PRACTICE GUIDELINES

IN
ANESTHESIA
SAEED A. RAZZAK - BOOK
 PRACTICE GUIDELINES
IN
ANESTHESIA
Editor
SK Malhotra MD FICA
Professor
Department of Anesthesia and Intensive Care
Postgraduate Institute of Medical Education and Research (PGIMER)
Chandigarh, India

Editorial Board Members

VP Kumra MD DAc FICA
Emeritus Consultant
Sir Ganga Ram Hospital, New Delhi, India
President
Indian College of Anaesthesiologists
B Radhakrishnan MD MPhil FICA
Principal
Academy of Medical Sciences
Kannur, Kerala, India
SM Basu MD DA (London) FICA
Ex-President
Indian Society of Anaesthesiologists

Indian College of Anaesthesiologists

Whole Constituent of
Indian Society of Anaesthesiologists
(Member of the World Federation of
Societies of Anaesthesiologists)

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Practice Guidelines in Anesthesia

First Edition: 2016

ISBN: 978-93-5152-988-0

Printed at
 Contributors
Abdul Qayoom Dar MD FRCA Bikash Ranjan Ray MD
Professor Assistant Professor
Department of Anesthesiology and Critical Care Department of Anesthesiology
Sher-i-Kashmir Institute of Medical Sciences All India Institute of Medical Sciences (AIIMS)
(SKIMS) New Delhi, India
Srinagar, Jammu and Kashmir, India [Link]@[Link]
qayoom777@[Link] Dalim Kumar Baidya MD
Amit Sharma MD Assistant Professor
Consultant Anesthesiology Department of Anesthesiology
Department of Anesthesiology and Critical Care All India Institute of Medical Sciences (AIIMS)
Army College of Medical Sciences and Base New Delhi, India
Hospital Dalimkumarb001@[Link]
New Delhi, India Girija Prasad Rath MD DM
dramitsharma@[Link] Additional Professor
Department of Neuroanesthesiology
Anil Agarwal MD MNAMS FICA
All India Institute of Medical Sciences (AIIMS)
Professor
New Delhi, India
Department of Anesthesiology
girijarath@[Link]
Sanjay Gandhi Postgraduate Institute of Medical
Sciences (SGPGIMS) Gundappa Parameswara MD FICA
Lucknow, Uttar Pradesh, India Senior Consultant Anesthesia
ani_sgpgi@[Link] Manipal Hospital Bengaluru
Adjunct Professor (Anesthesia)
Anjan Trikha MD FICA Kasturba Medical College
Professor Manipal, Karnataka, India
Department of Anesthesiology paramgundappa@[Link]
All India Institute of Medical Sciences (AIIMS)
New Delhi, India Jayashree Sood MD FFARCS PGDHHM FICA
anjantrikha@[Link] Chairperson
Department of Anesthesiology
Ashok Kumar Saxena MD FAMS FICA Pain and Perioperative Medicine
Professor Sir Ganga Ram Hospital, New Delhi, India
University College of Medical Sciences and Jayashreesood@[Link]
Guru Teg Bahadur Hospital
New Delhi, India JP Sharma MD FICA
profashoksaxena@[Link] Professor and Head
Department of Anesthesiology
BB Mishra MD Intensive Care and Pain Management
Chief Medical Officer Himalayan Institute of Medical Sciences (HIMS)
Dhanwantri Hospital Himalayan Institute of Hospital Trust (HIMT)
NTPC, Telangana, India Dehradun, Uttarakhand, India
bbm_58@[Link] jpshims@[Link]
vi Practice Guidelines in Anesthesia

Kamal Kishore MD P Ranjan MD

Assistant Professor Professor and Head
Department of Anesthesiology Division of Pediatric Anesthesia
Sanjay Gandhi Postgraduate Institute of Medical Institute of Medical Sciences
Sciences (SGPGIMS) Banaras Hindu University
Lucknow, Uttar Pradesh, India Varanasi, Uttar Pradesh, India
kamalkishore2@[Link] pushkarranjanbhu@[Link]

LD Mishra MD PhD FICA Parshotam Lal Gautam MD

Professor and Head Professor and Head
Department of Anesthesiology Department of Critical Care Medicine
Dayanand Medical College and Hospital
Institute of Medical Sciences
Ludhiana, Punjab, India
Banaras Hindu University
drplgautam@[Link]
Varanasi, Uttar Pradesh, India
ldmishra@[Link] Prashant Kumar MD PDFNA
Professor
Mahesh Kumar Arora MD
Department of Anesthesiology
Professor and Head Pt BDS Postgraduate Institute of Medical Sciences
Department of Anesthesiology University of Health Sciences
All India Institute of Medical Sciences (AIIMS) Rohtak, Haryana, India
New Delhi, India [Link]@[Link]
mkarora442@[Link]
Raminder Sehgal MD FICA
Mridula Pawar MD Senior Consultant
Professor Department of Anesthesiology
Vardhman Mahavir Medical College and Pain and Perioperative Medicine
Safdarjung Hospital Sir Ganga Ram Hospital, New Delhi, India
New Delhi, India ramindersehgal@[Link]
mridulapawar@[Link]
Rashmi Datta MD DNB
Mritunjay Varma MD FRCA (Gen Medicine and Aviation Medicine)
Consultant Consultant Anesthesiology
Anesthesia and Intensive Care Department of Anesthesiology and Critical Care
Newcastle-upon-Tyne Hospital, New castle, UK Army College of Medical Sciences and Base
[Link]@[Link] Hospital
New Delhi, India
Naresh Dua MD rashmidatta@[Link]
Consultant
Department of Anesthesiology RK Tripathi MD FICA
Professor and Head
Pain and Perioperative Medicine
Department of Anesthesia and Critical Care
Sir Ganga Ram Hospital, New Delhi, India
Era’s Lucknow Medical College
dua14@[Link]
Lucknow, Uttar Pradesh, India
Nidhi Kumar MD rk_tripathi32@[Link]
Assistant Professor Sarla Hooda MD
Department of Anesthesiology, Intensive Care Professor and Head
and Pain Management Department of Anesthesiology
Himalayan Institute of Medical Sciences (HIMS) Pt BDS Postgraduate Institute of Medical Sciences
Himalayan Institute of Hospital Trust (HIMT) University of Health Sciences
Dehradun, Uttarakhand, India Rohtak, Haryana, India
drnidhiaries@[Link] sarlahooda@[Link]
 Contributors vii

Seema Partani MD Susheela Taxak MD

Assistant Professor Professor
Department of Anesthesia Department of Anesthesiology
Pt BDS Postgraduate Institute of Medical Sciences
Geetanjali Medical College University of Health Sciences
Udaipur, Rajasthan, India Rohtak, Haryana, India
partaniseema@[Link] susheela_taxak@[Link]
SK Malhotra MD FICA T Prabhakar VSM MD PDCCC (Neuroanesth), FICA
Professor Principal Dean
Era’s Lucknow Medical College
Department of Anesthesia and Intensive Care
Lucknow, Uttar Pradesh, India
Postgraduate Institute of Medical Education and prabhu4903@[Link]
Research (PGIMER)
Chandigarh, India
Vinod Kalla MD
Emeritus Consultant
drskmalhotra@[Link] Sant Parmanand Hospital New Delhi, India
kallavinod@[Link]
Sunanda Gupta MD PhD FAMS FICA
Professor VP Kumra MD DAc FICA
Department of Anesthesia Emeritus Consultant
Geetanjali Medical College Sir Ganga Ram Hospital, New Delhi, India
President
Udaipur, Rajasthan, India Indian College of Anesthesiologists
[Link]@[Link] ved_kumra@[Link]
 Foreword
The specialties of anesthesia, intensive care and pain management are becoming dynamic
facets in the field of medicine. Continuous advancement is being made in improving the quality
care of patients undergoing surgical procedures. Practice Guidelines in Anesthesia is an integral
component that provides basic recommendations for anesthetic practice. The Indian College of
Anaesthesiologists (ICA) that is an academic branch of Indian Society of Anaesthesiologists has
come out with the first edition of Practice Guidelines in Anesthesia. The various chapters include the
topics covering preoperative preparations, monitoring, intra- and postoperative problems and their
management. It also covers the chapters dealing with pain management and the field of intensive
care therapy. All the chapters have been meticulously selected and authored by distinguished
clinicians.
The guidelines always provide the basic framework for carrying out the rational and acceptable
patient care. We must permit some amount of flexibility in individual situations and the
anesthesiologists should always exercise his own clinical experience and judgment. Moreover, each
hospital may modify these guidelines as per their local resources and infrastructure.
I applaud the efforts of Indian College of Anaesthesiologists in taking this unique initiative. I wish
to congratulate Dr SK Malhotra (Editor), and the editorial board members for their commendable
job.
I hope that the readers would find all topics interesting and beneficial in day-to-day anesthetic
practice.

VP Kumra MD DAc FICA

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

SK Malhotra
 Contents
1. Practice Guidelines for Postanesthesia Care Unit 1
Abdul Qayoom Dar
History 1; Managing PACU Staffing 1; Design and Staffing 2
Outpatient Surgery 12; Pediatric PACU 14

2. Perioperative Care of Ambulatory Anesthesia 17

Anil Agarwal, Kamal Kishore
Preoperative Assessment 18; Perioperative Care 18
Preoperative Preparation 18; Intraoperative Care 18
General Anesthesia 19; Regional Anesthesia 19
Peripheral Nerve block 19; Local Infiltration 19
Intravenous Regional Anesthesia 19
Postoperative Recovery and Discharge 20; Outcome Measures 20

3. Anaphylactic Reactions During Anesthesia 23

Anjan Trikha
Anaphylaxis 23; Etiology of Perioperative Anaphylaxis 23

4. Acute Pain Management Guidelines and Protocols: Evidencebased 32

Ashok Kumar Saxena
Definition 32; Aims of the Guidelines 33
ASA Task Force’s Recommendations for Providing
Postoperative Pain Management 34

5. Monitoring Standards in Anesthesia 45

Gundappa Parameswara
Section 1: Professional Standards 47
Section II: Monitoring the Anesthetic Equipment 48
Section III: Perioperative Care and Monitoring 49
Additional Monitoring 50
Section V: Monitoring during Regional Anesthesia, Anesthesia outside
the Operation Rooms and Monitored Anesthesia Care 51
Section VI: Monitoring during Transportation 51
Section VII: Monitoring in the Postoperative Ward 51

6. Head Injury: Assessment and Early Management 53

Girija Prasad Rath, Bikash Ranjan Ray
Definition and Classification of Head Injury 53

7. Guidelines to Quality Assurance in Anesthesia 60

Jayashree Sood
Quality Assurance Cycle 60; Provision of Anesthesia Services 61
Preoperative Examination 62; Preoperative Checklist 63
The Intraoperative Period 63; Records 63
xiv Practice Guidelines in Anesthesia

8. Preanesthetic Evaluation and Investigation 67

JP Sharma, Nidhi Kumar
Preanesthetic Evaluation 68; Investigation 70

9. Perioperative Fluid Management in Children 73

LD Mishra, P Ranjan
Fluid in Children with Burn Injury 74; Trauma 75

10. Central Venous Catheter Management Guidelines 76

Mahesh Kumar Arora, Dalim Kumar Baidya
Preparation of Resource and Training of Staff 76
Selections of Insertion Site and Type of Catheter 76

11. Inadvertent Perioperative Hypothermia 79

BB Mishra
Risk Factors 80; Patient Characteristics 81
Anesthesia Factors 81; Surgery Factors 82
Other Risk Factors 82; Gender 82
Surgery Risk Factors 83; Environmental Risk Factors 83
Consequences of IPH 83; Treatment of Hypothermia 84
Guidelines Recommendations 84

12. Practical Guidelines for Ultrasound Guided Nerve Blocks 87

Mridula Pawar
Review Basics of Ultrasound 87; Know Your Equipment 87
Anatomical Structures 88; How to Differentiate Tendons from Nerves? 88
How to Differentiate Artery from Vein? 89
Interscalene and Supraclavicular Block 89; Femoral Nerve Block 90

13. Epidural Analgesia: The Practice Guidelines 93

Mritunjay Varma
Complications 93; Catheter Insertion 94; Equipment 95
Patient Monitoring 95; Audit and Critical Incidents 97
Education 97

14. Monitored Anesthesia Care 99

Parshotam Lal Gautam
Monitoring during MAC 104

15. Management of Local Anesthesia Toxicity 109

Raminder Sehgal
General Guidelines 109; Prevention 110
Diagnosis 110; Management of LAST 111

16. Interhospital Transfer of Critically Ill Patients 113

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

Accompanying Medications 117; Accompanying Equipment 117

Aeromedical Considerations 119; Legal Issues 121

17. Practice Guidelines for Management of the Difficult Airway 127

SK Malhotra

18. Practice Guidelines in Obstetric Anesthesia 132

Sunanda Gupta, Seema Partani
Preanesthetic Requirements 132; Aspiration Prophylaxis 133
Guidelines for Regional Anesthesia in Obstetrics 133
Anesthesia for Cesarean Delivery 134; Removal of Retained Placenta 135
Postpartum Tubal Ligation 135
Management of Obstetric and Anesthetic Emergencies 135
Cardiopulmonary Resuscitation in Obstetric Patients 136

19. Checking Anesthesia Equipment 138

Susheela Taxak
Principles 138
Anesthesia Delivery System Checks 138

20. Perioperative Blood Transfusion 143

T Prabhakar, RK Tripathi
How Much Hemoglobin is Enough? 144
Blood Component Therapy 144; A Workable Guideline 145

21. Infrastructure Requirements for Operation Theater 148

Naresh Dua, VP Kumra
Utilization of Operation Theater 148; Infrastructure of Operation Theater 148
Aim of Planning 148; Requirements for Designing 149
Basic Architecture of the OT 149; Ventilation 151
Electrical 152

22. Preoperative Fasting Guidelines 155

Vinod Kalla

23. Anesthetic Care for MRI 157

Sarla Hooda, Prashant Kumar
Basic Physics 157; Specific Issues 158
Preparation and Techniques 158; Monitoring Equipment 158
Anesthesia for MRI 160; Planning and Safety 161

Index 163
 CHAPTER 1
Practice Guidelines for
Postanesthesia Care Unit
Abdul Qayoom Dar

Introduction from the frightening world of anesthesia and

surgery. The staff must be experienced and
Recovery from anesthesia is, for most patients, flexible to ensure proper early recovery as the
a smooth, uneventful emergence from an patient emerges from anesthesia and then
uncomplicated anesthetic and operation. For to facilitate intermediate recovery when the
anesthesiologists, involvement in optimizing patient achieves criteria for discharge to the
safe recovery from anesthesia is a key ward or directly home following ambulatory
component of perioperative medicine. Recovery surgery. These are important first steps to allow
is an ongoing process that begins when the patients to return to their normal activity.
intraoperative period has ended and continues
until the patient returns to the preoperative
physiological state and the process is divided History
into three phases: Although methods of general anesthesia have
• Early recovery (Phase 1) occurs from the been available for more than 160 years, PACUs
discontinuation of anesthetic agents until have become common only in the past 50 years.
the recovery of the protective reflexes and In 1863 Florence Nightingale wrote “It is
motor function. not uncommon, in small country hospitals, to
• Intermediate recovery (Phase 2) is the period have a recess or small room leading from the
during which the criteria for discharge from operating theater in which the patients remain
the Ambulatory Surgical Unit (ASU) are until they have recovered, or at least recovered
obtained. from the immediate effects of the operation.”
• Late recovery (Phase 3) lasts for several days In 1949, the Operating Room Committee for
and continues till the patient is back to his/ New York Hospital proclaimed: “Today it can be
her preoperative functional status and is able stated categorically that an adequate recovery
to resume daily activities. room service is a necessity to any hospital
Phase 1 recovery occurs in the post- undertaking modern surgical therapy.”
anesthesia Care Units (PACUs), which often face
the task of simultaneously caring for patients
Managing PACU Staffing
waking up from routine surgery, patients
recovering from regional anesthesia, critically ill • Staffing in the PACU has to be flexible to
postoperative patients, and children emerging provide a ratio of one nurse to one patient for
2 Practice Guidelines in Anesthesia

the initial 15 minutes of recovery care, then Equipment

one nurse to every two patients.
• An automated blood pressure device, pulse
• If critically ill patients are admitted, the ratio
oximetry, electrocardiographic monitoring,
is increased to as high as two nurses to one
and intravenous supports should be located
patient. A charge nurse should oversee the
by each bed.
nursing care.
• An area for charting and storage of bedside
• In most hospitals, the anesthesiologist
supplies is also necessary, with sterile
remains responsible for managing the
suction catheters, needles, syringes, gloves,
patient in the PACU.
and oxygen flow meter available at every
• PACU nurses consider 60 minutes to be a
bedside.
minimum period of time to check the patient
• Capability for arterial and central venous
in, process paperwork, and get the patient
pressure monitoring is also required in
ready for transfer to the floor.
hospitals where critically ill postoperative
patients use the PACU.
Design and Staffing • A supply of immediately available emergency
equipment should also be located in
Location and Size
the PACU and should include an airway
• The PACU should be located close to the cart consisting of oral and nasal airways;
operating suite to permit anesthesiologists orotracheal, nasotracheal, and tracheostomy
and surgeons to be nearby and allow rapid tubes; laryngoscopes; and self-inflating bags.
return of the patient to the operating room if A defibrillator capable of defibrillation,
necessary. synchronized defibrillation and external
• The size of the unit is determined by pacing should be available.
the surgical caseload of the institution. • A crash cart containing cardiopulmonary
Approximately 1.5 PACU beds per operating resuscitation equipment and emergency
room used is generally adequate. drugs should be available and fully stocked
• An open ward is optimal for patient at all times. Chest tube trays, cut-down trays,
observation; however, at least one positive and tracheostomy trays are necessary.
pressure and one negative pressure room
is a helpful addition to every PACU for the Routine Recovery
management of patients with either severe
immunosuppression or at risk to other • Some facilities require a minimal period
patients. of PACU observation after all surgical
procedures.
• Some patients may meet discharge criteria
Facilities
on arrival at the recovery room.
• The PACU ward itself should have • Instead of requiring a minimum PACU stay
large doors, adequate lighting, efficient for all patients, PACU stay can be adjusted
environmental control and sufficient according to patient and surgical factors.
electrical and plumbing facilities. • Sicker patients undergoing extensive surgery
• In addition to bed spaces, there should be a will require extended recovery.
central nursing station, as well as storage and
utility rooms. Transportation
• Each bed space should have piped-in
oxygen, air, and vacuum for gastric • After tracheal extubation, the patient is
suction. transferred from the operating room table to
 Practice Guidelines for Postanesthesia Care Unit 3

a stretcher with side rails that can be moved PACU, and the patient’s condition should be
into both the Trendelenburg and head-up recorded in the chart.
positions, if necessary.
• The patient should be transported from the
Postanesthesia Recovery Score
operating room in the lateral position to
(Modified Aldrete Score)
minimize the risk of airway obstruction or
aspiration of gastric contents from vomiting. Score Activity
• Most patients benefit by administration of 2
2 Moves all extremities voluntarily/on
to 4 of oxygen by nasal prongs or a cannula.
command
• Patients 60 years or older or those weighing
100 kg or more are at higher risk for 1 Moves two extremities
desaturation. 0 Unable to move extremities
Respiration
Report 2 Breathes deeply and coughs freely
• On arrival in the PACU, the anesthesiologist 1 Dyspneic, shallow or limited breathing
should give the nurse a full report of the 0 Apneic
events during surgery. Circulation
• This report should include the patient’s
name, age, surgical procedure, medical 2 BP + /- 20 mm of preanesthetic level
problems, preoperative medications, 1 BP + /-20–50 mm of preanesthetic level
allergies, anesthetic drugs and methods, 0 BP + /- 50 mm of preanesthetic level
fluid and blood replacement, blood loss, Consciousness
urinary output, gastric output, and surgical
or anesthetic complications encountered. 2 Fully awake
1 Arousable on calling
0 Not responding
Discharge
Oxygen Saturation
• Before discharge, a patient who has
2 SpO2 > 92% on room air
undergone anesthesia should meet certain
criteria. 1 Supplemental O2 req. to maintain SpO2
• The modified Aldrete score is a simple sum > 90%
of numerical values assigned to activity, 0 SpO2 < 92% with O2 supplementation.
respiration, circulation, consciousness, and
10 = Total score
oxygen saturation; a score of at least 9 out of
Score > 9 required for discharge
10 indicated patient readiness for discharge.
• The Postanesthesia Discharge Scoring Patients who have received regional
System modifies these required parameters anesthesia are less likely to have adverse
by including assessment of pain, nausea/ events including pain and nausea or vomiting,
vomiting, and surgical bleeding in addition but are more likely to have a degree of motor
to vital signs and activity. block. In view of these differences, Regional
• The anesthesiologist should see the patient Anesthesia PACU Bypass Criteria (RAPBC)
again before being discharged from the have been devised.
4 Practice Guidelines in Anesthesia

PACU Bypass Score Following stayed 60% and 26% longer, respectively) and
Regional Anesthesia length (i.e. for each 30-minute increase in
duration of surgery, the length of PACU stay
Parameters Score increased by 9%) of the surgical procedure.
Movement • General anesthesia versus sedation, and
Purposeful movement of at least one 2 American Society of Anesthesiologists (ASA)
lower and one upper extremity status were predictors of PACU length of
stay.
Purposeful movement of at least one upper 1
extremity but neither lower extremity • Patients with dizziness, postoperative nausea
and vomiting, cardiovascular events, and
No purposeful movement 0
pain stayed 31%, 25%, 23%, and 22% longer,
Blood pressure respectively, than did patients without these
Within 20% of baseline, without 2 adverse events.
orthostatic changes • A history of smoking also results in longer
Between 20% and 40% of baseline, 1 stays in the PACU.
without orthostatic changes
Less than 40% of baseline, or orthostatic 0 Organizational Factors
changes A variety of nonmedical factors are important
Level of consciousness predictors of prolonged PACU stay.
Awake, follows commands 2 • No available ward bed, waiting for test results,
transport delay, or lack of physician release
Arousable, follows commands 1
accounts for many delayed discharges from
Obtunded or persistently somnolent 0 the PACU.
Respiratory effort • In the ambulatory setting, even after
Able to cough involuntary on command 2 discharge criteria are met, delays of longer
than 30 minutes because of nonmedical
Able to cough involuntary but not on 1
reasons occur in 54% of outpatients,
command
with the most common reason being the
Dyspnea or apnea 0 unavailability of escorts to take them home
Pulse oximeter score or lack of their discharge medications.
SpO2 95% or more on room air 2
SpO2 95% or more with face mask or nasal 1 PACU Standards
cannula The ASA has Standards for Postanaesthesia
SpO2 less than 95% 0 Care, updated in October 1994, by the ASA
Total score 10 House of Delegates. These Standards apply
to postanesthesia care in all locations. These
Minimum Score to qualify for PACU bypass is Standards may be exceeded based on the
8. Patients considered for PACU bypass should judgment of the responsible anesthesiologist.
not require interventions for pain, postoperative They are intended to encourage quality patient
nausea and vomiting, or shivering. care. They are subject to revision from time to
time as warranted by the evolution of technology
Factors Influencing Stay in the PACU and practice.

Medical Issues Standard I

• The type (i.e. patients undergoing All patients who have received general
ophthalmologic and urologic procedures anesthesia, regional anesthesia or monitored
 Practice Guidelines for Postanesthesia Care Unit 5

anesthesia care shall receive appropriate post- • The patient shall be observed and monitored
anesthesia management. by methods appropriate to the patient’s
1. A PACU or an area which provides equivalent medical condition. Particular attention
postanesthesia care shall be available to should be given to monitoring oxygenation,
receive patients after anesthesia care. All ventilation, circulation and temperature.
patients who receive anesthesia care shall be During recovery from all anesthetics,
admitted to the PACU or its equivalent except a quantitative method of assessing
by specific order of the anesthesiologist oxygenation such as pulse oximetry shall be
responsible for the patient’s care. employed in the initial phase of recovery.
2. The medical aspects of care in the PACU shall This is not intended for application during
be governed by policies and procedures, the recovery of the obstetrical patient in
which have been reviewed and approved by whom regional anesthesia was used for labor
the Department of Anesthesiology. and vaginal delivery.
3. The design, equipment and staffing of • An accurate written report of the PACU period
the PACU shall meet requirements of the shall be maintained. Use of an appropriate
facility’s accrediting and licensing bodies. PACU scoring system is encouraged for
each patient on admission, at appropriate
Standard II intervals prior to discharge and at the time of
discharge.
A patient transported to the PACU shall be • General medical supervision and
accompanied by a member of the Anesthesia coordination of patient care in the
Care Team who is knowledgeable about PACU should be the responsibility of an
the patient’s condition. The patient shall be anesthesiologist.
continually evaluated and treated during • There shall be a policy to assure the
transport with monitoring and support availability in the facility of a physician
appropriate to the patient’s condition. capable of managing complications and
providing cardiopulmonary resuscitation for
Standard III patients in the PACU.
Upon arrival in the PACU, the patient shall be
re-evaluated and a verbal report provided to the
Standard V
responsible PACU nurse by the member of the
Anesthesia Care Team who accompanies the A physician is responsible for the discharge of
patient. the patient from the PACU.
• The patient’s status on arrival in the PACU • When discharge criteria are used, they
shall be documented. must be approved by the Department of
• Information concerning the preoperative Anesthesiology and the medical staff. They
condition and the surgical/anesthetic course may vary depending upon whether the
shall be transmitted to the PACU nurse. patient is discharged to a hospital room, to
• The member of the Anesthesia Care Team the Intensive Care Unit, to a short stay unit or
shall remain in the PACU until the PACU home.
nurse accepts responsibility for the nursing • In the absence of the physician responsible
care of the patient. for the discharge, the PACU nurse shall
determine that the patient meets the
Standard IV discharge criteria. The name of the physician
The patient’s condition shall be evaluated accepting responsibility for discharge shall
continually in the PACU. be noted on the record.
6 Practice Guidelines in Anesthesia

Complications • Laryngeal obstruction occurs secondary

to laryngeal spasm, direct airway injury, or
A large study of 18,473 PACU admissions in even vocal cord paralysis.
a university hospital in 1986 to 1989 found • If the airway obstruction is due to laryngeal
the incidence of PACU complications to be spasm, it can sometimes be relieved by
nearly 24%. The most common complications anterior displacement of the mandible. All
were nausea and vomiting (9.8%), need for patients with airway obstruction should
airway support (6.9%), hypotension (2.7%), receive oxygen by facemask (FiO2 of 1.0).
dysrhythmia (1.4%), hypertension (1.1%), • If the obstruction cannot be relieved by
altered mental status (0.6%), and major cardiac simple maneuvers, 10 mg dexamethasone
events (0.3%). Greater ASA physical status, intravenously may reopen the airway.
anesthesia duration between 2 hours and 4 • When the airway cannot be opened
hours, emergency procedures, and abdominal by physical means, positive-pressure
and orthopedic procedures had the highest ventilation with a bag, mask, and 100%
incidence of complications. oxygen is indicated. If succinylcholine has
been given, assisted ventilation should be
Respiratory Complications continued for at least 5 to 10 minutes, even if
Nearly two-thirds of major anesthesia-related the obstruction has been relieved.
PACU incidents may be respiratory. The major • For all cases of airway obstruction, if an
respiratory complications encountered in the adequate airway cannot be established by
PACU are airway obstruction, hypoxemia, simple physical or pharmacologic means,
hypercapnia, and aspiration. Prompt orotracheal intubation is necessary.
recognition plus treatment of these life- • The laryngeal mask airway may be helpful in
threatening problems is crucial. certain patients and has even been used to
In an evaluation of 24,157 consecutive PACU provide pressure support ventilation in the
admissions over a 33-month period, it was found PACU.
that for patients receiving general anesthesia, • In the very rare case in which the trachea
the risk of a critical respiratory event was 1.3% cannot be intubated, an emergency
(hypoxemia, 0.9%; hypoventilation, 0.2%; and cricothyroidotomy will relieve the
airway obstruction, 0.2%). Risk factors were obstruction. This procedure is probably
age older than 60 years, male gender, diabetes, safer than emergency tracheostomy because
obesity, emergencies, surgery longer than 4 excessive bleeding is common with the latter
hours, opioid or sedative premedication, and procedure performed under emergency
the use of thiopental as opposed to propofol. conditions.
• Patients with obstructive sleep apnea are
at high-risk for airway obstruction when
Airway Obstruction
sedated. Nasal continuous positive airway
• The most common cause of postoperative pressure (CPAP) can be very useful in these
airway obstruction is pharyngeal obstruction. patients after tracheal extubation.
• A combination of backward tilt of the head
and anterior displacement of the mandible is
often helpful.
Hypoxemia
• If the obstruction is not immediately • After major surgical procedures, all patients
reversible, a nasal or oral airway can be should receive oxygen therapy by facemask
inserted. Patients may better tolerate the or nasal prongs. The need for such therapy
nasal airway. The oral airway may stimulate can be guided by pulse oximetry and is
gagging and vomiting, as well as laryngeal needed for all those with SpO2 of less than
spasm. 92%.
 Practice Guidelines for Postanesthesia Care Unit 7

• Increased age, postanesthetic shivering, and lowest possible level consistent with
lowered cardiac output may aggravate the adequate perfusion of all organ systems.
degree of hypoxemia in postsurgical patients. Such treatment consists of diuretics, fluid
• Atelectasis is the most common cause of restriction, vasodilators, or dialysis if
an increased right-to-left shunt. Bronchial associated renal failure is present. Positive-
obstruction from secretions or blood is a pressure ventilation is useful in patients with
frequent cause of atelectasis. Lobar and severe hypoxemia or respiratory acidosis.
segmental collapse often results from Ventilation with end-expiratory pressure
bronchial obstruction with secretions and improves oxygenation by increasing lung
is best managed by providing adequate volume, not by decreasing lung water.
humidification of inspired gases, coughing, • Pulmonary embolism occurring in the
deep breathing, and postural drainage. immediate postoperative period is a
• Pneumothorax is another potential cause serious event that can lead to profound
of hypoxemia in the PACU. Pneumothorax hypoxemia. Patients at bed rest for
occurs as a result of direct lung or airway prolonged periods before surgery, patients
injury from trauma, rib fractures, or attempts who have undergone joint replacement
at percutaneous vascular cannulation. surgery, or parturients are particularly
Pneumothorax resulting from mechanical susceptible to emboli. The diagnosis
ventilation per se is rare unless airway is suspected in a patient with sudden
pressure is high. pleuritic chest pain, shortness of breath,
Treatment depends on the size of pleural effusion, or tachypnea. Massive
the pneumothorax and the patient’s emboli result in hypotension, pulmonary
condition. A 10 to 20% pneumothorax in hypertension, and elevated central venous
a spontaneously breathing patient can be pressure. Because the treatment of choice
observed with frequent upright chest X- is anticoagulation, establishment of an
rays. A pneumothorax of more than 20% in accurate diagnosis is imperative so that
a spontaneously breathing patient or any patients in the immediate postsurgical
pneumothorax in a mechanically ventilated period are not needlessly exposed to the
patient should be treated by insertion of a risks of anticoagulation.
chest tube for drainage. • Diffusion hypoxemia can occur but are rarely
Tension pneumothorax leads to circulatory seen in clinical practice because oxygen
compromise as a result of the pleural administration prevents manifestation of
cavity filling with air and compressing the these conditions. Diffusion hypoxia occurs
mediastinum. A 14-gauge needle inserted when N2O is replaced with air at the end of
into the second intercostal space can relieve the anesthetic.
the tension before chest tube insertion. Treatment of hypoxemia by facemask
• Pulmonary edema can also be a cause of oxygen is effective in restoring PaO2 in many
hypoxemia in the postoperative period. cases.
The most common time of appearance of If hypoxemia persists (PaO2 < 60 mm Hg)
pulmonary edema was within 60 minutes despite maximal oxygen therapy (FiO2 = 1.0),
of completion of surgery. Pulmonary edema Tracheal intubation and mechanical
was frequently detected by the presence of ventilation should be initiated.
wheezing. Prolonged airway obstruction can The use of CPAP by an external mask
cause “negative-pressure” pulmonary edema. (mask or nasal CPAP) is increasingly being
Current treatment of both forms of used for the treatment of patients with
pulmonary edema involves lowering severe hypoxemia who have adequate
hydrostatic pressure in the lungs to the carbon dioxide elimination (PaCO2).
8 Practice Guidelines in Anesthesia

Hypoventilation Hypotension
• Hypoventilation is defined as reduced • The recovery phase of anesthesia is usually
alveolar ventilation resulting in an increase associated with decreased ventricular
in PaCO2. preload, reduced myocardial contractility,
• During the postoperative period, or a profound reduction in systemic vascular
hypoventilation occurs as a result of poor resistance.
respiratory drive, poor respiratory muscle • Prompt diagnosis and treatment are
function, or a high rate of production of important because prolonged hypotension
carbon dioxide, or it can be a direct result of can result in hypoperfusion of vital organs
acute or chronic lung disease. and subsequent ischemic damage.
Central respiratory depression is seen • If hypotension persists despite attempts to
with any anesthetic. Narcotic-induced. restore intravascular volume, ventricular
respiratory depression can be reversed with preload must be further assessed. During this
the use of narcotic antagonists. time, administration of a vasopressor will
• When small doses are used, these agents prevent a prolonged period of hypotension
can reverse the narcotic-induced respiratory while hemodynamic monitoring is
depression without altering pain relief. established.
Titration of a small dose and increasing • Hypovolemic shock is characterized by low
the dose upward until an effect is seen can PAOP (< 5–10 mm Hg) with a normal low
avoid the sudden onset of severe pain along cardiac index (normal, 2.5–4.0 L/min/m2)
with the profound reflex tachycardia and and normal or elevated systemic vascular
hypertension. resistance.
• Failure of reversal of neuromuscular • Cardiogenic shock is characterized by
blocking drugs may result in inadequate increased PAOP (>15 mm Hg) with a low
respiratory muscle function postopera- cardiac index and elevated systemic vascular
tively. Hypermagnesemia potentates resistance.
neuromuscular blockade, as does • Septic shock, PAOP will usually be low with
hypothermia. a very high cardiac output and low systemic
• Obesity, gastric dilation, tight dressings, vascular resistance. The patient often has
and body casts also inhibit respiratory fever, an elevated white blood cell count, and
muscle function and can predispose to CO2 some other sign of systemic infection.
retention. Measurement of PaCO2 is the best • Treatment of such prolonged hypotension
method of detecting hypoventilation in the is now guided by following the variables of
postoperative period. Ventricular preload, cardiac output, and
• Treatment of serious respiratory failure urinary output. Hypovolemic shock is treated
necessitates emergency tracheal intubation. by intravenous administration of blood and
crystalloid.
• Cardiogenic shock is managed by first
Circulatory Complications
optimizing ventricular preload. Most
Critical cardiovascular events are the second patients have optimal cardiac output when
major group of life-threatening complications PAOP is increased to 15 to 20 mm Hg.
for patients in the PACU. In a study involving Occasional patients with severe, long-
more than 18,380 patients after general standing ventricular failure will require a
anesthesia, patients in whom hypertension or PAOP of 20 to 25 mm Hg to maintain cardiac
tachycardia developed in the PACU had more output. In addition to an optimal preload,
unplanned critical care admissions and a higher these patients also require inotropic
mortality. support.
 Practice Guidelines for Postanesthesia Care Unit 9

• Septic shock is managed by replacing the Dysrhythmias

fluid lost from capillary endothelial leak
with crystalloid. The use of albumin in this • Factors predisposing to the development of
situation is possibly harmful because the postoperative dysrhythmias are electrolyte
albumin can leak out into the interstitium and imbalance (especially hypokalemia),
draw intravascular fluid with it. A vasopressor hypoxia, hypercapnia, metabolic alkalosis
such as norepinephrine or phenylephrine and acidosis, and pre-existing heart disease.
could be introduced to improve blood • When a dysrhythmia occurs in a patient in
pressure. Use of vasoconstrictors for more the PACU, it is often a sign of some metabolic
than 24 hours may result in renal and or perfusion problem.
gastrointestinal ischemia. • The most common dysrhythmias are sinus
tachycardia, sinus bradycardia, ventricular
premature beats, ventricular tachycardia,
Hypertension and supraventricular tachyarrhythmias.
• Treatment of predisposing factors usually
• When hypertension develops in a patient in
will help in resolution of the dysrhythmias.
the PACU, it is often due to pain, hypercapnia,
hypoxemia, urinary retention, or excessive
Failure to Regain Consciousness
intravascular fluid volume. These etiologies
need to be ruled out. • Evaluation of a patient who does not regain
• Severe hypertension can lead to left consciousness after general anesthesia
ventricular failure, myocardial infarction, or requires careful assessment of the patient.
a dysrhythmia as a result of a sharp increase • Preoperative factors such as drug or alcohol
in myocardial oxygen consumption. intoxication should be sought. The most
• Acute hypertension may also precipitate common reason for persistent somnolence is
acute pulmonary edema or cerebral the residual effects of anesthetics, sedatives,
hemorrhage. Pre-existing hypertension is and preoperative medications.
present in more than half the patients in • Initial management should include
whom hypertension develops in the recovery pharmacologic reversal agents aimed at the
room. When hypertension does develop most likely sedative drug.
during recovery from anesthesia, it usually • Naloxone in small doses will increase the
begins within 30 minutes of the end of the ventilatory rate if narcotic sedation is the
operation. problem.
• β-blocking drugs such as labetalol and • Physostigmine (1.25 mg intravenously) can
esmolol are effective in treating hypertension reverse the effects of some sedatives and
during recovery. Labetalol, a combined α- inhaled anesthetics.
and β-blocking agent, is commonly used in • Flumazenil (up to 1.0 mg intravenously) can
the PACU. reverse the sedative and amnestic effects of
• Labetalol can be given in 5-mg increments the benzodiazepines.
intravenously, with the effect on blood • Because profound neuromuscular blockade
pressure apparent in several minutes. can make a patient appear unconscious,
Labetalol is also effective in neurosurgical such blockade should also be considered.
patients already receiving high doses of • Profound hypothermia (temperature
nitroprusside. < 33°C) can produce unconsciousness, as can
• Esmolol is an ultrashortacting β-blocker. Its profound abnormalities in serum glucose
short half-life means that it must be given as such as hyperglycemia or hypoglycemia.
a continuous infusion at rates of 25 to 300 μg/ Blood glucose, electrolytes, and blood gases
kg/min. should be evaluated in all such cases.
10 Practice Guidelines in Anesthesia

