hyponatremia
Glycine (1.5%)
220
Less
likelihood
of Transient postoperative
Transurethral Resection visual
syndrome,
syndrome
Hyperammonemia
Hyperoxaluria
Sorbitol (3.3%)
165
Same as Glycine
Hyperglycemia, possible
Lactic acidosis Osmotic
diuresis
Mannitol (5%)
275
Isosmolar solution Not Osmotic
diuresis
metabolized
possibility of actute
intravascular
volume
expansion.
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Complications of TURP:
Anesthetic complications:
Hypotension
Bradycardia. And Cardiac dysrhythmias
Hypoxia
Impeded respiratory muscle excursion
Reflex of stomach contents
Lower compartment syndrome in prolonged
surgery
Deep vein thrombosis
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Backache
Transient bacteremia and septicemia.
Peripheral nerve injury common personeal nerve, sciatic and femoral nerves.
Sciatic nerve by, exaggerated knee extension, thigh flexion and external hip
rotation.
Femoral nerve by, adduction and rotation of the thigh.
Common peroneal nerve by compression between fibula and stirrups.
Posterior tibial nerve by stirrups compression.
Saphenous nerve by compression between stirrups and medical malleolus.
Postoperative complications:
Bleeding and clots in catheter- urinary retention.
UTI - septicemia.
Thrombophlebitis.
Pain and neurapraxia in lower limb nerves.
Incontinence.
Retrograde ejaculation.
Erectile dysfunction.
Hypothermia.
TURP syndrome:
TURP syndrome is a general term used to describe a wide range of neurologic and
cardiopulmonary symptoms and signs caused by intravascular absorption of hypotonic,
bladder irrigating fluids during the procedure. In conscious or sedated patients, the
sudden onset of restlessness should raise the suspicion of TURP syndrome. TURP
syndrome may occur as quickly as 15 min after resection begins or upto 24 hours postoperatively. Incidence is 2%.
Etiology is metabolic encephalopathy due to intravascular absorption of irrigating
fluids.The signs and symptoms of the TURP syndrome are:
Cardiopulmonary
Hematologic and Renal
Central nerves system
Hypertension,
Hyperglycemia,
Nausea / Vomiting,
Reflex Bradycardia,
Hyperglycinemia,
Confusion,
Dysarrhythmias, CCF,
Hyperammonemia,
Restlessness,
Respiratory distress,
hyponatremia,
Blindness,
Pulmonary oedema,
Hypoosmolality,
Lethargy/Paralysis,
Hypoxemia, cyasnosis,
metabolic acidosis,
dilated/Non reactive Pupils,
Hypotension,
hemolysis/anemia,
Seizures
shock,
acute renal failure,
coma and Death.
death
Death
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Clinical features
Hypertension, Bradycardia, arrhythmias, angina, pulmonary
oedema and hypoxemia, ventricular failure and hypotension.
Water intoxication or Confusion and restlessness, twitching or seizures, lethargy or
Hypoosmolality
coma; dilated or sluggish pupils, papilloedema, low voltage
ECG, hemolysis.
Hyponatremia
CNS changes as above reduced inotropy, widened QRS
complex, low voltage ECG, T wave inversion in ECG.
Glycine toxicity
Nausea and vomiting, headache, transient blindness, loss of
light and accommodation reflexes (blink reflex preserved),
myocardial depression, ECG changes.
Hemolysis
Anemia, acute renal failure, chills, clammy skin, chest
tightness and bronchospasm, hyperkalemia resulting in
malignant arrhythmias or bradyasystole
Coagulopathy
Severe bleeding, primary fibrinolysis, disseminated
intravascular coagulation.
Glycine 1.5%:
(HO2-CCH2-NH2). A non-essential amino acid, which functions as
inhibitory Neurotransmitter. Glycine has a distribution similar to that of gamma amino
butyric acid (GABA); the latter is an inhibitory neurotransmitter in the brain. It has been
suggested that Glycine is also major inhibitory transmitter acting in the spinal cord and
brain system.
Normal plasma Glycine is 13 -17 mg/L. Glycine half-life is 85 min.
Glycine absorption has been shown to cause an average of 17.5% decrease in cardiac
output. The administration of the amino acid arginine reverses the myocardial
depressing effect of Glycine.
Glycine toxicity in patients undergoing TURP is uncommon, probably because most of
the absorbed Glycine is retained in the periprostatic and retroperitoneal spaces. Where
access to circulation is limited.
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Glycine may cause encephalopathy and seizures via its ability to potentiate the effect of
N methyl D aspartate (NMDA), an excitatory neurotransmitter. Magnesium exerts a
negative control on the NMDA receptor and hypomagnesemia caused by dilution may
increase the susceptibility to seizures.
For this reason, a trial of magnesium therapy may be indicated in patients who develop
seizures during TURP.
The most common metabolites of Glycine are Ammonia, Glyoxylic acid and Oxylic acids.
In some patients, excessive absorption of Glycine during TURP leads to
Hyperammonemia and hyperoxalurea. Hyperoxalurea could compromise renal function
in patients with co-existing renal disease, as it is often present in elderly patients
undergoing TURP.
Hyperammonemia: The signs and symptoms usually appear within one hour after
surgery. Typically, the patient becomes nauseated, vomits and then become comatose.
Deterioration in cerebral function has been documented at ammonia concentration
exceeding150 mol/L. The Hyperammonemia tends to occur postoperatively, probably
because Glycine absorption from the periprostatic space continues after surgery.
Ammonia is metabolized primarily in the liver. Ammonia increased in liver dysfunction
and in Arginine deficiency.
Prophylactic administration of Arginine or Ornithine prevents hyper ammonia.
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Bradycardia and hypertension by the Cushing reflex. Apparently, the hypervolemia and
hyponatremia that often accompany TURP promote cerebral oedema and this in turn
raises intracranial pressure and provokes neurological symptoms.
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Prevention:
Avoid over distention.
Avoid rough instrumentation.
Avoid patient movement and
Avoid extensive prostate or bladder tumour resection at one sitting.