• If one has reason to suspect hypoglycemia, • Preoperative neurotic personality traits tend
50% dextrose should be administered to increase postoperative pain, as does the
immediately and blood glucose fear of pain itself.
determination not awaited. If the diagnosis • The site of the operation certainly influences
remains unclear, a structural neurologic the severity of pain. In general, thoracotomy
abnormality should be sought. Raised and upper abdominal surgery appear to
intracranial pressure may occur after head be the most painful operations. Lower
trauma or neurosurgery. abdominal surgery is less painful.
• Intraoperative cerebral hypoxia from
hypoxemia or poor cerebral perfusion Opioids
can produce a diffuse encephalopathy.
Emergency computed axial tomographic • Morphine by titration is often the first step in
scanning can be used to evaluate the postoperative pain management.
presence of raised intracranial pressure or • Intravenous morphine titration every 5
an acute intracranial hemorrhage as the minutes with an unlimited number of boluses
cause of the delayed emergence. and early subcutaneous administration
• Rarely, overdose with lidocaine can be provided the best analgesic regimen in a
manifested as unconsciousness. Old age per study investigating different methods of
se does not account for delayed emergence titration.
from general anesthesia. • Administering morphine at the end of
surgery (1–3 mg intravenously every 5 or 10
minutes) instead of waiting until the patient
Postoperative Pain is in the PACU improves pain relief with
• One of the important jobs in PACU is less respiratory depression. Patients will
adequate control of pain during rest (rest need encouragement to cough and breathe
pain) and pain with activity (incident pain). deeply.
Rest pain is generally easier to alleviate. • Patient-controlled analgesia permits the
Incident pain is more difficult to manage. patient to determine the timing of analgesic
• The choice of a particular postoperative doses and allows for improved titration of
pain management regimen depends on analgesia. It also minimizes patient anxiety.
the anticipated pain intensity. Despite new Patients receiving this form of pain therapy
techniques and increased emphasis on should have it begun in the PACU. Morphine
relieving acute pain, postoperative pain has been the gold standard for this form of
remains undertreated. Reasons include therapy.
confusion about who is responsible for
analgesia, providers’ lack of knowledge Nonsteroidal Anti-inflammatory Drugs
regarding the effective dose ranges and • Nonsteroidal anti-inflammatory drugs
duration of action of opioids, and fears of (NSAIDs) can be part of an effective
respiratory depression and addiction. multimodal analgesia protocol that
includes instructing the patient to take pain
Risk Factors for Increased Pain medication as soon as discomfort occurs.
NSAIDs are useful for postoperative pain
• Many factors influence the onset, incidence, management because surgery causes both
and severity of postoperative pain. pain and inflammation.
• The very young and very old experience less • NSAIDs may be divided into three groups:
pain than do people in the middle years of NSAIDs with predominant analgesic effect
life. (ketorolac, naproxen), NSAIDs that are
 Practice Guidelines for Postanesthesia Care Unit 11

essentially anti-inflammatory (oxicams), Nerve Blocks

and NSAIDs that have both analgesic and
anti-inflammatory effects (diclofenac, • Regional anesthesia has been used for the
ketoprofen, indomethacin). relief of postoperative pain to avoid narcotic-
• Ketorolac, though not as potent as the induced respiratory depression. Instillation
narcotics, can be an effective alternative to of local anesthetic into a wound can be very
narcotic analgesics in the PACU. Depending efficacious and is simple to perform.
on the type of surgery, adding ketorolac • Continuous epidural blockade can provide
reduces the total opioid dose by a third (with good postoperative analgesia and, when
a range from 0% to 73%, depending on the done in the thoracic space, can permit early
type of surgery) and improves pain relief. postoperative ambulation.
• The risk for adverse events with ketorolac • Patients receiving epidural pain relief can be
increases with high doses, with prolonged ambulated earlier, thereby permitting earlier
therapy, or in vulnerable patients (e.g. the hospital discharge.
elderly). Ketorolac is as safe as ketoprofen • The use of regional anesthesia for
and diclofenac for the treatment of pain after postoperative pain relief appears to be
major surgery. best suited for patients with pre-existing
• When a postoperative anticoagulant was lung disease in whom narcotics would be
administered, patients who received hazardous and when a regional technique
ketorolac were likely to have surgical-site could relieve pain without adversely affecting
bleeding. respiration.

Epidural Analgesia Nausea and Vomiting

• The use of narcotics in the epidural space to • Postoperative nausea and vomiting are
control postoperative pain is a very effective common complications that result in patient
approach. discomfort, prolonged stay in the PACU,
• Morphine, 2 to 4 mg diluted to 10 mL, and rarely, one of the pulmonary aspiration
provides prompt analgesia with duration syndromes. Postoperative nausea and
of action of about 12 hours. Complications vomiting are multifactorial in etiology.
include late respiratory depression, which • Propofol-based anesthetics are consistently
can occur as long as 6 hours after injection associated with a lower incidence of
of the morphine. Significant respiratory postoperative nausea and vomiting than
depression occurs in less than 1% of patient other techniques are, even when potent
receiving epidural narcotics and can be antiemetics such as ondansetron are
reversed with naloxone. combined with inhaled drugs.
• Synthetic narcotics have also been used • A literature review of 27 publications found
successfully for epidural analgesia. that all but 3 contained evidence implicating
• About 15 to 20% of patients complain of nitrous oxide in postoperative nausea and
pruritus. Nausea and urinary retention have vomiting.
also been reported to be complications. • Patients undergoing laparoscopic surgery
The technique is most helpful when used and strabismus surgery are at increased risk
for patient undergoing major thoracic or for nausea and vomiting. Patients who are
abdominal surgery who are at high-risk menstruating have a higher risk of nausea
for complications of parenteral analgesic and vomiting after laparoscopy for tubal
therapy. ligation.
12 Practice Guidelines in Anesthesia

Drug Therapy for Nausea and Vomiting OUTPATIENT SURGERY

• The serotonin antagonists ondansetron, • Over 50% of all surgical procedures are
dolasetron, and granisetron are useful as performed on an outpatient basis, which
first-line drugs. is safe and effective for properly chosen
• Adding dexamethasone can reduce the patients.
frequency of nausea and vomiting, even when • These patients will need to be able to leave
compared with the serotonin antagonist the facility shortly after discharge from the
alone. There is little evidence of any clinically PACU.
relevant toxicity for dexamethasone in • Patients should always be accompanied
otherwise healthy patients. Late efficacy by another person. Because virtually all
seems to be most pronounced. anesthetic techniques impair psychomotor
• Metoclopramide is an effective and safe skills, driving or operating machinery should
antiemetic for both prevention and treatment not be attempted for 24 hours.
of postoperative nausea and vomiting. • Increasing efforts are being directed at
having patients completely bypass (“fast
Hypothermia and Shivering tracking”) the phase 1 PACU after general
anesthesia.
• Surgical patients may be admitted to the • Low-solubility inhaled anesthetics and
PACU with inadvertent hypothermia (i.e. propofol, the increasing frequency of
core temperatures < 36°C). minimally invasive surgery and titration
• Mild perioperative core hypothermia of anesthetic drugs by using the processed
may increase the risk of wound infection, electroencephalographic bispectral index
bleeding, cardiac complications, and (BIS) may allow patients to be awake, alert,
prolonged PACU stay. and mobile enough with no bleeding or
• The major adverse effects are patient nausea at the end of an operative procedure
discomfort, vasoconstriction, and shivering. such that they can safely bypass the
Full recovery sometimes takes many hours. PACU.
Shivering increases the metabolic rate and • A study of 302 patients receiving a propofol-
hence the need to increase cardiac output alfentanil-nitrous oxide anesthetic at four
and minute ventilation. institutions found that patients in the BIS
• Hypothermic patients should have group required lower propofol infusion
supplemental oxygen, warm intravenous rates, were tracheally extubated sooner, had
fluids and blood, and external warming. a higher percentage of patients oriented
External warming can be accomplished with on arrival at the PACU, had better PACU
forced hot air blown with use of Bair Huggers. nursing assessments, and became eligible
• Patients in whom shivering develops should for discharge sooner.
receive supplemental oxygen. • Patients admitted to the phase 1 PACU have
• Although many drugs have been used to an average length of stay of 30 minutes.
treat postanesthetic shivering, Pethidine Patients are typically discharged from the
(25–30 mg intravenously) is very effective in phase 2 PACU to home in 1 hour.
both stopping the shivering and decreasing • The potential benefits of fast tracking need
oxygen consumption. In some patients a to be considered against any possible
second dose is necessary. disadvantages such as the perception by
• Fentanyl is also effective, but for a shorter patients that they are being rushed out of the
interval. PACU too quickly.
 Practice Guidelines for Postanesthesia Care Unit 13

Fast Tracking (Contd...)

• Fast tracking is a clinical pathway that Saturation < 90% with supplemental oxygen 0
involves transferring patients from the Postoperative Pain Assessment
operating room to ASU directly without None or mild discomfort 2
entering the PACU. Moderate to severe pain controlled with 1
• Achieving an Aldrete score of 9 or 10 in the intravenous analgesics
operating room has been used to bypass the Persistent severe pain 0
PACU. However, the Aldrete scoring system Postoperative Emetic Symptoms
does not address pain, nausea and vomiting, None or mild nausea with no active vomiting 2
which are common side effects in the PACU. Transient vomiting or retching 1
• White and Song have devised a scoring
Persistent moderate to severe nausea and 0
system that includes pain and emetic vomiting
symptoms within the Aldrete scoring system.
Total Possible Score 14
Under this system, a score of 12 with no score
less than 1 in any category provides criteria
for bypassing the PACU (White PF, Song D Discharge Criteria from Ambulatory
Anesth Analg. 1999;88:1069–72) Surgical Unit (ASU)
• Discharge of patients home from ASU
White and Song Scoring System requires strict adherence to validated criteria
to ensure safety and to prevent litigation.
Parameters Score • Criteria for safe discharge home from ASU
Level of Consciousness have been developed as postanesthesia
Awake and oriented 2 discharge score system (PADS) by Chung
Arousable with minimal stimulation 1 et al. and subsequently modified by Awad
Responsive only to tactile stimulation 0 and Chung (Chung F, et al. Can J Anaesth,
Physical Activity 1995;42:1056-8 and Awad IT, Chung F Can J
Able to move all extremities on command 2 Anaesth. 2006; 53: 858-72).
Some weakness in movement of extremities 1
Unable to voluntarily move extremities 0 Postanesthesia Discharge Score
Hemodynamic Stability System (PADS)
Blood pressure less than 15% of baseline 2
MAP value Parameters Score
Blood pressure 15%–30% of baseline MAP 1 Vital Signs
value
Within 20% of preoperative baseline 2
Blood pressure more than 30% of baseline 0
MAP value 20–40% of preoperative baseline 1
Respiratory Stability 40% of preoperative baseline 0
Able to breathe deeply 2 Activity Level
Tachypnea with good cough 1 Steady gait, no dizziness, consistent with 2
Dyspnea with weak cough 0 preoperative level
Oxygen Saturation Status Requires assistance 1
Maintains value > 90% on room air 2
Unable to ambulate/assess 0
Requires supplemental oxygen (Nasal 1
Prongs) Nausea and Vomiting

(Contd...) (Contd...)
14 Practice Guidelines in Anesthesia

(Contd...) • In addition to basic PACU equipment, an

air-O2 blender is necessary so that a 100%
Minimal: Mild, no treatment needed 2
inspired O2 concentration can be avoided
Moderate: Treatment effective 1 in preterm infants at risk for retrolental
Severe: Treatment not effective 0 fibroplasia.
Pain • Code carts should be stocked with
equipment specific to children, including
VAS = 0–3 2
cuffed and uncuffed endotracheal tubes,
VAS = 4–6 1 several sizes of pediatric masks, oral and
VAS = 7–10 0 nasal airways, laryngoscopes, and a carbon
Surgical Bleeding
dioxide detector.
• The cart should also have intraosseous
Minimal: Does not require dressing change 2 needles in the event that the code team is
Moderate: Required upto two dressing 1 unable to start an intravenous line.
changes with no further bleeding • A drug manual (e.g. a laminated sheet
Severe: Required three or more dressing 0 attached to the code cart) with common
changes and continues bleeding pediatric dosages should be immediately
Total Score 10 available.

Patient score > or equal to 9 are fit for discharge. Parental Presence
Patients are often discharged in 1 to 2 hours or
less following ambulatory surgery. Many ASUs • Although parental presence in phase 2 or
use outcome based criteria for discharge instead step-down recovery is common, parental
of numerical scoring like PADS and include the visitation in the phase 1 PACU remains
following: somewhat controversial.
• Alert and oriented to time and place • Particular subsets of patients, especially
• Stable vital signs those who suffer from developmental delay
• Pain controlled by oral analgesics or sensory deficit, may benefit from having
• Nausea or emesis controlled their parents close by to help calm them
• Able to walk without dizziness when they awaken.
• Regional anesthesia block appropriately • Visitation in the PACU may also reduce
resolved parental anxiety and increase parental
• No expected bleeding from the operative site satisfaction.
• Given discharge instructions and • Parents in the PACU should be allowed to see
prescriptions their child only after the child has regained
• Patient accepts readiness for discharge consciousness and no longer requires the
• Adult present to accompany patient home. staff’s immediate attention.
• The nursing staff must be comfortable
with having parents in the recovery area.
PEDIATRIC PACU
Parents need to be made aware that they
• Caring for a pediatric patient after anesthesia may be asked to leave if the child becomes
requires special preparation and knowledge unstable.
of the potential postoperative complications
specific to children. Specific Postoperative Problems
• Not all PACUs are dedicated solely to
Emergence Delirium
pediatric recovery, so it is important that staff
with pediatric experience be available. • Pediatric patients will on occasion
• Children can be safely fast-tracked after emerge from anesthesia disoriented and
ambulatory surgery. inconsolable. This phenomenon is termed
 Practice Guidelines for Postanesthesia Care Unit 15

emergence delirium and may even require uncomplicated anesthesia. These events
restraint of the patient. may be secondary to underlying neurologic,
• Emergence delirium has been associated cardiac, or pulmonary disease.
with the use of less soluble anesthetics as • Patients with anemia are at higher risk for
opposed to more soluble anesthetics such as apnea.
halothane. • Ex-preterm infants who are less than 45 to
• Adequate analgesia with opiates or NSAIDs 60 weeks’ postconceptual age are admitted
may reduce the incidence of delirium. for monitoring after surgery for at least 12
Inviting the parents to visit in the PACU may to 18 hours. The overall risk of apnea in
help calm a child. patients less than 48 weeks’ postconceptual
• When evaluating a patient with suspected age is 5%, and this risk does not decrease to
emergence delirium, life-threatening less than 1% until patients reach 54 weeks’
complications such as hypoxia, acidosis, or postconceptual age.
increased intracranial pressure should be • Intravenous caffeine, 10 mg/kg, has been
ruled out. used to treat apneic episodes in preterm
infants and has been recommended for
Postintubation Croup prophylaxis against postoperative apnea.

• Postintubation subglottic edema is a Conclusion

complication that can occur in 1 to 6%
of patients younger than 4 years. Even a Recovery from anesthesia is, for most patients,
minimal amount of airway edema can cause a smooth, uneventful emergence from an
significant obstruction, especially at the level anesthetic. Recovery is an ongoing process
of the cricoid cartilage, the narrowest section that begins when the intraoperative period has
of the pediatric airway. ended and continues until the patient returns
• Patients who have a history of Down’s to the preoperative physiological state. Trained
syndrome or other congenital airway nursing personnel look after the patients’
stenosis, a surgical procedure in and airway, breathing, circulation and provide
around the airway, recent upper respiratory comfort in the form of pain relief and warmth
infection, coughing on the endotracheal till they are ready for discharge from PACU.
tube, prone position, or traumatic intubation Before discharge, a patient should meet certain
are at increased risk. criteria referred to as “The modified Aldrete
• Appropriate therapy includes cool mist by score” and the patient’s condition at discharge
face tent and nebulized racemic epinephrine should be recorded in the patient’s notes and
(0.5 mL of 2.25% epinephrine in 2.5 mL of handed over to the nursing personnel from the
normal saline). respective wards.
• Corticosteroids such as dexamethasone PACU should have facilities to take care of
have also been used to treat airway edema, patients with hypoxia and other respiratory
but no data support their routine use for complications, hypotension and other
postintubation subglottic edema. circulatory complications, delayed awakening
• Rarely does a patient require reintubation. from anesthesia, treat nausea and vomiting if
any and prevent and treat hypothermia and
shivering.
Postanesthetic Apnea
It should be a safe process from anesthesia
• Former preterm infants (born before 37 and surgery in the operating room to discharging
weeks’ gestation) are at increased risk a fully awake, stable and pain free patient back
for apnea and bradycardia after even to the ward.
16 Practice Guidelines in Anesthesia

Further Suggested Reading 3. Nicholau TK. The postanesthesia care unit. In:
Miller RD, editor. Miller’s Anesthesia. 8th edn.,
1. American Society of Anesthesiologists:
Practice guidelines for postanesthetic care. Philadelphia, PA: Elsevier; [Link].2924-46.
Anesthesiology. 2002; 96:742-52. 4. Cohen IT, Deutch N, Motoyama EK. Induction,
2. Practice Guidelines for Postanaesthetic Care maintenance and recovery. In: Smith’s
An Updated Report by the American Society of
Anesthesiologists Task Force on Postanaesthetic Anesthesia for infants and children, 8th edn.,
Care Anesthesiology. 2013;118:291-307. Philadelphia, PA: Elsevier, 2015.p.365-94
 CHAPTER 2
Perioperative Care of
Ambulatory Anesthesia
Anil Agarwal, Kamal Kishore

Ambulatory surgery is defined as ‘any operation appropriate neither for every patient nor for
or procedure or any outpatient intervention every surgical procedure.
where the patient is discharged on the same As far as the data is concerned National
working day’. It gained popularity in 1960 health statistics report USA state that among all
when first unit of ambulatory anesthesia was surgical procedures more than 60% of surgeries
established but formal development occurred were conducted on ambulatory basis and
with the formation of Society for Ambulatory less than 0.8% needed inpatient admission.3
Anesthesia (SAMBA) in 1984. Although data is not available for India, there is
The need for day care surgery is expanding huge potential for ambulatory anesthesia and
with the change in financial situation of the surgery in view of large population and massive
world. Recent advances of anesthesia, surgery growth of private sector.
and pain management have resulted in a vast For providing optimal perioperative care
expansion of this modality and resulted in during ambulatory surgery and anesthesia
decreased hospitalization.1 The availability of one should always consider patient selection
rapid, short acting anesthetic, analgesic and criteria and preoperative assessment,
muscle relaxant drugs have clearly facilitated the surgical procedures and their duration,
recovery process after surgery and development preparation, anesthetic management, recovery,
of minimally invasive surgical procedures postoperative complications and organization.
have added wings to ambulatory anesthesia.2 Patient selection: Ambulatory surgery should
The facilities of ambulatory anesthesia can be accompanied by minimum disturbances in
be attached to main hospital or office based postoperative physiology and uncomplicated
which involves the conduct of anesthesia in recovery.4 There must be certain criteria
a location that is integrated to a physician’s for determining patient selection for
office. The advantages of ambulatory anesthesia ambulatory procedures. It is recommended
are personal attention, care, service, ease that multidisciplinary approach, with agreed
of scheduling, greater privacy, lower cost, protocols for patient’s assessment including
increased efficiency and decreased nosocomial inclusion and exclusion criteria for day
infection. Despite advantages of ambulatory care surgery, should be agreed locally with
anesthesia one must remember that it is not anesthesia department. These should take into
for every anesthesiologist or surgeon nor account:
18 Practice Guidelines in Anesthesia

• Patient medical status (specific diagnosis, and laboratory investigations.10 Although

co-morbid conditions and duration of the National Institute of Health and Clinical
therapy) Excellence (NICE) guidance on preoperative
• Degree of stability of medical status investigations is widely used, one recent study
• Patient’s psychological status showed no difference in the outcomes of day
• Patient’s support system at home surgery patients even when all preoperative
• Intensity and duration of postprocedural investigations were omitted.11 The concerned
monitoring anesthesiologist should carefully consider
• Risk of developing complications [deep vein the following specific factors while deciding
thrombosis (DVT) and pulmonary embolism anesthesia in their ambulatory unit:12
(PE)]. • Abnormalities of major organ systems, and
Mostly patients being treated in ambulatory stability and optimization of any medical
surgical units belong to ASA physical status I illness.
and II but with the improved anesthesia and • Difficult airway, morbid obesity and/or
surgical techniques, patients with medically obstructive sleep apnea.
stable ASA physical status III and IV are also • Previous adverse experience with anesthesia
being allowed with the same low incidence of and surgery.
morbidity.5 The complications and the duration • Current medications and drug allergies,
of stay can be minimized if pre-existing medical including latex allergy.
conditions are stable for more than three • Time and nature of the last oral intake.
months before scheduled operation.6 Now a • History of alcohol or substance use or abuse.
days a full term infant for more than one month; • Presence of a adult who assumes
an elderly patient with multiple comorbidities responsibility specifically for accompanying
are acceptable for day care procedures. It is ideal the patient from the ambulatory unit.
for children because of minimum separation
from their parents and risk for hospital acquired
Perioperative care
infection.7,8
There are few contraindications for The anesthesiologist providing patient care in
ambulatory procedures:9 the ambulatory setting should adhere to the
• Potentially life-threatening chronic illnesses standard protocols and guidelines to assure
• Morbid obesity complicated by symptomatic optimal safety and comfort of the patient.
cardiorespiratory problems (e.g. angina,
asthma) Preoperative preparation
• Multiple chronic centrally active drug
therapies or active cocaine abuse Optimal preoperative preparations reduce the
• Ex-premature infants less than 60 weeks risks adherent to ambulatory surgery, improve
postconceptual age requiring general patient outcome and make surgery more safer
endotracheal anesthesia and acceptable for the patient. Appropriate
• No responsible adult at home to care for the fasting protocol and medications (to be taken or
patient on the evening after surgery. withheld) before surgery should be ascertained.
Measures should be taken to minimize the
patient’s anxiety.
Preoperative Assessment
Preoperative assessment of outpatients is Intraoperative care
increasingly important to avoid costly delays
or last minute cancellations. The assessment of Appropriate selection and patient preparation
the medical condition of the patient should be is very important for ambulatory surgery.
based on recent history, physical examination The ideal outpatient anesthetic should have
 Perioperative Care of Ambulatory Anesthesia 19

a rapid and smooth onset of action, produce period.15 Central neuraxial blocks (spinal and
intraoperative amnesia and analgesia, provide epidural anesthesia) are offered commonly in
optimal surgical conditions and adequate day care surgery. Residual blockade in spinal
muscle relaxation with a short recovery period, or epidural anesthesia may cause problem like
and have no adverse effects in the postdischarge postural hypotension and urinary retention
period. Standard intra-operative monitoring despite return of sensory or motor function. So
guidelines for ambulatory surgery should be it is important to choose the most appropriate
followed. local anesthetic and adjuvant combination
The choice of anesthesia technique depends so as to avoid prolonged local anesthetic
on surgical and patient factors. Anesthetic effect. Suggested criteria before attempting
technique should ensure minimum stress ambulation after neuraxial block include the
and maximum comfort for the patient along return of sensation in the perianal area (S4-5),
with considering the risk and benefit of that plantar flexion of the foot at preoperative levels
technique. The anesthetic technique in of strength and return of proprioception in the
ambulatory anesthesia can range from local big toe.16
anesthetic infiltration to sedation to general
anesthesia. Although there is no ideal technique
Peripheral Nerve block
or drug for day care procedures, a knowledge
of options available is important for optimal The peripheral nerve blocks like bracheal
surgical conditions and fast-track recovery.9 plexus or femoral sciatic nerve block can
provide profound and prolonged anesthesia
to an extremity and are very popular in
General anesthesia
ambulatory anesthesia. Use of ultrasound
General anesthesia remains the most widely enhances the accuracy of block. Continuous
used anesthetic technique for ambulatory infusion local anesthetic can decrease the
surgery despite higher incidence of side effects need for intravenous opioid analgesics and
than regional anesthesia. LMA insertion shows enhance the patient satisfaction and mobility.17
minimal cardiovascular response, better In paediatric patients peripheral nerve block
tolerance and less airway complications in can be performed immediately after general
lighter plane of anesthesia than endotracheal anesthesia and caudal nerve block is most
intubation. Total intravenous anesthesia (TIVA) preferred in this segment of patients.
is an advantageous technique in ambulatory
anesthesia using propofol and fentanyl
Local Infiltration
(remifentanyl is preferred if available) utilizing
a computer based drug delivery system. It Infiltration of local anesthetic at the surgical
avoids the risk of failure of regional block, site is the simplest and safest method of
residual muscle paralysis and lesser side effects postoperative pain relief. Patient comfort can be
in the form of decreased postoperative nausea improved if intravenous sedation and analgesia
vomiting (PONV). Use of newer inhalational is used to complement it. It can be used as a sole
agents like sevoflurane and desflurane shows anesthesia technique for superficial procedures
faster emergence than intravenous agents.13,14 (inguinal hernia, breast lump, few plastic
surgery procedures).18
Regional Anesthesia
Intravenous regional
Regional anesthesia can offer advantages for
anesthesia
ambulatory surgery with respect to speed of
recovery, decreased nursing care and more The intravenous regional anesthetic (IVRA)
effective analgesia in early post operative technique with 0.5% lidocaine is a simple and
20 Practice Guidelines in Anesthesia

reliable technique for short superficial surgical criteria and this resulted in earlier discharge
procedures (< 60 minutes) limited to a single for up to 20% of the outpatients studied (Table
extremity. It is more cost effective technique 2.1).21
for outpatient hand surgery than general
anesthesia.9
Outcome measures
The ambulatory surgery continues to grow
Postoperative recovery
but ambulatory centers should develop the
and discharge methods to measure the outcome during early
There are three phases of recovery after and late postoperative period. The incidence of
ambulatory anesthesia, i.e. early, intermediate major morbidity is very low but certain clinical
and late. anesthesia outcome like incision pain, nausea,
During early recovery phase the patient vomiting preoperative anxiety and pain of
emerge from anesthesia, recover their protective intravenous line insertion should be avoided.22
reflexes and resume early motor activity. As per Delayed discharge and unexpected hospital
the patient’s need, the oxygen supplementation, admission after outpatient surgery are the most
analgesic or antiemetic medications are commonly identified outcome measures after
administered. Modified Aldrete score is ambulatory anesthesia (Table 2.2).23
commonly used to assess the fitness of patient
to shift to recovery area.
Modified postanesthesia
During intermediate phase patient start TABLE 2.1 discharge scoring (PADS) system.
voiding, ambulate, drinks fluid and prepare
Vital Signs
for discharge. Anesthesia technique and
Within 20% of the
medications used mainly affect the intermediate 2
preoperative value
phase. Other factors that prolong this phase
20%–40% of the
are female gender, advanced age, prolonged 1
preoperative value
surgery, larger blood loss, postoperative
40% of the preoperative
pain and nausea and vomiting and spinal 0
value
anesthesia.19,20
Ambulation
The late recovery phase starts after
2 Steady gait/no dizziness
the discharge of the patient till complete
physiological and psychological recovery and 1 With assistance
patient resumes their normal daily activity. The 0 No ambulation/dizziness
surgical procedure itself has the highest impact Nausea and Vomiting
on late recovery. 2 Minimal
Another objective discharge criteria has been 1 Moderate
developed for patient readiness for discharge 0 Severe
is called as Postanesthesia Discharge Scoring Pain
System (PADSS). It is based on five major 2 Minimal
criteria which include (a) vital signs, including 1 Moderate
blood pressure, heart rate, respiratory rate, and
0 Severe
temperature; (b) ambulation and mental status;
Surgical Bleeding
(c) pain and postoperative nausea and vomiting;
2 Minimal
(d) surgical bleeding; and (e) fluid intake/
output. This was later modified by Chung F et al 1 Moderate
who eliminated input and output as a discharge 0 Severe
 Perioperative Care of Ambulatory Anesthesia 21

Factors alleged to delay discharge and lead to unanticipated admissions after ambulatory
TABLE 2.2 surgery
Delayed Discharge
Preoperative
• Female gender
• Increasing age
• Congestive heart failure
Intraoperative
• Long duration of surgery
• General anesthesia
• Spinal anesthesia
Postoperative
• Postoperative nausea and vomiting
• Moderate-to-severe pain
• Excess drowsiness
• No escort
Unanticipated Admissions
Surgical
• Pain
• Bleeding
• Extensive surgery
• Surgical complications
• Abdominal surgery
• Otorhinolaryngology and urology surgery
Anesthesia
• Nausea and vomiting
• Somnolence
• Aspiration
Social
• No escort
Medical
• Diabetes mellitus
• Ischemic heart disease
• Sleep apnea

Conclusion them. In future the ambulatory care will reach

people in geographically distant areas as well.
Ambulatory anesthesia is a faster growing
subspecialty of anesthesia. One should be
careful about choosing the patients, optimizing References
them preoperatively, planning optimal
1. Gangadhar S, Gopal T, Sathyabhama, Paramesh
anesthesia technique, using appropriate K. Rapid emergence of day-care anesthesia: A
monitoring system, caring their postoperative review. Indian J Anaesth. 2012;56(4):336-41.
complications and discharging them with 2. Michaloliakou C, Chung F, Sharma S. Anesth
optimal advice to make it more beneficial for Analg. Preoperative multimodal analgesia
22 Practice Guidelines in Anesthesia

facilitates recovery after ambulatory laparoscopic 14. Elliott RA, Payne K, Moore JK. Clinical and
cholecystectomy. 1996;82(1):44-51. economic choices in anesthesia for day surgery:
3. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory A prospective randomized controlled trial.
surgery in the United States, 2006. Natl Health Anesthesia 2003; 58:412.
Stat Report. 2009;28(11):1-25. 15. Liu SS, Strodtbeck WM, Richman JM, Wu
4. Duncan PG. Day surgical anesthesia: Which CL. A comparison of regional versus general
patients? Which procedures? Can J Anaesth. anesthesia for ambulatory anesthesia: A meta-
1991;38:881. analysis of randomized controlled trials. Anesth
5. Warner MA, Shields SE, Chute CG. Major Analg. 2005; 101:1634-42.
morbidity and mortality within 1 month of 16. British Association of Day Surgery. Spinal
ambulatory surgery and anesthesia. JAMA. 1993; Anesthesia for Day Surgery Patients. London:
270:1437. BADS, 2010.
6. Junger A, Klasen J, Benson M, et al. Factors 17. Hadzic A, Arliss J, Kerimoglu B, et al. A
determining length of stay of surgical day-case comparison of infraclavicular nerve block versus
patients. Eur J Anaesthesiol. 2001;18:314. general anesthesia for hand and wrist day-case
surgeries. Anesthesiology. 2004; 101:127-32.
7. Verma R, Alladi R, Jackson I, Johnston I, Kumar
18. Kehlet H, White PF. Optimizing anesthesia for
C, et al. Day case and short stay surgery:
inguinal herniorraphy: General, regional, or
2. Anesthesia. 2011;66(5):417-34.
local anesthesia? (Editorial). Anesth Analg. 2001;
8. Collins CE, Everett LL. Challenges in pediatric
93:1367-69.
ambulatory anesthesia: kids are different.
19. Edler AA, Mariano ER, Golianu B, et al. An analysis
Anesthesiol Clin. 2010;28(2):315-28. of factors influencing postanesthesia recovery
9. Paul F White, Matthew R Eng. Ambulatory after pediatric ambulatory tonsillectomy and
(Out Patient) anesthesia. Miller 7th edn, 2010. adenoidectomy. Anesth Analg. 2007; 104:784-9.
pp.2419-2460. 20. Chung F, Mezei G. Factors contributing to a
10. Borkowski RG. Ambulatory anesthesia: prolonged stay after ambulatory surgery. Anesth
preventing perioperative and postoperative Analg. 1999; 89:1352.
complications. Cleve Clin J Med. 2006;73 21. Chung F, Chan VW, Ong D. A postanesthetic
(Suppl 1):S57-61. Review. discharge scoring system for home readiness
11. Chung F, Yuan H, Yin L, Vairavanathan S, Wong after ambulatory surgery. J Clinical Anesth. 1995;
DT. Elimination of preoperative testing in 7:500-6.
ambulatory surgery. Anesthesia and Analgesia. 22. Macario A, Weinger M, Carney S. Which clinical
2009;108:467-75. anesthesia outcomes are important to avoid?
12. Office based surgery guidelines. Massachusetts The perspective of patients. Anesth Analg.1999;
Medical society. Update 2011. 89:652.
13. Reader J. Clinical ambulatory anaesthesia book. 23. Chung F. Factors affecting recovery and discharge
Cambridge University press; Cambrideg, UK. following ambulatory surgery. Can J Anaesth.
[Link].1-185. 2006; 53:858-72.
 CHAPTER 3
Anaphylactic Reactions
During Anesthesia
Anjan Trikha

Anaphylaxis ‘anaphylactoid’ reactions for non-IgE mediated

reactions producing the same clinical picture as
Anaphylaxis represents the most severe form of anaphylaxis.2
immediate hypersensitivity reaction. Anaphylaxis occurring during anesthesia is
The World Allergy Organization and a life-threatening complication. The incidence
the European Academy of Allergology and of such perioperative anaphylactic reactions
Clinical Immunology defined anaphylaxis in is estimated to be between 1 in 10000 and 1 in
20031 as “a severe, life-threatening generalized 20000 anesthetic administrations3,4 and the
or systemic hypersensitivity reaction.” They mortality is estimated to be 3 to 9%.5
classified anaphylaxis into two types—allergic
anaphylaxis (mediated by an immunological etiology of Perioperative
mechanism) and non-allergic anaphylaxis
Anaphylaxis
(mediated by non-immunological mechanisms
which were previously known as anaphylactoid Anaphylactic reaction can occur to almost all
reactions). agents to which the patient is exposed during
The American Academy of Allergy, Asthma the perioperative period. Neuromuscular
and Immunology, in 2010 defined anaphylaxis blocking agents (NMBA) are the most common
as one of the three clinical scenarios—(1) The cause, with the most frequently reported
acute onset of a reaction (minutes to hours) drug being succinylcholine.6 The incidence of
with involvement of the skin, mucosal tissue anaphylactic reactions to NMBAs vary between
or both and at least one of the following— different countries, which could be explained
(a) respiratory compromise, (b) reduced by varying levels of environmental exposure
blood pressure or symptoms of end-organ to chemicals containing the same quaternary
dysfunction, (2) Two or more of the following ammonium structure as NMBAs. For instance,
that occur rapidly after exposure to a likely extensive use of pholcodine containing cough
allergen for that patient–involvement of the syrup in Norway had resulted in increased
skin/mucosal tissue, respiratory compromise, rates of sensitization to NMBAs, especially
reduced blood pressure or associated symptoms rocuronium.7
and/or persistent gastrointestinal symptoms, Atracurium and mivacurium can lead to
(3) Reduced blood pressure—after exposure to direct release of histamine from mast cells
a known allergen. It continued to use the term and can cause nonallergic anaphylaxis.
24 Practice Guidelines in Anesthesia

Pancuronium, cisatracurium and vecuronium Nonsteroidal anti-inflammatory drugs

seem to have lower potential for causing (NSAIDs) inhibiting COX–1 enzyme can cause
anaphylactic reactions.6 Allergy to one NMBA non-immunogenic anaphylactic reactions.11
can also cause cross sensitization to other Paracetamol can be rarely involved while
NMBAs.8 selective COX-2 inhibitors appear to be safe.
Natural rubber latex is the second most Antiseptic solutions containing chlorhexidine,
common agent involved in perioperative cetrimide, and povidone iodine, dyes such
anaphylaxis. IgE antibodies to water soluble as methylene blue and Patent Blue V, radio-
Hev b (Hevea brasiliensis) proteins present in contrast agents, blood and blood products
latex are responsible for causing such reactions. are other agents implicated in perioperative
Patients with atopy, children undergoing anaphylaxis.11 Reports of anaphylaxis to many
multiple surgical procedures, such as for spina other drugs including protamine sulfate,
bifida, or patients with allergy to certain fruits heparin, ranitidine, ondansetron, tranexmic
are at increased risk for latex allergy.9 acid, neostigmine and even to the newer reversal
Antibiotics are an important cause of agent sugammadex have been published.
anaphylaxis showing an increasing trend over Inhalational anesthetics are an exception and
the years in many studies.6 The most commonly no case of anaphylaxis to such agents has been
implicated agents are beta-lactam antibiotics reported till date.
(penicillins and cephalosporins), followed by Some patients are more prone to develop
quinolones.10 perioperative anaphylaxis. The risk factors for
Anaphylactic reactions to intravenous developing anaphylaxis to specific agents are
induction agents are rare. Anaphylaxis to summarized in Table 3.1.
thiopentone has been reported in the past,
but presently the incidence is rare probably
Clinical Features
because of the declining use of thiopentone.11
Anaphylaxis with the present preparation of The grading of severity of anaphylactic reactions
propofol is rare as cremaphor EL (a potent is given in Table 3.2.
anaphylactic agent) is no longer used in it.10 The most commonly reported signs in
Similarly anaphylactoid reactions to etomidate severe grade III or IV reactions are absence of
have been reported but are rare.12 peripheral pulse, desaturation and difficulty to
Opioids like morphine, pethidine and ventilate.15 Itching, cough, nausea, vomiting,
codeine can lead to direct histamine release and difficulty in breathing, and abdominal cramps
cause nonallergic anaphylaxis whereas this is are some other common symptoms in a awake
not seen with fentanyl and other newer agents.10 patient.
Local anesthetics are a rare cause of Cardiovascular manifestations are the
anaphylactic reactions, but they can lead to most common signs during perioperative
type 4 delayed hypersensitivity reactions.10 The anaphylaxis.16 These are hypotension,
ester group of local anesthetics are potentially tachycardia or bradycardia (the latter
immunogenic while the amide ones are usually representing a more severe reaction), cardiac
not.10 The preservative methyl paraben used in arrhythmias, anaphylactic shock, acute
many local anesthetic preparations could be coronary events and cardiac arrest. In many
responsible for anaphylaxis. cases cardiovascular collapse may be the
Intravenous colloids have been implicated in sole manifestation. An acute coronary event
perioperative anaphylaxis, the incidence being associated with a hypersensitivity reaction is
greatest with gelatin based colloid solutions. known as Kounis syndrome.17 Mucocutaneous
It is lower with dextran and rare with hydroxyl signs might not be present initially in grade
ethyl starch.10 III or IV reactions as there will be cutaneous
 Anaphylactic Reactions During Anesthesia 25

TABLE 3.1 Risk factors for developing perioperative anaphylaxis11,13

Anesthetic agent Risk factors
For all anesthetic 1. Previous unexplained reaction during general anesthesia
medications 2. Female sex
3. Hereditary angioedema
4. Multiple drug allergy syndrome
5. Mastocytosis
Neuromuscular Exposure to quaternary ammonium ion containing compounds, e.g. Cough syrups
blocking agents containing pholcodine and cosmetics
Latex 1. History of atopy
2. Children with spina bifida
3. History of multiple surgeries, multiple urinary catheterizations
4. Food allergy especially to fruits such as banana, papaya, chestnut, etc.
5. Healthcare professionals
Antibiotics 1. History of penicillin allergy
2. Multiple episodes of infection and exposure to antibiotics, e.g. chronic smokers with
repeated lung infections
Colloids Gelatin allergy
Propofol Allergy to soy or egg (doubtful)

TABLE 3.2 Grading of severity of anaphylactic reactions14

Grade Features
I Mucocutaneous signs: erythema, urticarial rash, with or without angioedema
II Moderate multisystem involvement: Mucocutaneous signs with cardiovascular and/or respiratory
changes—hypotension/ tachycardia/ difficulty to ventilate/dyspnea/cough/gastrointestinal
disturbances
III Severe life-threatening mono or multisystem involvement: Cardiovascular collapse with tachycardia
or bradycardia, with or without bronchospasm/mucocutaneous signs/gastrointestinal disturbances
IV Cardiac arrest

vasoconstriction due to cardiovascular Differential Diagnosis

collapse.14 Commonly seen respiratory findings
during anaphylaxis are bronchospasm, Signs and symptoms similar to those occurring
difficulty to ventilate and desaturation. Usually during an anaphylactic reaction can occur
bronchospasm is associated with cardiovascular due to many other reasons during anesthesia
signs.14 such as hypotension due to exaggerated
The timing of anaphylactic reactions drug effects/overdose or drug interactions.
is generally within seconds to minutes of Other common causes are—parasympathetic
administering an intravenous agent, most responses to laparoscopy, peritoneal traction,
commonly at induction. In case of latex allergy, flushing of the skin due to venous obstruction
it is delayed and occurs intraoperatively. The or head down position, shock due to blood
timing of the reaction and its relation to the loss, bronchospasm, hypoxia or difficulty in
etiology is shown in Table 3.3 as given by the ventilation due to asthma, blocked endotracheal
BSACI guidelines 2009.18 tube, esophageal intubation or pulmonary
26 Practice Guidelines in Anesthesia

TABLE 3.3 Timing of anaphylactic reaction and the associated etiologies

Within minutes of induction Intraoperative Towards end of surgery
NMBAs IV NSAID /paracetamol Rectal NSAID
IV induction agents, opioids, IV opioids, antibiotics IV opioids
antibiotics Local anesthetics Colloids
Colloids; with in few minutes from Neostigmine
start of infusion Latex rubber allergy
Latex rubber allergy
Dyes/contrast media
Chlorhexidine
Povidone iodine

edema and cardiovascular collapse due to Immediate management of

myocardial infarction or air embolism. Often, it TABLE 3.4 perioperative anaphylaxis
becomes difficult to diagnose an anaphylactic • I ncrease FiO2 to 100%
reaction during anesthesia and it requires a high • Rapid airway control (intubate if necessary)
level of suspicion along with clinical correlation. • Stop the suspected agents if possible
• Inform the surgical team and end surgery as
soon as possible.
Management Guidelines • Intravenous fluids, elevate lower limbs
• Maintain anesthesia with inhalational agents
The latest guidelines for treatment of immediate
• Drugs depending upon the severity (adrenaline,
hypersensitivity reactions during anesthesia beta agonists, antihistaminics, vasopressin,
was published in 2011 by the French Society steroids)
for Anesthesia and intensive care and the • Close monitoring (institute invasive monitoring
French Society of Allergology,15 approved if needed)
by the members of European Network for • Call for help whenever necessary
Drug Allergy. The management will depend
upon whether the patient is under regional
or general anesthesia and also on the severity
Grade II and III Reactions
of the reaction. The management is outlined
in Table 3.4 and specific strategies depending Intravenous boluses of adrenaline should be
on the severity5 are discussed here. The doses given. Dose depends on the severity (10–20
recommended for pediatric use are shown in mcg for grade II and 100–200 mcg for grade
Table 3.5. III reactions). This can be repeated every 1
to 2 minutes till adequate blood pressure
is achieved. When repeated boluses are
Grade I Reactions
required, an intravenous infusion of 0.05 to
General measures such as 100% oxygen, 0.1 mcg/kg/min can be used as an alternative.
stopping the suspected agent and administering When there is no intravenous access, 0.3 to
intravenous fluids are usually sufficient for the 0.5 mg of adrenaline can be administered
management of grade I reactions. Additionally, intramuscularly and repeated depending on the
a H1 antihistaminic (diphenhydramine 0.5 response. Intratracheal route in an intubated
– 1 mg/kg) together with H2 antihistaminic patient is an alternative. In patients on beta-
(ranitidine 1 mg/kg) can be used.5 blockers, if the first dose of adrenaline (100
 Anaphylactic Reactions During Anesthesia 27

TABLE 3.5 Management of perioperative anaphylaxis in children—recommended drug doses5

Drug Dose
Grade IV reaction—10 mcg/kg boluses
Adrenaline
Grade II or III reactions—start at 1 mcg/kg and titrate according to response
Glucagon 20–30 mcg/kg (infusion rate—5 mcg/min)
Inhaled salbutamol 50 mcg/kg which can be repeated every 10—15 minutes (maximum dose—1500 mcg/kg)

mcg) is not effective, it should be increased diagnosis of the reaction and the etiology rests
without delay to 1 mg at 1 to 2 minutes intervals. upon collective evidence from an accurate
If not responding, intravenous glucagon 1 to 2 clinical history, tests performed in the acute
mg is to be given at 5 minutes intervals. Instead, phase and tests performed later. It is the
an infusion of glucagon 0.3 to 1 mg/hour (5 to 15 anesthetist’s responsibility to direct the patient
mcg/kg) can be used. for a complete work-up.
Infusion of large volumes of intravenous
crystalloids may be necessary to replenish the
Clinical History
intravascular volume. Colloids can be used
when the requirement of crystalloids exceeds A detailed clinical history of all the risk factors
30 mL/kg. If a colloid is suspected of causing has to be obtained including history of previous
the reaction, it should be avoided. The infusion exposure to suspected agents and comorbid
set is to be changed when an intravenous fluid conditions like mastocytosis or asthma. An
is suspected of causing the reaction. In case accurate history of the anaphylactic event has to
of bronchospasm, inhaled beta agonists like be obtained and the anesthetic chart has to be
salbutamol can be administered. Intravenous reviewed if available.
beta agonists can be used in refractory cases.
In case of no response to high dose of Tests in the Acute Phase
adrenaline, other drugs can be used. Intravenous
noradrenaline can be started at the rate of 0.1 Serum Tryptase
mcg/kg/min or terlipressin can be used in a
Tryptase is an enzyme specific to mast cells
2 mg bolus. Steroids are not important in the
and the serum levels increase during an allergic
immediate management. Hydrocortisone 200
anaphylactic reaction. It has a short half-life and
mg bolus every 6 hours can be used to attenuate
serum samples for tryptase estimation should
late manifestations of shock.
be collected early after the reaction. The AAGBI
guidelines recommend collecting three samples
Grade IV Reaction—Cardiac Arrest for serum tryptase estimation—first sample
External cardiac compressions are to be immediately after the initial resuscitation,
initiated along with intravenous adrenaline 1 mg second sample after 1 hour and the third sample
boluses every 1 to 2 minutes. Cardiopulmonary after 24 hours of the reaction.18 The third sample
resuscitation is to be continued as per guidelines gives the baseline tryptase values of the patient
for circulatory failure. which may be increased in some patients (e.g.
Mastocytosis). An increased tryptase level
suggests an anaphylactic reaction but a negative
Investigation of a Suspected
result does not exclude it. False positive
Perioperative Anaphylaxis5,18
results are seen in the following conditions
The initial diagnosis of a perioperative —mastocytosis, myocardial ischemia, severe
anaphylactic reaction is presumptive. The final trauma, hypoxia, end stage renal failure, heroin
28 Practice Guidelines in Anesthesia

toxicity, blood dyscrasias such as acute myeloid negative control or a diameter of at least half the
leukemia, myelodysplastic syndrome.19 diameter of the positive control wheal. A positive
IDT result is the appearance of an erythematous
Histamine Levels wheal (often pruritic) after 20 minutes, the
diameter of which is at least equal to twice that
Plasma histamine levels are elevated in both of the postinjection wheal.5 As cross –reactivity
allergic and nonallergic anaphylactic reactions. is quite common with NMBAs, after a positive
The half-life is very short and sample for test to one NMBA, all other available NMBAs
histamine estimation should be preferably should be tested.
collected within the first 30 minutes of the
reaction. Similarly, urine histamine levels are
also elevated after an anaphylactic reaction. Provocative Tests
They are the gold standard tests for diagnosing
IgE assay hypersensitivity to an agent. They can be used
The measurement of specific IgE in the serum when skin tests are negative or not validated
by radioallergosorbent test (RAST) is a valuable (e.g. NSAIDs). The test involves reproduction
test while investigating the etiology of an of allergic symptoms by providing a challenge
anaphylactic reaction, especially when skin dose of the suspected agent. But provocative
tests are negative. They can be tested either tests have a limited role in perioperative
during an acute reaction or later along with anaphylaxis as anesthetic agents have potent
skin tests. Currently specific IgE assays have pharmacological effects and challenge tests can
been described for latex, NMBAs, thiopentone, lead to catastrophic consequences. Their role is
chlorhexidine and penicillin group of drugs.5 therefore limited to latex allergy, NSAIDs, local
anesthetics and beta lactam antibiotics.5
All testing should be done at a place where
Late Investigations necessary personnel and facilities exist for
Skin Tests resuscitation of the patient in case of an
anaphylactic reaction during testing.
Skin tests are the reference tests for diagnosing
immediate hypersensitivity reactions. There
are two types of skin tests which act as an Administering Anesthesia to a
indirect evidence of IgE mediated allergy—skin Patient with History of Drug Allergy/
prick tests (SPT) and intradermal tests (IDT). Anaphylaxis5
They are to be performed 4 to 6 weeks after
Preanesthetic Allergy Work-up
the occurrence of the anaphylactic reaction.
When performed earlier the probability of false Routine screening is not recommended for
negative tests increases. all patients scheduled for a surgery under
For anesthetic drugs SPT or IDT or both in anesthesia. However, it is important to
succession can be done. For latex allergy, SPT is identify patients with risk factors during the
to be done and for antibiotics, IDT is to be done. preanesthetic visit. Allergy workup should
The concentrations of different agents used for be done in patients with a previous history of
skin tests should be according to a standardized anaphylaxis during anesthesia and in those
protocol to avoid false positive results. The with a history of latex allergy. If the patient has
recommended concentrations5 for various not been worked up previously, allergy testing
agents are listed in Table 3.6. to all NMBAs and latex has to be done. If the
A positive SPT result is defined as the patient has been investigated previously, then
appearance of a wheal after 20 minutes that the results of the drug allergy tests are to be
has a diameter 3 mm greater than that of the documented. If the previous reaction was to
 Anaphylactic Reactions During Anesthesia 29

TABLE 3.6 Recommended concentrations of various agents for skin tests5

Agents Skin prick tests Intradermal tests
mg/mL Dilution mg/mL Dilution mcg/mL
Atracurium 10 1/10 1 1/1000 10
Pancuronium 2 Undiluted 2 1/100 20
Rocuronium 10 Undiluted 10 1/200 50
Vecuronium 4 Undiluted 4 1/10 400
Suxamethonium 50 1/5 10 1/500 100
Thiopentone 25 Undiluted 25 1/10 2500
Propofol 10 Undiluted 10 1/10 1000
Etomidate 2 Undiluted 2 1/10 200
Midazolam 5 Undiluted 5 1/10 500
Ketamine 10 1/10 10 1/10 1000
Morphine 10 1/10 1 1/1000 10
Fentanyl 0.05 Undiluted 0.05 1/10 5
Bupivacaine 2.5 Undiluted 2.5 1/10 250
Lidocaine 10 Undiluted 10 1/10 1000
Ropivacaine 2 Undiluted 2 1/10 200
Chlorhexidine 0.5 Undiluted 1/100 5
Povidone iodine 100 Undiluted 1/10 1000
Methylene blue 10 Undiluted 1/100 100

a NMBA, all new NMBAs are to be tested. In Combination of H1 and H2 antihistaminic has
patients with a history of allergy to NSAIDs or not been found superior to H1 antihistaminic
paracetamol, provocative testing can be done if alone.5 Current evidence suggests that
the intervention is not an emergency. premedication with steroids is of limited value
Allergy work-up is not necessary for in preventing anaphylaxis.20
patients with a history of allergy to a drug not
used during anesthesia. All patients with a
Anesthetic Technique
documented allergy should be educated about
the problem and should be advised to wear In an Emergency
bracelets or carry cards indicating their drug
allergy at all times. Local and regional techniques are preferred
in patients with history of hypersensitivity
reaction during previous anesthesia with no
Premedication allergy work-up. A latex-free environment has
Routine premedication is not recommended. to be provided. If general anesthesia is needed,
Premedication with H1 antihistaminics has been then muscle relaxants and histamine releasing
shown to decrease the severity of nonallergic agents are to be avoided. Anti–COX-1 NSAIDs
anaphylactic (anaphylactoid) reactions but it are to be avoided and selective COX-2 inhibitors
is ineffective in allergic anaphylactic reactions. can be used.5
30 Practice Guidelines in Anesthesia

In a Patient with Documented Allergy Work-up World Allergy Organization, October 2003. J
Allergy Clin Immunol. 2004;113(5):832-6.
The agent for which allergy is documented has 2. Lieberman P, Nicklas RA, Oppenheimer J, et al.
to be avoided. Antibiotic prophylaxis should The diagnosis and management of anaphylaxis
be preferably administered before induction practice parameter: 2010 update. J Allergy Clin
of anesthesia. In case of an adverse reaction, Immunol. 2010;126(3):477-80
it is easier to resuscitate an awake patient 3. Fisher MM, Baldo BA. The incidence and
when compared to an anaesthetized patient, clinical features of anaphylactic reactions during
anesthesia in Australia. Annales Francaises
as anesthetic drugs can profoundly alter the
d’Anesthesie et de Reanimation 1993;12: 97-104.
cardiovascular physiology. If the previous 4. Laxenaire MC. Epidemiology of anesthetic
reaction was to a muscle relaxant, all muscle anaphylactoid reactions. Fourth multicenter
relaxants are preferably avoided or a NMBA to survey (July 1994-December 1996). Annales
which skin test was negative can be used.5 Francaises d’Anesthesie et de Reanimation.
In case of latex allergy, the patient should be 1999;18: 796-809.
kept as the first case in the operation list and 5. Mertes PM, Malinovsky JM, Jouffroy L;
a latex-free environment has to be provided. Working Group of the SFAR and SFA, Aberer
W, Terreehorst I, Brockow K, Demoly P; ENDA;
Latex containing things in the operating room
EAACI Interest Group on Drug Allergy. Reducing
could be gloves, foley’s catheters, suction tubes, the risk of anaphylaxis during anesthesia: 2011
nasogastric tubes, nasopharyngeal airways, updated guidelines for clinical practice. J Investig
breathing circuits, masks, reservoir bag, Allergol Clin Immunol. 2011;21(6):442-53.
ventilator bellows, blood pressure measuring 6. Dong SW, Mertes PM, Petitpain N, et [Link]:
cuff, wires of monitors, injection ports of Hypersensitivity reactions during anesthesia.
infusion sets, syringes, multi dose injection Results from the ninth French survey (2005-
vial stoppers, adhesives, elastic bandages, etc. 2007). Minerva Anestesiol. 2012;78(8):868-78.
It is important to identify the latex containing 7. Florvaag E, Johansson SG, Irgens Å, de Pater
GH. IgE-sensitization to the cough suppressant
things and provide a latex-free alternative
pholcodine and the effects of its withdrawal from
wherever possible. Other strategies to minimize the Norwegian market. Allergy. 2011;66(7):955-60.
contact with latex containing items should be 8. Mertes PM, Laxenaire MC, Alla F. Anaphylactic
carried out when latex-free alternative cannot and anaphylactoid reactions occurring
be provided for certain items, e.g. Wires/cords during anesthesia in France in 1999–2000.
of monitoring devices (pulse oximeter/ECG/ Anesthesiology. 2003;99(3):536-45.
non invasive blood pressure) can be placed in 9. Niggemann B, Breiteneder H. Latex allergy
stockinet and secured with tapes.21 in children. Int Arch Allergy Immunol.
2000;121(2):98–107.
10. Mertes PM, Tajima K, Regnier-Kimmoun MA, et
Conclusion al. Perioperative anaphylaxis. Med Clin North
Am. 2010;94(4):761-89.
Anaphylaxis is a life-threatening complication 11. Harper NJ, Dixon T, Dugué P, et al; Working Party
and it is imperative that every anesthetist of the Association of Anaesthetists of Great.
must be well prepared to handle it when the Britain and Ireland. Suspected anaphylactic
situation arises. Also, it is the responsibility reactions associated with anesthesia. Anesthesia.
of the anesthetist to direct such a patient for a 2009;64(2):199-211.
complete allergy work-up as a future exposure 12. Moorthy SS, Laurent B, Pandya P, et al.
Anaphylactoid reaction to etomidate: report of a
to the same agent can be catastrophic.
case. J Clin Anesth. 2001;13(8):582-4.
13. Liccardi G, Lobefalo G, Di Florio E, et al. Cardarelli
References Hospital Radiocontrast Media and Anesthetic-
Induced Anaphylaxis Prevention Working
1. Johansson SG, Bieber T, Dahl R, et al. Revised Group. Strategies for the prevention of asthmatic,
nomenclature for allergy for global use: Report anaphylactic and anaphylactoid reactions
of the Nomenclature Review Committee of the during the administration of anesthetics and/or
 Anaphylactic Reactions During Anesthesia 31

contrast media. J Investig Allergol Clin Immunol. 18. Ewan PW, Dugué P, Mirakian R, et al. BSACI.
2008;18(1):1-11. BSACI guidelines for the investigation
14. Dewachter P, Mouton-Faivre C, Emala CW. of suspected anaphylaxis during general
Anaphylaxis and anesthesia: controversies anesthesia. Clin Exp Allergy. 2010;40(1):15-31.
and new insights. Anesthesiology. 2009;111 19. Michalska-Krzanowska G. Tryptase in diagnosing
(5):1141-50. adverse suspected anaphylactic reaction. Adv
15. Mertes PM, Laxenaire MC. Allergy and
Clin Exp Med. 2012 May-Jun;21(3):403-8.
anaphylaxis in anesthesia. Minerva Anestesiol.
20. Sheikh A. Glucocorticosteroids for the treatment
2004;70(5):285-91
16. Laxenaire M, Mertes PM, GERAP. Anaphylaxis and prevention of anaphylaxis. Curr Opin Allergy
during anesthesia. Results of a 2 year survey in Clin Immunol. 2013;13(3):263-7.
France. Br J Anaesth. 2001;21(1):549–58. 21. American association of nurse anesthetists:
17. Kounis NG. Coronary hypersensitivity disorder: Latex allergy protocol. [Link]
the Kounis syndrome. Clin Ther. 2013;35 resources2/professionalpractice/Documents/
(5):563-71. PPM%20Latex%20Allergy%[Link]
 CHAPTER 4
Acute Pain Management Guidelines
and Protocols: Evidencebased
Ashok Kumar Saxena

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

Underassessment and undertreatment of of resources and clinical requirements. It is for

pain appears to be common in the developing sure that these guidelines being developed are
nations and even in the developed world. based on the available evidence in the literature.
We have to accept that even their application
cannot guarantee any specific outcome.1
Definition
Acute pain is the most frequently
ASA Task Force defines acute pain as pain that is encountered variety of pain all over the world.
present in a surgical patient after a procedure.1 It is an important and significant aspect of
In the opinion of ASA Task Force, acute childbirth, surgeries, trauma and acute medical
pain management in the perioperative setting illness.2 Acute pain is also responsible for
is referred to as actions done before, during, being the reason in more than two-thirds of
and after a procedure to reduce or eliminate consultations in emergency department.3
postoperative pain before discharge.1 Whereas pain is considered to be an
Acute pain management guidelines are experience with sensory, cognitive, and
being developed as a measure of providing emotional components, nociception refers to
optimum pain relief. They need to be reviewed at neural process by which stimuli that can elicit
regular intervals and can be adopted, modified pain are detected by the nervous system.
or rejected with the changing and upcoming Despite recent advances in the development
evidence which emerges from time to time.1 of newer opioids and non-opioids molecules,
They may or may not be adopted completely and despite the use of minimally invasive
in a particular set-up, and can be modified in surgery, millions and millions of people not only
a specific set-up depending on the availability in developing nations, but also in developed
 Acute Pain Management Guidelines and Protocols: Evidencebased 33

world continue to suffer because of inadequate a. Level 1: The literature contains observational
assessment and undertreatment. comparisons (e.g., cohort, case-control
It is very well established that uncontrolled research designs) of clinical interventions
and unrelieved acute pain not only results or conditions and indicates statistically
in high degree of suffering and discomfort, significant differences between clinical
but also results in terrible consequences like interventions for a specified clinical outcome.
delayed wound healing, loss of body weight, b. Level 2: The literature contains
increased hospital stay, and the ultimate risk of noncomparative observational studies with
development of chronic persistent postsurgical associative (e.g., relative risk, correlation) or
pain.4-7 descriptive statistics.
c. Level 3: The literature contains case reports.
Aims of the Guidelines
Category C
1. To facilitate the safety and effectiveness of
acute pain management in the perioperative Equivocal literature—indeterminate information
setting. in the literature which can be beneficial and
2. To reduce the risk of adverse outcomes. harmful in various interventions.1
3. To maintain the patient’s functional a. Level 1: Meta-analysis did not find significant
abilities, as well as physical and psychologic differences among groups or conditions.
well-being. b. Level 2: The number of studies is insufficient
4. To enhance the quality of life for patients to conduct meta-analysis, and (1) RCTs
with acute pain during the perioperative have not found significant differences
period.1 among groups or conditions or (2) RCTs
report inconsistent findings.
c. Level 3: Observational studies report
Scientific Evidence inconsistent findings or do not permit
All these guidelines are based on scientific inference of beneficial or harmful
evidence which have been defined as follows: relationships.

Category D
Category A
Insufficient evidence from literature.1
Supportive literature—based on randomized
The lack of scientific evidence described as
controlled trials (RCT)1
inadequate or silent.
a. Level 1: The literature contains multiple
RCTs and findings are supported by
meta-analysis. Opinion-based Evidence
b. Level 2: The literature contains multiple Obtained from survey data, open-forum
RCTs, but the number of studies is insufficient testimony, internet-based comments, letters,
to conduct a viable meta-analysis editorials.1
c. Level 3: The literature contains a single
randomized controlled trial. Category A
Expert opinion1
Category B In this category, survey responses can be
Suggestive literature— information obtained obtained from the “Task force” appointed expert
from observational studies.1 consultants.
34 Practice Guidelines in Anesthesia

Category B • Briggs et al, Camp et al, Clarke et al,

Davis et al, Enhfors et al and Bardiau
Membership based opinion.1
et al, suggest that educational content
In this category, survey responses can be
should range from basic bedside pain
obtained from the active ASA members using a
assessment to pharmacological as well
5 point score:
as nonpharmacological techniques.12-18
1. Strongly agree
• The above authors also recommends
2. Agree
that anesthesiologists and healthcare
3. Equivocal
personnel should use standardized and
4. Disagree
validated instruments for evaluation and
5. Strongly disagree
documentation of pain intensity.12-18 At
every cost, pain should be implemented
Category C as a 5th vital sign in each hospital.
• In the opinion of Bardiau et al, Gould et
Consensus based opinion.1
al, Mackintosh et al, Miaskowski et al ,
In this category, information can be obtained
Pesut et al, Sartain et al, Stacey et al and
through open forum testimony from previous
Stedler et al, anesthesiologists should
updates, internet based comments, letters, and
be available all the time (24 hours
editorials informally evaluated and discussed.
availability) to consult with ward nurses,
surgeons or other physicians involved
ASA Task Force’s in providing perioperative pain services
recommendations for (Category D evidence). Adverse effects
providing post operative associated with the analgesic therapy
pain management should be documented and promptly
dealt with.19-27
Institutional Policies and Procedures • The above authors also recommends
that anesthesiologists providing
Providing Perioperative Pain
perioperative analgesia services
Management.1 should do with in the frame work of
It includes: the acute pain services. Observational
1. Education and training for healthcare studies indicate that acute pain
providers services are associated with reduction
2. Monitoring of patient outcomes in perioperative pain (Category B2
3. Documentation of monitoring activities evidence). They should participate in
4. Monitoring of outcomes at an institutional developing standardized institutional
level policies and procedures.19-27
5. 24-hours availability of anesthesiologists
providing perioperative pain management Preoperative Evaluation of the Patient
6. Use of a dedicated acute pain service.
• In the opinion of Gleman et al, Harmer et It includes:
al, Rose et al and White anesthesiologists 1. Directed history and preoperative pain
offering perioperative analgesia services mapping.
as a perioperative physician should be 2. Directed physical examination and relevant
knowledgeable and skilled with regard investigations.
to the effective and safe use of the 3. Acute pain control plan
available treatment options (Category • Furdon et al suggest a directed
B2 evidence).8-11 pain history and preoperative pain
 Acute Pain Management Guidelines and Protocols: Evidencebased 35

mapping (e.g. medical record review, personnel, patient and family education
current medications, adverse effects, regarding their important roles in
pre-existing pain conditions, medical achieving comfort, reporting pain, and
conditions that would influence a in proper use of the recommended
pain therapy, nonpharmacologic analgesic methods (Category C2
pain therapies, alternative and evidence).
complementary therapies.28 (Category • Overestimation of the risk of adverse
D evidence). events and addiction are the common
• Furdon et al emphasise on a directed misconceptions that should be
physical examination and relevant dispelled.
investigations.28 • Optimal use of PCA and other
• In the opinion of Anderson and Daltroy sophisticated methods, such as patient
et al, acute pain control plan should be —controlled epidural analgesia (PCEA)
included in the anesthetic preoperative depending on the infrastructure
evaluation.29,30 Implementation of pain available.
management protocol is associated • And other analgesic methods should be
with reduced analgesic use, shorter discussed at the time of the preanesthetic
time to extubation, and shorter time to evaluation through brochures and
discharge (Category B2 evidence). videotapes to educate patients about
therapeutic options.
Preoperative Preparation • In the opinion of Elsass et al, Griffin
et al, Knoerl et al, Lam et al, and Lilja
of the Patient
et al such structured preoperative
It includes: education may also include instruction
1. Adjustment or continuation of medications in behavioural modalities for control of
whose sudden cessation may provoke a pain and anxiety.32-36
withdrawal syndrome
2. Treatments to reduce pre-existing pain and Perioperative Techniques
anxiety
for Pain Management
3. Premedications before surgery as part of a
multimodal analgesic pain management Perioperative techniques for postoperative pain
program management include, but are not limited to the
4. Patient and family education, including following single modalities:
behavioral pain control techniques.30-36 1. Central regional (i.e. neuraxial) opioid
• Appropriate titration, adjustment or analgesia.37,38
continuation of medications in order 2. PCA with systemic opioids.40,41 RCTs
to avert withdrawal syndrome should report equivocal findings regarding the
be included in patient preparation analgesic efficacy of IV PCA techniques
(Category D evidence). when compared with nurse or intravenous
• Daltroy et al and Egbert et al emphasize analgesia (Category 2 evidence). Meta-
on the treatment of pre-existent analyses of RCTs report improved pain
pain, preoperative education by scores when IV PCA morphine is compared
encouragement and instructions with intramuscular morphine (Category
of postoperative pain management A1 evidence). Meta-analyses of RCTs
therapy.30,31 indicate more analgesic use when IV PCA
• Anesthesiologists offering perioperative with a background infusion of morphine is
analgesia services should impart, in compared with IV PCA without background
collaboration with other healthcare infusion (Category A1 evidence).
36 Practice Guidelines in Anesthesia

3. Peripheral regional analgesic techniques, • These modalities should be used in

including but not limited to intercostal preference to intramuscular opioids
blocks, plexus blocks, and local anesthetic ordered as needed.
infiltration of incisions.41,42 Meta-analyses • Therapy should be selected according to
of RCTs report improved pain scores when individual anesthesiologist’s skills and
preincisional infiltration of bupivacaine the safe application of the modality.
is compared with saline (Category A1 • Special caution should be applied when
evidence). continuous infusion modalities are
Meta-analyses of RCTs are equivocal used because drug accumulation may
for pain scores and analgesic use when contribute to adverse events.40,42
post-incisional infiltration of bupivacaine
is compared with saline (Category C1
Multimodal Approach for
evidence). Meta-analyses of RCTs report
Pain Management
improved pain scores when preincisional
infiltration of ropivacaine is compared • Multimodal techniques for pain
with saline (Category A1 evidence). Meta- management include the administration
analyses of RCTs report less analgesic use of two or more drugs that act by different
when preincisional plexus blocks with mechanisms and at different sites in the
bupivacaine are compared with saline nervous system, resulting in additive
(Category A1 evidence). and synergistic analgesia with lowered
4. TAP block—Carney et al have recently adverse effects of sole administration of
shown that transversus abdominis plane individual analgesics. These drugs may
block (TAP) provides effective postoperative be administered via the same route or by
analgesia with reduced pain scores at rest different routes.44-46
and with movements in patients undergoing • Schmid et al47 and Subramaniam et al48
total abdominal hysterectomy. Perhaps the have shown that low dose Ketamine play a
block of the abdominal wall (musculature significant role in providing postoperative
and skin) is a more strategic and effective pain relief when used as an adjuvant
approach than simple skin infiltration.43 analgesic to local anesthestic, opioids and
• Boldt et al and Murphy et al suggest other analgesics. In the opinion of Aubrun
that anesthesiologists who manage et al, and Engelhardt et al, sometimes lack
perioperative pain should use of effect of Ketamine may be due to too
therapeutic options such as epidural low dose of Ketamine or not planning to
or intrathecal opioids, systemic opioid continue the dose in the postoperative
PCA, and regional techniques after period.49,50
considering the risks and benefits for the • Regional blockade with local anesthetics
individual patient.39,40 should be considered.51,52
• RCTs comparing preoperative or • Tramer et al53 and Koinig et al54 observed
preincisional intrathecal morphine or that at very high doses, perioperative
epidural sufentanil with saline placebo intravenous Magnesium sulfate reduces
report inconsistent finding regarding postoperative morphine consumption but
pain relief (Category C2 evidence). RCTs not the pain scores.
comparing preoperative or preincisional • Latest ASA Task Force Practice guidelines for
epidural morphine or fentanyl with acute pain management in the perioperative
postoperative epidural morphine setting state that unless contraindicated,
or fentanyl are equivocal regarding patients should receive an around the clock
postoperative pain scores (Category C2 regimen of NSAIDs, Cyclooxygenase-2-
evidence). selective inhibitors, or acetaminophen.55-58
 Acute Pain Management Guidelines and Protocols: Evidencebased 37

Improved pain scores reported when Types of Multimodal Techniques

intravenous morphine is combined with
ketorolac (Category A1 evidence). Findings Two or more analgesic agents, one route versus
for acetaminophen are equivocal (Category a single agent, one route1
C2 evidence). • Epidural or intrathecal analgesia with
• Andrieu et al59 and Lavand et al60 have opioids combined with:
shown efficacy of intrathecal Clonidine for – Local anesthetics versus epidural
postoperative analgesia following radical opioids
prostatectomy58 and elective cesarean.59 – Local anesthetics versus epidural local
Also Famery et al observed lower pain scores anesthetics
following epidural Clonidine infusion for – Clonidine versus epidural opioids
spine surgery.61 • IV opioids combined with:
• Dexmedetomidine may be given during – Clonidine versus IV opioids
the postoperative period to reduce PCA – Ketorolac versus IV opioids
morphine requirements. Lin et al62 and – Ketamine versus IV opioids
Tufanogullari et al63 observed that patients – Oral opioids combined with NSAIDs,
on dexmedetomidine required less COXIBs, or acetaminophen versus oral
morphine. opioids
• Dosing regimens should be administered to • Dexamethasone.
optimize efficacy while minimizing the risk Two or more drug delivery routes versus a
of adverse events.55-58 single route1
• Alpha 2 δ ligands like gabapentin or • Epidural or intrathecal analgesia with
pregabalin alone or in combination opioids combined with IV.
with dexamethasone can also be used • Intramuscular, oral, transdermal, or
perioperatively in adequate doses for their subcutaneous analgesics versus epidural
opioid sparing effects. Clinical trials with opioids.
gabapentin or pregabalin for postsurgical • IV opioids combined with oral NSAIDs,
pain have been conducted by Mathiesen COXIBs, or acetaminophen versus IV
et al,64,65 Jokela et al,66 Agarwal et al67 and opioids.
Gilron.68 IV opioids combined with alpha 2 δ • Nonpharmacologic, alternative, or
ligands like gabapentin or pregabalin, report complementary pain management
lower pain scores (Category A1 evidence). combined with pharmacologic pain
• Huang et al noticed lower pain scores management versus pharmacologic pain
following perioperative Celecoxib management.
administration for pain management
in patients undergoing total knee Continuous Multimechanistic
arthroplasty.55 Post-operative Analgesia
• The choice of medication, dose, route, and
duration of therapy should be individualized. • Pergolizzi et al suggest rationale
• Moodie et al observed lower mean for transitioning from intravenous
morphine consumption in the intranasal Acetaminophen and opioids to oral
Ketorolac group patients undergoing major formulations.71
abdominal or orthopedic surgery.69 • Pergolizzi et al emphasize that the use of
• In patients undergoing total hip arthroplasty IV. Acetamoniphen and opioids in the
under spinal anesthesia, perioperative preoperative period could transition to
intravenous Dexamethasone can be oral formulations of the same agents in
considered as Kardash et al have shown that the same proportions for postsurgical pain
it reduces pain upon standing at 24 hours.70 management.71
38 Practice Guidelines in Anesthesia