Transient bacteremia and septicemia:
The prostate harbors many bacteria, which can be a source of introperative and
post-operative bacteremia via prostatic venous sinuses.
This risk is further increased by the presence of an indwelling catheter.
About 30% of patients undergoing TURP have infected urine preoperatively, and
half of them sustain bacteremia post-operatively.
Hypothermia:
Irrigating fluids stored at room temperature are frequently used during TURP.
Heat loss due to irrigation and significant absorption of this fluid may result in a
decrease in patient's body temperature and cause shivering.
Several liters of irrigation solution pass through the bladder during TURP, which
can reduce body temperature at the rate of 1 degree per hour. About half of all
patients undergoing TURP become hypothermic shivering at the conclusion of
surgery.
Use of warmed irrigating solutions has been shown to be efficacious in reducing
this heat loss and resultant shivering. But warming of fluids might cause
increased bleeding due to vasodilatation. And operating whenever possible in a
warm environment.
Use of systemic and intrathecal opioids decreases post-operative shivering from
cold.
Conclusion:
TURP remains the gold standard for the treatment of men with BPH. Improvement in
surgical technique, perioperative monitoring of fluids and electrolytes, anesthetic care
and the availability of video endoscopy have diminished intra operative and post
operative morbidity and mortality. The incidence of complication of transurethral
surgery is inversely proportional to the experience of surgeon.
PREOPERATIVE EVALUATION FOR ELECTIVE SURGERIES
Introduction: The anesthetic
preoperative evaluation includes the acquisition of
medical information and assessment of the patient's physiologic status but also offers
brief opportunity to help to alleviate the patient and family's anxiety or fear about
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Irritability of nervous
Excitement stimulants
Rest and adequate sleep in
system
hospital sedatives
Resistance to anesthesia
Chronic alcoholism smoking Premedication
1. To make perioperative care more efficient and less expensive.
2. To utilize the operative experience to motivate the patient to more optimal
health and thereby improve perioperative and / or long term out come.
Risk assessment: The overall risk for surgical complications depends on individual
factors and the type of surgical procedure. Eg: Advanced age, co-existing diseases like
respiratory, cardiac, malnutrition and diabetes mellitus. With respect to type of surgery,
urgent and emergency procedures constitute higher risk situations than elective
procedure.
High risk referred to here is primarily surgical procedure derived risk of
cardiac/pulmonary complications. Cardiovascular complications are more common in
adults, and pulmonary complications are more common in children.
American society of anesthesiologists physical status classification:
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Status
ASA class 1. Normal healthy patient
Disease level
No organic, physiological, biochemical or
psychiatric disturbance. Or, Normal.
ASA class 2. No. functional limitation
Mild to moderate systemic disturbance
that may be related to the reason for
surgery, Eg. Mild heart disease, DM, mild
HTN< anesmia, old age, obesity and mild
chronic bronchitis.
ASA Class 3. Some functional limitation
Severe systemic disturbances that may or
may not be related to the reason for
surgery. Eg. Angina, severe DM, Cardiac
failure.
ASA Class 4. Functionally incapacitated
Severe systemic disturbance that is life
threatening with or without surgery. Eg.
Marked cardiac insufficiency, persistent
angina, and severe respiratory, renal or
hepatic insufficiency.
ASA class 5. Patient who is not expected to Moribund patient who has little chance of
survive with or without surgery in 24 hrs
survival but is submitted to surgery as a
last resort (resuscitative effort)
ASA class 6. Brain dead patient
Dead patient brought for organ removal
for transplant purpose.
Emergency operation (E)
Any patient in whom an emergency
operation required.
Medical problems discovered on preanesthetic evaluation that could prompt a change in
patient management.
History:
1. History of present illness and its treatments. Including indications for surgery.
And history of recent infections like URTI or Pneumonia.
2. When the patient last visited with her/his primary care physician.
3. Exercise tolerance, including activity level. Most important is to determine the
patients cardiovascular reserve. To know this, ask about maximum amount, the
patient can walk or the greatest number of floors patient can climb without the
need to stop ability to do 4 metabolic equivalents (MET) of exercise.
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Physical examination:
GPE: Examination of eyes for abnormal movement and skin for signs of jaundice,
cyanosis, nutritional abnormalities like anaemia (pallor) and dehydration. Fingers are
checked for clubbing. Look for the built of patient, weight and height.
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Airway perceived, as
difficult to intubate
Asthma
DM, insulin
dependent
Drug abuse
Social history
Gastro esophageal
reflex or hiatus
hernia
Antibiotic prophylaxis
Pacemaker or
Cardiovascular disease
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electrocardiogram
Peripheral motor
neuropathy
Pregnancy or
uncertain pregnancy
status
Pulmonary
tuberculosis
Renal insufficiency
Genitourinary disease
Genitourinary / pregnancy
2010
implantation obtain
repolarizing equipment or
magnet. Use lectrocautery with
altered position. Use bipolar
electrocautery
Avoid depolarizing muscle
relaxants.
Monitor foetal heart rate, use
roal antacids, adjust induction
of anesthesia, determine status
of pregnancy.
Use disposable breathing circuit
or clean equipment. Ensure
adequate treatment of patient
prior to surgery.
Monitor fluid status
intraoperatively
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b)
c)
d)
e)
Suspicion of infection.
Hemoglobin of 9g/dl is adequate for patients over 3 months of age but should
exceed 10g/dl for younger patients.
Asymptomatic anaemia prior to non-blood loss surgery should not be treated
preoperatively. Because patients survive anesthesia and type-A surgery when
hemoglobin levels are about 8g/dl.
Surgically acceptable values: Hematocrit 29% to 57% for men,
27% to 54% for women
White blood cell count - 2400 to 16000/mm3 for both men and women.
Blood grouping and cross matching would be warranted for all patients
undergoing procedure involving possible blood loss of more than 2units/70 kg
body weight.(type B or / and type C surgical procedures).
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A patient taking aspirin 2g/70kg of body weight daily, or large closes of aspirin
i.e., more than six 325mg tablets a day should be evaluated. and also those
patients who is consuming aspirin continuously, sufficiently early to ensure that
there is no appreciable level of acetylsalicylic acid in the blood for 24 hours
before surgery. Because this is the period in which acetyl salicylic acid would
have to be absent for the generation of the approximately 50,000 new platelets
/mm3 needed for normal platelet aggregation. Chart 1
Screening for diabetes may soon shift from random blood glucose levels to
determinations of the concentration of glycosylated hemoglobin (HbA 1c).
Hypertension
Cardiac disease
Diabetes mellitus
Patient on drugs that can affect electrolyte balance eg: diuretics, ACE inhibitors
or drugs whose level may be affected by renal functioneg. Digoxin.
As a baseline for major surgery eg. Aortic aneurysm, Oesophagectomy,
hepatectomy.
Age >60 yrs.
Positive urine albumin
Patient on TPN
Patient having bowel preparation for surgery.
Recent vomiting and diarrhoea.
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Abnormal hepatic or renal function might change the choice and does of
anesthetic or adjunct drugs.
Albumin level was an important predictor of perioperative morbidity and
mortality in every surgical speciality. Changes in this level after enteral nutrition
have been important predictors of perioperative outcome in malnourished or
otherwise very sick patients. It may therefore time to add this laboratory test for
patients undergoing surgical class C procedure and for patients who have
physiologic age of over 85 are undergoing surgical class B procedure.
Antibody test for hepatitis A and C are useful after infection has occurred, which
reduces the medico legal risks posed by post anesthetic jaundice.
ECG.
a)
b)
c)
d)
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Chest X-Ray:
a)
Those with cardiac or irreversible ln11monary disease (not Asthmatics and who
have, not had a chest X-ray in the past 6 months.
b)
Close exposure to TB (family members) in the past year.
Certainly it may be important to know about the existence of the following conditions
before proceeding to anesthesia and surgery. Tracheal deviation or compression,
mediastinal masses. Pulmonary nodules, a solitary lung mass, aortic aneurysm.
Pulmonary oedema, pneumonia, atelectasis, new fractures of the vertebrae, ribs, and
clavicles, dextrocardia, and cardiomegaly. However, the chest radiograph would not
detect the degree of chronic lung disease requiring a change in anesthetic technique any
better than would the history or physical examination.
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Chest radiographs are not warranted for any asymptomtic patients who are less than
75 years of age and free of risk factors. In fact this conclusion may apply to those older
than 75 yrs of age as well.
2)
Valsalva test
3)
4)
Cough test
5)
6)
Pulse oximetry
1)
Vital capacity
2)
3)
or
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sniders test
4)
5)
6)
b)
c)
d)
Normal or slightly
FVC
Normal or slightly
FEV1
FEV1/ FVC
Normal
FEF25-75%
Normal
to
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b)
Morbid obesity
c)
Cervical spine
a)
Downs syndrome
b)
c)
Trauma patient
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Minor surgery
Hb or HCT
(hematocrit)
HB or HCT
(hematocrit)
Hb or HCT
Major surgery
CBC
65 to 75
6 Months 6 yrs
6 yrs to 40 yrs
40 to 65 yrs
Adult female of
childbearing age
group pregnancy
test
CBC
CBC
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The PPAC is an integrated partnership having visible alliances with the departments of
anesthesia, nursing, surgery, (OBG) obsterics and gynaecology and always with the
hospital or health system administration.
The anesthesia preoperative evaluation clinic is a constructive partnership working
towards the achievement of common goals. The sharing of resources and budgetary
costs is apportioned.
Goals of the anesthesia preoperative evaluation
clinic:
Decreased cost
Efficient quality service
Enhanced clinical productivity
Timely access to clinic
Enhanced patient education
Patient and surgeon satisfaction
Reduced length of stay in the hospital
Operational goals for a preoperative and
preprocedure assessment clinic (PPAC)
1. To improve patients (clients) perception
of the preoperative evaluation experience by
increasing personalized patient care , comfort and convenience.
2. To provide centralized site for preoperative evaluation.
3. To institute an anesthesia scheduling system for timely patient access and flow.
4. To ensure the presence of an anesthesiologist on site when patients are present.
5. To appoint medical director of the PPAC coordinate all activities.
6. To ensure the availability of medical records and surgical notes at the time of
preoperative evaluation.
7. To decrease logistical shuffling of patients to multiple hospital service areas.
8. To integrate and co-ordinate services through on-site facilities for admitting /
registration, insurance authorization. laboratory test and electrocardiographic
studies.
9. To improve the education of patients and families about the elements of their
surgical procedure and the proposed anesthesia care. Including postoperative
pain control options.
10. To educate patients about what to expect regarding post operative feeding and
discharge needs.
11. To ensure and co-ordinate cost effective ordering of preoperative laboratory and
diagnostic studies.
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4.
Dont Know
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Informed consent:
The preoperative assessment culminates in giving the patient a reasonable explanation
of the options available for anesthetic management; general, regional, local or topical
anesthesia, intravenous sedation, or a combination thereof. Monitored anesthesia care,
refers to monitoring the patient during a procedure performed with intravenous
sedation or local anesthesia administered by the surgeon. Regardless of the technique
chosen, consent must always be obtained for general anesthesia in case other
techniques prove inadequate.
Consent must be informed to ensure that the. patient has sufficient information about
the procedure and their risks to make a reasonable and prudent decision whether to
consent. It is generally accepted that not all risks need to be detailed. Only risks that are
realistic and have resulted in complications in similar patients with similar problems. It
is generally advisable to inform the patient that some complication may be life
threatening.
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Preop diagnosis:
Proposed Operation:
Medications
Alcohol
Tabacco
Present problems:
CVS
RS
Diabetes
Neurological
Arthritis/Musculo-skeletal
Renal
Hepatic
Other
Previous anesthetics:
Family hisotyr
Last oral intake
Physical Examination
Temp:
Heart / CVS
Lungs / RS
Airway
Teeth
BP:
PR:
RR:
Extremities
Neurological
Other
Laboratory investigations
HCT / Hb
ECG
Urine
Blood glucose
BUN
Sr. Creatinine HBS Ag
Electrolytes
Ht:
Wt:
2010
NA
Ca
Cl
Mg
Plan : General
Regional
Monitored anesthesia care
ASA class
Signature:
Chest X-ray
Albumin
HIV
K
HCO3
CO2
Invasive monitors
Special techniques.