• Oral fixed dose combination (Tramadol pharmacokinetics as applicable to children,

+ Acetamoniphen) or loose dose should preferably involve a multimodal
combinations could be used, as appropriate approach.82
to meet the needs of individual patients.72-78 • Behavioral techniques addressing the
emotional component of pain should be
Special Populations adopted whenever feasible.81,82
• Kokki, Dalens and Kawaraguchi et al
Pediatric patients emphasize that in the multimodal approach,
Children’s pain matters–for the child, For the sedative, analgesic, and local anesthetics
family, and for the society are all essential components of analgesic
Very low birth weight infants may be regimens for painful procedures.83-85
admitted in the neonatal ICU for months • There is substantial body of evidence
together, and obviously they are highly that various analgesic medications are
vulnerable to pain from recurring procedures synergistic with sedative agents, it is
due to immaturity of their CNS and rapid brain important that appropriate monitoring be
development occurring in the last trimester used during the procedure and recovery.83-85
of fetal life.79 Also Grunau et al80 suggest that • The emotional component of pain is
prolonged untreated pain suffered early in life, essentially strong in infants and children
independent of morphine exposure, may have and presence of parents in familiar
long lasting effects on the individual pattern of surroundings makes all the more difference.
stress hormone responses in vulnerable infants. Millions of children undergo surgery
• Optimal care for infants and children each year in developing nations and
requires special attention to the biophysical assessment of their pain has its own unique
nature of pain. Pediatric population problems. Despite the limited resources,
presents developmental differences in a successful pain management protocol
their experience and expression of pain was developed and tailored to the specific
and sufferings, their response to analgesic setting of the Medical Research Council
pharmacotherapy. pediatric ward in the Gambia, West
• Caregivers may assume that pain is not Africa.86 This protocol would serve as an
present and defer treatment. Safe methods example for other developing nations in
of providing analgesia are underutilized similar settings. Also regional anesthetic
for fear of opioid-induced respiratory techniques can be utilized to provide more
depression. However the emotional effective multimodal postoperative pain
component of pain is particularly strong in management.87
infants and children.
• The task force (of American Pain Society) on Geriatric Patients
pain in infants recommended that aggressive
and proactive pain management is essential • Elderly patients are more likely to undergo
to streamline the undertreatment of pain in surgery because of various underlying
children.81,82 medical and surgical conditions.1
• The task force (of American Pain Society) • Pain is often undertreated and elderly
on pain in infants recommended that patients are more vulnerable to the
perioperative care for children undergoing detrimental effects of such undertreatment.88
painful procedures or surgery requires • Bergh et al observed that the physical,
detailed pain assessment and therapy.82 social, emotional, and cognitive changes
• Each analgesic administration should be associated with aging have an impact on
based on body weight and comorbidity, and perioperative pain management.88
 Acute Pain Management Guidelines and Protocols: Evidencebased 39

• These geriatric patients may have all of analgesics are usually not suitable for the
together different attitudes than younger cognitively impaired.89
adult patients in expressing pain and • The literature is insufficient to evaluate the
seeking appropriate therapy. application of pain assessment methods or
• Altered pharmacokinetics in geriatric pain management techniques specific to
patients as based on physiological changes these populations.
in the drug distribution and metabolism • This special population may require
of analgesic drugs and local anesthetics additional interventions to ensure optimal
requires frequent dose alterations. perioperative pain management.
• Pain assessment and therapy should be • Anesthesiologists should consider a
integrated into the perioperative care of therapeutic trial of an analgesic in such
geriatric patients. patients with increased blood pressure and
• Pain assessment tools and methods heart rate or agitated behavior when causes
appropriate to a patient’s cognitive abilities other than pain have been excluded.
should be used. Extensive and proactive
evaluation and questioning may be Pain in Childbirth
necessary to overcome barriers that hinder
communication regarding unrelieved • Acute pain during childbirth is a well
pain.88,89 established cause of pain in a parturient.
• Anesthesiologists should recognize that Obviously in developing world, analgesia
geriatric patients may respond differently during labor is a “luxury” that is not
than younger patients to pain and analgesic readily available due to shortage of drugs,
medications, often because of comorbidity. equipment and medical personnel and poor
• Strict dose titration is essential for infrastructure.
minimizing the adverse effects such as • Epidural block cannot be offered to the
somnolence in this vulnerable group, majority of mothers in developing nations
because of concomitant medication with as it is expensive (especially in hospital
some complimentary agents. with poor infrastructure and in the absence
of health insurance facilities). Hence
Kuczkowsi and Chandra innovated a
Critically Ill and Cognitively
single shot spinal anesthetic during labor.90
Impaired Patients
They achieved high degree of maternal
Recently Sandra et al in a systematic review satisfaction with minor side effects in
of behavioral pain assessement tools noted majority of women. This technique could
that patients who are critically ill, cognitively be adopted by other developing nations
impaired (e.g. Alzheimer’s disease/ dementia), also.
or who otherwise have difficulty communicating
(e.g. cultural or language barriers) present Genetics and Gender
unique challenges to perioperative pain
management.89 • ASA Task Force believes that patient’s
• Techniques that reduce drug dosages race, ethnicity, culture, gender and
required to provide effective analgesia may socioeconomic status have significant
be suitable for such patients (e.g. regional bearing on access to the treatment as well as
analgesia and multimodal analgesia). pain assessment by the doctors and nurses.
• Behavioral modalities and techniques such • The genetic predisposition and single
as PCA that depend upon self-administration nucleotide polymorphism may influence
40 Practice Guidelines in Anesthesia

the doses and pharmacokinetics of few that many anesthesiologists and institutions
analgesics. are taking initiative to overcome some of these
barriers and may be in a couple of years, we can
look forward to optimal acute pain management
Conclusion in the developing world.
With the background of barriers to optimal acute “All things are possible for those who believe,
pain management in the developing countries, Believe and your belief will create the fact”
it is not surprising that acute pain in several
settings is not well managed in the developing References
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 CHAPTER 5
Monitoring Standards
in Anesthesia
Gundappa Parameswara

Introduction of Societies of Anesthesiology constituted and

International Task Force in 1989 to (a) guide
There have been concerns regarding safety and assist anesthesia providers, professional
standards for safe surgery including anesthesia societies, hospital administrators, and the
all over the world. The WHO safety check list of governments in improving the quality and
“Safe Surgery Saves Lives” has been introduced safety of anesthesia (b) update and improvise
to promote better outcome, reduce morbidity minimum mandatory monitory standards as
and mortality associated with surgery. applicable to each country, depending on the
Anesthesia may cause adverse outcome in medicolegal, cultural norms and customs,
terms of morbidity as well as mortality. The racial, endemic and environmental factors.
essential of monitoring, basically in the form The recommendations of ITF were accepted
of clinical monitoring during anesthesia for by WFSA in 1992. Subsequently most countries
Oxygenation, Ventilation and Circulation has have formulated and adapted their own version
been found to be inadequate and sometimes of monitoring standards modifying suitability to
unsatisfactory. Need for additional monitoring the requirements and available resources of their
devices to supplement the clinical monitoring, country. The Indian Society of Anesthesiologists
was found necessary. Fortunately, technolgical mostly adapted and formulated guidelines on
explosion and innovations have made monitoring in 1996 based on recommendations
monitoring equipment available practically of WFSA, and subsequently in 2008 minimum
for all parameters that may change during monitoring standards were codified by this
anesthesia. More and more monitors are being author.
added every year in this competitive field of It is a well recognized fact that monitors
medicine including anesthesia. themselves do not reduce or prevent an adverse
Recognizing the fact that monitoring of vital outcome. They provide warning of impending
parameters plays an important role in reducing deterioration in the patient condition. It is the
morbidity and mortality related to anesthesia, ‘man behind the machine’ an alert and trained
the American Society of Anesthesiologists in anesthesiologists who should interpret these
1986 under Dr H Ketcham Morrel took first step in numbers and changes, act and take appropriate
codifying “minimum monitoring standards” for action to prevent any untoward effect. It is also
anesthesia. Subsequently, the World Federation recognized that monitors may also malfunction,
46 Practice Guidelines in Anesthesia

which should be recognized immediately and irrespective of level of infrastructure, resources,

replaced. Unfortunately human error may also training or organization. These Highly
creep in preventing and recognition of problem. Recommended Or Mandatory standards are
This aspect can be only reduced by properly applicable for health care organization with
trained professional and by continuous update Level–1 or Basic Infrastructure, such as Small
of the literature. Not all monitors are ‘essential’ hospitals or health-care centers with sparsely
in reducing morbidity or mortality during equipped operating rooms, where general
anesthesia. Availability of more monitors, or regional anesthetics are administered for
and more information is unlikely to reduce simple and uncomplicated cases. They are not
untoward effect, if effective treatment is not applicable if only a superficial procedure under
available. Hence a set of “minimum or core local anesthesia is performed. (2) The Level-2 or
monitors” which have proved their reliability Intermediate Infrastructure hospitals or health-
improved the safety of anesthesia constitutes care facilities such as district or bigger hospitals,
the minimum standard of monitoring. where adequately equipped operation
Technological revolution and availability theaters may perform many major surgeries,
and affordability of monitors have made which may not require intensive care should
necessary the review of these guidelines. Most have a monitoring standard of Anesthesia as
countries have recently revised their guidelines classified as Highly Recommended (Mandatory
in keeping with the requirements, resources, Standards) and certain additional monitors
safety of patients and legal requirements. regarded as Recommended standards. (3) The
The WFSA revised the guidelines in 2010, Level-3 or hospitals or Optimal Infrastructure
incorporates and elaborate upon the core constitutes healthcare facilities such as
components of the Safe Anaesthesia part of medical college hospitals, corporate or other
the 2008 World Health Organization’s World referral centers with facilities to perform
Alliance for Patient Safety “Safe Surgery Saves complicated and have intensive care facilities.
Lives” global initiative. The Indian College of These healthcare facilities may perform all
Anesthesiologists on behalf of Indian Society of complicated surgeries, even requiring intensive
Anesthesiologists has reviewed the guidelines care facilities. The monitoring standards in these
on the monitoring standards in anesthesia hospitals should have Highly Recommended
following the WFSA recommendations. These (Mandatory Standards) + Recommended
standards are intended to provide guidance and certain additional monitors regarded as
and assistance to anesthesia professionals, Suggested standards. It should be recognized
their professional societies, hospital and here that depending upon the facilities and
administrators, and governments for improving resources, WFSA recommends different grades
and maintaining the quality and safety of and difficulties of anesthetic procedures being
anesthesia care. performed. Correspondingly, the level of
WFSA has adapted standardized WHO monitoring should appropriately increase.
terminology, which other countries may have For precise understanding, the Indian
modified to their convenience. As per WFSA, (1) College of Anesthesiologists has used slightly
a minimum set of monitors which are necessary different nomenclature. The word Mandatory
to be used in ALL anesthetic procedures to is used instead of Highly Recommended.
maintain a minimum standard of anesthesia The following table summarizes the practice
is termed Highly Recommended in bold letters. standards and infrastructure facilities and
This is equivalent to Mandatory Standards nomenclature used by Indian College of
to be adapted for any anesthetic procedures Anesthesiologists.
 Monitoring Standards in Anesthesia 47

Level Infrastructure Type of Health- Type of Surgery Anesthesia ICA Nomenclature

care Facility Performed Standards
Level – 1 Basic Small Hospitals Uncomplicated Highly Minimum
with sparsely Simple Recommended Mandatory
equipped surgeries, Standards Standards
operating rooms Emergency
management
of Trauma and
Obstetrics (but
no LSCS)
Level – 2 Intermediate Bigger, District All types of Highly Mandatory +
level hospitals, surgeries Recommended + Recommended
with well not needing Recommended
equipped intensive care.
operation rooms. management
May be without of trauma and
Intensive Care obstetrics
Facility including LSCS
Level – 3 Optimal Medical College All types of Highly Mandatory +
Hospitals, complicated Recommended + Recommended +
Corporate surgeries, Recommended + Suggested
hospitals and trauma, Suggested
referral hospitals obstetrics, and
with intensive superspecialty
care facility surgeries

Section – 1: Professional may be a trainee anesthesiologist or nurse

Standards anestheiologist or anesthesia technician.
d. A qualified anesthesiologist or his assistant
Anesthesiologist should be present throughout the conduct
a. The Anesthesiologists providing anesthesia of anesthetic procedure. At the end of
service to any surgical procedure should be the procedure, he or his assistant should
a qualified and certified having undergone accompany the patient to recovery or
appropriate training and accredited with postoperative ward, and handover the
a diploma (DA) or degree (MD or DNB) in patient to designated incharge of the ward.
Anesthesiology. It is Recommended that The anesthesiologists is responsible for
anesthesia be given only by qualified and overall care of the patient, and should be
accredited anesthesiologists. available for any consultation as required.
b. Paramedical or nonmedical persons The anesthesiologists should provide same
(Nurses) cannot provide anesthesia unless, care whether the patient is subjected to
they are appropriately trained and certified General Anesthesia, Regional Anesthesia or
to have undergone sufficient training in Monitored Anesthesia Care.
anesthetic procedure. They may provide e. It is recognized that under certain
anesthesia only as an assistant and under circumstances, the anesthesiologists
supervision of qualified Anesthesiologists. in charge, may require brief temporary
c. It is Recommended that anesthesiologist absence. In such situation, a responsible
may be assisted by another person, who assistant or another anesthesiologists should
48 Practice Guidelines in Anesthesia

be given hand over the charge of the patient. etc. so as to update the knowledge of
In case an anesthesiologists working alone, practice of anesthesia.
an emergency life saving situation calls for
absence of anesthesiologists attending on a
Professional Organisation Standards
patient, the surgeon should stop operating
and assume responsibility of the patient and a. It is Recommended that anesthesiologists
monitor the patient till the anesthesiologists should enroll as member of their
returns. professional body, locally, regional or at
f. It is Mandatory to record all the core data national levels.
of the patient in the anesthesia record. The b. The professional should set standards
preoperative evaluation, intraoperative core of practice, continuing professional
data and post operative vital parameters development and certify and accredite
should be properly recorded. The such programme. These organizations
intraoperative vital parameters like heart should form links with appropriate groups
rate, blood pressure, oxygen saturation within the region and/or country and
should be recorded at intervals not longer internationally.
than ten minutes, and earlier, if the clinical c. These organization may collect data
condition is unstable. nationally and encourage formation of
g. It is Recommended that individuals or protocols for safe practice of anesthesia.
departments collect cumulative data to
facilitate the progressive enhancement of Section – II: Monitoring the
the safety, efficiency, effectiveness, and
Anesthetic Equipment
appropriateness of anesthesia care.
1. It is the institutional responsibility to provide
appropriate anesthetic machines and
The Institutional Standards
equipment, and maintenance, calibration
a. It is the responsibility of the management and renewal of equipment should be done
of the Institution or hospital to procure and recorded periodically as recommended
appropriate monitors and facilities, in by the manufacturers.
adequate numbers and in proper working 2. The concerned anesthesiologists shall be
condition, before any anesthetic procedures familiar with the set-up, proper use and
are undertaken. Appropriate additional trouble shooting of the equipments. For more
recommended monitors must be provided complex equipment, the anesthesiologist
before providing anesthesia for high-risk should be appropriately trained regarding
patients. its usage before equipment or monitor is to
b. The management should ensure that be used.
these monitors and facilities are serviced 3. The anesthesiologist should check all the
at regular intervals and ensure working anesthetic equipment and monitors before
condition before providing anesthesia. connecting them on the patient. Alarm
c. It is Suggested that institutes peer review the setting should be appropriately set for upper
collective data and develop protocols. It is and lower limits and ensured that they are
Suggested to institute confidential incident working properly before commencing
reporting, to promote discussion and anesthesia.
analyzed and suggest remedies. a. In children and other uncooperative
d. It is Suggested that the institutes should patients, who may not allow monitors
encourage attendance at conferences, to be placed before anesthesia, patients
Continued Medical Education Programme, may be induced anesthesia and
 Monitoring Standards in Anesthesia 49

monitors connected as soon as possible. iii. If anesthetic machine does not have a
Till then, clinical monitoring of pulse hypoxic guard, then an Oxygen analyzer
and auscultation shall be carried out. fitted with low oxygen alarm set at
4. All anesthetic equipment should have a low appropriate level should be connected to
and high parameter audible alarms set at the inspired limb of the patient circuit.
appropriate values and should always be iv. Oxygenation of the patient should be
activated and loud enough to be heard. monitored clinically by observation of pink
color of the skin and mucous membrane
Section – III: Perioperative and absence of cyanosis. There must be
Care and Monitoring adequate, illumination of the patient for
proper observation of color.
Preoperative Care v. It is Mandatory to monitor oxygenation
of patient with pulse oximeter which
a. The patient should be evaluated
displays both the saturation and heart rate.
preoperatively by the anaesthesiologists
The pulse oximetry should have variable
or his competent assistant. All relevant
pitch pulse tone and low oxygen alarm
investigations should be checked and an
which is audible clearly. Display of pulse
appropriate anaesthesia plan should be
plethysmography by the pulse oximeter is
formulated. It is Recommended to follow
strongly Recommended.
Protocols and check list, if available, before
conduct of anaesthesia.
b. Anaesthesiologists should check availability Airway and Ventilation
and working condition of all the equipments i. For every patient undergoing anesthesia, it
and monitors needed before conduct of is Mandatory to monitor for ventilation.
anaesthesia. ii. The ventilation should be monitored by
c. It is Mandatory to fill the relevant clinical monitoring of chest excursion which
components of the World Health should be synchronous thoracoabdominal
Organization Safe Surgery Checklist. movement, observation of the rebreathing
bag (if breathing spontaneously) and
Intraoperative Monitoring ausculatation of chest for breath sounds.
It is Mandatory to monitor (a) Oxygenation Quantitative measurement of expired
(b) Airway and Ventilation and (c) Circulation of volume is strongly Suggested.
a patient before administration of anaesthesia. iii. When the ventilation is controlled by a
mechanical ventilator, it is Mandatory
to have a low pressure or low volume
Oxygenation alarm fitted to the ventilator to detect
i. For every patient undergoing anesthesia, disconnection or leak in the patient’s circuit.
it is Mandatory to give supplemental The alarm should give a clear audible signal.
oxygenation of at least 30% during iv. It is Highly Recommended to monitor
anesthesia and monitor for oxygenation ventilation by continuous monitoring of
ii. It is Mandatory for all patients to receive end-tidal CO2 by capnography, both for
an assured inspired oxygen concentration spontaneous and controlled ventilation.
of at least 25%. This may be ensured by The capnograph should be provided
appropriate anesthetic machine, which has with adjustable appropriate high and low
Oxygen or hypoxic guard set to minimum of pressure alarm levels to detect both under
25% of Oxygen. These anesthetic machine and over ventilation of the patient.
should also be fitted with oxygen failure v. Whenever an endotracheal intubation or
device and oxygen failure alarm. laryngeal mask or I-gel is inserted, It is Highly
50 Practice Guidelines in Anesthesia

Recommended to confirm the position of the v. It is Mandatory for every patient undergoing
tube, LMA or I-gel by monitoring end-tidal anesthesia to be monitored for blood
CO2 measurement by capnography. When pressure. It shall be mandatory for blood
capnography is used, its use should be pressure to be monitored with a noninvasive
continued till the endotracheal tube, LMA blood pressure monitor. They shall be
or I-gel is removed. recorded frequently not longer than five
vi. It is Mandatory to monitor ventilation minutes.
in Level 2 and Level 3 hospitals, where vi. It is Mandatory for every patients at high-
complicated and high-risk patients are risk for anesthesia (ASA Grade III and
subjected for anesthesia. above) patients, who are hemodynamically
vii. During regional anesthesia (with no unstable, those requiring inotropic support,
sedation) or local anesthesia (with no and for surgeries with expected blood loss
sedation), the adequacy of ventilation shall more than 20% of the body weight, shall
be evaluated by Clinical observation of have blood pressure monitored by an
qualitative clinical signs. During moderate continuous intra-arterial pressure tracing.
or deep sedation the adequacy of ventilation vii. For patients undergoing surgery in the
shall be evaluated by continual clinical above category, it is strongly Recommended
observation of qualitative respiratory to monitor central venous pressure by any
clinical signs. It is strongly Recommended appropriate method.
to monitor end-tidal CO2, unless precluded
or invalidated by the nature of the patient,
Additional Monitoring
procedure.
Certain Additional monitoring may be needed
for neonatal, prolonged or complex procedures.
Circulation
i. For every patient under anesthesia, it is
Temperature
Mandatory for Circulatory Functions to be
monitored. a. It is Recommended that facility to
ii. It is Mandatory for every patient subjected monitor temperature of the patient either
to anesthesia, shall be monitored by intermittently or continuously should be
continuous tracing of Electrocardiogram. available or should be monitored frequently.
The ECG monitoring should be continued b. The temperature should be monitored
into the postoperative or recovery ward till continuously in neonatal, young patient,
he is discharged to the ward. Geriatric patients and in patients
iii. It is Mandatory to have a defibrillator undergoing complex or prolonged surgery.
available in the operation theater, kept c. Measures to maintain body temperature by
charged and ready for use in case of cardiac body warming devices or Recommended.
arrest.
iv. It is Mandatory for every patient to
Neuromuscular Monitor
be monitored for circulatory function
continually evaluated by at least one of the a. It is Suggested that when neuromuscular
following: palpation of a pulse, auscultation blocking drugs are used, a peripheral nerve
of heart sounds, monitoring of a tracing of stimulator should be available and used as
intra-arterial pressure, or pulse oximetry. necessary.
The pulse rate may be recorded from b. It is Recommended that whenever
palpation or from ECG or pulse oximeter patients with neuromuscular diseases,
monitors. receiving neuromuscular blocking muscle
 Monitoring Standards in Anesthesia 51

relaxants, shall be monitored for degree of Anesthesiologists, or his assistance with

neuromuscular block by a peripheral nerve adequate knowledge and experience, till
stimulator the patient is handed over to a responsible
person in the recovery room, and a brief
summary of case and proper instructions is
Depth of Anaesthesia
explained to the person in charge.
a. Every patient undergoing general anesthesia 3. Patient should be shifted only when his
should be monitored regularly for depth of hemodynamic status is stable.
anesthesia clinically. 4. Patient should be continued to be monitored
b. It is Suggested to monitor inspired and with ECG, pulse oximeter and NIBP or
expired gas concentration of volatile invasive arterial monitoring as needed.
anesthesthetic agent. 5. If a patient requires mechanical ventilation
c. The use of brain function monitors is during transport, it is Recommended that
controversial and is not universally ventilation should be monitored with a
recommended. However use of Brain capnograph for end-tidal CO2 monitors, and
function Monitor is Suggested in patients disconnection alarm for ventilator such as
who may have high-risk of awareness under airway pressure monitoring.
anesthesia. 6. Should the patient require transfer to
another part of the hospital or outside, the
standard of monitoring should be same as
Section – V: Monitoring during detailed above applicable for postoperative
Regional Anesthesia, recovery ward area.
Anesthesia outside the
operation Rooms and Section – VII: Monitoring in the
Monitored Anesthesia Care Postoperative Ward
1. It is Recommended that the standards of 1. Every patient undergoing anesthesia shall
monitoring should be same as patient be transported to a postoperative recovery
undergoing general or regional anesthesia ward, and monitored by a competent and
or anesthesia outside the operating rooms responsible and dedicated qualified person,
should be similar to patient undergoing till the patient recovers his vital reflexes.
surgery inside the operating rooms. 2. Every patient shall be monitored in the post-
2. It is Mandatory for all patients should be operative recovery area with continuous
monitored by: monitoring of ECG, pulse oximeter and
a. Electrocardiography NIBP. Additional monitors like continuous
b. Pulse oximetry monitoring by direct arterial pressure
c. Noninvasive blood pressure monitoring, CVP, etc. shall be monitored as
Suggested above.
Section – VI: Monitoring 3. Pain relief: It is Mandatory to employ
During Transportation appropriate medication and modalities to
prevent and alleviate postoperative pain.
1. All patients who have received anesthesia 4. A postoperative recovery chart shall be
shall be monitored continuously till he maintained by recovery ward staff detailing
recovers from anesthesia and all reflexes are level of consciousness, hemodynamic
active. status, and respiration. They shall be charted
2. Patients, while transferring to the at least every 15 minutes and earlier, if any
postoperative recovery area shall changes are noted towards deteriorating
be accompanied by the responsible condition of the patient.
52 Practice Guidelines in Anesthesia

5. Patient shall be transferred out of recovery 4. Kotur PF. Monitoring the Anesthesiologists.
or postoperative ward, only when the patient Editorial I.: Indian J Anaesth. 2002;46(4):244-245.
has completely recovered from the effect of 5. Practice Advisory for Intraoperative Awareness
and Brain Function Monitoring. Task Force
all anesthetic drugs, and all his reflexes are
Report. Anaesthesiology. 2006:104;847-64.
intact and clinical condition of the patient is 6. Recommendations for Standards of Monitoring
stable. during Anaesthesia and Recovery – 4th edn: The
6. If the clinical condition of the patient is Association of Anaesthetists of Great Britain and
not stable, he should be transferred to Ireland, March. 2007.
appropriate intensive care units further 7. Recommendations for the Safe Transfer of
management. Patients with Brain Injury. Neuroanaesthesia
Society of Great Britain and Ireland & Association
of Anaesthetists of Great Britain and Ireland,
bibliography London, 2006.
8. Standards for Basic Anesthetic Monitoring—
1. Checking Anaesthetic Equipment. Association Approved by the ASA—House of Delegates on
of Anaesthetists of Great Britain and Ireland, October 21, 1986, and last amended on October
London, 2004. 25, 2005. Anesthesiology: Standards Guidelines
2. Immediate Post Anaesthetic Recovery. and Statements: Park Ridge, IL.,USA 1998.
Association of Anaesthetists of Great Britain and 9. Standards of Basic Anesthetic Monitoring.
Ireland, London, 2002. American Society of Anesthesiologists 2010.
3. International Standards for a Safe Practice of 10. Thompson JP Mahajan RP. Monitoring the
Anaesthesia 2010; World Federation of Societies monitors—beyond risk management. British
of Anaesthesiologists. e-Newsletter 2010. Journal of Anaesthesia. 2006;97:1-3.
 CHAPTER 6
Head Injury: Assessment and
Early Management
Girija Prasad Rath, Bikash Ranjan Ray

Head injury is a major public health and socio- the head or the presence of a scalp wound or
economic problem throughout the world. It is a those with evidence of altered consciousness
major cause of death, especially among young after a relevant injury’.10 However, the term
adults,1 and life-long disability is common ‘head injury’ has been replaced with ‘traumatic
in those who survive. Although high-quality brain injury (TBI)’ as this new term captures
prevalence data are scarce, it is estimated that the importance of the brain in these injuries.
in the USA, 5.3 million people are living with The WHO Task Force defined TBI to be “any
a head injury-related disability,2 and in the confusion and disorientation state at the time of
European Union approximately 7.7 million accident”.11 The severity of head injury is based
people who have experienced head injury have on the Glasgow Coma Scale (GCS) (Table 6.1).
disabilities.3 Mortality following head injury The treatment of head injured patients requires
has been reported in the range of 39 to 51%.4,5
The role of specialized and trained trauma care
team supervised by emergency physicians have
TABLE 6.1 Glasgow Coma Scale (GCS) Score
been highlighted for improvement in functional
neurological outcome.6,7 This chapter focuses Behavior Response Score
on the initial assessment and management of Eye opening Spontaneous 4
head injury in the prehospital and emergency To speech 3
department (ED), and to provide a practical To pain 2
None 1
approach for management of these patients.
Most of the literature is according to the Best verbal Oriented 5
recommendations proposed in the Brain response Confused 4
Trauma Foundation (BTF)8 and Advanced Words (Inappropriate) 3
Sounds (Incomprehensible) 2
Trauma Life Support (ATLS) by American
None 1
College of Surgeons.9
Best motor Obeys command 6
response Localize pain 5
Definition and Classification Flexion to pain–Normal 4
(Withdrawal) 3
of Head Injury Flexion to pain–Abnormal 2
The broad definition used for head injury Extension to pain 1
includes ‘patients with a history of a blow to None
54 Practice Guidelines in Anesthesia

the rapid assessment of injuries and institution ventilation. The debate of whether prehospital
of life-saving measures (Table 6.2). intubation in severe TBI is beneficial remains
The prehospital phase: It is the most important to be controversial; with specific focus on (a)
period in the management of TBI as most of who should do it–paramedics or emergency
the outcomes are related to the presence of a physicians14 and (b) whether rapid sequence
high incidence of prehospital secondary brain induction (RSI) improves the outcome.15
insults.12,13 The Brain Trauma Foundation (BTF) Recent studies suggest that prehospital
proposed recommendations for prehospital intubation of TBI patient should not be done
management of TBI with a standard protocolized if oxygen saturation is more than 90%.16 RSI
approach which were later revised in 2008. and intubation should be carried out in the
Most of these recommendations were aimed to prehospital settings by trained personnel. A
minimize the effects of secondary brain injury higher rate of mortality and a lower incidence
following primary insult. The contributory of good neurologic outcome reported in the RSI
factors to the secondary injury have been group.14 Hyperventilation was implicated for the
the presence of hypoxemia, hypotension, possible reason behind increase in mortality in
hypercarbia, hypoglycemia, hyperglycemia, the RSI group. Because of these contradictory
hyperthermia, and seizures. evidences, no firm recommendation is available
at present for prehospital intubation.
Initial evaluation and management: All
The goal of prehospital fluid resuscitation is
patients with TBI should be assessed in the
to optimize cerebral hemodyanamics. Isotonica
prehospital setting for hypoxemia (saturation
fluids are most commonly used. Hypertonic fluid
< 90%) and hypotension (systolic BP < 90 mm
resuscitation is recommended for severe TBI
Hg). The GCS score which is a quick reproducible
(GCS < 8). However, in a recent study, Bulger et
scoring system to classify head injury should be
al did not find any improvement in the 6 month
used for assessment. It is composed of three
outcome with the use of hypertonic saline.17 The
components: eye opening, verbal response
end point of fluid therapy and the ideal fluid for
and the best motor response. It should be
TBI patients is yet to be determined.
used repeatedly to determine improvement or
deterioration over the time. The GCS score can, Ventilation strategy: The intubated patients
however, be affected by various pretrauma and should be ventilated so as to maintain
post-trauma factors. Reversible conditions like normocarbia (PaCO2 35–40 mm Hg).
alcohol intoxication, narcotic overdose and Prophylactic hyperventilation (PaCO2 < 35 mm
hypoglycemia should be ruled out. The GCS Hg) should be avoided and used only if there
should only be evaluated after airway, breathing is clinical evidence of cerebral herniation or
and circulation are assessed and stabilized. acute neurological deterioration. The clinical
signs of cerebral herniation include dilated
Airway management: Most of the evidence and unreactive pupils, asymmetry in pupils,
supports the need of aggressive airway extensor posturing or no motor response.
management in prehospital settings in patients Targeted ventilation (PaCO2 30–39 mm Hg) at the
with hypoxemia or GCS score less than 8 either emergency department was found to decrease
by endotracheal intubation or with bag mask mortality (21.2% vs. 3.7%) in comparison with
ventilation achieved outside the target range.18
Classification of severity of head Hypothermia has been observed as a
TABLE 6.2 injury based on glasgow coma management strategy in TBI, but the results
scale (GCS) score
are still remaining inconclusive. Fox and
Severity of head injury GCS Score colleagues carried out a quantitative systemic
Mild 13–15 review and analyzed 12 studies involving 1327
Moderate 9–12 patients.19 Early induction of mild to moderate
Severe 8 and less hypothermia was found to decrease mortality
 Head Injury: Assessment and Early Management 55

and improve neurologic outcome in TBI patients • In the absence of any of these risk factors,
with maximal benefit in long-term advocation the patient should be observed, and to be
of hypothermia. The National Acute Brain transferred to the hospital if the symptoms
Injury Study: Hypothermia II (NABIS: H II) was worsen or any of these risk factors appears. If
a multicenter randomized trial of patients with there is no one to supervize the patients then
severe TBI who received either early cooling to also the patients should be transferred to the
33°C maintained for 48 hours or treatment at hospital for observation.
normothermia.20 Patients were enrolled either
Management children with TBI: The children
during transport to the hospital or in the ED.
cannot be considered as small adults, and
The investigators did not find any differences
mechanisms and outcome after TBI in them
in outcome between the groups. Bukur and
may differ. The basic concept of treatment
colleagues21 reported higher mortality due
does not differ from adult patients during the
to prehospital hypothermia in moderate to
prehospital phase. Whether the endotracheal
severe brain injured patients. The inconclusive
intubation in pediatric TBI patients during
evidence regarding the role of hypothermia is
this period is beneficial is under investigation.
due to differences in the study methodology.
Gerritse et al showed that on-scene emergency
Transportation: Patients with severe TBI tracheal intubation was performed effectively
should be transported directly to a center by a physician-based system as compared to
where facilities for CT scan, operating room, paramedics.24 All other management strategies
neurosurgical care, and the ability to monitor such as normocapnia, avoidance of hypoxia
and manage intracranial hypertension are and hypotension, osmotherapy, and avoidance
available. Prehospital team should be trained of hyperthermia are similar to established
to transport these patients so that they could be recommendations for adults.25
operated during “Golden Hour”. The transport
Assessment at the ED: As the timing is crucial,
method, duration and presence of physician in
the approach for a TBI patient should be
the transport team have been found to affect the
systematic, rapid and accurate. This approach is
outcome.22,23
termed as the “initial assessment” and includes:
Criteria to refer a patient to ED of a hospital: • Preparation
Patients who have sustained head injury should • Triage
be transferred to the ED of a hospital if they have • Primary survey (ABCDEs)
any of the following risk factors:8,9 • Resuscitation
• Lack of full consciousness or unconsci • Adjuncts to primary survey and resuscitation
-ousness • Consideration of the need for patient transfer
• Any focal neurological deficit after the injury • Secondary survey (Head-to-toe evaluation
• Suspicion of skull fracture or penetrating and patient history)
injury • Adjuncts to the secondary survey
• History suggestive of high energy head injury • Continued post-resuscitation monitoring
• Convulsion after the injury and re-evaluation
• Amnesia for events, before or after the injury • Definitive care.
• Persistent headache after the injury
• Any episode of vomiting after the injury Preparation: All necessary personnel and
• History of previous cranial neurosurgical resources should be present in the ED at the
intervention time of the patient’s arrival. Proper functioning
• History of coagulation disorder of airway equipment (e.g. laryngoscopes and
• Current anticoagulation therapy tubes) should be organized and placed where it
• Current drug or alcohol intoxication is immediately accessible. Warmed intravenous
(IV) crystalloid solutions and appropriate
56 Practice Guidelines in Anesthesia

monitoring devices should be available. All • GCS 8 or less.