M.D
(Resident)
(Staff)
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Patient consent
Anesthetic alternatives and risks ranging from tooth damage to life threatening events
have been explained and accepted.
Patients signature
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Morbid obesity (BMI > 30 kg/m2) is the most common and a major risk factor for
ohstructive sleep apnea (OSA)
Prevalent ECG findings in obese patients are low QRS voltage, left ventricular
hypertrophy or strain, left atrial abnormality and T-wave flattening in the
inferior and lateral leads. In right ventricular hypertrophy or strain - right axis
deviation, right bundle branch block.
The obese may have limited cardiac reserve and poor tolerance for stress
induced by hypotension.
The proper positioning of the patient, placement of monitoring devices and
establishment of intravenous sites are more difficult to accomplish.
Thyroid dysfunction:
We should aim to avoid imposing surgery on any patient whose thyroid function is
clinically abnormal.
In hyperthyroidism anti cholinergic drugs (especially atropine) are avoided as
they interfere with the sweating mechanism and cause
A patient with a large goiter and an obstructed airway can be handled in the
same way as any other patient with problematic airway management.
Preoperative medication should avoid excessive sedation and an airway should
be established often with the patient awake. A firm armored endotracheal tube is
preferable and should be passed beyond the point of extrinsic compression.
In hypothyroidism patients, anesthetic requirement will be decreased and
enlarged tongue may hamper the endotracheal intubation. There is increased
incidence of myasthenia gravis in hypothyroidism patients, and it is advisable to
use a peripheral nerve stimulator to guide administration of muscle relaxants.
Serum calcium level should be monitored because changes in the calcium level
may alter the duration of muscle relaxation. The three substances that regulate
serum concentrations of calcium, phosphorous and magnesium are parathyroid
hormone, calcitonin and vit. D which act on kidney, bone and gut, severe
hypercalcemia can occur in hypolemia. ECG shows shortened PR or QT intervals.
Normal intravascular volume and electrolyte status should be restored before
commencement of anesthesia and surgery.
Hypercalcemia can be corrected by hydration and diuresis. Complications of this
intervention include hypomagnesaemia and hypokalemia.
Hypocalcaemia: Most common cause is hypoalbuminemia. In hypocalcaemia cardiac
contractility is affected. ECG reveals prolongation of QTc interval.
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Hypertension:
Blood pressure mm of Hg:
Category
Systolic
Diastolic
Optimal
< 120
< 80
Normal adult
< 130
< 85
Normal Adolescence
100
75
Normal early children
85
55
Normal infants
70
45
High normal
130-139
85-89
Hypertension
Stage 1
140-159
90-99
Stage 2
160-179
100-109
Stage 3
180
110
Control hypertension to prevent complications. Search for end organ damage
CNS, coronary arteries, myocardium, aorta, carotid arteries, and kidneys and
peripheral blood vessels.
We use such preoperative data to determine the individualized range of values
that we consider tolerable by a particular patient during and after surgery. That
is if BP is 180/100 mm of Hg and heart rate is 96/min on admission without
sighs and symptoms of myocardial ischaemia, we feel confident that the patient
can tolerate these levels during surgery. If during the night. BP decreases to
80/50 mm of Hg and heart rate to -l8/inin and the patient does not awake with
signs of a new cerebral deficit, we believe that the patient can safely tolerate such
levels during anesthesia.
Routinely administer all anti-hypertensive drugs preoperatively, except ACE
inhibitors or angiotensin-11 antagonists. Because ACE inhibitors are associated
with hypotension during induction.
In patients on ACE inhibitor during general anesthesia if refractory hypotension
occurs vasopressin is the drug of choice.
Ischemic heart disease
The presence of coronary artery disease, its severity, and the time of the most
recent myocardial tissue death, the arteries affected, ventricular function and
reserve and the complications and treatment of the disease are important
informations to the anesthesiologist.
Preoperative testing:
Elevated levels of cardiac enzymes
Treadmill exercise testing, bicycle ergometry, dipyridamole thallium imaging,
dobutamine stress test, echocardiography, preoperative Holter monitoring, non
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Bilirubin mg/dl
< 2.5
2.5-4
>4
Albumin gm/dl
> 3.5
3-3.5
<3
Prothrombin time (seconds prolonged)
1-4
4-6
>6
Encephalopathy
0
1-2
3-4
Ascites
None
Easy
Difficult
Nutritional status
Excellent
Good
Poor
Operative mortality (Approximate %)
0-10
4-31
19-76
The assessment is based on the sum of a number of key clinical features. Grade A
corresponds to low risk (0-10%) grade B patients should be optimized preoperatively.
Grade C patients should not undergo elective surgery if possible.
Gastro esophageal reflux disorder (GERD):
Consider antacid prophylaxis
Rapid sequence intubation
Antiemetics to control postoperative nausea and vomiting.
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Kidneys:
Renal failure is normally treated with dialysis and renal transplantation. Patients
presenting for elective surgery should be well controlled.
Electrolytes, acid base balance, fluid status must be carefully checked.
A patient with established renal failure should be assessed for anaemia.
It is important to note the fistula (AV) which must be carefully protected during
surgery. Renal excretion of drugs and the metabolites of other will be impaired.
So drugs dosage should be attached.
Musculoskeletal system:
For osteoporosis and painful joints.
Poor mouth opening, an immobile neck, atlanto-occipital instability.
Rheumatoid arthritis:
The skin which is delicate and easily traumatized.
Anaemia which does not always respond to iron.
The lungs for nodules and fibrosis.
Patients are usually on a number of drugs these often have associated side effects
such as DM, HTN, electrolyte imbalance (Corticosteroids) folate deficiency, liver
and pulmonary dysfunction (methotrexate) renal failure and HTN
(cyclosporine). GERD (NSAIDS).
PREOPERATIVE MEDICATION
various goals for preoperative medicine
1. Relief of anxiety
2. Sedation
3. Amnesia
4. Analgesia
5. Drying of airway secretions
6. Prevention of autonomic reflex responses
7. Reduction of gastric fluid volume and increased pH.
8. Antiemetic effects
9. Reduction of anesthetic requirements
10. Facilitation of smooth induction of anesthesia
11. Prophylaxis against allergic reactions.
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which was the safer of the two drugs but eventually ether won the day. When in 1858
John Snow, who was England's leading physician anesthetist, died, his place was taken
by J. T. Clover, and partly due to the influence of these two pioneers, the administration
of anesthetics in the UK has always been in the hands of medical men and, as time has
passed, in the hands of specialists in the subject.
Meanwhile, nitrous oxide still had its friends in the US, and in 1863 G. Q. Colton,
who introduced it to Wells, embarked on a campaign of popularization of the gas. Its
disadvantages were difficulty in administration and the asphyxia inseparable from its
use. The latter was partly overcome by Edmund Andrews of Chicago who in 1868 gave
it with 20% oxygen, and by Paul Bert of Paris who gave it under pressure 10 years later.
The first major war in which anesthetics were used was the Crimean War (1854-1855).
It is an interesting fact, however, that even 25 years after Morton introduced the use of
ether in surgery, operations were still being performed in the complete absence of any
form of anesthesia, even in European teaching-Hospitals.
During the next 40-50 years there were few significant changes in anesthesia, but in the
1920s the pace of progress quickened. In the 1920s, ether and chloroform were the
main agents used but ethyl chloride and nitrous oxide were often employed for
induction. Simpsons open drop method was the most popular, while the first Boyle
machine appeared in 1917. One of the early pioneers was Sir Geoffrey Marshall, who
gained experience of anesthesia while serving in the R.A.M.C. in. the First World War.
Before the 1930s the anesthetist administered one or two volatile agents to produce
unconsciousness, muscle relaxation and deafferentation. This gave place to various
techniques of so-called balanced anesthesia and so the amount of toxic drugs to which
the patient was exposed was reduced and the hazard of general anesthesia made less.
Among other innovations were the popularization of endotracheal techniques by Ivan
W. Magill and E. Stanley Rowbotham, the appearance of bromethol (Avertin), divinyl
ether, cyclopropane and trichloroethylene, and the induction of anesthesia by
intravenous barbiturates in the early 1930s. Because of the difficulty of obtaining
relaxation of the jaw and larynx with ether, blind nasotracheal intubation became
increasingly used. Controlled respiration was used with cyclopropane so that when
curare was first tried out by Harold Griffith in Montreal in 1942, the way to deal with
hypoventilation and apnoea was well established, and soon intermittent positivepressure ventilation became routine practice.
Local analgesia made its appearance in 1884 when Carl Koller of Vienna
demonstrated the use of cocaine for topical analgesia in the eye. Infiltration and regional
block followed from this. Spinal analgesia was first described by August Bier in Kiel in
1898 and extradural block by Fernand Cathelin and Jean Athanese Sicard in Paris in
1901 and by Fidel Pages of Madrid in 1921 and Achille Mario Dogliotti of Turin in 1931.
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The two world wars stimulated both surgery and anesthesia, and following each, the
number of doctors who continued their anesthetic work, learnt under service
conditions, into civilian life had a considerable influence on the development of the
specialty.
Technical improvements were slowly accompanied by academic recognition, but
not always by adequate financial rewards. The first examination for the Diploma in
Anesthetics was held in London in 1935 and the first chair in anesthetics was created in
Oxford, with R. R. Macintosh as professor, 2 years later. Ralph Waters was appointed as
the first professor of anesthesia in a university in the US in 1933. In the UK the
recognition of anesthesia as a specialty with full equality with other medical and
surgical specialties was secured in 1948 with the introduction of the National Health
Service, and since then anesthesia has not only kept pace with the rapid advances made
in surgery, but has in many instances enabled these advances to be made. In recent
decades the scope of the anesthetist's work has widened and now takes in not only preoperative assessment and postoperative care, but supervision of intensive therapy
units, pain services, and in many cases research and postgraduate education. An
enormous development in the use of monitoring equipment, some of it highly
sophisticated, has taken place in the last 20 years. Among those workers who remember
clinical anesthesia in the 1930s and early 1940s, few would disagree with the statement
that what is known as 'modern anesthesia' commenced with the introduction of the
muscle relaxants.
Following a joint congress of anesthetists in London in 1951 of which Sir Ivan
Magill was President, and a similar meeting in Paris the same year, it was decided to
form a Federation of Societies of Anesthesiologists and the first Congress of the new
body was held in Scheveningen in Holland in 1955. Other similar congresses have been
held in Toronto (1960), Sao Paulo (1964), London (1968), Kyoto (1972), Mexico City
(1976). Hamburg (1980), Manila (1984), Washington (1988) and The Hague (1992).
Among training courses arranged by the World Health Organization were those of the
Anesthesiology Centre in Copenhagen (1950-1973) and in Manila (under the guidance
of Professor Quintin Gomez).
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SIR-IVAN-MAGILL (1888-1986)
Ivan-Whiteside Magill was born in Larne, Northern Ireland in an integral part
of UK.
His birth in 1888 took place 42 yrs after Mortons first use of ether and just two
years after the discovery of local analgesia using cocaine.
He attended the grammer school and then became a medical student at Queens
university qualifying in 1913.
He became a house surgeon at the Stanley hospital in Liverpool and with the
outbreak of 1914-1918 war, joined the RAM and served with the Irish-Guards at
the battle of Loos. When peace cane again, Magill posted to the Queens hospital
in Kent.
With a young colleague, Stanley Rowbotham, they started giving anesthesia for
reconstructive operations on the face and jaws in wounded soldiers. Under the
care of Harold-Gilles who later became a world famous pioneer of plasticsurgery.
Here after trial and groon, they first did tracheal intubation first using twonarrow gum elastic tubes. One afferent and the other efferent, for the insufflation
of ether vapour under slight positive pressure, and then employing a single widebore rubber tube for spontaneous breathing.
They are also among the first to develop the technique of nasotracheal intubation
by the so called blind-method.