emergency medical personnel should be aware • Loss of protective laryngeal reflex
of a guided protocol for acquiring additional • Inadequate ventilation (hypoxemia or
medical assistance when required. Standard hypercarbia)
precaution equipment as per Occupational • Spontaneous hyperventilation (PCO2 < 30
Safety and Health Administration (OSHA) and mm Hg )
American College of Surgeons Committee • Irregular respiration.
on Trauma (ACS COT) recommendations However, the risks associated with intubation
including face masks, gloves, head gear and should also be assessed. Hypoxia, ICH, full
water impervious gown should be available to stomach, and co-existent injuries including
all personnel during handling of the patients. cervical spine instability and maxillofacial
injuries may be present. Careful preparation
Triage: Triage involves the sorting of patients
and pre-oxygenation are mandatory. Airway
based on their needs for treatment and the
devices and adjuncts such as laryngeal mask
resources available to provide that treatment.
airway, Airtraq,® or Glidescope® may be
Treatment is rendered based on the ABC
useful, and alternative means of oxygenation
priorities (Airway with cervical spine protection,
and ventilation must be available.26 In some
Breathing, and Circulation with hemorrhage
cases, cricothyrotomy may be required.
control). Other factors that may affect triage
Before administering anesthetic drugs the
and treatment priority include injury severity,
hemodynamic status of the patient should
salvageability, and available resources.
be assessed. The primary goal would to
Primary survey and resuscitation: Brain injury prevent decreases in CPP with maintenance
often is adversely affected by secondary insults. of hemodynamic stability. Anesthetic agents
The mortality rate for patients with severe brain should allow rapid control of the airway while
injury who have hypotension on admission is attenuating increases in ICP and providing
more than double that of patients who do not hemodynamic stability. Usually thiopentone
have hypotension. The presence of hypoxia and propofol are the preferred agents but
in addition to hypotension is associated with should be avoided in presence of hypotension.
an increase in the relative risk of mortality Etomidate (0.2–0.4 mg/kg) may be used as
by 75%. The primary goals in the emergency an alternative as it effective in reducing ICP
management of TBI include prevention of simultaneously maintaining a hemodynamic
hypoxemia, maintenance of blood pressure stability. For rapid sequence intubation,
and reduction in ICP. Therefore, it is imperative succinylcholine or rocuronium may be used.
that cardiopulmonary stabilization be achieved Although succinylcholine is known to produce
rapidly in patients with severe brain injury. a small increase in ICP, this is not clinically
It includes 5 steps in a particular sequence: significant and should be used particularly if
1. Airway maintenance with cervical spine difficult airway is anticipated. Moreover, the
protection use of other anesthetic agents will also help to
2. Breathing and ventilation obtund the effects of succinycholine on ICP.
3. Circulation with hemorrhage control According to BTF recommendations, the aim
4. Disability: Neurologic status is to maintain a PaO2 more than 60 mm Hg and
5. Exposure/Environmental control: Completely PaCO2 in between 35 and 40 mm Hg. Aggressive
undress the patient, but prevent hypothermia. hyperventilation should be tried if clinical
Stabilization of the airway, breathing and or radiological evidence of increased ICP is
circulation (ABC) are the priority of all EDs present. Maintenance of blood pressure and
before attending other injuries. Patients with CPP is of paramount importance in TBI. The
the following conditions require immediate most common cause of hypotension in these
tracheal intubation and mechanical ventilation: patients is due to hemorrhage, hypovolemia,
 Head Injury: Assessment and Early Management 57

and aggressive diuresis with mannitol. Hence, • GCS less than 13 on initial assessment in the
aggressive fluid resuscitation with fluids should ED.
be instituted. Isotonic crystalloid solutions are • Indication in mild head injury:
preferred. The controversy continues regarding – High risk
the use of colloids versus crystalloids in TBI. – GCS less than 15 at 2 hours after the injury
A post hoc analysis of 460 TBI patients from on assessment in the ED.
the SAFE trial27 found that the patients of TBI – Suspected open or depressed skull
resuscitated with 4% albumin had a significantly fracture.
higher mortality at 2 years of injury as compared – Any sign of basal skull fracture
to the patients resuscitated with 0.9% saline. [hemotympanum, ‘panda’ eyes, CSF
The CHEST (crystalloid versus hydroxyethyl leakage from the ear or nose (Battle’s
starch) trial on 7000 intensive care patients sign)].
included a very small number of TBI patients – Vomiting more than 2 episodes.
and no reliable conclusions could be made in – Age more than 65 years.
these patients.28 Use of vasopressors has been • Medium risk
recommended if hemodynamic stability is not – Amnesia before impact more than 30
achieved with fluids. As per the BTF guidelines, minutes.
the target end-point of resuscitation is to – Dangerous mechanism of injury
maintain a systolic BP of more than 90 mm Hg. (pedestrian struck by vehicle, occupant
Neurologic evaluation: As soon as the patient’s ejected from vehicle, fall from elevation
cardiopulmonary status is managed, a rapid and more than 3 feet.
focused neurologic examination is performed. For patients who have sustained a head injury
It consists primarily of determining the GCS with no other indications for a CT head scan and
score, pupillary light response, and focal who are having warfarin treatment, a CT head
neurological deficit. The presence of drugs, scan should be performed within 8 hours of the
alcohol, intoxicants, and other injuries should injury. A provisional written radiology report
also be ruled out before assessment. The GCS should be made available within 1 hour of the
should be determined before administering scan being performed.
sedatives or paralytic agents. Investigating injuries to the cervical spine: For
cervical spine scanning, multiplaner
Secondary survey: It is instituted once primary
reformatting CT imaging facility should be
survey is completed and resuscitation and
available. MRI should be done if there are
normalization of vitals is in process. It includes
presence of neurological signs and symptoms
history and head to toe survey of patient
with suspected cervical spine or vascular injury.
including repeated neurologic evaluation,
For adults who have sustained a head injury and
complete laboratory and radiological
have any of the following risk factors, perform
evaluation.
a CT scan of cervical spine within 1 hour of the
Imaging: The investigation of choice for risk factor being identified:
detecting clinically important head injury is • GCS less than 13 on initial assessment
CT scan of head. Although magnetic resonance • The patient has been intubated
imaging (MRI) provides additional information • Plain x-rays are technically inadequate (e.g.:
regarding the injury, it should not be used desired view is unavailable)
as a primary imaging modality due to safety, • Plain x-rays are suspicious or definitely
logistic and resources reasons. For adults who abnormal
have sustained a head injury and have any of • A definitive diagnosis of cervical spine injury
the following risk factors, perform a CT head is needed urgently
scan within one hour of the identification of • The patient is having other body areas scanned
following risk factors:29 for head injury or multi-region trauma.
58 Practice Guidelines in Anesthesia

The patient is alert and stable; there is clinical Discharge and Follow-up: Patients admitted
suspicion of cervical spine injury and any of the to the hospital following head injury may be
following apply: discharged after resolution of all the significant
• Age 65 years or older sign and symptoms, provided the patients can
• Dangerous mechanism of injury (fall from be observed at the home.9 Verbal and written
height of more than 1 meter or 5 stairs; axial advice should be given to the patient and the
load to the head; high-speed motor vehicle family, which should include:
collision; ejection from a motor vehicle; • Sign and symptoms requiring return to the
accident; bicycle collision) ED
• Focal peripheral neurological deficit • Details about recovery process
• Paresthesia in the upper or lower limbs. • Contact details of hospital services
A provisional written radiology report should • Information regarding return to day-to-day
be made available within 1 hour of the scan activities.
being performed. Adults, who have sustained a • All patients should be informed about the
head injury and have neck pain or tenderness need for follow-up and rehabilitation, if
but no indications for a CT cervical spine scan, required.
perform 3- view cervical spine X-rays within
1 hour if either of these risk factors are identified:
CONCLUSION
• It is not considered safe to assess the range of
movement in the neck. The early assessment and management
• Safe assessment of range of neck movement of TBI patients is complex and requires a
shows that the patient cannot actively rotate coordinated and stepwise approach beginning
their neck to 45° to the left and right. from the scene of the accident to transfer
• X-rays should be reviewed by clinicians of patient to neurosciences care center,
trained in their interpretation, within 1 hour. involving paramedics, emergency physicians,
Transfer from hospital to a neuroscience neurointensivists, and neurosurgeons. Further
unit: Neurosurgeon should be involved in research is needed to devise protocols for early
care of all the patients who have significant management to prevent the onset and mitigate
abnormalities on imaging in order to decide the effects of secondary brain injury. Training
the ‘surgically significant’ patients and further programmes particularly for the paramedics
management.9 Regardless of imaging, other should be planned and implemented to step
reasons for discussing a patient’s care plan down the present burden of TBI.
with a neurosurgeon and admission into a
neurosciences center include: REFERENCES
• Persistent coma (GCS 8 or less) after initial
1. Maas AI, Stocchetti N, Bullock R. Moderate and
resuscitation severe traumatic brain injury in adults. Lancet
• Unexplained confusion, which persists for Neurol. 2008;7:728-41.
more than 4 hours 2. Langlois JA, Sattin RW. Traumatic brain injury
• Deterioration in GCS score after admission. in the United States: research and programs of
• Progressive focal neurological signs the Centers for Disease Control and Prevention
• A seizure without full recovery (CDC). J Head Trauma Rehabil. 2005;20:187-8.
• Penetrating head injury 3. Tagliaferri F, Compagnone C, Korsic M, et al. A
systematic review of brain injury epidemiology in
• Cerebrospinal fluid leak
Europe. Acta Neurochir (Wien). 2006;148:255-68.
• Absence of CT scan facilities 4. Lannoo E, Van Rietvelde F, Colardyn F, et al.
• No reliable companion at home Early predictors of mortality and morbidity
• Presence of significant injuries, intoxication, after severe closed head injury. J Neurotrauma.
skull fracture. 2000;17:403-14.
 Head Injury: Assessment and Early Management 59

5. Bulger EM, Nathens AB, Rivara FP. Brain Trauma 17. Bulger EM, May S, Brasel KJ, et al. Out-of-hospital
Foundation: Management of severe head injury: hypertonic resuscitation following severe
Institutional variations in care and effect on traumatic brain injury: A randomized controlled
outcome. Crit Care Med. 2002;30:1870-6. trial. JAMA. 2010;304:1455-64.
6. Myburgh JA, Cooper DJ, Finfer SR, et al. 18. Caulfield EV, Dutton RP, Floccare DJ, et al.
Epidemiology and 12 month outcomes from Prehospital hypocapnia and poor outcome
traumatic brain injury in Australia and New after severe traumatic brain injury. J Trauma.
Zealand. J Trauma. 2008;64:854-62. 2009;66:1577-82.
7. Klemen P, Grmec S. Effect of pre-hospital 19. Fox JL, Vu EN, Doyle-Waters M, et al.
advanced life support with rapid sequence Prophylactic hypothermia for traumatic brain
intubation on outcome of severe traumatic brain injury: A quantitative systematic review. CJEM.
injury. Acta Anaesthesiol Scand. 2006;50:1250-4. 2010;12:355-64.
8. Brain Trauma Foundation; American 20. Clifton GL, Valadka A, Zygun D, et al. Very early
Association of Neurological Surgeons; Congress hypothermia induction in patients with severe
of Neurological Surgeons; Joint Section on brain injury (the National Acute Brain Injury
Neurotrauma and Critical Care, AANS/CNS: Study: Hypothermia II): a randomised trial.
Guidelines for the management of severe head Lancet Neurol. 2011;10:131-9.
injury. J Neurotrauma. 2007;24(Suppl):S1-106. 21. Bukur M, Kurtovic S, Berry C, et al. Pre-hospital
9. Advanced trauma life support (ATLS®): the hypothermia is not associated with increased
ninth edition. ATLS Subcommittee; American survival after traumatic brain injury. J Surg Res.
College of Surgeons’ Committee on Trauma; 2012;175:24-9.
International ATLS working group. J Trauma 22. Bulger EM, Guffey D, Guyette FX, et al. Impact of
Acute Care Surg. 2013;74:1363-6. prehospital mode of transport after severe injury:
10. Jennett B. Epidemiology of head injury. Arch Dis A multicenter evaluation from the Resuscitation
Childhood. 1998;78:403-6.
Outcomes Consortium. J Trauma Acute Care
11. Carroll LJ, Cassidy JD, Holm L, et al.
Surg. 2012;72:567-7.
Methodological issues and research
23. Franschman G, Verburg N, Brens-Heldens V,
recommendations for mild traumatic brain
et al. Effects of physician based emergency
injury: the WHO Collaborating Centre Task Force
medical service dispatch in severe traumatic
on Mild Traumatic Brain Injury. J Rehabil Med.
brain injury on prehospital run time. Injury.
2004;43:113-25.
2012;43:1838-42.
12. Wu X, Hu J, Zhuo L, et al. Epidemiology of traumatic
24. Gerritse BM, Draaisma JM, Schalkwijk A, et al.
brain injury in eastern China, 2004: A prospective
large case study. J Trauma. 2008;64:1313-9. Should EMS-paramedics perform paediatric
13. Pearson WS, Ovalle F Jr, Faul M, et al. A review tracheal intubation in the field? Resuscitation.
of traumatic brain injury trauma center visits 2008;79:225-9.
meeting physiologic criteria from The American 25. Zebrack M, Dandoy C, Hansen K, et al. Early
College of Surgeons Committee on Trauma/ resuscitation of children with moderate-to-
Centers for Disease Control and Prevention severe traumatic brain injury. Pediatrics.
Field Triage Guidelines. Prehosp Emerg Care. 2009;124:56-64.
2012;16:323-8. 26. Rozet I, Domino KB. Care of the acutely
14. Davis DP, Koprowicz KM, Newgard CD, et al. unstable patient. In: Cotrell JE, Young WL
The relationship between out-of-hospital airway (Eds.) Neuroanesthesia. 5th edn. Philadelphia,
management and outcome among trauma PA:Mosby. 2010. p.165
patients with Glasgow Coma Scale Scores of 8 or 27. Myburgh J, Cooper DJ, Finfer S, et al. Saline
less. Prehosp Emerg Care. 2011; 15:184-92. or albumin for fluid resuscitation in patients
15. Bernard SA, Nguyen V, Cameron P, et al. with traumatic brain injury. N Eng J Med.
Prehospital rapid sequence intubation improves 2007;357:874-84.
functional outcome for patients with severe 28. Myburgh JA, Finfer S, Bellomo R, et al.
traumatic brain injury: a randomized controlled Hydroxyethyl starch or saline for fluid
trial. Ann Surg. 2010;252:959-65. resuscitation in intensive care. N Engl J Med.
16. Badjatia N, Carney N, Crocco TJ, et al. 2012;367:1901-11.
Brain Trauma Foundation; BTF Center for 29. Stiell IG, Wells GA, Vandemheen K, et al. The
Guidelines Management. Prehosp Emerg Care. Canadian CT Head Rule for patients with minor
2008;12(Suppl 1):S1-52. head injury. Lancet. 2001;357(9266):1391-6.
 CHAPTER 7
Guidelines to Quality
Assurance in Anesthesia
Jayashree Sood

Quality is described in terms of degree of A quality improvement (QI) program in

excellence for a specific purpose. Quality anesthesia focuses on measuring and improving
assurance in anesthesia practice is administering the above components of care.
anesthesia of the highest order which can be
expected in that setting and is a focus on patient Quality Assurance Cycle
safety Patient safety is a fundamental objective
of anesthesia care because anesthesia by itself
has no therapeutic value. Quality assurance
in anesthesia care improve patient safety and
satisfaction.
Quality of care, which determines quality
assurance, is usually measured in terms of three
indicators—structure, process and outcome as
described by Donabedian.
Structure refers to the setting in which
care was provided, that is the personnel and
facilities used to provide healthcare services
and the manner in which they are organized.
The structure must be adequate to perform its
mission.
Process of care includes the sequence and Quality assurance in anesthetic practice may be
coordination of patient care activities indicating broadly divided into:
what is actually done. The process must be 1. Practice guidelines, policies or protocols
workable and efficient. 2. Anesthesia record
Outcome of care refers to changes in health 3. Risk management
status of the patient following the delivery of 4. Adverse incident reporting
medical care. 5. Critical incident analysis
Proactive guidelines are systematically 6. Peer review
developed statements to assist the anesthesia 7. Audit
practitioner in specific clinical circumstances. 8. Cost effectiveness
 Guidelines to Quality Assurance in Anesthesia 61

9. Regulation and licensing of anesthesia have an annual maintenance contract. An

personnel. oxygen analyzer along with other alarms should
be in place. A suction machine, preferably
electrical, is essential. A defibrillator is
Provision of Anesthesia
mandatory in all places providing anesthesia.
Services
A laryngoscope and endotracheal tubes should
Qualification of the Anesthesiologist be present. Equipment required to maintain a
difficult airway including stylet, bougie and an
It is important to understand that anesthesia LMA is recommended. All equipment must be
services are being provided under different examined regularly by an authorized body and
settings in India. They are being provided in replaced when required. Specific monitoring
major hospitals where are all anesthesiologists required for the concerned surgeries should
are qualified. be available, e.g. temperature monitoring for
They are also being provided in the rural long surgeries, CVP and other noninvasive
settings where the qualification of the concerned cardiac output monitoring in major surgical
anesthesiologist may be questionable. It is procedures. All the concerned parameters
essential that any clinician administering should be recorded at regular intervals in the
anesthesia should be qualified, either a diploma anesthesia chart.
or a masters degree. No clinician without these
qualifications should be allowed to administer
anesthesia. In the private setting, qualified Sterilization of Equipment
anesthesiologists are practicing either as The protocol for infection control prepared
free standing or a group practice and should by the hospital authorities should be strictly
understand the legal implications of group adhered to. The color coded bags for hospital
practice. waste disposal should be used. All syringes and
needles should be destroyed and disposed off in
Operating Room Services color coded bags.
Equipment which needs to be sterilized
The operating room where anesthesia services should be done according to hospital protocol.
are to be provided should conform to the
standards being provided by other major
hospitals. The operating room should be safe Monitoring Equipment
against electric and fire hazards. All necessary Mandatory monitoring should be available
clearances should be obtained before surgeries which includes heart rate, blood pressure
are begun. and oxygen saturation. So a monitor which
Major hospitals should have a medical gas includes all three should be kept. A capnogram
pipeline system which should be certified is mandatory for all intubated patients and
by the concerned authorities. If however, laparoscopic surgeries.
in smaller hospitals, pipeline system is not
available, there is should be free availability
Drugs
of gas cylinders. In rural set-ups, oxygen
concentrators should be in place. Before Those drugs which are required for providing
beginning the first case of the morning, the general and regional anesthesia should be
preanethetic check list for gas pipeline and freely available. A regular supply of thiopentone
anesthesia machine should be done and sodium, neuromuscular blocking drugs
documented. The breathing circuit, routine including suxamethonium and nondepolarizing
equipment, vacurim suction and drugs should drugs, analgesic, atropine and the reversal drugs
be checked. The anesthesia machine should is mandatory.
62 Practice Guidelines in Anesthesia

Drugs including lignocaine and bupivacaine that this form can be consulted when anesthesia
which are necessary for regional anethesia is being administered to them.
procedures should be present. Emergency All comorbidities should be optimized
drugs should be kept ready in a dedicated slot preoperatively.
so that they are immediately available when Investigations should be done according to
required. Drugs which have exceeded their shelf guidelines set by the respective organizations
lives should be replaced with new ones. (our PAC Diag Guidelines). Hemoglobin
estimation and routine urine examination
Preoperative Examination should be done for all cases since anemia is
a common finding in our country and some
All patients posted for surgery should have a patients may be reporting to the hospital for
preanesthetic evaluation by the anesthesiologist. the first time. Routine urine examination is
There should be a preanesthetic evaluation a very simple test which reveals involvement
form which should be filled for all patients so of several organs, e.g. kidney and endocrines.
 Guidelines to Quality Assurance in Anesthesia 63

Fasting instructions are very essential to be Whenever an obstetric delivery is being

followed. done, the anesthesiologist is responsible only
Although international guidelines allow clear for the mother, while a neonatologist must be
fluids 2 hours before surgery, they may not be so present for neonatal resuscitation.
rigidly followed by patients in our country since An anesthesia chart should be maintained
many individuals do not realize the importance for all patients. Documentation of all events in
of fasting, therefore fasting instructions should the perioperative period are mandatory.
be given very clearly.
Before elective surgery the minimum
Records
duration of fasting should be 8 hours after a
normal heavy meal and 6 hours after a light Maintaining records is of the utmost
meal or infant formula. importance. All changes in the intraoperative
Premedication with an oral anxiolytic should period should be documented. All variables
be given according to hospital protocol, unless including heart rate and blood pressure should
there is a contraindication. be recorded regularly according to the clinical
The plan of anesthesia should be explained situation. Oxygen saturation must be monitored
to the patient. Plan of postoperative analgesia continuously and recorded at regular
should be discussed with the patient. Informed intervals. End-tidal CO2 should be monitored
consent should be taken. continuously if the trachea is intubated and if
it is a laparoscopic surgical procedure. Alarms
should not be disabled.
Preoperative Checklist
The intraoperative documentation should
A preoperative safety checklist adapted from also include the details of drugs administered,
the WHO, must be followed. It may be modified their time of administration route and dose.
according to the institution where it is being The volume and type of fluids administered
used. Our hospital safety checklist as given: should be written in the perioperative period.
Patient identification, surgical procedure Urine output, if the patient catheterized should
and side of operation must be documented and be measured and recorded.
verified by the anesthesiologist, surgeon and
technician.
Post-anesthesia Care Unit
Recovery room facility should be available
The Intraoperative Period
wherever anesthesia services are being
The anesthesia machine, equipment drugs and provided.
suction should be checked before each case. The recovery room should be equipped with
All syringes filled with drugs should be labeled. essential monitoring equipment.
An intravenous access should be obtained The anesthesiologist should accompany the
even for minor procedures under LA. The patient to the recovery room.
anesthesiologist or his assistant must remain The vital signs of all patients brought to the
with the patient throughout the intraoperative recovery room should be monitored—oxygen
period whether it is general, regional or saturation, blood pressure and heart rate.
monitored anesthesia care. An accurate record of the immediate recovery
The anesthesiologist is responsible for the period should be maintained.
perioperative anesthetic care of the patient. Supplemental oxygen and suction machine
Simultaneous administration of general or in working condition are mandatory. Emergency
regional anesthesia by one anesthesiologist an drugs and defibrillator should be immediately
more than one patient is not allowed. available.
64 Practice Guidelines in Anesthesia

Discharge from the PACU is the responsibility documented for all patients. ‘Discharge Criteria’
of the anesthesiologist. There should be a check should be followed. The anesthesiologist must
list to decide whether the patients are ready to have the authority to discharge these patients.
be shifted to the room.
Guidelines for Obstetric Analgesia
Discharge Criteria after
Obstetric analgesia services should only
Daycare Surgery be extended to those facilities who have an
If a hospital has a day care centre, there should experienced anesthesiologist with adequate
be a “vital signs” monitoring chart which is training in obstetric anesthesia.
 Guidelines to Quality Assurance in Anesthesia 65

A hospital planning to introduce obstetric Guidelines for Acute Pain

analgesia services needs proper infrastructure Management
with well trained nurses and adequate
Protocols for pain management in the
monitoring facilities in the labor suite.
postoperative period should be made and
All emergency equipment should be
followed by the pain physicians.
available in case a complication occurs during
VAS score and other vital signs should
any procedure.
be documented. The back and the epidural
Informed consent should be taken before
catheter dressing should be examined daily.
initiating the regional anesthesia.
An anesthesiologist should be available
An intravenous access should be obtained in all
immediately in case of an adverse event.
these parturients. Hospital protocols made for the
initial dose of local anesthetic and the subsequent
top ups should be followed. Monitoring of vital Anesthesia ‘Outside the Box’
signs should be done and documented. A qualified anesthesiologist should provide
The anesthesiologist should remain with anesthesia care in these remote locations.
the patient till adequate pain relief is obtained. Appropriate anesthesia equipment with
Subsequently should be immediately available oxygen, routine and emergency drugs and
if required. Top up doses to be given only by a suction machine should be available.
qualified anesthesiologist. Clear fluids may be Fasting status should be checked before
allowed in established labor. inducing anesthesia.
66 Practice Guidelines in Anesthesia

Adverse Incident Reporting 4. Duration of hospitalization

5. Analysis of mortality data.
All adverse events including life-threatening or Development of protocols, guidelines and
unusual complications, adverse drug reactions programm enhance the quality of care.
should be reported.
Critical incidents are events that cause, or
had the potential to cause, patient injury if not Further Reading
noticed and corrected in a timely manner. 1. Benn J, Arnold G, Wei I, Riley C, Aleva F. Using
quality indicators in anaesthesia: Feeding back
Audit data to improve care. Br J Anaesth. 2012;109:80-91.
2. Archer JC. State of the science in health
All data should be audited. professional education: Effective feedback. Med
Criteria based audit evaluates performance Educ. 2010;44:101-8.
according to predetermined criteria. 3. Hetimiller ES, Martinez EA, Pronovost PJ. Quality
The audit should be reviewed regularly to improvement. In: Miller RD, [Link]’s
Anesthesia. 7th ed. Philadelphia: Churchill
ensure that remedial steps are taken whenever
Livingstone; 2010. pp. 81-92.
required. 4. Haller G, Stoelwinder J, Myles PS, McNeil J. Quality
and safety indicators in anesthesia: A systematic
Quality Assurance in ICU review. Anesthesiology. 2009;110:1158-75.
5. van der Veer SN, de Keizer NF, Ravelli AC,
Quality of care in ICU can be assessed by Tenkink S, Jager KJ. Improving quality of care.
1. Measurement of patient satisfaction A systematic review on how medical registries
2. Analyzing frequency of delivery of care provide information feedback to health care
3. Monitoring of complications providers. Int J Med Inform. 2010;79:305-23.
 CHAPTER 8
Preanesthetic Evaluation
and Investigation
JP Sharma, Nidhi Kumar

INTRODUCTION patients. It is advisable to evaluate the patient

again in the night before surgery, which helps
Preanesthetic evaluation is mandatory for in diagnosing and managing any new sign,
safe anesthesia practice and if properly done, symptoms.2
reduces perioperative complications and Even emergency cases associated with
also helps to decrease postsurgical morbidity higher mortality and morbidity, require a more
and mortality, which depends not only on abbreviated evaluation. Short relevant history,
the surgical procedure itself, but also on fasting status and quick assessment of airway
the patient’s preoperative physical status. and review of relevant investigations available
Subsequent preoperative optimization of the with the patients help reducing perioperative
patient’s condition reduces operative and complications in emergency cases.
anesthesia-related risks. Preanesthetic check-up is a team approach
Patients often have comorbidities that involving an anesthetist, surgeon and
require careful assessment and coordination. physician/super specialist to optimize patients
There are several models available for the general condition to make him suitable so he
preoperative anesthetic assessment clinic, most can tolerate anesthetic and surgical stress.
of which rely both on anesthetists and specialist Perioperative care of the patient as well as
nurses.1 All hospitals should aim to provide efficiency in the OT is always enhanced by close
appropriately staffed clinics. The visit to the communication with all.3
pre-operative clinic also gives the patients an Preferably preanesthetic check-up should
opportunity to discuss the choices of anesthetic be done by anesthesiologist responsible for
technique, methods for pain relief and the providing anesthesia to that patient.
risks, in a calmer atmosphere than immediately Preoperative evaluation services should be
before the operation. It also helps in making such that every patient is fully informed about
good rapport with the patients. By having their proposed procedure/alternatives and the
appropriate discussion and counseling gaining interventions that will need to be undertaken,
patient’s confidence also helps in reducing estimate the level of risk for every patient, ensure
requirements of premedication by assuring and every patient understands their own individual
reassuring the patients. Bedside PAC should risk so that they can make an informed decision
be considered in those who are unable to visit about whether to proceed to surgery, identify
PAC rooms like orthopedic patients and sick co-existing medical illnesses and optimally
68 Practice Guidelines in Anesthesia

prepare patients whilst taking into account the the reports. The waiting period for surgery after
urgency of the operation and identify patients bare metal stent placement is generally 3 to 4
with a high-risk of complications in the peri- weeks, while for drug eluting stents it is for 6 to
operative period and define the appropriate 12 months. The anesthesiologist must weigh the
postoperative level of care (day stay, inpatient, risk of regional versus general anesthesia when
ward).4,5 these patients are taking antiplatelet drugs.12,13
Any recent episode of fever, cough, cold or flu
is enquired as it can increase the postoperative
Preanesthetic Evaluation
pulmonary complications. History of dyspnea,
Review of hospital charts and prior anesthesia wheeze, stridor, snoring, sleep apnea and any
records, if any available with the patient, helps pre-existing lung disease is obtained. Patients
in detecting the presence of a difficult airways, with obstructive and restrictive lung disease
individual response to surgical stress and should be assessed by bedside lung function
specific anesthetics, any drug interactions, tests. FEV1/FVC ratio is greatly decreased in
increased nausea vomiting or delayed recovery, obstructive lung disease and is nearly normal in
respiratory assistance in postanesthetic care restrictive lung disease.
and history of malignant hyperpyrexia.6,7 Asthma is an important co-existing disease
The history should include the duration and encountered by the anesthesiologist. Frequent
the course of his illness; any pre-existing disease use of bronchodilators, hospitalization and
and chronic medications. History of smoking requirement of systemic steroids indicate
and alcohol intake and artificial devices if severity of disease.14
any like hearing aids, false eyes, pacemaker, Any significant history regarding jaundice,
dentures should be asked.7 Patient having ascites, malaena, vomiting of altered blood
history of chronic smoking should be advised to and altered sensorial should be taken. Such a
quit smoking since it causes increased sputum history increases the potential of dehydration,
production, decreased ciliary function of the electrolyte disturbances, and anemia in the
respiratory epithelium and increased airway patients. Patients with liver disease have altered
sensitivity which lead to difficulty during and protein binding, volume of distribution of drugs
after anesthesia.8,9 as well as coagulation abnormality.15 They show
History of chest pain, palpitations, prolonged effect of sedative drugs and some are
breathlessness, orthopnea, syncope, ankle resistant to muscle relaxants due to increased
swelling have to be ruled out. If the history of volume of distribution. Patients with history
chest pain is present then further investigations of heartburn, acid reflux may require antacid
and possible treatment should be taken in close prophylaxis and rapid sequence induction.
cooperation with the cardiologist. Functional Renal disease have to be ruled out though
evaluation of cardiovascular risk is done by history and if present determine the stage and
observing vigor and stamina in walking.10,11 whether the patient has ever required dialysis.
Adults with prior myocardial infarction (MI) Renal insufficiency increases risk because it
almost always have coronary artery disease. produces—anemia, electrolyte disturbances,
The risk assessment for noncardiac surgery peripheral neuropathy, abnormalities in drug
is based on the time interval between MI and metabolism and excretion, contribute to
surgery, and if it is less than 30 days than the bleeding because of a functional platelet deficit
patients are at high-risk. If the patient has a associated with renal impairment.16
pacemaker, determine the type and model, Among the endocrine disease, diabetes,
date of implantation and when the battery thyroid, parathyroid disease, pituitary and
life and performance were last interrogated. adrenal disease can increase the perioperative
If prior cardiac catheterizations or coronary risk substantially. History to rule out such
revascularizations have been performed, obtain diseases include frequently waking up at night
 Preanesthetic Evaluation and Investigation 69

to urinate, sweating much more than others is a very life-endangering condition and can
every now and then, chronic deep seated result in arrhythmia or heart attack. An EKG
headaches, facial flushing even when not is advised in such patients preoperatively. A
exercising, consistently feeling warmer or colder large thyroid mass can distort upper airways,
than others, history of weight gain, depression, producing inspiratory stridor or wheeze. In such
steroid intake, history of muscle cramps in legs, cases X-ray chest should be done for evidence of
etc. tracheal deviation and narrowing.23 If there are
Majority of diabetics develop secondary any concerns regarding airway compromise, a
disease in one or more organ system, which CT scan is performed to determine the extent
must be identified preoperatively so that and location of tracheal narrowing or detect
an appropriate plan can be developed for tracheal invasion. Indirect laryngoscopy is
perioperative management. Signs of autonomic often performed preoperatively by ENT surgeon
dysfunction should be assessed which may to document vocal cord function. This is an
predispose to hemodynamic instability during invaluable tool for the anesthetist to assess the
anesthesia and increases risk of pulmonary laryngeal inlet and any deviation from normal
aspiration due to gastroparesis. Positioning anatomy.
injuries during surgery are more common in In patients taking long-term steroid therapy,
these patients. Long standing diabetes causes one should have a high index of suspicion
glycosylation of proteins which significantly of adrenal cortical suppression and cushing
affects temporomandibular, atlantooccipital, syndrome. Determine when, how much, for
and cervical spine resulting in difficulty what reason, and for how long the patient took
in intubation. Diabetic patients should be a steroid. Steroid-induced adrenal suppression
scheduled for surgery as the first case of the may persist for up to a year after even relatively
day to prevent prolonged fasting. An attempt short courses of corticosteroids in doses above
should be made to control blood sugar within 10 mg/d. If this has occurred, coverage with
a range of 100 to 200 mg/dL.17 Type 2 diabetics stress doses of steroids starting just before
not receiving insulin and undergoing minor surgery and continuing for 48 to 72 hours is
surgery usually can be managed satisfactorily advised.
without insulin.18 However, diabetic patients Prolonged or unusual bleeding from cuts,
scheduled for major surgery, who are receiving nosebleeds, minor bruises, tooth extractions,
hypoglycemic medication or who have poor or surgery should be sought and whether such
glycemic control, should be established on excessive bleeding required blood transfusion.
insulin therapy preoperatively. Continuous Any serious bleeding problem in any family
intravenous infusion of insulin is a better member or blood relative is considered
option than intermittent subcutaneous bolus important. Use of any medications such as
regimens19 and, at least in perioperative cardiac aspirin, NSAIDs, anticoagulants known to
surgical patients, may be associated with affect blood clotting must be asked. Antiplatelet
improved outcome.20 Although intermittent agents like, clopidogreal or ticlopidine, warfarin,
intravenous bolus regimens are still used, this and nonsteroidal anti-inflammatory drugs, oral
approach is difficult to recommend.21,22 contraceptives, estrogens should be considered
Patients having thyroid swelling, preoperative for stopping before surgery Clopidogreal
assessment should focus on evaluation of must be stopped seven days preoperatively.
signs and symptoms of hyperthyroidism and However, low dose (75 mg) aspirin should be
hypothyroidism. Hyperthyroid patients have continued whenever possible for most surgical
higher resting heart rates in comparison to specialities.24-26
normal subjects. Thyroid storms due to high Neurological status is assessed by whether
overloads of thyroid hormones that accelerate the patient is well oriented to time and
their heart rate to as high as 300 beats a minute, place. If history of seizure, convulsion is
70 Practice Guidelines in Anesthesia

present– consider increased resistance to function of the patient. The basic algorithm of
competitive neuromuscular blockers and avoid inspection followed by palpation, percussion
exposure to epileptogenic drugs. History of and auscultation should be followed for all the
stroke or paralysis, tremor, migraine headaches, systems.
nerve injury, or any other disorder of the A basic concern of the anesthesiologist is
nervous system should be asked. Medications always the patient’s airways. Evaluation of
like antidepressant, sedative, tranquilizing, or airways involves determination of thyromental
antiseizure medications should be enquired. distance, ability to flex base of neck and
In case of pediatric patients birth history extend the head, and examination of oral
relating to mode of delivery, cry at birth, cavity, including dentition. The Mallampatti
jaundice, and history of apnea should be asked. classification has become the standard for
Weight especially in pediatric patient helps in assessing the relationship of the tongue size
assessing the dose requirement of anesthetic relative to the oral cavity.27 For neuraxial block
drugs. In patients with history of acute episode examine the spine to rule out infection of
of respiratory tract infection, rule out whether the overlying skin, any scar mark, scoliosis,
it is viral or infective in pathology, auscultation kyphosis, etc.
of chest must be done and an X-ray chest if
needed. Weigh the risk benefits of surgery
INVESTIGATION
and anesthesia and if surgery is required then
standard guidelines should be followed. Patients It is generally accepted that the clinical history
posted for cleft lip and cleft palate surgery, any and physical examination represent the best
other congenital anomaly should be ruled out. method of screening for the presence of disease.
An observant anesthesiologist starts Routine laboratory tests in patients who are
assessing the patient as soon as the patient apparently healthy on clinical examination and
enters the clinic. An outlook of the patient as history are not beneficial or cost effective. If a
he enters the clinic gives us an idea of the built, relevant investigation has been performed in
respiratory pattern, level of comfortness on the preceding 4 months a repeat investigation
sitting, economic status of the patient. Non- is not warranted, unless there is a significant
invasive blood pressure monitor and pulse change in the patient’s condition.
oxymeter are important tools helping in quick Patients under the age of 40 years without
assessment of the patient. The general physical any co-existing disease do not require any
examination of the patient includes palpation investigations preoperatively in western
of the pulse for rate, rhythm, character and set-up. But in India a complete hemogram
volume, arterial blood pressure in both arms, and urine microscopy is advised in pediatric
and in at least one arm 2 minutes after the as well as adult patients. Hemoglobin helps
patient assumes the upright position after lying assessing the allowable blood loss for a patient
down. SpO2 monitor with plethysmography and also the need of any blood transfusion
usually available in preanesthetic clinics helps intraoperatively.28-30 A pregnancy test should be
assessing pulmonary status. Patient should be obtained for women of childbearing potential.
examined for pallor, icterus, cyanosis, clubbing, A preoperative electrocardiogram is required
dehydration, edema and lymphadenopathy. for patients with cardiovascular or respiratory
Signs of congestive heart failure can be assessed diseases, male patients older than 40 to 45
by engorged neck veins, hepatomegaly, ascites, years of age and women older than 50 years
ankle edema, basal crepitations. of age, and patients with multiple risk factors
Assessment of pattern of ventilation, undergoing high-risk cardiovascular surgeries.
respiratory rate, ronchi and crepitation should Clinical characteristics that may necessitate
be done. Oxygen saturation on room air by pulse a preoperative chest X-ray include smoking,
oxymetry gives some clue regarding pulmonary recent upper respiratory infection, chronic
 Preanesthetic Evaluation and Investigation 71

obstructive pulmonary disease, and cardiac only goal is to match the intensity of the process
disease.31 Preoperative spirometry may be to the patient’s level of fitness and complexity of
appropriate in patients with existing chronic the procedure.
pulmonary disease or asthma.31
Further cardiac or pulmonary testing like References
echocardiography and pulmonary function test
should be guided by the findings of the basic 1. Van Klei WA, Hennis PJ, Moen J, et al. The
preoperative evaluation. accuracy of trained nurses in preoperative
health assessment: results of the OPEN study.
Assessments of nutritional and fluid and
Anesthesia. 2004;59:971-8.
electrolyte status is an essential component 2. Greenberg CC, Regenbogen SE, Studdert DM,
of preoperative evaluation. Malnourished et al. Patterns of communication breakdowns
patients are at increased risk for surgical resulting in injury to surgical patients. Journal
morbidity and mortality. Assessing serum of the American College of Surgeons. 2007;204:
albumin level provides information about the 533-40.
patient’s nutritional condition. Serum urea 3. Rushforth H, Burge D, Mullee M, et al. Nurse-led
and electrolytes is advised in patients with paediatric pre-operative assessment: an
equivalence study. Paediatric Nursing. 2006;18:
clinical evidence of renal disease, symptomatic
23-9.
cardiovascular disease, diabetes, patients on 4. Rai M, Pandit J. Day of surgery cancellations after
drugs like diuretics, digoxin, steroids, others nurse-led pre-assessment in an elective surgical
causing electrolyte disturbances. Serum centre: the first 2 years. Anesthesia. 2003;58:
potassium and magnesium should be carefully 685-7.
monitored and corrected in patients taking 5. Kinley H, Czoski-Murray C, George S, et al.
diuretics because these abnormalities can Effectiveness of appropriately trained nurses
predispose to perioperative arrhythmias. in pre-operative assessment: randomised
Similarly, it is important to monitor serum controlled equivalence/non-inferiority trial.
British Medical Journal. 2002; 325: 1323.
glucose during the perioperative period,
6. Gibby GL, Gravenstein JS, Layon AJ, et al. How
especially in diabetics or patients taking often does the preoperative interview change
steroids.28,29,32,33 Coagulation profile is indicated anesthetic management? Anaesthesiology. 1992;
in patients with clinical evidence of liver disease 77:1134.
including a history of hepatitis, bleeding 7. Roizen MF, Kaplan EB, Schreider BD, et al:
disorder, anticoagulants.34 The relative roles of the history and physical
These recommendations must be used examination, and laboratory testing in
with the clinical information obtained from an preoperative evaluation for outpatient surgery:
The Starling curve in preoperative laboratory
accurate history and examination. If, for any
testing. Anaesthesiol Clin North Am. 1987;5:15.
reason, there is doubt regarding these tests 8. Theadom A, Cropley M. Effects of preoperative
then advice should be sought. This encourages smoking cessation on the incidence and risk of
communication between the surgeon and the intraoperative and postoperative complications
anesthetist which is essential for the well-being in adult smokers: a systematic review. Tob
of the patient. Control. 2006;15:352-8.
9. Thomsen T, Tønnesen H, Møller AM. Effect of
preoperative smoking cessation interventions
Conclusion on postoperative complication and smoking
cessation. Br J Surg. 2009;96:451-61.
By improving the planned admission process,
10. Eagle KA, Berger PB, Calkins H, et al. ACC/
one may enhance the patient experience and AHA Guideline Update for Perioperative
the clinical process, as well as the efficiency Cardiovascular Evaluation for Noncardiac
and productivity of the institution. Preoperative Surgery—Executive Summary. A report of the
assessment and planning should form a natural American College of Cardiology/American Heart
part of the process for all planned surgery. The Association Task Force on Practice Guidelines
72 Practice Guidelines in Anesthesia