Those anesthetists, who learnt how to perform blind nasal intubation, soon
realized its great advantages.
In addition intubation provided a clear airway, prevented laryngeal spasm and
enabled the lungs to be protected against foreign material.
Magill devoted big professional life to the administration of anesthetics and was
selected to the staffs of various hospitals in London.
Magill was a man of practical ingenuity and over the years originated developed
many new pieces of equipment and development of technique for the safely of
his patients and the convenience of his surgeons.
He introduced
Magills laryngoscope
Laryngeal forceps
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Contributions:
He established the first laboratory of gross-anatomy to be used at the clinic and
this was important for his teaching of the techniques of regional analgesia which
had been stimulated there by Gaston-Lobat.
In 1925 Lundy developed the theory and practice of balanced anesthesia.
Lundy used thiopentone on 18th June 1934 and continued throughout his
professional life to advocate its use. Though, it was used by waters of Madison
first.
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On 1942 be opened the first post anesthesia observation room in the world at St.
Marys hospital Rochester.
Dr. Lundy was the author of the textbook Clinical anesthesia published in 1942,
which deals with the Modern-anesthesia.
Lundy received many medals awards and honours from academic bodies
throughout the world.
He reward from Chicago and continued to practice anesthesia at Seattle.
Contributions:
In 1912 be became interested in N2O and O2 anesthesia and in 1917 got coxeter,
the instrument maker to copy James-Taylor Gwathmeys gas oxygen machine
which became the first Boyle-apparatus.
He introduced gas oxygen into France for use in anaesthetizing wounded soldiers
in the First World War and for this received the decordation of OBE.
After the First World War, he visited US and brought bailer introduced DAVISSGAG to British throat surgeons.
He was an early user of Magills endotracheal-techniques.
He was elected FRCS and DA in 1935.
A founder member of the association of anesthetists of great Britain and Ireland
in 1932.
In 1907 wrote the first edition of his textbook practical anesthetics the third
edition of which was prepared by his junior colleagues C.Langton Hewer.
Boyle was a character and was universally known as Cockie.
His anesthetic machine, modified in every particular is used in most Britishhospitals today.
Krapp and Taub synthesized a new barbiturate, hexabarbitons later to become
known as Evipan.
Helnut - Weese saw that this might be the long awaited short-acting and safe
agent for induction of anesthesia.
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He was soon able to show that it fulfilled his expectations and in 1932 he
published his results, thus becoming undisputed creator of practical clinical
modern intravenous anesthesia.
He won recognition at the international conference of anesthesia at New-York
in 1938 during which he was elected as an honorary member.
During the II-world war, Weese investigated the possibility of producing a
synthetic plasma volume expander, and as a result, polyvinyl-pyrrolidone
became
available
and
saved
many lives. He died following a fall from a chair
in his
laboratory, an unusual event in a man well used to climbing in the high Alps.
CARL-KOLLER (1857-1944)
o Carl-Koller was the first medical man to make use and to publicize the
analgesic properties of cocaine to prevent the pain of a surgical-operation.
Birth: He was born in 1857 in Schuttenhofer.
The son of a Jewish businessman.
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Education: He was educated in Vienna, thought of studying law. Served for two
years as a conscript in the imperial army and finally enrolled as a medicalstudent in the University of Vienna.
While still an undergraduate Koller published the results of some highly
regarded experimental pathological investigations into the embryology of the
mesoderm of the chick.
He qualified as a doctor in 1882 at the age of 25 and became a member of the
dept of ophthalmology. In 1884, at the age of 27 be published the analgesic
properties of cocaine.
Koller was dissatisfied with the standards of anesthetists and restlessness cough
and vomiting during surgery. He began to realize that this problem would only
be solved if he could find some drug which, when instilled in to the conjunctival
sac would abolish pain, with this, view, he tried morphine and other sedative
drugs, but of course without success.
Sigmund-Freud who was working in the department neurology investigated a
new drug cocaine: he knew that it deadened mucous membranes but was not
clear to its effects on muscular contraction and asked Koller to do some
experiments to elucidate this problem.
Freud then went on holiday while Koller set to work with cocaine. He started by
applying some to his own tongue and was immediately stuck as others had been
before him, by its strange power to deaden all sensation. He immediately
realized that, this might be the agent be had been looking for to act as a local
analgesic in his eye operations. He quickly get about investigating its analgesic
effects in the experimental pathology laboratory on animals, than on himself on
his friends and lastly on his patients.
He satisfied himself that not only did it works but that it worked extremely well
and lost no time in making his discovery public. He wrote a short a preliminary
report and asked his friend, to read it for him at forthcoming meeting of the
German Ophthalmological Society to be held in Heidelberg, which Koller
himself was not able to attend. His demonstrated with 2% cocaine solution in the
OPD caused a sensation in the meeting. The date was 15th September 1884. The
following month Keller read two full papers became the imperial medical society.
This cocaine news (event) spread throughout Europe and the US and Koller
became a notable figure. But Koller did not get senior post in the academic dept
of eye-surgery.
Koller was, however a restless and somewhat awkward man and decided to try
his luck once more in Vienna but he found it hard.
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Koller fought with sobers and he decided to leave Vienna. He arrived to NewYork in 1888 and where he spent the remainder of his active life. He soon built
up a thriving hospital and private practice and established a solid reputation as
first class ophthalmologist. Koller received many medals, scrolls and
commendations from various academic bodies. Koller was its true begetter. He
died, in 1944 at the age of 86.
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Clover died at the age of 57. He is buried in Brampton cemetery, London, his
grave-being 200 yards from that of John-Snow.
HELMUT-WEESE (1897-1954)
o Helmut-Weese deserves an honoured place in the history of anesthesia as
the first man to make intravenous induction a safe and practical
procedure.
Birth: he was born in Munich in to a family originating from the German part of
Poland, son of a lecturer in the history of art.
When Helmut-Weese was nine, the family moved to Berne. Where his father
became a private dozent at the university.
He decided to study medicine and attended the universities of Berne, Munich and
Zurich where he qualified.
His first post was internal medicine and then he changed to pharmacology.
He paid particular attention to the study of digitalis wrote a book on it and as a
result, he became well known both inside and outside Germany to physicians as
well as to pharmacologists.
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WILLIAM-STEWART HALSTED
Halsted is famous for his early experiments with new local-analgesic solutions of
cocaine.
Birth: he was born in to a substantial family in the New-York city.
He was educated at Yale-college where his athletic prowess surpassed his
academic abilities.
Decided to study medicine, he entered the college of physicians and surgeons in
New-York in 1874, and graduated 3yrs later.
While a resident at Roosevelt hospital, new-York, in 1878, he became friendly
with William H. Welch.
Next 2yrs be spent in post-graduate studies in Austria and in Germany.
When he returned home, he entered surgical-practice in New-York city.
Halstead was one of the first to recognize the importance of the discovery of
cocaine, and with some of his colleagues commenced to experiment with the new
drug on them.
Contributions:
He originated nerve-block or regional analgesia.
He showed that a reduction in the circulation of a part of the body, by using
Esmarch bandage would prolong the effects of local analgesia.
He demonstrated that, for skin analgesia, Intradermal injection distensionmethod was superior to subcutaneous injection.
He was the first surgeon to block the nerves of the face the brachial plexus, the
internal pudendal and posterior tibial nerves.
In 1886, his-uncontrolled addiction to cocaine led to his admission to a
psychiatric hospital. He seems to have exchanged the craving for cocaine for the
craving for morphine possibly as a result of therapy, and remained off and on, a
morphine addict in the rest of his life.
On discharge from hospital his personality was seen to have changed, and he
now appeared as a slow, meticulous rather morose may who gave great attention
to the smallest detail of what occupied him.
In 1889, Halsted was appointed, the first professor of surgery in Johns-Hopkins
University and chief surgeon to the hospital.
During the next 30 yrs of his life he made his clinic world-famous and became
one of the founding fathers of 20th century surgery becoming mentor, guide,
philosopher and friend to countless young colleagues.
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His enthusiasm for regional analgesia warned and in later life he always
preferred to operate on unconscious patients. He died following a second
operation for gallstones and obstructive jaundice.
e) Among his contributions to surgery were, his radical operation, for the
removal of the whole breast with its lymphatic drainage for the relief of breast
cancer.
f) In 1890, he introduced the use of rubber-gloves in to surgery.
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dome and day is celebrated as ether day. Ether was given to Gilbert Abbott who was
a printer and journalist by Dr. John Collins warren who removed a tumour from the
jaw of his patient Gilbert-Abbott without producing pain.
Oliver Wendell-Holmes professor of anatomy and physiology at Harvard medical
school, said this priceless gift to humanity went forth from the operating theatre of the
Massachusetts-general hospital, and the man to whom the world owes it is; Dr. T.W.G.
Morton.
Much wrangling occurred between Morton and Jackson as who should be given credit
for the discovery.
Fate: Morton was sever in his lifetime officially recognized as the pioneer of ether,
anesthesia. Morton spent his later years forming at Needham, Massachusetts. Morton
died of cerebral-hemorrhage quite suddenly in central part, New-York city on 15 July
1868.
The inscription on his tombstone in mount Auburn cemetery, Boston, composed
by Henry J. Bigelow reads.
Inventor whom, in all time, surgery was agony, by whom pain in surgery was
averted and annulled; since whom, science has control of pain.
History of ether:
It was given in London and Paris in 1846, Robert Liston was the first surgeon to
operate under ether in England.
JOHN-SNOW (1813-1858)
Birth: Born in New York on 15th March 1823.
John-Snow was the eldest of 9 children of a farmer. After Morton, John snow was
the first-whole time anesthetist.
Education: John-Snow started his medical studies at the age of 14 yrs in New-Castle. He
was one of the eight medical students who entered the Newcastle-on-Tyne medical
School at its inception in 1832.
He was a student of Mr. William Hard-Castle.
John-Snow worked at the New castle infirmary and became interested in the
first-cholera epidemic in 1831-1832. In 1836 he migrated to London, traveling on foot
and attended lectures at the Hunterian school of Anatomy in great windmill street and
also at west minister hospital. He passed the M.D. exam in London, and appointed as a
lecturer in forensic medicine at Alder gate school of medicine. He spent rest of his life in
London as a general practitioner.
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Contributions to anesthesia:
1. John-Snow invented an ether inhaler in 1847 and adapted face-piece of Dr.
Francis-Sibson, later he invented his own.
2. Snow became the leading anesthetist in London and wrote a book in On
inhalation of ether in surgical operations. He described five stages or degrees of
anesthesia.
3. He emphasized the importance of knowing depth of anesthesia.
4. John-Snow used chloroform instead of ether, and after knowing that it causes
cardiac failure he invented percentage chloroform inhaler.
5. In 1853 Snow originated the method of chloroform in labor analgesia (pain)
when he acted as an anesthetist at the birth of Queen Victorias 8th child prince
Leopold. He gave his royal-patient 15 minimal doses intermittently on a
handkerchief. The administration lasting 53 mins.
6. John-Snow introduced amylene as an inhalational anesthetic in 1856.
7. In his later years, Snow proved that cholera is a water born disease; he ordered
for the removal of broad-street pump handle in 1854 in London and so
terminated the third cholera-epidemic.
Fate: John Snows health was poor and suffered from phthisis and from nephritis being
treated for the kidney disease by Richard Bright. He experimented with many
substances to see if they pressed anesthetic properties trying many of them on him.
John suffered from paralysis and died on 11th June 1858.
Near the site of pump, in broad wick street, a public house has been named the
John snow. Snows graveyard in Brompton cemetery was restored in 1938 by
anesthetist from Britain and U.S states.
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Bier introduced the tin-helmet into the German army in the First World War.
In later life he came to hold unorthodox ideas advocated physical education calisthenics
etc. He died in 1949 at Sauer in the German at the age of 88.
ARTHUR E. GUDEL
Birth: Born in Cambridge city, Indiana
Education: Received his medical education at the Indiana school of medicine.