(Committee to Update the 1996 Guidelines in diabetic patients after cardiac surgical
on Perioperative Cardiovascular Evaluation procedures. Ann Thorac Surg. 1999;67:352-60.
for Noncardiac Surgery). Anesth Analg. 2002; 21. Hall GM. Insulin administration in diabetic
94:1052-64. patients: return of the bolus? Br J Anaesth. 1994:
11. Chassot PG, Delabays A, Spahn DR. Preoperative 72:1-2.
evaluation of patients with, or at risk of, coronary 22. Hirsch IB, McGill JB, Cryer PE, et al. Perioperative
artery disease undergoing non-cardiac surgery. management of surgical patients with diabetes
Br J Anaesth. 2002;89:747-59. mellitus. Anesthesiology. 1991;74:346-59.
12. Dupuis JY, Labinaz M. Noncardiac surgery 23. Franklyn JA. The management of
in patients with coronary artery stents: what hyperthyroidism. N Engl J Med. 1994;330:1731-9
should the anesthesiologist know? Can J Anesth. 24. Kearon C, Hirsh J. Perioperative Management
2005;52:356. of Patients Receiving Oral Anticoagulants. Arch
13. Riddell JW, Chiche L, Plaud B, et al. Coronary Intern Med. 2003;163:2532-3.
stents and noncardiac surgery. Circulation. 2007; 25. Eckman MH. “Bridging On the River Kwai”: The
116:378. Perioperative Management of Anticoagulation
14. Kabalin CS, Yarnold PR, Grammer LC. Low Therapy. Med Decis Making. 2005;25:370-3.
complication rate of corticosteroid treated 26. Dunn AS, Wisnivesky J. Perioperative
asthmatics undergoing surgical procedures. Management of Patients on Oral Anticoagulants:
Arch Intern Med. 1995;155:1379. A Decision Analysis. Med Decis Making. 2005;
15. Strunin L. Preoperative assessment of the patient 25:387-97.
with liver dysfunction. Br J Anaesth. 1978;50: 27. Mallampati SR, Gatt SP, Gugino LD, et al.
25-34. A clinical sign to predict difficult tracheal
16. Kheterpal S, Tremper KK, Heung M, et al. intubation: A prospective study. Canadian
Development and validation of an acute kidney Anesthetists’ Society journal 1985;32(4):429-34.
injury risk index for patients undergoing 28. Kaplan EB, Sheiner LB, Boeckmann AJ, et al. The
general surgery: results from a national data set. usefulness of preoperative laboratory screening.
Anesthesiology. 2009;110:505-15. JAMA. 1985;253:3576-81.
17. Coursin DB. Perioperative management of the 29. McKee RF, Scott ME. The value of routine
diabetic patient. 55th ASA Annual Refresher preoperative investigations. Ann R Coll Surg
Course Lectures, 2004, 210. Engl. 1987;69:160-2.
18. Thompson J, Husband DJ, Thai AC, et al. 30. Lunn JN, Elwood PC. Anaemia and surgery. Br
Metabolic changes in the non-insulin- Med. 1970;3:71-3.
dependent diabetic undergoing minor surgery: 31. Archer C, Levy AR, McGregor M. Value of routine
effect of glucose–insulin–potassium infusion. Br preoperative chest X-rays: A meta analysis. Can J
J Surg.1986;73:301-4. Anaesth. 1993;40:1022.
19. Christiansen CL, Schurizek BA, Malling B, et 32. Campbell IT, Gosling P. Preoperative biochemical
al. Insulin treatment of the insulin‐dependent screening. Br Med J. 1988;297:803-4.
diabetic patient undergoing minor surgery. 33. Catchlove BR, Wilson Macl R, Spring S, et al.
Continuous intravenous infusion compared with Routine investigations in elective surgical
subcutaneous administration. Anesthesia.1988; patients. Med Jf Aust. 1979;107-10.
43: 533-77. 34. Rohrer MJ, Michelotti MC, Nahrwold DL.
20. Furnary AP, Zerr KJ, Grunkemeier GL, et al. A prospective evaluation of the efficacy of
Continuous intravenous insulin infusion reduces preoperative coagulation testing. Ann Surg.
the incidence of deep sternal wound infection 1988;208:554-7.
 CHAPTER 9
Perioperative Fluid
Management in Children
LD Mishra, P Ranjan

Fluid management in children needs a special 3. Severity of surgical and nonsurgical trauma.
knowledge and skill more so in neonates This may comprise the largest volume of
Over transfusion in this age group may lead fluid loss or fluid redistribution, which
to pulmonary edema and other associated derives largely from the ECF compartment.
respiratory complications, due to ill developed 4. Blood loss and fluid deficit must be
kidney functions adequately replaced to support systemic
The variability in fluid requirement is due to blood pressure. In this regard, following
the differences in the rate of caloric expenditure possibilities should always be kept in
and growth, the ratio of body surface area to mind before calculating the required fluid
body weight, degree of renal function maturity replacement.
and the amount of total body water (TBW) The main aim of perioperative fluid
at different ages. In comparison to grown up management is to maintain an adequate
children and adult, infants have greater fluid intravascular volume without the development
needs because of high BMR and growth; surface of hyponatremia. Children are at risk of
area-to-weight ratio is about three times greater, developing hyponatremia in the perioperative
hence higher insensible fluid loss; and greater period, mainly due to following factors:
urinary excretion of solutes combined with • Prehydration with hypotonic fluid.
lower tubular concentrating ability. • Nausea, pain and stress associated with
Following four major components are surgery that may lead to stimulation of ADH
mainly used to determine the hourly rates of release during and after surgery.1
intraoperative fluid volume administration in • The limited ability of children to excrete a
children. large water load.
1. Maintenance fluid is mainly based on Acute hyponatremia results in increased
caloric expenditure at different ages. water content in neurons (Brain edema)
2. Estimated volume deficit incurred during without a change in solute content. This may
preoperative fasting or by other fluid cause symptoms such as headache, nausea,
deficits; one-third of such deficits may be and vomiting or muscle weakness in children.
replaced during the first hour of surgery Younger children are more susceptible to more
while the remaining volume may be infused severe hyponatremic encephalopathy due
over the complete duration of the surgery. to a large brain-to-skull ratio.2 Isotonic fluid
74 Practice Guidelines in Anesthesia

infusion is mostly recommended during the Acceptable isotonic fluids are Lactated
perioperative period. Ringer lactate solution Ringer’s solution and normal saline.
contains all the essential components and Normal saline is probably the most
is nearly isonatremic (Na+=130 mEq/L), and commonly used crystalloid administered
isotonic but also contains K+(4 mEq/L), Ca++(0.9 during craniotomies in children as it is slightly
mmol/L), Cl–(109 mEq/L) and lactate (27.7 hyperosmolar (308 mOsm/kg) compared with
mmol/L). It is widely acceptable and most serum osmolarity (285–290 mOsm/L) and
suitable fluid in children during perioperative therefore helps to prevent cerebral edema.
period. High energy supply is especially Caution: (1) Large quantities of Normal saline
important in preventing hypoglycemia in produce a hyperchloremic metabolic acidosis
children who have greater energy requirements and hypernatremia in children.5 (2) Lactated
(e.g. premature but full-term neonates). It may Ringer (273 mOsm/L) is slightly hypo-osmolar
sometimes lead to hyperglycemia (in 0.5–2% of and large quantities of its infusion can increase
pediatric patients). This disorder is less common chances of cerebral edema formation.
in children receiving regional anesthesia, which
reduces the hyperglycemic effects of surgery.
Fluid in children
It has been suggested that a solution of Ringer
lactate with 1% Dextrose is sufficient to prevent with burn injury
both hypo- and hyperglycemia in most children Children often sustain burn injuries while
excluding premature and term neonates.3 playing with the crackers or during freak
However, in pediatric neurosurgical fire accidents. The most appropriate fluid
patients, perioperative fluid management necessary to resuscitate a burn shock in child
becomes more challenging due to blood loss is still debatable. Adequacy of volume of fluid
which is difficult to measure and possibilities of and replacement of extracellular salt into the
cerebral edema. Inadequate fluid replacement burned tissue are the most reliable predictors
leads to cardiovascular instability, and over of successful resuscitation.6 In such patients
hydration with hypo-osmotic solutions may Crystalloid (Lactated Ringer’s solution) is the
cause cerebral edema. It is worth mentioning most popular currently used resuscitation fluid.
that diuretics, used to reduce brain bulk cause However hypertonic saline may be beneficial
intravascular volume shifts with electrolyte in modulating the inflammatory cascade
disturbances specially in smaller children. and restoring hemodynamic parameters
Colloid containing solutions often have and microcirculatory flow. Rate of fluid
been used during neurosurgery because administration should be titrated to maintain a
albumin is excluded from the extracellular fluid urine output of 1mL/kg/hr.
of the brain. Ringer lactate increases brain water Central venous pressure (CVP) monitoring
content and may raise the intracranial pressure is very useful in guiding fluid therapy. It is the
(ICP), hence may lead to cerebral edema, but true reflection of right heart filling pressure,
not with hydroxyethyl starch when used for fluid provided the tip of the catheter is properly placed
replacement in neurosurgical children. These in the central circulation. Once resuscitation
are due to differences in osmolality, rather is complete fluid infusion can be decreased to
than the colloidal osmotic pressure, of the two a maintenance rate that depends on the size
solutions.4 Other studies have also proved the of burn and expected extra evaporative losses.
superiority of colloids for plasma expansion in Various formulas have been suggested as a guide
children. to initiate and maintain fluid resuscitation in
Dextrose containing solutions are harmful children who sustain burn injury, but the actual
and cause global and regional cerebral ischemia rate of fluid administration must be dictated by
that may cause neurological damage. patient response (i.e. urine output).
 Perioperative Fluid Management in Children 75

Trauma oncotic pressure, prolonged maintenance

of intravascular volume and smaller volume
When a child who has sustained multiple
required compared with crystalloid solutions.
injuries presents for surgical intervention,
For these reasons, colloids may also be
the fluid status must be quickly assessed
beneficial in children with head trauma because
before induction of anesthesia by physical
the smaller volume of fluids administered may
examination, and the fluid resuscitation must
reduce the likelihood of cerebral edema.
be continued in case of ongoing blood loss or
third space fluid losses.
The aim of fluid resuscitation should be References
to maintain normovolemia and osmolar to 1. Robertson G, Antidiuretic hormone. Normal and
oncotic pressures in the intravascular space. disordered functions. Endocrinol Metab Clin
Crystalloids (Ringer lactate) solution or normal North Am. 2001; 30: 671-94.
saline are most commonly used in the initial 2. Moritz M, Ayus JC. Disorders of water metabolism
stages of resuscitation. Hypertonic saline in children: Hyponatremia and hypernatremia.
solution (3%) has also been used as it increases Pediatr Rev. 2002;23:371-80.
serum osmolality and thereby maintains 3. Berleur MP, Dahon A, Murat I, et al. Perioperative
infusions in paediatric patients: Rationale for
intravascular volume for longer periods and
using Ringer lactate solution with low dextrose
with small volume administered than isotonic concentration. J Clin Pharm Ther. 2003;28:31-40.
solutions.7 4. Steurer MA, Berger TM. Infusion therapy for
The decision to administer glucose neonates, infants and children. Anaesthesist
containing solutions must be based on 2011;60(1):10-22.
blood glucose level. The issue of glucose 5. Peterson B, Khanna S, Fisher B. Prolonged
administration is of greater importance in head hypernatremia controls elevated intracranial
trauma victims because elevated blood glucose pressure in head injured paediatric patients. Crit
Care Med. 2000;28:1136-43.
levels have been found to correlate significantly
6. Neelya A, Nathen P, Highsmith R. Plasma
with indicators of the severity of brain injury proteolytic activity following burns. J Trauma
and poor neurological outcomes. 1988;28:362.
Colloid solutions such as 5% albumin 7. Bailey AG, McNaull PP, Jooste E, et al. Perioperative
and hydroxyethyl starch have also been used crystalloid and colloid fluid management in
for fluid resuscitation. Benefits of colloid children: where are we and how did we get here?
solutions include their ability to increase colloid Anesth Analg 2010;110(2):375-90.
 CHAPTER 10
Central Venous Catheter
Management Guidelines
Mahesh Kumar Arora, Dalim Kumar Baidya

Introduction infection control should be properly trained

in indications of CVC, aseptic procedure to
Central venous catheters (CVC) are routinely be followed, catheter maintenance checklist
used in emergency department (ED), operating and appropriate infection control measures
room (OR) and intensive care units (ICU) of CRBSI.
for management of patients. This allows • Regular assessment should be done as to
measurement of central venous pressure the adherence to these guidelines.
(CVP), infusion of vasoactive medications, • Whenever feasible strict aseptic precautions
parenteral nutrition, etc. However, insertion to be followed and standard equipment set
and maintenance of CVC may be associated to be used for CV catheterization.
with several risks and various complications. • An assistant should be used whenever
Injury to the surrounding structures (arterial possible and a SOP should be followed for
puncture, hematoma, pneumothorax, etc.) insertion and maintenance of CVC.
and catheter related blood stream infections
(CRBSI) are among the major concerns. These Selections of Insertion Site
complications may be minimized by adherence
and Type of Catheter
to proper guidelines and developing standard
operating procedures (SOP) of the particular • Benefits of inserting CVC at a particular
institute. The following guideline has been site should be weighed against the risk
developed based on available evidence in of mechanical complication vs risk of
literature and may be followed to improve infectious complications.
outcome. However, individual institutes are • Any contaminated or potentially
encouraged to develop their SOPs depending contaminated site (e.g. adjacent to surgical
on local resource availability and feasibility. wound or tracheostomy site) should be
avoided.
• Femoral site should be avoided.
Preparation of Resource and
• Prefer subclavian vein over internal jugular
Training of Staff vein or femoral vein to minimize infectious
• Healthcare personnel involved in the risk.
insertion and maintenance of CVC and • Subclavian site should be avoided in
professionals involved in the hospital patients with chronic kidney disease and in
 Central Venous Catheter Management Guidelines 77

those on hemodialysis to avoid subclavian once in 7 days. However, dressing should be

vein stenosis. changed if it is soiled or become loose.
• Use a CVC with minimum number of ports • Local antibiotic ointment should not be
or lumens required. used at the catheter insertion site as it may
• If a catheter has been inserted in emergency promote fungal infections.
situation violating the sterile precautions • Chlorhexidine impregnated sponge
then it should be replaced within 48 hours. dressing may be used if CRBSI rates remain
• Chlorhexidine-silver sulfadiazine high in spite of proper adherence to aseptic
impregnated or minocycline-rifampicin strategy.
impregnated catheters may be used when • Catheter site should be visually inspected
intended duration of catheter stay is six days daily through the transparent dressing.
or more. However, this should be considered • Systemic antibiotic prophylaxis should not
in an institute only after a comprehensive be used routinely for prevention of CRBSI.
strategy to reduce CRBSI has failed. However, this may be considered in immune
• However, use of antibiotic coated CVCs compromised hosts and high-risk neonates.
does not replace the adherence to strict • Prophylactic antibiotic lock solutions may
aseptic precautions. be used in patients with long-term catheters
with history of CRBSI.
• Routine change of CVC to prevent CRBSI
Aseptic Precautions and
should not be performed.
Infection Control Measures • In case of fever due to suspected CRBSI,
• Proper hand hygiene should be performed guide-wire exchange of catheter should not
with soap water or alcohol based hand rubs. be performed.
• Maximal barrier precautions should be • Guide-wire exchange of catheter may be
obtained including cap, mask, sterile gown, performed for a malfunctioning catheter if
sterile gloves for insertion of CVC and no evidence of infection is present.
during guidewire exchange of CVC. • If guide-wire exchange is performed, new
• Skin insertion site should be prepared with set of sterile gloves should be used after
> 0.5% chlorhexidine preparations with removing the old catheter (i.e. before
alcohol. If chlorhexidine is not available handling the new catheter).
or contraindicated 70% alcohol or iodine • All components of the pressure monitoring
preparations may be used as alternative. systems including transducer, calibration
Safety of chlorhexidine has not yet been kit, flush solution should be kept sterile.
established in neonates. • The transducer along with the flush solution
• Proper antiseptic skin preparation should and tubing should be changed at 96 hours
be followed during dressing change as well. interval.
• The antiseptic solution should be allowed to • Continuous flush system should be used
dry. to maintain the patency of the pressure
• After insertion of catheter sterile gauze monitoring system. This will ensure
or sterile, transparent, semipermeable minimal manipulation of the system.
dressing should be used to cover the • Parenteral nutrition or dextrose containing
catheter site. solutions should not be used through the
• The transparent dressing should be changed pressure monitoring lines.
once in 5 to 7 days. The gauze dressing • Fluid administration sets that are
should be changed once in two days. For continuously used should be replaced at
tunnelled CVC for long-term use, the an interval of 96 hours or more but within
dressing should be changed not more than seven days.
78 Practice Guidelines in Anesthesia

• Administration sets used for blood, blood • Final position of the catheter tip should
products, parenteral nutrition should be be confirmed by chest radiography
replaced every 24 hours. or fluoroscopy or continuous
• A CVC should be removed whenever electrocardiography.
clinically deemed not necessary.
• A CVC should be removed if infection of the Limitation
skin site is suspected and a new CVC should
be inserted at a different place if necessary. The existing international guidelines in
• CVC ports or lumens should be capped relation to use of CVC are based on literature
when not in use. All the access ports should comprising data from western world and there
be wiped with antiseptic solutions before is paucity of data from the Indian subcontinent.
each use. Consequently the recommendations in the
current guideline are largely influenced by
international societies like Center for Disease
Precautions to Prevent Control and prevention (CDC), Infectious
Mechanical Injury Disease Society of America (IDSA), Society of
Critical Care Medicine (SCCM), etc. Although
• The site of catheterization should be chosen
basic recommendations regarding aseptic
based on clinical skill and experience of the
precautions or prevention of mechanical
person inserting the catheter and need of
injuries may remain similar, those on infection
the patient.
control measures should take into consideration
• Access in the upper body (neck, chest)
the local data on CRBSI. Therefore, the current
should be preferred over lower body to
guideline may require further introspection and
reduce the risk of thrombotic complications.
modifications with increased publication of
• While inserting CVC in neck or chest
related data from large centers of our country.
(internal jugular or subclavian),
Trendelenuerg position should be used.
• Real time ultrasound should be used for Further Reading
internal jugular vein cannulation. 1. Mermel LA, et al. Clinical practice guidelines for
• Real time ultrasound may be used for the diagnosis and management of intravascular
subclavian or femoral vein cannulation. catheter related infection: 2009 update by
• In case of any uncertainty regarding guide- Infectious Disease Society of America. Clin
Infectious Disease. 2009;49:1-45.
wire placement, it should be checked
2. O’Grady N, et al. Guideline for the prevention
by using ultrasound or transesophageal of intravascular catheter related infections. Clin
echocardiography or fluoroscopy or Infectious Disease. 2011;52:e1-e32.
continuous electrocardiography. 3. Practice Guidelines for central venous access: A
• After placement of catheter it should report by American Society of Anesthesiologists
be confirmed by venous waveform and Task Force on Central venous access.
pressure measurement. Anesthesiology. 2012;116:539-73.
 CHAPTER 11
Inadvertent Perioperative
Hypothermia
BB Mishra

Introduction Further to this are:

Inadvertent perioperative hypothermia (IPH) is • Anesthetic-induced peripheral vasodila­
a recognized and common side effect occurring tation (with associated heat loss) means that
during surgery. IPH is a recognized side-effect patients can often get cold while waiting for
of general and regional anesthesia when normal surgery.
thermoregulation is inhibited. Hypothermia • Exposure of the body during preparation for
is defined as a core temperature less than surgery.
36°C (96.8°F). It is not unusual for patient core • Fluid deprivation as part of the fasting
temperatures to drop to less than 35°C within regime before induction of general
the first 30 to 40 minutes of surgery and if not anesthesia (large variations in current
managed intraoperatively, many of these are practice from 2 hours to more than 12
likely to be hypothermic on admission to the hours), often resulting in patients being dry
recovery ward.1 and poorly perfused.
Hypothermia is graded as: • Impaired heat distribution which can be
• Mild (core temperature 35.0–35.9°C) further complicated by the lack of warming
• Moderate (34.0°C–34.9°C) of intravenous solutions.
• Severe (≤ 33.9°C). During the first 30 to 40 minutes of
Inadvertent perioperative hypothermia is a anesthesia, a patient’s temperature can drop
common but preventable complication of peri- to below 35.0°C. Reasons for this include
operative procedures, which is associated with loss of the behavioral response to cold and
poor outcomes for patients. the impairment of thermoregulatory heat-
Hypothermia is defined as a patient core preserving mechanisms under general or
temperature of below 36.0°C. Adult surgical regional anesthesia, anesthesia-induced
patients are at risk of developing hypothermia peripheral vasodilatation (with associated heat
at any stage of the perioperative pathway. loss), and the patient getting cold while waiting
Hypothermia may be found at any stage of for surgery on the ward or in the emergency
the perioperative period, from pre-induction department.
through to the postoperative recovery.2 Reasons It is important to prevent inadvertent
for hypothermia include the loss under perioperative hypothermia.
anesthesia, of the behavioral response to cold The control of normal body temperature
and the impairment of thermoregulatory heat is a well established, and changes to body
preserving mechanisms.1 temperature have been discussed in this
80 Practice Guidelines in Anesthesia

narrative review. Whilst a normal range exists There is acceptable evidence comparing
forbody temperature, adult patients being clonidine with placebo given at induction of
prepared for surgery can experience largely anesthesia, to show that there is no significant
downward trends within this normal range, effect on core temperature at 60 minutes
which is then compounded by induction of intraoperatively, or 15 or 60 minutes after
anesthesia. extubation.
Typical patterns following induction There is good evidence when comparing
of anesthesia see a dramatic fall to core clonidine to placebo given at the end of surgery,
temperature in the first hour of anesthesia, with to show that there is no significant effect of
as much as 1.5°C lost to core temperature, and clonidine on core temperature at 15, 20, 60 or
the body’s normal thermoregulatory response to 120 minutes after extubation.
initiating heat gain impaired due to anesthesia.
Normal body temperature range for the Benzodiazepines
purpose of this guideline is 36.5°C to 37.5°C,
enabling all preventive measures (active There is weak evidence comparing a higher
warming) to aim to restore patient core dose (50 μg/kg IM) of midazolam with no
temperature to at least 36.5°C. premedication given in the preoperative
phase, to show significantly lower patient core
temperatures preoperatively. The evidence
Risk Factors suggests a larger effect for increased doses.
• Pharmacological agents: There is acceptable evidence comparing
– Pre-medication: Alpha 2-adrenergic midazolam with no premedication given in the
antagonists, Clonidine preoperative phase, to show significantly higher
– Benzodiazepines: Midazolam patient core temperatures intraoperatively.
Benzodiazepine antagonists, There is weak evidence comparing midazolam
Flumazenil with no treatment given at the end of anesthesia,
– Anticholinergics: Atropine, to show no significant difference in patient core
Glycopyrrolate temperatures intraoperatively and up to 30
– Cholinesterase Inhibitors: Physostigmine minutes postoperatively, but significantly lower
– IV Induction Agents: Ketamine, Propofol temperatures at 60 minutes postoperatively.
– Inhalational Agents: Halothane,
Isoflurane, Xenon, Nitrous oxide Flumenazil
– Opioids: Pethidine, Morphine, There is good evidence comparing flumenazil
Alfentanil, Remifentanil with no treatment given to patients as they
– Other Centrally acting analgesics: startto awake, showing significantly lower
Tramadol, Nefopam patient core temperatures 20 to 60 minutes
– Serotonin Antagonists: Ondansetron3, postoperatively.
Dolasetron and Granisetron
Anti-muscarinic Agents
Alpha 2-adrenergic Antagonists
There is weak evidence comparing atropine
There is acceptable evidence comparing with placebo given preoperatively, to show a
clonidine with placebo given in the preoperative statistically significant increase in patient core
phase, to show no significant effect on core temperature at the end of the preoperative
temperature 30 minutes after induction of period. There is weak evidence comparing
spinal anesthesia and weak evidence to show glycopyrronium to placebo given preoperatively,
a significantly lower temperature for clonidine to show no significant difference in patient core
after 180 minutes. temperature at the end of anesthesia.
 Inadvertent Perioperative Hypothermia 81

Physostigmine preoperatively, to show there is no significant

difference in patient core temperature at the
There is weak evidence comparing IV end of anesthesia.
physostigmine to placebo when given at the end There is acceptable evidence comparing
of anesthesia, to show no significant difference tramadol to placebo given just before regional
in patient core temperature 15 minutes anesthesia, to show there is no significant
postoperatively.4 difference in patient core temperatures at 15
minutes intraoperatively, but significantly
Drugs for Induction of Anesthesia lower temperatures at 30 to 90 minutes. There is
acceptable evidence comparing nefopam with
There is weak evidence comparing ketamine
placebo given just before regional anesthesia,
to placebo given at induction of anesthesia, to
to show there is no significant difference in
show statistically significantly higher patient
patient core temperatures at 15, 30 and 60
core temperatures at 30 and 60 minutes
minutes intraoperatively, but significantly
intraoperatively and acceptable evidence for
lower temperatures at 90 minutes. There is good
the end of surgery.
evidence comparing tramadol to placebo given
at the beginning of wound closure, to show there
General Anesthesia Drugs is no significant difference in the incidence of
IPH. When Granisetron was compared with
There is insufficient evidence to determine if
Placebo, Granisetron treated patients were
there is a difference in patient core temperature
warmer.
intraoperatively between isoflurane and
Risk factors investigated by the cohort studies
propofol.
(multivariate analyses) or RCTs
There is insufficient evidence to determine if
The following risk factors have been investigated:
there is a difference in patient core temperature
intraoperatively between xenon or nitrous
oxide in addition to isoflurane, compared with Patient Characteristics
isoflurane alone. There is insufficient evidence
• Age
to determine if there is a difference in patient
• Blood pressure (1 case control study)
core temperature intraoperatively between
• BMI (no studies; but body fat, body weight, 1
0.5% and 1.0% halothane.
body weight/surface area reported)
• Gender
Analgesia—opioids • Height
There is acceptable evidence when comparing • Heart rate (1 case control study)
pethidine to placebo given just before spinal • Length of preoperative starvation (no
anesthesia, to show there is no significant studies)
difference in patient core temperature • Temperature in the preoperative phase
intraoperatively. • Temperature at first Anesthetic intervention
There is good evidence comparing pethidine • ASA grade
to placebo given at the end of surgery, to show • Score of acute physiologic system (SAPS II)
there is no significant difference in patient core • Pre-existing medical conditions (diabetes
temperature postoperatively. mellitus, thyroid disease, corticosteroid
disease, cardiac disease).
Analgesia—other Centrally
Acting Analgesics Anesthesia Factors
There is weak evidence comparing tramadol • Duration of anesthesia
to tramadol with glycopyrronium given • Type of anesthesia
82 Practice Guidelines in Anesthesia

• Anesthesia: end expiratory pressure Conclusion for Body Fat/Weight and

• Height of spinal block. Height as a Risk Factor
Increased body weight may have a small
Surgery factors protective effect on the incidence of
• Urgency of operation: urgent, emergency, perioperative hypothermia in ICU. The evidence
elective for body weight and body fat intraoperatively
• Type of surgery is inconsistent. There is no significant effect of
• Magnitude of surgery (major, intermediate, height on IPH.
minor)
• Laparoscopic/open surgery Conclusion for Diabetes
• Duration of surgery Diabetes without neuropathy is not a risk factor
• Patient position intraoperatively. for IPH, but patients with diabetic neuropathy
have significantly lower core temperatures than
Other Risk Factors diabetics without neuropathy after 3 hours of
surgery.
• Irrigation fluids volume
• IV fluids volume
Preoperative Temperature
• Blood transfusion
• Blood loss A low preoperative temperature is a significant
• Packed erythrocytes risk factor for IPH.
• Forced air warming
• Temperature monitoring Effect of Type of Anesthesia
• Particular hospital.
Meta-analysis of two studies (one very large)
showed the incidence of IPH in ICU or PACU
Environmental Factors was significantly higher for combined general
Theater temperature. and regional anesthesia compared with general
or regional anesthesia separately.
Conclusion for Age as a Risk Factor Some studies reported less incidence of IPH
with regional anesthesia. In patients undergoing
The evidence suggests that age is not an general (mainly) or combined or regional
important risk factor for the incidence of anesthesia, an increase in theater temperature
hypothermia either intraoperatively or is protective of patients becoming hypothermic,
postoperatively, although the data on core both intraoperatively and in ICU.5
temperature suggests that older people (over
60 years) have lower temperatures after 3 hours Duration of Anesthesia
of surgery and in PACU. There is evidence that
older patients take longer to rewarm to 36°C In the studies that covered a wide range of
post–operatively. durations of anesthesia or surgery, there was
weak evidence to show a significant effect
of duration of surgery, above and below two
Gender
hours, on the incidence of IPH in ICU. There
No significant effect of gender is found on the may have been a dependence on the definition
incidence of IPH. of hypothermia.

ASA as Risk Factor Height of Spinal Block

ASA Grade > 1 is a risk factor for IPH and the risk There is weak evidence to show a significant
increases with ASA Grade. effect of the height of spinal block in regional
 Inadvertent Perioperative Hypothermia 83

anesthesia, with a high level of block giving 3. Blood transfusion: There is acceptable
lower core temperatures. evidence to show that transfusion of
unwarmed blood (4°C) as an independent
risk factor increases the risk of IPH
Positive End Expiratory Pressure
intraoperatively.
There is insufficient evidence to determine if a
positive end expiratory pressure has an effecton
Environmental risk factors
the incidence of hypothermia.
1. Theater temperature: There is good evidence
that an increase in theater temperature
Surgery Risk Factors
is protective of patients becoming
1. Magnitude of surgery: There is good hypothermic, both intraoperatively and in
evidence to show a significant effect of ICU.
magnitude of surgery on the incidence of There is weak evidence to show
IPH intraoperatively or in ICU, with major significantly higher core temperatures
surgery and intermediate surgery both intraoperatively for patients undergoing
increasing the incidence of IPH. Although surgery in a warmer theater (21 to 24°C)
there is heterogeneity between studies, each compared with a cooler theater (18 to 21°C).
is significant separately. There is acceptable evidence to show
2. Urgency of surgery: There is acceptable that the effect of theater temperature has
evidence to show no significant effect of more effect for general anesthesia when
urgency of surgery (elective/emergency) on compared with regional anesthesia.
the incidence of IPH in ICU. 2. Theater humidity: There is weak evidence
3. Type of surgical procedure: There that theater humidity is not an independent
is acceptable evidence to show no risk factor for IPH.
significant difference in core temperatures
intraoperatively between laparoscopic and
CONSEQUENCES OF IPH
open procedures causing perioperative
hypothermia. There is acceptable evidence to show a
4. Patient position intraoperatively: There is significant dependence of the incidence of
insufficient evidence to determine if there is surgical wound infection on the incidence of
an effect of patient position intraoperatively IPH.
on the core temperature intraoperatively. There is acceptable evidence to show a
significant dependence of the incidence of
Other morbid cardiac events, both on the incidence of
IPH, and on the absence of forced air warming
1. Intravenous fluid infusion: There is intraoperatively.
weak evidence that a higher volume of There is acceptable evidence to show
intravenous fluid is a minor risk factor for dependence approaching significance of the
perioperative hypothermia in ICU, but a incidence of mechanical ventilation on the
lack of information on the warming of fluids incidence of IPH.
was alimitation.
2. Irrigation fluids: There is acceptable
Temperature Measurement/Monitoring
evidence to show a large significant effect
of room temperature irrigation fluid volume • Core body temperature—normal range:
on the incidence of IPH in PACU. Lower 36.8°C–37.9°C
volumes of fluids (below 20 liters) resulted • Oral temperature: 36.0°C to 37.6°C
in less hypothermia. • Rectal temperature: 34.4 to 37.8°C
84 Practice Guidelines in Anesthesia

• Axilla temperature: 35.5 to 37.0°C – Reflective blanket.

• Ear temperature: 35.6 to 37.4°C – Reflective clothing.
• Forehead temperature: 36.1 to 37.3°C Results showed that the incidence of
adverse events like Myocardial infarction and
ventricular arrhythmias was lower significantly
Methods of Recording Temperature
in the warmed groups.
Examples of diverse methods of intermittent The incidence of shivering was lower in the
temperature measurement within clinical warmed groups.
effectiveness reviews were: Incidence of hypothermia was significantly
• Sublingual devices (Conahan 1987; less in the forced air warmed Group.8
Goldberg 1992)
• Tympanic membrane devices (Hynson
Complications of Warming Devices
1992; Nelskylä 1999; Johansson 2003)
• Nasopharyngeal devices (Stone 1981; Wills The most common adverse effects were burns
2001; Champion 2006) and infection. Although many potential sources
• Esophageal devices (Tølløfsrud 1984a; of adverse effects can be identified, there does
Tølløfsrud 1984b; Youngberg 1985; not seem to be empirical support that indicates
Joachimsson 1987; Ouellette 1993; Mouton that warming systems increase the risk of
1999; Saad 2000; Nguyen 2002; Farley 2004; infection if properly used.9
Hamza 2005)
• Rectal devices (Eckerbom 1990)
GUIDELINEs RECOMMENDATIONS
• Pulmonary artery devices (Bäcklund 1998).
Emerging technology has recently (Smith 1.1 Perioperative Care
2000) seen a shift towards the use of
1.1.1 Patients should be informed that:
tympanic membrane thermometers.
• Staying warm before surgery will
lower the risk of postoperative
Treatment of Hypothermia complications.
• They should bring additional
Types of Intervention clothing.
1.1.2 When using any temperature
The following interventions were to be
recording or warming device,
considered:
healthcare professionals should:
• Be trained in their use.
• Active Warming Mechanisms 1.1.3 Healthcare professionals should:
• Be aware of, and carry out,
The following types of warming mechanisms
any adjustments that need to
were considered under active warming:6
be made in order to obtain an
– Forced air warming
estimate of core temperature
– Electric blanket
from that recorded at the site of
– Water mattress
measurement.
– Radiant heating
– Warmed blankets
– Heating gel pad. 1.2 Preoperative Phase
– Warming of IV Fluids7
1.2.1 Patients should be managed as
higher risk if any two of the following
• Thermal Insulation Mechanisms apply:
The following mechanisms were considered • ASA grade II to V (the higher the
under thermal insulation: grade, the greater the risk).
 Inadvertent Perioperative Hypothermia 85

• Preoperative temperature below induction of anesthesia and then every

36.0°C. 30 minutes until the end of surgery.
• Undergoing combined general 1.3.2 Standard critical incident reporting
and regional anesthesia. should be considered for any patient
• Undergoing major or arriving at the theater suite with a
intermediate surgery. temperature below 36.0°C.
• At risk of cardiovascular 1.3.3 Induction of anesthesia should not
complications. begin unless the patient’s temperature
1.2.2 Healthcare professionals should is 36.0°C or above (unless there is a need
ensure that patients are kept to expedite surgery because of clinical
comfortably warm while waiting for urgency, for example bleeding or critical
surgery. limb ischemia).
1.2.3 Special care should be taken to 1.3.4 In the theater suite:
keep patients comfortably warm • The ambient temperature should
when they are given premedication be at least 21°C while the patient is
(for example, nefopam, tramadol, exposed.
midazolam or opioids). • Once forced air warming is
1.2.4 The patient’s temperature should be established, the ambient temperature
measured and documented in the may be reduced to allow better
hour before they leave the ward or working conditions.
emergency department. • Using equipment to cool the surgical
1.2.5 If the patient’s temperature is below team should also be considered.
36.0°C: 1.3.5 The patient should be adequately
• Forced air warming should be covered throughout the intraoperative
maintained throughout the phase to conserve heat, and exposed
intraoperative phase. only during surgical preparation.
1.2.6 The patient’s temperature should 1.3.6 Intravenous fluids (500 mL or more)
be 36.0°C or above before they and blood products should be warmed
are transferred from the ward or to 37°C using a fluid warming device.
emergency department (unless there 1.3.7 Patients who are at higher risk of
is a need to expedite surgery because inadvertent perioperative hypothermia
of clinical urgency, for example and who are having anesthesia for less
bleeding or critical limb ischemia). than 30 minutes should be warmed
1.2.7 On transfer to the theater suite: intraoperatively from induction of
• The patient should be kept anesthesia using a forced air warming
comfortably warm device.
• The patient should be 1.3.8 All patients who are having anesthesia
encouraged to walk to theater for longer than 30 minutes should be
where appropriate. warmed intraoperatively from induction
of anesthesia using a forced air warming
device.
1.3 Intraoperative Phase
1.3.9 The temperature setting on forced
The intraoperative phase is defined as total air warming devices should be set
anesthesia time, from the first anesthetic at maximum and then adjusted to
intervention through to patient transfer to the maintain a patient temperature of at
recovery area of the theater. least 36.5°C.
1.3.1 The patient’s temperature should be 1.3.10 All irrigation fluids used intraoperatively
measured and documented before should be warmed in a thermostatically
86 Practice Guidelines in Anesthesia

controlled cabinet to a temperature of References

38 to 40°C.
1. Cochrane Handbook for Systematic Reviews of
Interventions 4.2.5 [updated May 2005] (2007)in:
1.4 Postoperative phase Higgins J, Green S, (Eds) The Cochrane Library,
Issue 3, 2005. Chichester, UK:John Wiley & Sons,
The postoperative phase is defined as the 24
Ltd.
hours after the patient has entered the recovery 2. Abelha FJ, Castro MA, Neves AM, et al.
area in the theater suite. Hypothermia in asurgical intensive care unit,
1.4.1 The patient’s temperature should BMC Anesthesiology, 2005;5:7.
be measured and documented on 3. Powell RM, Buggy DJ. Ondansetron given before
admission to the recovery room and induction of anesthesia reduces shivering after
then every 15 minutes. general anesthesia. Anesthesia and Analgesia.
• Ward transfer should not be arranged 2000;90(6):1423-7.
4. Rohm KD, Riechmann J, Boldt J, et al.
unless the patient’s temperature is
Physostigmine for the prevention of post
36.0°C or above. Anesthetic shivering following general
• If the patient’s temperature is below anesthesia—a placebocontrolled comparison
36.0°C, they should be actively with nefopam. Anesthesia. 2005;60(5):433-8.
warmed using forced air warming 5. Berti M, Casati A, Torri G, et al. Active
until they are discharged from the warming, not passive heat retention, maintains
recovery room or until they are normothermia during combined epidural-
comfortably warm. general anesthesia for hip and knee arthroplasty.
1.4.2 Patients should be kept comfortably Journal of Clinical Anesthesia. 1997;9(6):482-6.
6. Camus Y, Delva E, Sessler DI, et al. Pre-induction
warm when back on the ward.
skin-surface warmingminimizes intraoperative
• Their temperature should be core hypothermia, Journal of Clinical Anesthesia.
measured and documented on 1995;7(5):384-8.
arrival at the ward. 7. Reynolds L, Beckmann J, Kurz A. Perioperative
1.4.3 If the patient’s temperature falls below complications of hypothermia. Best Pract Res
36.0°C while on the ward: Clin Anaesthesiol. 2008;22(4):645-57.
• They should be warmed using 8. Sessler DI. Temperature regulation and
forced air warming until they are monitoring. In: Miller RD, Eriksson LI, Fleisher
LA, Wiener-Kronish JP, editors. Miller’s
comfortably warm
Anesthesia. 7th ed. Phidelphia: Churchill
• Their temperature should be Livingstone/Elsevier; [Link].1533-6.
measured and documented at least 9. Moola S, Lockwood C. Effectiveness of
every 30 minutes during warming. strategies for the management and/or
If these guidelines are followed, prevention of hypothermia within the adult
incidence of IPH can be drastically perioperative environment. Int J Evid Based
controlled. Health. 2011;94:337-45.
 CHAPTER 12
Practical Guidelines for
Ultrasound Guided Nerve Blocks
Mridula Pawar

Direct ultrasound visualization significantly high-frequency sound waves in response to

improves the outcome of most techniques in an electrical signal.
regional anesthesia.1 Such direct visualization • Most of regional blocks are performed with
can improve the quality of nerve blocks and linear transducers–high scan line density
avoid complications. Apart from seeing the produces the resolution necessary for nerve
targeted structures, it is possible to visualize imaging.
distribution of local anesthetic. In case of wrong • Small curved probes are used for
distribution, needle can be repositioned under supraclavicular and infraclavicular nerve
vision and block can be redone. blocks.
• Ulnar aspect of operator ‘s Hands must be
Review Basics of Ultrasound close to the skin of the patient to control the
transducer and needle.
• Body parts like blood, fluid conduct sounds • Long axis images will be shown with proximal
poorly (echo lucent) and appear dark. Body side on the left and distal side on the right.
parts with low water like air and bone reflect • These views are useful for seeing distribution
all the sound so appear light. Body parts in of local anesthetic along the nerve path in
between appear dark to light. one image. It is easier to see nerve in short
• Ultrasound waves of lower frequencies axis and slide along the nerve path for its
penetrate deeper than high frequency. identification.
• Hyperechoic reverberation artifact may be • Right handed operators prefer a right hand
seen with metallic foreign bodies like block screen bias so that they can see their hands
needle. and display during the procedure.
• Local Anesthetic injected for regional block • Needle viewing:
is anechoic. – Needle tip viewing is critical to the
• Nerves, muscles and tendons are sensitive to safety and success of the block which
transducer manipulation. depends on Angle of insonation, needle
gauge, motion, echogenic modifications,
Know Your Equipment receiver gain.
• Ultrasound transducer consists of array – Bevel of the needle should face the
of piezoelectric crystals that produce transducer to improve needle tip visibility.
88 Practice Guidelines in Anesthesia

– Bevel of the needle should be towards the • In-plane approach, needle bevel must be
nerve so that it will not puncture it. turned so that the catheter slides along the
– In-plane vs out-of-plane approach: nerve but not around the nerve.
Out-of-plane has shorter needle path • Long axis in-plane approach: It will allow
but because of un-imaged needle nerve, needle and catheter view at the same
path, it may cross the plane of imaging time but it is difficult to keep all in the plane
without recognition. In-plane approach of imaging by transducer manipulation
is direct visualization of needle tip and and because of long path taken by needle
injection. Needle tip is visualized before in the tissue and catheter placement is like
advancement but has long needle path. tunneling.
– Needle may be moved slightly or inject • Short axis in-plane approach: One may inject
less than 1 mL test dose to improve tip local anesthetic or saline and withdraw
visibility. needle back a little before threading a
– Avoid rapid jabbing motion of the needle catheter.
which may cause puncture of vital
structures or paresthesia.
Anatomical Structures
– When angle of approach is more than
30 degrees, an echogenic needle (with Precise identification of structures is paramount
roughened surface) is useful. to attain the goals of ultrasound guided regional
nerve block
• Skin and subcutaneous tissue: Skin is
Sonographic Signs of Successful
hyperechoic, subcutaneous tissues are
Injection of Local Anesthetic hypoechoic with septa parallel to skin.
• Should clarify the nerve boarder- view nerve • Peripheral nerves: These have fascicular
in short axis to evaluate circumferential or honey comb echo texture because of
distribution of drug. hypoechoic (nerve tissue and hyperechoic
• Successful drug injection will track along connective tissue.
the nerve- (short axis sliding assessment) , it • Nerves that are surrounded by hyperechoic
should track along nerve divisions. fat are easier to visualize as the nerve boarders
• Successful injection should separate the are clearer, as compared to nerves which are
connected structures like blood vessel or surrounded by hypoechoic muscles.
other peripheral nerves. • When scanning superficial nerves, apply
• Before you inject local anesthetic, be sure generous amount of acoustic coupling gel.2
to see the needle tip and other anatomical
structures. If tissues do not move upon local How to Differentiate
anesthetic injection, stop, needle tip may
Tendons from Nerves
be may be into a blood vessel. Frequent
aspirations, injection pressure, and patient • Cross sectional area is constant along the
response are all important factors. nerve path while change in cross sectional
are of tendon is substantial.
Ultrasound-guided Catheter • At high frequency of insonation > 10 MHz,
Placement for Peripheral fascicular echotexture of nerve can be
distinguished from fibrillar echotexture of
Nerve Blocks
tendon.
• In-plane and out-of-plane approach can be • There is branching of nerves but not of
used for catheter placement. tendons.
 Practical Guidelines for Ultrasound Guided Nerve Blocks 89

• There are often adjacent vessels but is comfortable and arm is lowered by
infrequent with tendons. gravity.
• Patient’s head is turned to opposite side from
How to Differentiate the block.
• The operator stands either at the head of the
Artery from Vein
bed or at the side of the bed.
• Visible pulsation from the artery are
observed when compression is applied with Equipment
transducer, or apply Doppler as almost every
peripheral nerve has a long running path • A small curved or small linear (20–25 mm
with accompanying artery or vein. foot print, frequency 10–14 MGz) transducer
• Arteries have thicker valves than vein and do is preferred.
not have valves. • A compact transducer is can be rocked back
• Veins are thin walled and easily compressed to improve needle visibility.
with transducer. • Ulnar aspects of both hands of the operator
must be placed for the best control of needle
and transducer.
Interscalene and
• A short (50 mm), broad (21 Gauge) echogenic
Supraclavicular Block needle is used for optimum control and
Anatomy visibility.

• In brachial plexus is seen stacked between

Procedure
anterior and middle scalene muscles, block
is referred as interscalene block. If brachial • Multiple injection technique is used to
plexus is seen as a compact group of nerves ensure complete plexus anesthesia.
lying superior and lateral to subclavian • Initial aim of the needle is deep (caudal
artery, it is referred as supraclavicular elements of the plexus) so that brachial
block. Ultrasound guided block burrs the plexus rises closer to skin surface with
distinction between the two. injection of local anesthetic. Subsequent
• Monofascicular ventral rami of brachial needle passes become easier.
plexus is hypoechoic and may be difficult to • A sterile transparent dressing can be used to
identify in between scalene muscles. cover the transducer.
• Best nerve visibility is near first rib in short • Approximately 15 to 20 mL of local anesthetic
axis and imaging plane must face caudally at is injected watching for the distribution of
the brachial plexus. the local anesthetic around the trunks of the
• Supraclavicular region is more consistent plexus. The local anesthetic is injected in 5
and can be used to trace the plexus back to mL aliquots followed by aspiration for blood.
interscalene groove. All local anesthetic has epinephrine added to
• Perform the block where imaging is most make a solution of 1: 400 000 that acts as an
reliable. intravascular marker as well as minimizing
• The number of visualized components of systemic absorption.
the brachial plexus (five ventral rami, three • If the distribution is inadequate, the needle
trunks and six divisions) vary with the angle can be repositioned and the injection
of the transducer and its position in the neck. continued.
• A peripheral-nerve catheter can then be
threaded into the interscalene space, all the
Position
time watching with the ultrasound where the
• Semi sitting position with head of the catheter passes in relationship to the nerve
bed elevated to 45 to 60 degrees. Patient trunks.
90 Practice Guidelines in Anesthesia

• Final confirmation of catheter placement is Procedure

confirmed by injection through the catheter
of a few milliliters of local anesthetic (can • Begin by scanning the subgluteal region near
also use air/local anesthetic combination) posterior midline. If imaging is difficult, can
that again confirms proximity to the brachial trace sciatic nerve proximally from popliteal
plexus with the ultrasound. fossa.
• When an accompanying artery is identified
on the lateral side of sciatic nerve, place the
Sciatic Nerve Block needle tip in connective tissue between artery
Used for regional anesthesia for lower extremity and the nerve. This requires puncturing the
surgery and usually combined with femoral connective tissue and slowly injecting as the
nerve block. needle is withdrawn to identify the correct
layer surrounding the nerve.
Anatomy • Fascia surrounding the sciatic nerve is very
thick, so it is important to get right needle
• Sciatic nerve (L4-S3) is the largest nerve in position and drug distribution.
the body with transverse diameter of 17 mm, • Perforating arteries usually can be seen
hyperechoic seen as ‘bright triangle’, difficult crossing the anterior side of the nerve.
to visualize in gluteal region and thigh. • Supine approach:
• Short axis view with sliding of the transducer – Obtain a long axis view of the femur with
is usually better than long axis view to confirm the transducer placed on the anterior
nerve identity and distinguish it from the aspect of thigh. Bone is identified by bright
adjacent tendons of semitendinosus-biceps cortical surface and acoustic shadowing.
and semimembranosus. Now slide the transducer medially to get
• Sciatic nerve lies between the greater a long axis view of the sciatic nerve at
trochanter (lateral) and ischial tuberosity approximately twice the depth of femur.
(medial). Sciatic nerve appears as an echogenic
linear, wide and straight structure lying
Equipment deep to adductor magnus muscle. If
• A broad medium frequency linear probe, femoral artery is visible, the transducer
5 cm foot print or larger will be required. has slide too medially.
• Initial depth setting of 40 to 60 mm. – Sciatic nerve will bow like a string as the
• Needle -20G, 90 mm in length. block needle approaches.
– When the local anesthetic is in correct
tissue plane, the injection will track
Position along the proximal-distal course of the
• Prone, lateral or supine. nerve and on both anterior and posterior
• Prone position allows the most stable assess side.
for proximal sciatic nerve block. In plane – This block is performed 2 to 5 cm distal to
technique from lateral side is easy. the lesser trochanter of the femur, external
• Patients who cannot lie prone, lateral rotation of the leg promotes access to the
position with hip bump to provide stability is sciatic nerve.3
another relatively easy alternative.
• Operator stands on side of the patient. Femoral Nerve Block
• Anterior approach to proximal sciatic nerve is
used in patients who are difficult to position Femoral nerve is the largest branch of lumbar
lateral or prone. It is deeper than other plexus and innervates anterior thigh, the patella,
approaches and is used in thin patients. medial leg and foot.
 Practical Guidelines for Ultrasound Guided Nerve Blocks 91

Anatomy lifts the nerve towards the surface. This is

especially important when catheter is placed.
• Femoral nerve is oval or triangular in cross • Successful injection not only surrounds the
section, size of 3 mm anteroposterior and 10 femoral nerve but also tracks along its small
mm mediolateral in inguinal region. distal branches.
• Lies lateral to femoral artery. • Out of plane approach has been found to be
• It is covered by echogenic subcutaneous very safe and effective.5
tissue and fascia.
• Lies on hypoechoic iliopsoas muscle
interface of bright fascia and dark muscle, Complications
nerve can be difficult to visualize. Although ultrasound may not completely
prevent complications, it can facilitate early
Position recognition of them.
• Intravascular injection should be suspected
Supine position with leg slightly abducted with in the absence of visible local anesthetic
the nerve in short axis view. spread.
• Intraneural injection can be recognized by
Equipment nerve expansion.6
• In fact this expansion, rather than pain on
• High frequency linear probe of 38 to 50 mm injection7 may be the most reliable indicator
foot print. With initial depth setting of 25 to of intraneural needle placement.
30 mm. • Paresthesia or pain is not a sensitive indicator
• Needle of 20G, 70 mm length. of intraneural puncture or injection. It is
inappropriate to assume that intraneural
Procedure injection is benign. Factors that may prevent
injury include the intraneural injection of
• Both out-of-plane and in-plane approaches only a small volume of fluid and the use of a
have been used as it is not important to short-beveled needle.8,9
position the needle tip adjacent to the nerve.
• The best visibility is proximal to inguinal
References
crease.
• The tilt of transducer strongly influences 1. Marhofer P, greher M, Kapral S, et al. Ultrasound
femoral nerve visibility due to anisotropic guidance in regional anesthesia. Br J Anesth
effect.4 2005; 94:7-17.
2. Thain LM, Downey DB. Sonography of peripheral
• Begin by scanning with the probe along the
nerves: technique, anatomy, and pathology.
inguinal crease. Slide proximally until the Ultrasound. 2002;18:225-45.
common femoral artery and femoral nerve 3. Vloka JD, Hadzic A, April E. Anterior approach to
are seen in short axis view. Best Femoral the sciatic nerve block: the effect of leg rotation.
Nerve imaging is usually 1 to 2 cm proximal Anesth Analg. 2001;92(2):460-2.
to the inguinal crease. 4. Soong J, Schafhalter-Zoppoth I, Gray AT. The
• Approach short axis view of the femoral importance of transducer angle to ultrasound
nerve, in-plane from lateral side. visibility of the femoral nerve. Reg Anesth Pain
• Place the needle tip through the facia iliaca Med. 2005;30:505.
5. Sites BD, Spence BC, et al. Characterizing novice
at the lateral corner of femoral nerve.
behavior associated with learning ultrasound
• Inject underneath the femoral nerve between guided peripheral regional anesthesia. Reg
nerve and iliopsoas muscle. Anesth Pain Med. 2007;32:107-15.
• The needle tip should be placed in the layer 6. Bigeleisen PE. Nerve puncture and apparent
under the femoral nerve so that the injection intraneural injection during ultrasound-guided
92 Practice Guidelines in Anesthesia

axillary block does not invariably result in 8. Mitchell Fingermana, James G Benonisb,
neurologic injury. Anesthesiology. 2006; Gavin Martinc. A practical guide to commonly
105:779-83. performed ultrasound-guided peripheral-nerve
7. Moore DC. Perineural space versus nerve’s blocks. Current Opinion in Anaesthesiology.
2009,22:600-7.
perineurium-beware the latter are potential
9. Ki Jinn Chin, Vincent Chan. Ultrasound-guided
expressways to the spinal cord! Reg Anesth Pain peripheral nerve blockade. Current Opinion in
Med. 2007; 32:368. Anaesthesiology. 2008,21:624-31.
 CHAPTER 13
Epidural Analgesia:
The Practice Guidelines
Mritunjay Varma

Introduction • Postdural puncture headache syndrome

(including sub-dural hematoma).
Epidural analgesia is highly effective for • Drug administration errors (especially wrong
controlling acute pain after surgery or trauma route)
to the chest, abdomen, pelvis or lower limbs. • Pressure sores
It has the potential to provide excellent pain • Superficial infection around catheter
relief, minimal side-effects and high patient • Epidural hematoma or abscess
satisfaction when compared with other methods • Meningitis
of analgesia. However, epidural analgesia can • Spinal cord ischaemia.
cause serious, potentially life-threatening • Permanent harm, e.g. paraplegia, nerve
complications; safe and effective management injury.
requires a coordinated multidisciplinary
approach. All practitioners should be aware of
the complications associated with the use of Patient Selection and Consent
epidural analgesia. Some complications can be Patient selection for epidural analgesia should
fatal or result in permanent harm. be based on a careful risk/benefit analysis for
each patient.
Complications Risk factors include: impairment of
Frequent complications include: coagulation (pathological or therapeutic);
• Hypotension; respiratory depression (opioid infection; compromised immunity; duration
use); motor block of epidural catheterization; cardiovascular
• Urinary retention stability; and inadequate postoperative
• Inadequate analgesia monitoring capability.
• Pruritus (opioid use). Continuous epidural analgesia is a
significant procedure with specific and
Infrequent but well recognized complications potentially serious complications; therefore,
include: informed patient consent should be obtained.
• Cardiovascular collapse The process of obtaining consent should
• Respiratory arrest comply with national and local guidance.
• Unexpected development of high block, e.g. There should be a discussion of the risks
catheter migration, intrathecal, injection; and potential benefits of epidural analgesia,
local anesthetic toxicity. including information.
94 Practice Guidelines in Anesthesia

on late complications that may occur after These staff must be immediately available to
discharge from hospital. A summary of this respond to adverse events. Oxygen and full
discussion should be documented in the resuscitation equipment must be available.
patient’s notes. Consent should be facilitated by Patients receiving epidural analgesia should
written patient information. be situated close to the nurses’ station, thus
ensuring close supervision. If nursing in a
single room is being considered, a full risk
Personnel, Staffing Levels and
assessment with respect to the epidural should
Ward Environment
be undertaken and staff should be sure that
The Department of Anesthesia should ensure appropriate monitoring and care can take place
that there are designated personnel and clear in this environment.
protocols to support the safe and effective Before the patient returns to the ward, the
use of epidural analgesia. This should be the responsible anesthetist should be assured
responsibility of a multidisciplinary acute pain that the ward is sufficiently staffed to ensure
service including a consultant anesthetist and safe management of the epidural. A system
clinical nurse specialist(s) with support from of communication should exist to inform the
pharmacy. The service should ensure that anesthetist and theater staff if this is inadequate.
appropriate documentation, administrative There should be 24-hour access to:
routines and audit are in place. Ultimate 1. Medical staff, trained and competent in the
responsibility for the epidural in fusion remains management of epidurals, immediately
with the practitioner who instituted it (or available to attend patients;
supervising consultant if inserted by a trainee). 2. Senior anesthetic advice and availability;
However, immediate supervision of the patient and
may be passed to the acute pain service and 3. A resuscitation team with a resident doctor
properly trained ward staff. An agreed form of with appropriate competencies.
communication should be used to facilitate this
transfer of supervision.
Catheter insertion
Trainee and Staff and Associate Specialist/
Specialty doctors must possess appropriate Epidural catheter insertion must be performed
competencies before performing epidural using an aseptic technique. This should include
injections and establishing infusions without hand washing, sterile gloves, sterile gown, hat,
the direct supervision of a consultant or senior mask, appropriate skin preparation and sterile
colleague. drapes around the injection site. The tip of
There must be adequate hand over of the epidural catheter should be positioned
information between on-call staff about patients at a spinal level appropriate for the surgery.
who are receiving epidural analgesia. Ideally, an A catheter placed in a low position may be
up-to-date list of ongoing epidurals should be associated with poor analgesia and need for
maintained and readily available. large volumes of infusion in adults.
Nurses with specific training and skills The catheter should be secured in order to
in the supervision of epidural analgesia and minimize movement in or out of the epidural
management of its complications must be space. It is advisable to tunnel the catheter if it
present on the ward and on every shift (i.e. has to be kept in situ for 3 to 5 days. The dressing
24-hour cover). Staffing levels and expertise should allow easy visibility of the insertion
should be sufficient to enable adequate site and catheter. Anesthetists inserting
monitoring and care to be given to all patients epidural catheters should be aware of, and
receiving epidural analgesia. adhere to, local infection guidelines (including
 Epidural Analgesia: The Practice Guidelines 95

use of prophylactic antibiotics in special developed that will enable NHS institutions to
circumstances). perform all epidural, intrathecal and regional
Local guidelines should be in place with infusions and boluses with devices that will not
respect to the insertion and removal of epidurals connect with intravenous Luer connectors or
in patients on anticoagulants or with impaired intravenous infusion spikes.
coagulation. All staff should be aware of, and Resuscitation equipment, oxygen and
adhere to, these guidelines. appropriate drugs must be readily available
wherever epidural infusions are employed.
Equipment
Drugs for Epidural Analgesia
Ideally, equipment for epidural insertion and
infusion should be standardized throughout There should be a limited number of solutions
the institution so that it is familiar to all staff approved and available for epidural infusions in
providing or supervising epidural analgesia. every hospital. They should be prepared under
Staff must be trained in the use of this strict sterile conditions in specifically designed
equipment. units. Many are available commercially. Any
Infusion pumps should be configured variation from this should occur in exceptional
specifically for epidural analgesia with pre-set circumstances only and with the agreement of
limits for maximum infusion rate and bolus size; the responsible consultant after a risk/benefit
lock-out time should be standardized if used for analysis.
PCEA. Pumps should be designated for epidural Epidural infusions should be labeled ‘For
analgesia only and should be labeled as such. Epidural Use Only’.
There should be a documented maintenance Epidural infusions should be stored in
program. separate cupboards or refrigerators from
The epidural infusion system between those holding intravenous and other types of
the pump and patient must be considered as infusions in order to reduce the risk of wrong
closed; there should be no injection ports. route administration.
An antibacterial filter must be inserted at the The lowest possible effective concentration
junction of epidural catheter and infusion line. of local anesthetic should be used in order to
Effective management of epidural analgesia preserve motor function as much as possible.
may require the administration of a bolus This improves patient satisfaction and aids
injection of solution into the system. This may be detection of neurological complications. If
performed using the syringe within the pump, higher concentrations are required, the infusion
thus not breaching the system. If a separate rate should be reduced periodically to allow
handheld syringe is used, the injection must assessment of motor block.
be performed using a strict aseptic technique. The use of drugs beyond licence should be
Bolus injections must be performed by staff consistent with local hospital guidelines.
with appropriate training and competencies
and more intensive monitoring of the patient is Patient monitoring
required immediately after the injection.
Epidural infusion lines should be clearly Patients must be monitored closely throughout
identified as such. The National Patient Safety the period of epidural analgesia. It should
Association (NPSA), UK has recommended the be performed by trained staff aware of its
use of yellow tubing to differentiate epidural/ significance and action required in response to
spinal lines from arterial (red), enteral (purple) abnormal values.
and regional (gray) in fusions. Monitoring should include:
In November 2009, the NPSA, UK • Heart rate and blood pressure
recommended that equipment should be • Respiratory rate
96 Practice Guidelines in Anesthesia

• Sedation score after stopping the epidural infusion. A clear

• Temperature protocol should be in place describing the
• Pain score actions required in this situation, including
• Degree of motor and sensory block. informing senior anesthetic staff and immediate
In addition, requirements for monitoring will availability of suitable imaging and surgical
be determined by the nature of the surgery, and expertise.
condition and age of the patient. Records must be kept of the monitoring
The frequency of observations should be described above as well as epidural infusion
determined by normal clinical considerations. rate, total amount used, inspection of epidural
With respect to the epidural, they should be insertion site, patency of intravenous access
more frequent in the first 12 hours of the epidural and integrity of pressure areas.
infusion, after top-up injections, changes of Staff should be aware that increased or
infusion rate and in periods of cardiovascular or breakthrough pain may indicate surgical
respiratory instability. complications including the development of
Monitoring should follow clear written compartment syndromes. Special care should
protocols and compliance to these should be be taken when interpreting physical signs in
audited. patients who may have sustained neurological
Epidural blockade can cause hypotension. damage.
However, when hypotension occurs after
surgery, other common causes should be
Epidural Analgesia in Children
considered and excluded, e.g. bleeding,
myocardial insufficiency, sepsis, pulmonary All the recommendations in this guideline
embolus, dehydration. apply also to neonates, infants and children but
Pain scores (at rest and on movement or methods of monitoring and assessment scores
deep breathing) and sedation scores will help must be appropriate for developmental age.
to identify inadequate or excessive epidural Dosing regimens for children must be
drug administration. Monitoring protocols adapted for age and weight with maximum
should give clear guidance on actions required dosage clearly defined to minimize the risk of
if analgesia is inadequate. cumulative local anesthetic toxicity, especially
Sedation is often the most sensitive in neonates and infants < months of age.
indication of opioid induced respiratory Clear protocols for prescription, monitoring
depression. Monitoring of sensory and motor and troubleshooting of pediatric epidural
block is essential for the early detection of infusions should be used. Infusion devices
potentially serious complications. The Bromage should be programmed and double checked
Scale is an accepted tool for the measurement with extreme care as there is an increased
of motor block. An increasing degree of motor risk of error when managing small infants
weakness usually implies excessive epidural and neonates. Hourly assessments are
drug administration. However, it can indicate recommended, especially in the first 12 hours.
very serious complications including dural There should be regular review of the need to
penetration of the catheter, or the development continue the infusion, especially after 48 hours.
of an epidural hematoma or abscess. Therefore, Motor block should be assessed and
it is essential that protocols are in place to documented formally using an age-appropriate
manage the scenario of excessive motor block. assessment. A clear action plan should be in
An epidural abscess or hematoma can place if motor block persists or progresses.
cause severe, permanent neurological damage Spread of local anesthetics in neonates
and must be detected and treated as soon as and infants is extensive and low catheters
possible. This diagnosis must be considered if can be used to provide an effective block for
excessive motor block does not resolve rapidly thoracolumbar dermatomes without using
 Epidural Analgesia: The Practice Guidelines 97

unacceptable doses of local anesthetic. Whilst • Frequency of observations

caudal catheters are effective, these can become • Maintenance of intravenous access
soiled unless carefully dressed or tunnelled throughout the infusion period
away from the insertion site. • Identification and management of early and
Compartment syndrome is a particular late complications
concern after very prolonged procedures, after • Management of inadequate analgesia;
lower limb surgery and when the patient has Management of accidental catheter
been positioned during surgery in other than dis-connection
the standard supine position. • Instructions for removal of the epidural
An anesthetist with appropriate catheter and monitoring for complications
competencies and training should be • Insertion and removal of epidural catheters
immediately available to attend a child who is in patients receiving anticoagulants
receiving an epidural infusion. • Pain management after cessation of the
Written and verbal advice should be epidural infusion
provided to patients and carers alerting them to • Management of opioid and local anesthetic
the signs and symptoms of an epidural abscess toxicity
and what to do if they occur. Many children are • Mobilisation after epidural removal, e.g.
discharged before the mean time of onset of during enhanced recovery programs.
these signs and symptoms.
Audit and critical incidents
Documentation, Guidelines
There should be regular audits concerned
and Protocols with epidural analgesia. These could include:
Contemporaneous records must be kept of efficacy and patient satisfaction; incidence
events throughout the period of epidural of complications; adherence to management
analgesia. This includes consent, insertion protocols.
and removal of the catheter, prescription of There should be clear procedures for the
the infusion, monitoring, additional doses reporting of, and response to, critical incidents
and notes about any complications or adverse associated with the use of epidural analgesia.
events.
Safety is enhanced by the use of standard Education
pre-printed prescription forms rather than
hand written prescriptions that might be There should be formal, documented training
misinterpreted. Contact telephone and/or in place for doctors and nurses who are
bleep numbers for expert medical and nursing responsible for supervising patients receiving
personnel must be printed on documents that epidural analgesia.
are kept on the ward, and near to the patient. Training programs should include
induction and regular update sessions and be
Protocols and guidelines should include: commensurate with the responsibilities of the
• Over all management of patients with staff involved.
epidural infusions
• Instructions for the use of the pump
• Description of the drug concentrations used Further Reading
in the hospital 1. Brauer M, George JE, Seif J, Farag E. Recent
• Description of infusion rates and how to advances in epidural analgesia. Anesthesiology
adjust them Research and Practice 2012;14.
• Instructions for changing epidural solution 2. Hawkins JL. Epidural analgesia for labour and
bags or syringes delivery. N Engl J Med 2010;362:1503-10.
98 Practice Guidelines in Anesthesia

3. Moriarty A. Pediatric epidural analgesia. 6. Unic Stajanovic D, Babic S, Jovic M. Benefits,

Pediatric Anesthesia 2012;22:51-5. risks and complications of perioperative use
4. Richard B, Alan JR, Vincent WS Chan. Spinal, of epidural anesthesia. Med Arch 2012;66:
Epidural, and Caudal Anesthesia. In: Miller RD, 340-3.
editor. Miller’s Anesthesia. 8th edn. Philadelphia, 7. Freise H, Van Aken HK. Risks and benefits of
PA: Churchill Livingstone/Elsevier, 2015.p. thoracic epidural anaesthesia. Br J Anaesth 2011;
1684-720. 107: 859-68.
5. Silva M, Halpern SH. Epidural analgesia for 8. Glieder L, Rebelo H, Oliviera R, Neves A. Regional
labour: current techniques. Local and Regional analgesia in intensive care. Rev Bras Anestesiol
Anaesthesia 2010;3:143-53. 2012;62:724-30.
 CHAPTER 14
Monitored Anesthesia Care
Parshotam Lal Gautam

Description or Definition of care and postanesthesia care, thus care needs

Procedure/Service adherence to same principles and standard
of care as for any other anesthetic procedure.
Monitored anesthesia care (MAC) as words During MAC, the anesthesiologist provides
define, refers to the patient care being monitored multiple specific services in addition to
by anesthesia personnel present during a monitoring such as diagnosis and treatment
procedure and does not necessarily/implicitly of clinical problems, support of vital functions,
indicate the level of anesthesia needed. Often psychological support, administration of drugs
it amounts to light sedation in addition to and anesthetic agents or other medications as
monitoring vitals and well-being of patient. necessary for patient safety during procedure.2
However, MAC provider must be prepared, and If the patient loses consciousness and the ability
competent enough to rescue airway during to respond purposefully, the anesthesia care is
sedation, manage medical problems, and a general anesthetic, irrespective of whether
qualified to switch over to general anesthesia airway instrumentation is required. MAC
whenever necessary to accomplish procedure. should be subject to the same level of payment
This requirement is either because of patient as general or regional anesthesia.
characteristic or procedure based. Thus the
service mandates assessment of patient and Practice Guidelines: Broadly speaking practice
preparation of procedure suite like properly guidelines and standards are the same as
equipped OR. To be more specific in definition, applicable to any general or regional anesthesia.
ASA house of delegates updated MAC definition Preanesthetic assessment, preparation,
on September 2, 2008.1 They defined MAC as monitoring and perioperative care need to
a specific anesthesia service for a diagnostic executed in a similar way with same level of
or therapeutic procedure. Indications for alertness, spirits, precautions and standard of
monitored anesthesia care include: care. MAC can be as easy and safe as any GA
• The nature of the procedure procedure in ASA 1 or 2 undergoing simple
• The patient’s clinical condition and/or procedure or it can be as hard and difficult as
• The potential need to convert to a general or any major surgery in patient with ASA physical
regional anesthetic. status 5.
MAC includes all aspects of anesthesia Preanesthetic assessment: An essential
care—a preprocedure visit, intraprocedure component of MAC is the assessment and
100 Practice Guidelines in Anesthesia

management of a patient’s actual or anticipated Class 2 - The hard and soft palate, uvula
physiological derangements or acute medical and upper portion of the tonsils
problems that may occur during a procedure or are visible
surgery. Class 3 - The hard and soft palate and the
• General assessment: The anesthesiologist uvula base are visible
need to perform a thorough review of Class 4 - Only the hard palate is visible.
the patient’s medical history, tests and Patients with Class 3 or 4 Mallampati
examination as required for general scores are considered to be at higher risk
anesthesia. of intubation difficulty. Anesthesiologists
• Cognitive function: Ability to verbally should assess airway for feasibility of mask
communicate with the patient is important as ventilation.5,6 Obesity, unfavorable upper
it helps in sedation monitoring, reassurance lip bite test/mandibular protrusion test and
and assessment of patient’s well-being. elderly age group are considered reliable
• Cardiorespiratory reserve and physical risk factor to predict difficult ventilation.
fitness: Poor cardiorespiratory reserves Considering other parameters such as
are often the indication for MAC over thyromental distance, receding mandible,
GA. Although American Society of bucked teeth along with Mallampati’s Class 3
Anesthesiologists (ASA) physical status does and 4 increase overall predictability of these
not contribute directly that patient should be airway assessment for difficult intubation
done under MAC or GA, but MAC provider and ventilation.7 While the Mallampati score
should assess ASA physical status class for and other predictors of difficult airway do not
assessing a patient before surgery as high- determine a need for monitored anesthesia
risk patient may be considered more safe care, it may be considered in determining
under MAC.3 risk for airway obstruction. Obese patients
P1 – A normal, healthy patient particularly with obstructive sleep apnea are
P2 –  A patient with mild systemic at risk of airway obstruction after sedation.
disease It may be difficult and challenging even for
P3 –  A patient with severe systemic an experienced anesthesiologist to secure
disease airway and ventilation. Moreover if MAC is
P4 –  A patient with severe systemic administered outside the operation theater
disease that is a constant threat to suite, preparation for difficult airway should
life be stand by or easily accessible in high-risk
P5 –  A moribund patient who is not airway.
expected to survive without the • Procedure explanation, briefing and
operation consent: Patient should be explained
P6 –  A declared brain-dead patient about anesthetic technique and procedure.
whose organs are being harvested. Monitored anesthesia care is considered a
• Airway assessment: The Mallampati matter of patient choice. In these settings,
score is considered a predictor of difficult physician should discuss the risks and
tracheal intubation and is routinely used benefits of monitored anesthesia care and
in preoperative anesthesia evaluation. The general anesthesia. Shared decision-making
score is obtained by having the patient extend is recommended. Monitored anesthesia care
the neck, open the mouth, and extend the may be appropriate whenever specific risk
tongue while in a seated position. Patients factors or significant medical conditions
are scored from Class 1-4 as follows:4 are present and carries a potential risk for
Class I - The tonsils, uvula and soft palate sedation during procedure by a surgeon or
are fully visible proceduralist. These conditions include:8
 Monitored Anesthesia Care 101