Qualifying in 1908. Gudel lost three fingers of his right hand at the age of 13 but
nevertheless, be become skilled pianist.
Started as a general practitioner / anesthetist
He became a lecturer in the university of Indiana polis, during which time he was
practicing anesthetist in that city. Gave anesthetics in France during First World
War. Later he went to Los Angles where he became associate clinical professor
of Anesthesiology, at the University of Southern-California School of medicine. A
leading pioneer of American anesthesia.
Contribution:
Administration of nitrous oxide and air for obstetrics and minor surgery.
Description of the anesthetic properties of divinyl-ether
Reintroduction with R.M. waters of a cuffed tracheal tube
Systemization of the signs of inhalational anesthesia (Guedels stages)
Pharyngeal airway
Introduction of controlled respiration using ether
Classic description of the clinical use of cyclopropane.
Bier received the Hickman medal from the Royal society of medicine in 1991.
Distinguished service award of the American society of anesthesiologists in 1951.
There is a Gudel-memorial anesthesia centre in San Francisco, together with an
eponymous lecture established in his honor by the university of California medical
centre in Los-Angeles.
Died in California in 1956
Stages of anesthesia:
1. Stage of analgesia
2. Stage of excitement
3. Stage of surgical anesthesia
a. Regular breathing to cessation of eye movement
b. Commencement of intercostals paralysis
c. Complete (total) paralysis of intercostal paralysis
d. Complete diaphragmatic paralysis
4. Apnoea cardiopulmonary arrest
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His contributions to the growing specialty were numerous and important and he wrote
more than a hundred papers. Among the more noteworthy arc the following: insistence
on proper training programmes for young anesthetists; encouragement on careful note
keeping during anesthesia by means of punch-cards; the introduction of cyclopropane
into anesthetic practice; the development of the to-and-fro carbon dioxide absorption
system; a re-evaluation of chloroform; pioneering use of thiopentone in 1934;
endobronchial intubation.
He exercised a great influence on anesthesia in the US and in the UK during 1930-1950
and trained many anesthetists who later occupied important posts in universities in the
US and in Europe. He was one of the most important founding fathers of anesthesia as
we know it today. He received numerous medals, citations and honours from academic
bodies throughout the world and lived to enjoy 30 years of retirement, latterly growing
citrus fruit in Florida, where he died in Orlando on 19 December 1979.
HELMUT WEESE
Deserves an honoured place in the history of anesthesia as the first man to make
intravenous induction a safe and practical procedure. He was born in Munich into a
family originating from the German part of Poland, and the son of a lecturer in the
history of art. When he was nine, the family moved to Berne where his father became a
privatdozent at the University. Switzerland had a great influence on his development.
He decided to study medicine and attended the Universities of Berne. Zurich and
Munich where he qualified. His first post was in internal medicine under von Romberg,
and then he changed to pharmacology in 1925 and worked with W. Straub. He did well
in the new discipline and in his own turn became privatdozent. He paid particular
attention to the study of digitalis, wrote a book on it and as a result, became well known
both inside and outside Germany to physicians as well as to pharmacologists. When in
1928, F. Eicholtz who had previously described the effects of bromethol (Avertin)
moved to Konigsberg and then to
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wrote with Dr Freda Bannister, was the first anesthetic book to be published by
Blackwell Scientific Publications Ltd, in 1941. Robert Macintosh was first and foremost
a clinical anesthetist and his name became "associated with many practical pieces of
equipment, the most famous being the Macintosh laryngoscope. He had an enormous
and worldwide influence on the evolution of anesthesia. He travelled to many countries,
including the underdeveloped ones, and his work was recognised by bestowal of
honorary degrees from Universities in Argentina, France and Poland. He was made an
Honorary Fellow' of the Faculties of Anesthetists in England, Ireland and Australia and
an Honorary Doctor of Science in the University of Wales. He was knighted in 1955.
The Corporate Organization of Anesthesia in Britain.
The Society of Anesthetists was founded in 1893 by J. F. W. M. Silk (1878-1943) of
King's College Hospital, and forty anesthetists joined it. First president, Woodhouse
Braine (1837-1907) of Charing Cross Hospital, with Silk as Honorary Secretary and
Dudley W. Buxton (1855-1931) of University College Hospital, as Treasurer. Published
first volume of Transactions in 1898. In 1908 was incorporated into the Anesthetic
Section of the new Royal Society of Medicine. The first society of anesthetists in the
world which had as its object the discussion of problems of anesthesia and the
advancement of the science and art of the subject. The Scottish Society of Anesthetists
dates from 1914.
The Association of Anesthetists of Great Britain and Ireland was founded in 1932 to
perform functions that could not be performed by the Anesthetic Section of the Royal
Society of Medicine. These were (and are): to promote the development and study of
anesthetics and their administration and the recognition of the administration of
anesthetics as a specialized branch of medicine; to co-ordinate the efforts and activities
of anesthetists; to represent anesthetists and to promote their interests; to promote
the establishment of diplomas and degrees in anesthesia; to encourage and promote cooperation and friendship between anesthetists; and to do all such lawful things as may
be incidental or conducive to the attainment of such objects. The first president was
Henry Featherstone (1894-1967) of Birmingham with W. Howard Jones of Charing
Cross Hospital as Secretary and Z. Mennell (1876-1959) of St Thomas Hospital, London
as Treasurer. At this time there were only fifty specialist anesthetists in the whole of the
UK.84 (For a description of the 'Arms' of the Association, see Boulton T. B. Anesthesia,
1974, 29, 627.)
The Faculty of Anesthetists of the Royal College of Surgeons of England was created in
1948 at the request of the Association of Anesthetists. The Fellowship (FFARCS) was
proposed in 1946 and the first examinations Qheld in 1953. A. D. Marston (1891-1962)
of Guy's Hospital was the first dean.
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The College of Anesthetists was created in 1989 when a new charter allowed the Faculty
of Anesthetists to evolve to collegiate status. It became The Royal College of Anesthetists
in 1992.
The Faculty of Anesthetists of the Royal College of Surgeons in Ireland was founded in
1959. The first examination for its fellowship taking place in 1961.
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