• High risk of complications due to severe half-time is a reflection of plasma drug decay,
comorbidity (ASA Physical status 3 or more) the effect-site concentration is the important
• Morbid obesity or obstructed sleep apnea or factor in determining wakefulness. Effect-
difficult airway site drug concentrations lag behind plasma
• Inability to follow simple commands concentrations and may be further delayed due
(cognitive dysfunction, intoxication, or to low cardiac output that will slow onset time.
psychological impairment) Aged patient may be more sensitive to sedatives
• Spasticity or movement disorder and patients with chronic use of these drugs
complicating procedure. may be tolerant. Practice guidelines for pain
• History or anticipated intolerance or management and discharge are the same as any
addiction to standard sedatives, such as other postoperative care following anesthetic
i Chronic opioid use exposure.
ii. Chronic benzodiazepine use Commonly used drugs for MAC and their
– Extremes of age, i.e., younger than 18 concerns: Although under MAC patient may
years or age 70 years or older require no sedation to deep sedation equivalent
– Patients who are pregnant full general anesthesia as defined by the latest
– Acutely agitated, uncooperative patients definition by ASA, but moderate sedation
and anxious patient is mostly used in outpatient settings. The
• Preoperative instructions: Preoperative most commonly used agents for monitored
instructions and prescription such as fasting, anesthesia care (MAC) are midazolam, fentanyl
anxiolytics, aspiration prophylaxis and and propofol. Each of these drugs, however,
concurrent medications are the same as for causes respiratory depression.9-11 A frequently
any routine general anesthetics. used combination is an short acting opioid and
MAC technique: An intravenous catheter is benzodiazepine (for example, fentanyl with
secured through which anesthetic drugs can midazolam) at doses individualized to obtain
be administered. Monitor vitals as done for the desired sedation level. Other drugs and
other general anesthetics (See below). MAC drug combinations have also been utilized for
provider has to be with patient all times to this purpose. It is one’s individual choice and
monitor patient’s well-being, and adjust the comfort level with the drug depending upon
level of sedation as needed. During MAC, the one’s experience. While both benzodiazepines
provider can adjust the level of sedation to a and opioids can cause respiratory depression,
desired level ensuring patient comfort and particularly when used in combination because
safety to accomplish the procedure. Comforting of synergic effects caused by knocking down
patient with reassurance, psychological hypoxic and hypercapnic drives respectively.
support and physical comfort plays key role Thus effective reversal agents should be
to accomplish procedure uneventfully. In available. Propofol is another agent that has
addition to the sedation, surgeon will often been gained popularity over the last couple
use local anesthetics for pain relief if deemed of decades by virtue of its property of quick
for surgery or procedure. After detailed onset and fast recovery with minimal or no
assessment, anesthetic workstation is prepared postoperative hang over and nausea, and
as practised for any other anesthetic procedure. facilitating fast tracking. It is increasingly used
The combination of drugs (analgesic, amnesic, to provide sedation for procedures as an agent
and hypnotics) should be used to have of choice. Propofol has a short context-sensitive
minimum of side effects to facilitate recovery. half-time even after prolonged infusions, and a
Titration of drugs is tricky. It is important to short effect-site equilibration time making it a
know the onset, duration and context sensitive suitable choice for sedation in hemodynamically
half life of drugs. While context-sensitive stable patient. However, there have been
102 Practice Guidelines in Anesthesia

concerns about potential side effects and 15 minutes after the return of consciousness
safety when used by non-anesthesiologists.10 from propofol anesthesia and two hours after
Propofol does not reliably produce amnesia in midazolam despite the return to a normal state
subhypnotic doses and may lead to hypotension of consciousness.
in sick patient. Rapid administration of propofol Other relatively recent additions are
has the potential to induce apnea, hypotension α2 agonist dexmedetomidine. Its use is
and general anesthesia, and there is no progressively increasing with awareness of
pharmacologic antagonist to reverse its action physicians. Dexmedetomidine, because of its
making it unsafe by non-anesthesia personnel analgesic properties with lack of respiratory
without airway management training. ASA has depression, makes it baseline effective, safe,
offered practice guidelines for the provision of suitable for “cooperative sedation” in a broad
sedation by non-anesthesiologists, stating that range of surgical procedures. Dexmedetomidine
personnel must be prepared to respond to deep results in better patient satisfaction, less opioid
sedation and loss of airway protection should requirements, and less respiratory depression. It
these complications inadvertently occur during is gaining popularity with increasing experience
sedation.12-14 Midazolam even in low doses with drug.16-21
produce reliable amnesia. MAC and elderly patients: Population aging is
MAC provider should understand the a worldwide phenomenon. Nearly more than
effect site equilibrium, context sensitive half 30% of population are above 65 years of age. It
life and recovery characteristics of sedatives has been estimated that elderly people require
to avoid over dosage and enhance recovery. surgery four times more often than the rest
While the elimination half-time of midazolam of the population, and that this number will
is relatively short, the context-sensitive half- increase by 25% by 2020.22 Those caring these
time is roughly twice that of propofol, and patients must consider the normal decline in
is associated with prolonged postoperative functional reserve in patients aged patients
sedation and psychomotor impairment. and associated comorbid medical problems.
Effect-site equilibration concept is very Some of procedures like cataract surgery,
relevant to titrate boluses of drugs. Thiopental, dental treatment, endoscopies, radiological
propofol, and alfentanil have short values procedures, carotid endartectomies, etc. are
while midazolam, sufentanil, and fentanyl common procedures which can be done
have long values respectively so one has to easily under MAC and regional block without
be careful while administering these drugs. having problems of GA. Thus monitored
Even using the shortest value for midazolam anesthesia care (MAC) is an attractive option
(0.9—5.6 m), 2.7 minutes is required for 87.5% in these settings. MAC provider should be
effect-site equilibration of a bolus dose. Low aware of geriatric problems and issues which
cardiac output is another factor that will slow one can face during preoperative evaluation,
onset time.15 The Cpss50 of benzodiazepine intraoperative assessment and postoperative
decreases significantly as a function of age, discharge. Two core concepts are important
so it has to be used cautiously in geriatric while assessing functional status of aged patient;
patients. Elimination of fentanyl is shorter than one functional loss reserves of organ systems
sufentanil’s, its context-sensitive half-time is and secondly this loss varies from person
twice that of sufentanil’s at two hours and 8 to 10 to person.23 Despite availability of various
times longer at five hours. There is no constant instruments to evaluate functional status
relationship between elimination half-life and and health associated quality of life, the best
context-sensitive half-time. Protective airway practical tool is self reported walking ability.24-27
reflexes are depressed by sedation, debilitation, Most of geriatric population is frail and frailty
and advanced age. Complete recovery of the makes a person more vulnerable to disability
swallowing reflex is expected approximately during and after stress.28 The components
 Monitored Anesthesia Care 103

of the frailty syndrome include mobility; advantage of this type of anesthesia service, as
muscle weakness; poor exercise tolerance; opposed to general anesthesia, is that there are
unstable balance; and factors related to body typically fewer anesthesia related side-effects
composition such as weight loss, malnutrition, and quick recovery leading to less loss of working
and muscle wasting. Frailty is reliable predictor days. Currently MAC is the first choice in 10 to
of mortality and hospital admission.29,30 Elderly 30% of all the surgical procedures.35 The use of
patients have poor compensatory response MAC has been increasing rapidly over the last
for the stress, hypovalemia, hypoxia and decade to patients with lower anesthetic risk.36,37
hypercarbia associated with sedation and The proportion of gastrointestinal (GI) tract
hypothermia. Elderly patients have increased procedures performed with anesthesia services
sensitivity to all sedatives and opioids (doubled increased from approximately 14% in 2003 to
by age 80 years, quadrupled by age 90 years more than 30% in 2009, with wide geographic
with benzodiazepines). Anesthetic dosing for variation in the use of these services. A complex
boluses should be in halved and infusions set of factors have been proposed that contribute
reduced by as much as two-thirds. Pain is best to this increased use of anesthesia services
treated using smaller doses in a multimodal including patient and physician preferences,
regimen, the aim being to reduce adverse effects clinical need, regulatory requirements, and
while ensuring adequate pain relief.31 Low financial considerations.34,37 Commonly
dose intravenous ketamine may 0.5 to 1 mg/ performed procedures are under MAC are:
kg helps to reduce dose of other drugs. Oral or • Endoscopies of the upper and lower GI tract
intravenous administered NSAIDs can be give as • Bronchoscopy
pre-emptive analgesia. In elderly NSAIDs may • Extracorporeal lithotripsy
be reduced to 50% of adult dose. Hypovolemia • Transvaginal ovum retreival
and dehydration, which are common in the • Radiotherapy and imaging for infants
elderly, may aggravate the risk of acute renal • Angiography, pace-maker, central venous
insufficiency following use of NSAIDs.32,33 catheter, and venous filter placements
Sedatives, especially propofol in association • Ocular surgical procedures
with angiotensin-converting enzyme (ACE) • Arthroscopy, carpal tunnel repairing, other
inhibitors may cause hypotension.34 Presence of minor orthopedic procedures
common metabolic disorder of aged population • Minor surgical procedures, hernia surgical
diabetes mellitus and hypertension may also repair
add up to the problem. • Perineal minor surgical procedures,
Commonly performed procedures under MAC hemorrhoid surgical repair
and their concerns: Variety of procedures can • Diagnostic and therapeutic hysteroscopy
be performed under MAC. There are different • Bladder endoscopy, prostate transurethral
inherent problems, concerns and requirements resection.
related to patient status, procedure and MAC. As these services are not necessarily be
MAC is often indicated, when procedures can limited to operation theater but other remote
be done easily without general anesthesia areas of hospital also. It is difficult to create
but surgeon or physician is uncomfortable ideal theater conditions to which most of us
without anesthesiologist’s involvement. These are used to. Some of specific procedures have
patients are either too sick to be considered particular concerns in MAC such as sharing of
safe for sedation or general anesthesia for given airway in dental and facial plastic procedures.
procedure. Or the procedure is too simple As surgeon shares his field with anesthesiologist
where general anesthetics can be avoided to and in these settings, while picking of sedatives
fast track, and procedure can be done with and analgesics one must consider specifically
minimal postoperative problems and care. The preservation airway reflexes.
104 Practice Guidelines in Anesthesia

MONITORING DURING MAC to verbal commands, either alone or

accompanied by light tactile stimulation.
Communication and observation: The No interventions are required to maintain a
patient’s response to verbal command should patent airway, and spontaneous ventilation
be continually evaluated for effective titration is adequate. Cardiovascular function is
of sedation. The patient should be observed usually maintained.
for adverse effects of sedation and procedural • Deep sedation/analgesia is a drug-induced
stress: diaphoresis, pallor, shivering, cyanosis, depression of consciousness during which
and acute changes in neurologic status. patients cannot be communicated or easily
Monitoring level of sedation: Level of sedation aroused but respond purposefully following
is a continuum status. With the same drug and repeated or painful stimulation. The ability
dosage patient may have different response to independently maintain ventilatory
and level of sedation. It is difficult to predict function may be impaired. Patients may
particularly in some patients with history of require assistance in maintaining a patent
use/abuse and tolerance of drugs. According to airway, and spontaneous ventilation may
OAA/S scale, a score of 3 to 4 means a moderate be inadequate. Cardiovascular function is
level of sedation-analgesia, while a score of 1 usually maintained, but may deteriorate
to 2 means unconsciousness; for obtaining a secondary to airway and ventilation
MAC, a score higher than 3 is required, while for impairment. This is a particular problem in
scores less than this point the patient has to be elderly and morbidly obese patients.
considered in general anesthesia (Box 14.1).38 • General anesthesia is a drug-induced
Although sedation is a continuum process, depression of consciousness during which
but ASA in 2004, defined different levels of patients are unresponsive to even painful
sedation to simplify the understanding of need stimulation. The ability to independently
of rescue airway management. maintain ventilator function is often
• Minimal sedation (anxiolysis) is a drug- impaired. Patients often require assistance
induced state during which patients should in maintaining a patent airway, and positive-
be able to communicate and respond pressure ventilation may be required because
normally to verbal commands without of depressed spontaneous ventilation or
any tactile stimulation. Although cognitive drug-induced depression of neuromuscular
function and coordination may be impaired, function. Cardiovascular function may be
ventilator and cardiovascular function are impaired.
unaffected. He is fully alert to protect his Pulse Oximetry: In addition to sedation’s
airway. potential hypoxic effects, other predisposing
• Moderate sedation/analgesia (“conscious” factors include obesity, pre-existing upper
sedation) is a drug-induced depression airway obstruction and respiratory disease, age
of consciousness during which patients extremes, and the lithotomy position. The ASA
communicate and respond purposefully Committee on Professional Liability analysis of

Box 14.1: The Observer Assessment of Alertness/Sedation Scale (OAA/S scale)

Answering Vocal expression Facial expression Eyes only to calling
Ready to calling Normal Normal Normal 5
Slow to calling Initial slowing Medium relaxing Medium relaxing 4
Slowing Slowing Marked ptosis 3
Only to loud calling Incomprehensible words — — 2
Only to shakes Incomprehensible words — — 1
 Monitored Anesthesia Care 105

closed claims revealed that respiratory events Postoperative pain management: Postoperative
constituted the single largest source of adverse pain after day surgery may last more than 3 days
outcomes. and affect quality of life for more than 7 days.39
Capnography: Sidestream capnographs have Organizative aspects such as clear instructions
been adapted for use with face masks, nasal at discharge, availability of analgesic drugs and
airways, and nasal cannulae. follow-up are key factors,40 especially in geriatric
day surgery. Acetaminophen has few side effects
Cardiovascular system: The ECG must
and no anti-inflammatory action, and is widely
continuously be displayed and NIBP measured
used due to its high safety profile including
and recorded at least every five minutes. The
patient with poor hepatic function. At the
pulse should be monitored palpation, oximetry,
recommended therapeutic doses of 1 g 6 hourly
or auscultation. Precordial stethoscope is an
is usually well tolerated. Multimodal analgesic
inexpensive, effective and essentially a risk-free
strategy does excellently in relieving pain with
tool.
negligible side effects in the elderly population.
Temperature: There is still the opportunity for Tramadol is well tolerated and effective and is
inadvertent hypothermia, particularly during indicated in the case of moderate-to-severe
regional and conscious sedation techniques pain. Slowly titrating the dose is effective in
in the elderly. Malignant hyperthermia is rare reducing PONV. Confusion is concern after use
during MAC because the common triggering of narcotics and semisynthetic narcotics in the
agents are rarely used. Hyperthermia can still elderly. Three stages of recovery exist; early,
occur as a result of thyroid storm or malignant intermediate and late recovery. The early and
neuroleptic syndrome. intermediate recovery stages occur in either
Preparedness to manage adverse effects of drugs in OR or PACU, whereas late recovery refers to
and procedure: the resumption of normal daily activities after
• Adverse events/effects secondary to deep discharge from hospital. Early recovery is the
sedation and procedure: Airway obstruction, time interval during which patients emerge from
hypoventilation, hypotension, arrhythmias, anesthesia, recover control of their protective
claustrophobia, excessive movement and reflexes, and resume early motor activity.
poor tolerance of procedure. During this phase of recovery vital signs and
• Local anesthetic over dosage/toxicity: It oxygen saturation are carefully monitored and
is important particularly in patient with supplemental oxygen, analgesics, or antiemetics
compromised cardiovascular reserves. The can be readily administered. The modified
more acidic pH of an acute hypercapnic Aldrete score or modified postanesthetic
state in sedated patient with hypoventilation discharge scoring (PADS) is commonly used to
lead to a degree of intracellular ion trapping assess the fitness of patients to be discharged.
and high intracellular concentration. During the intermediate recovery period,
Low perfusion in compromised cardiac patients are usually cared for in a reclining chair
output may slow elimination and delay and progressively begin to ambulate, drink
recovery from toxicity. Hypoxia and acidosis fluids, void, and prepare for discharge. The
potentiates cardiovascular toxicity. late recovery period starts when the patient is
PACU care and discharge after MAC: It is discharged home and continues until functional
important to see that there is someone to look recovery is achieved and the patient is able to
after these patients at home after discharge. resume normal activities of daily living. The
Particularly elderly patients because of delayed anesthetics, analgesics, and antiemetics can
recovery of cognitive function and age related also have an effect on the patient’s recovery
frailty, may have poor oral intake. Pain is major during the postdischarge period. However, the
issue which if severe can lead to readmission. surgical procedure itself has the highest impact
Good pain relief is very satisfying to the patient. on the patient’s full functional recovery.
106 Practice Guidelines in Anesthesia

Principles and policies for discharge are same as Box 14.2: Modified postanesthesia discharge
that for GA: Postanesthetic discharge scoring scoring (PADS) system
(PADS) system is a simple objective cumulative Vital Signs
index that measures the patient’s home
2 Within 20% of the
readiness; it is based on five major criteria: preoperative value
(1) vital signs, including blood pressure, heart
1 20–40% of the preoperative
rate, respiratory rate, and temperature; (2) value
ambulation and mental status; (3) pain and 0 40% of the preoperative value
PONV; (4) surgical bleeding; and (5) fluid
Ambulation
intake/output. Patients who achieve a score
2 Steady gait/no dizziness
of 9 or greater and have an adult escort are
considered fit for discharge (or home ready). 1 With assistance
The requirement for patients to drink and 0 No ambulation/dizziness
void before discharge is no longer considered Nausea and Vomiting
mandatory. A modified postanesthetic 2 Minimal
discharge scoring system was developed that 1 Moderate
eliminated input and output as discharge 0 Severe
criteria and resulted in earlier discharge for up Pain
to 20% of patients (Box 14.2).41 2 Minimal
Complications of MAC: Anxiolytics, sedatives 1 Moderate
and analgesics used during a MAC depress 0 Severe
the central nervous system (CNS) in a dose- Surgical Bleeding
dependent way and synergistically. Age 2 Minimal
related alteration in pharmacokinetics and
1 Moderate
pharmacodynamics, and pathophysiological
0 Severe
changes associated with medical condition may
lead to difficulty in optimal titration of desired From Chung F, Chan VW, Ong D. A post-anesthetic
discharge scoring system for home readiness after
level of sedation. The spectrum of sedation ambulatory surgery. J Clin Anesth. 1995;7:500.
level is continuum process, and this spectrum
is an unbroken line which goes from a minimal
state of sedation to a profound unconscious conclusion
state, going through the conscious sedation
required during a MAC. At times higher levels of MAC is an attractive option where so ever
sedation may compromise airway, ventilation feasible irrespective of ASA physical status. In
and circulation. The other side effects are sick patient with ASA status 3 or more it results
PONV, prolonged sedation, dysphoria, agitaion, in minimal physiological derangement while
etc. While patient agitation may be due to in healthy patients with ASA status 1 and 2, it
pain and anxiety but it can also be caused by leads to quick recovery and back to work early.
serious issues which need immediate attention However general anesthesia may be required
such as hypoxia, hypercarbia, impending local to accomplish procedure in some cases. Patient
anesthetic toxicity, and cerebral hypoperfusion. assessment including history, examination and
Other less severe causes are: bladder distention, investigations should be like any other type
hypothermia, hyperthermia, pruritus, nausea, of anesthesia. Infrastructure preparation and
positional discomfort, IV site infiltration, monitoring should be of similar to OT suite.
prolonged tourniquet inflation, or a member Verbal communication is important to titrate
of the surgical team leaning on the patient. sedation and calm down anxious patient to
Recovery ideally should be complete and rapid. facilitate surgery/procedure. Selection of patient
The patient should be awake or arousable during and then selection of drugs/ drug combination
the procedure, and be able to communicate. is important for smooth, safe and quick recovery.
 Monitored Anesthesia Care 107

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Claim Database revealed oversedation leading
1. American Society of Anesthesiologists (ASA). to respiratory depression played a pivotal role
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Approved by the House of Delegates on October 2006;104:228-34.
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2005;22(8):638-40. Dexmedetomidine for monitored anesthesia
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Care (MAC): the Blue Cross and Blue Shield sedation. Anesth Analg. 2002;95:461-6.
Association last reviewed 3/2013. 20. Abdalla MIM, Mansouri FA, Bener A.
9. Bailey PL, Pace NL, Ashburn MA, et al. Frequent Dexmedetomidine during local anesthesia. J
hypoxemia and apnea after sedation with Anesth. 2006;20:54-6.
midazolam and fentanyl. Anesthesiology. 21. McCutcheon C, Orme R, Scott D, et al. A
1990;73:826-30. comparison of dexmedetomidine versus
10. ASA Task Force on Sedation and Analgesia by conventional therapy for sedation and
Non-Anesthesiologists. Practice guidelines for hemodynamic control during carotid
sedation and analgesia by non-anesthesiologists. endarterectomy performed under regional
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11. Bhananker SM, Posner KL, Cheney FW, et al. 22. Naughton C, Feneck RO. The impact of age on
Injury and liability associated with monitored six-month survival in patients with cardiovascular
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23. Frederick E. Sieber, Ronald Pauldine. Geriatric 31. Ekstein M, Gavish D, Ezri T, Weinbroum AA.
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24. Gabriella Bettelli. Anesthesia for the elderly co-prescription of ACE inhibitors and NSAIDs. J
outpatient: preoperative assessment and R Soc Med. 2001;94:657-8.
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postoperative pain management. Current selective NSAIDs and selective COX-2 inhibitors
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25. Hardy SE, Gill TM. Factors associated with 2007;62:26-34.
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disabled older persons. Arch Intern Med. 2005; increases vascular relaxation in aging rats
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26. Alexander NB, Guire KE, Thelen DG, et al. Self- converting enzyme inhibitor captopril. Anesth
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reported walking ability predicts functional
35. Albertin A, Fanelli G. Monitored anesthesia care.
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36. Liu H, Waxman DA, Main R, et al. Utilization
27. Guralnik JM, Simonsick EM, Ferrucci L, et al. A of anesthesia services during outpatient
short physical performance battery assessing endoscopies and colonoscopies and
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reported disability and prediction of mortality 307(11):1178-84.
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49:M85-M94. clinical care: the case of anesthesia services for
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Designing randomized, controlled trials aimed 38. Ghisi D, Fanelli A, Tosi M, et al. Monitored
at preventing or delaying functional decline and anesthesia care Minerva Anestesiol.
disability in frail, older persons: A consensus 2005;71:533-8.
report. J Am Geriatr Soc. 2004; 52:625-34. 39. Beauregard L, Pomp A, Chinire M. Severity
29. Fried LP, Tangen CM, Walston J, et al. Frailty in and impact of pain after day surgery. Can J
older adults: Evidence for a phenotype. J Gerontol Anaesth.1998;45:304-11.
A Biol Sci Med Sci. 2001;56:M146-M156. 40. Solca M, Savoia G, Mattia C, et al. Pain control in
day surgery: SIAARTI Guidelines. Min Anestesiol.
30. Fleisher LA, Pasternak LR, Herbert R, et al.
2004;70:5-24.
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41. Chung F, Chan VW, Ong D. A post-anesthetic
outpatient surgery in elderly patients: importance discharge scoring system for home readiness
of patient and system characteristics and location after ambulatory surgery. J Clin Anesth.
of care. Arch Surg. 2004; 139(1):67-72. 1995;7:500.
 CHAPTER 15
Management of Local
Anesthesia Toxicity
Raminder Sehgal

Local anesthetics are generally safe and in the operation theater, labor room or the
effective but have the potential to cause wards and are based on the currently available
adverse side effects. These effects vary from literature and focus on prevention, timely
allergic reactions commonly seen with esters, detection and stepwise treatment of LAST.
methemoglobinemia produced by Prilocaine,
local muscle or nerve damage to severe central
GENERAL GUIDELINES
nervous system (CNS) and/or cardiovascular
system (CVS) toxicity which can be life- • Local anesthetics should be used by
threatening. Local anesthetic systemic toxicity physicians who are competent and have
or LAST occurs as a result of high plasma the skill necessary to administer local
levels of local anesthetics which may be due anesthetics and recognize the signs and
to overdosing (concentration x volume), rapid symptoms of toxicity. A physician competent
absorption from injection site, diminished to provide resuscitation including CPR and
tolerance or unintentional intravascular provide postanesthesia care should also be
injection. The severity of LAST depends upon available.
the local anesthetic compound, patient risk • Resuscitation equipment including oxygen,
factors which alter its pharmacokinetics suction, equipment to manage the airway
(cardiac, hepatic and renal failure, extremes (laryngoscope, endotracheal tubes, bougies,
of age, pregnancy), acid-base status, tissue supraglottic airway devices), equipment to
vascularity, rate of drug administration and provide ventilation (selfinflating bag and
the location and technique of the block. The face mask), vital sign monitor, emergency
CNS is more sensitive to local anesthetic than drugs required during cardiopulmonary
the CVS. The relative CV/CNS ratio describes resuscitation (CPR) and 20% intralipid should
the dose required to produce arrhythmias or be available wherever local anesthetics are
cardiovascular collapse versus that required to used.
produce seizures. Lower the ratio, more toxic • A thorough preanesthetic check-up
is the drug. The CV/CNS ratio for bupivacaine should be done for all patients to identify
is 2.0, for ropivacaine 2.2 and for lignocaine comorbidities and drug intake likely to affect
7.1 indicating higher cardiotoxicity potential the LAST.
of bupivacaine. These practice management • Informed consent should be obtained before
guidelines apply to the use of local anesthetic embarking on the procedure.
110 Practice Guidelines in Anesthesia

• An intravenous access should be ensured least one circulation time between each
before injecting local anesthetic and should increment.
be kept in place till its effect has worn off. • Aspirate frequently between injections
(every 3–5 mL) to observe for blood.
• Maintain constant verbal contact with
PREVENTION
the patient and monitor for signs of LAST.
• Choose the local anesthetic agent with Clinical signs of toxicity may be delayed up
the best safety profile. The dose and to 30 minutes.
concentration should be the lowest one
which will achieve the desired clinical effect.
DIAGNOSIS
Dose reduction is particularly important in
patients at risk of LAST like those at extremes • Look for CNS and CVS signs and symptoms
of age (< 4 months and > 70 years), those with of LAST which are biphasic, with initial
ischemic heart disease or conduction defects stimulation followed by depression.
and hepatic or renal failure.
The CNS manifestation includes:
• Consider the use of ultrasound during
• Pre-excitation: Tinnitus, light headedness,
peripheral nerve blocks for accurate
confusion, circumoral numbness,
placement of local anesthetic around the
paresthesia, diplopia.
nerves thus reducing the dose required for
• Excitation: Agitation, shivering, tremors,
desired effect. Ultrasound guidance also
twitching, convulsions.
reduces the onset time, increases success
• Depression: Unconsciousness, respiratory
rate and reduces the chance of accidental
depression, respiratory arrest.
intravascular placement.
Respiratory or metabolic acidosis increases
• Consider the use of a benzodiazepine for
cerebral blood flow thus increasing drug delivery
premedication as it can lower the probability
to the brain, and in turn increases the CNS
of seizures and make the patient comfortable.
toxicity. Acidosis also decreases intracellular
• Consider the use of test dose with a reliable
pH, causes ion trapping and decreases plasma
marker of intravascular placement.
protein binding to increase free base. Thus
Adrenaline given in a concentration of 10 to
immediate control of airway, oxygenation and
15 mcg/mL detects intravascular placement
controlling the seizures is of utmost importance.
if it produces increase in heart rate by ≥ 10
to 15 beats per minute or increase in systolic The CVS manifestation includes:
blood pressure by ≥ 15 mm Hg. For children • Hyperdynamic phase: Tachycardia,
adrenaline 5 mcg/kg produces a rise in hypertension, arrhythmia.
systolic blood pressure by 15 mm Hg. This test • Progressive hypotension due to peripheral
dose is not reliable in the elderly, patients on vasodilation.
beta blockers and patients who are sedated • Conduction block: Increased PR interval and
or anesthetized. Low cardiac output states QRS duration, bradycardia or asystole.
prolong drug circulation and may not show • Ventricular arrhythmia: Ventricular
hemodynamic alterations reliably. Caution tachycardia, ventricular fibrillation, Torsades
should be exercised as false negative result de Pointes.
are also reported. Fentanyl 100 mcg can also Note that the CNS toxicity precedes CVS
be used as a test dose in laboring patients. It toxicity but in case of direct intravascular
produces drowsiness in case of intravascular injection the CNS symptoms may be bypassed.
injection. With more potent local anesthetics, the cardiac
• Administer local anesthetic slowly in small toxicity may manifest simultaneously with
increments of 3 to 5 mL with a pause of at seizures or may even precede it.
 Management of Local Anesthesia Toxicity 111

MANAGEMENT OF LAST arrhythmogenic potential and is seen to

• Immediate measures: result in poorer outcome in bupivacaine
– Stop injection of local anesthetic. induced asystole).
– Call for help. – Avoid vasopressin (Has poorer outcome).
– Maintain airway, use supraglottic airway – Avoid calcium channel blockers and beta-
devices or endotracheal tube if required. adrenergic receptor blockers.
– Ventilate lungs with 100% oxygen to – Use amiodarone for arrhythmia.
prevent hypoxia, hyperventilate to – Consider sodium bicarbonate to maintain
prevent acidosis which potentiates the pH > 7.25.
severity of LAST. – Consider therapy with H1 and H2
– Secure intravenous access if not already blockers.
in place. – Consider transcutaneous or intravenous
• Control seizures with: pacemakers for bradyarrhythmia.
i. Intravenous midazolam 2 to 5 mg (drug of – Consider cardiopulmonary bypass as
choice) or a bridging therapy till local anesthetic
ii. Thiopentone 50 to 100 mg in small levels decrease in the tissues.
incremental doses or – Continue CPR for at least 60 minutes
iii. Propofol 1 mg/kg in small incremental as good neurologic recovery is possible
doses. after prolonged cardiac arrest from local
iv. If seizures persist, administer muscle anesthetics.
relaxant in small doses (succinylcholine 1 – Observe patient for at least 12 hours after
mg/kg). the injection.
Note: Use lowest effective dose of thiopentone • Start lipid emulsion therapy at the earliest
and propofol as it can cause hypotension and sign of LAST (prolonged seizures. arrhythmia,
severe myocardial depression. rapid progression of toxicity), soon after the
Muscle relaxants also help by facilitating airway management as follows:
controlled ventilation thus preventing hypoxia, – Give initial bolus of 20% intralipid
hypercarbia and acidosis which exacerbates emulsion 1.5 mL/kg lean body weight
cardiotoxicity. over 1 minute.
Evidence is emerging on the early use of – Simultaneously start intravenous infusion
lipid emulsion to control seizures and prevent of 20% intralipid emulsion at the rate of 15
cardiac toxicity. mL/kg/h (0.25 mL/kg/minute).
Consider use of sodium bicarbonate to – If cardiovascular stability is not achieved,
prevent/treat acidosis. give a maximum of two repeat boluses
• Treat hemodynamic instability to maintain of 20% intralipid emulsion, keeping 5
coronary perfusion, cardiac output and minutes between each bolus.
oxygenation: – Double the rate of infusion to 30 mL/kg/h
– Use vasopressors to treat hypotension (0.5 mL/kg/minute) after 5 minutes if
and atropine to treat bradycardia cardiovascular stability is not achieved.
– Use amiodarone (150 mg) to treat – Continue 20% intralipid infusion
arrhythmias. throughout resuscitation and till 10
– Do not use lignocaine to treat arrhythmia. minutes after the patient is stable and
It may add to the cardiotoxicity. adequate circulation is restored.
• Manage cardiac arrest and arrhythmias Caution: Do not exceed the maximum
using standard BLS and ACLS protocol with cumulative dose of intralipid (12 mL/kg).
following modifications: Do not use propofol as a substitute for lipid
– Use small dose of adrenaline 10 ot emulsion. (Has low lipid content and causes
100 mcg boluses in an adult (It has myocardial depression).
112 Practice Guidelines in Anesthesia

Prevention is the key to avoiding potentially 4. Cox B, Durieux ME, Marcus MAE. Toxicity of
serious consequences of local anesthetic local anaesthetics. Best Practice & Research
toxicity. Selecting a safe local anesthetic in Clinical Anaesthesiology. 2003;17(1):111-36.
correct dose, close monitoring for signs of LAST 5. Dewaele S, Santos AC. Toxicity of local
and instituting early treatment will prevent anesthetics. NYSORA- The New York School of
progression to more serious systemic toxicity. Regional Anesthesia. [Link] accessed.
Timing of lipid emulsion is controversial but 24.9.13.
evidence is emerging which supports early 6. Neil JM, Bernards CM, Butterworth JF, et al.
administration at the first sign of toxicity. ASRA Practice Advisory on Local Anesthetic
Systemic Toxicity. Reg Anesth Pain Med.
Bibliography 2010;35(2):[Link]. accessed.
7. Perioperative ACLS. 2011; [Link].
1. AAGBI Safety Guide. Management of severe local accessed 24.9.13.
anaesthetic toxicity. 2010. [Link]. 8. Rajan N. Management of severe local anaesthetic
2. Adam VN, Markic A, Sakic K, et al.
toxicity. Update in Anaesthesia. www.
Local Anaesthetic Toxicity. Period Biol.
2011;113(2):141-6. [Link]. accessed 24.9.13.
3. Bern S, Weinberg G. Local Anesthesia toxicity 9. Weinberg GL. Lipid infusion therapy:
and lipid resuscitation in pregnancy. Current Translation to clinical practice. Anesth Analg.
Opinion in Anestheiology. 2011;24:262-7. 2008;106:1340-2.
 CHAPTER 16
Interhospital Transfer
of Critically Ill Patients
Rashmi Datta

INTRODUCTION is both within a given hospital (intrahospital

Acutely-ill patients are routinely transferred transfer) to undergo tests and procedures or
to alternate locations to obtain additional between hospitals (Interhospital transfer), as
technical, cognitive, or procedural care, that patients may require transfer to other facilities
is not available at the existing location, either for specialized services. Critically ill patients in
to a higher level of care or for a specialty particular commonly require such secondary
service. Although they may appear stable, transfers and are at high-risk for complications
the physiological reserves of these patients en route.
are limited. Even minor adverse physiologic Interhospital transfers can also be either
changes can cascade into life-threatening Emergency transfer due to either lack of
complications. Therefore, transportation diagnostic facilities, staff, clinical expertise
may be considered to represents a period of and/or facilities for safe and effective therapy
cardiopulmonary instability. This is why few in the referring hospital or Semi-urgent inter-
advocate considering performing diagnostic/ hospital transfer. Non-emergency inter-hospital
therapeutic procedures within the hospital or transfer is typified by the nonurgent, planned
the site of accident itself.1-3 transportation of patients, with a medical
Acutely ill patients are at increased risk of need for transport, to and from a healthservice
morbidity and mortality during transport.3,4 provider and between health care providers.
Risk can be minimized and outcomes improved This will encompass a wide range of vehicle
with careful planning, the use of appropriately types and levels of care consistent with the
qualified personnel, and selection and patients needs.3,6-8
availability of appropriate equipment.3-5
During transport, there can be no hiatus in the TRANSPORT TRIANGLE
monitoring or maintenance of a patient’s vital
functions. There are three essential participants during
The transportation may be either primary an interhospital transfer, i.e. referring
transfer (or extra hospital transfer) when patients doctors, Critical Care Transport Team (CCTT)
are transported from the site of occurrence of personnel and receiving doctors. The triangle
accident to the place where they first receive of these three is called transport triangle
medical aid or secondary transfer. The latter (Figure 16.1).
114 Practice Guidelines in Anesthesia

members have to be informed about the risks

and benefits and consent obtained. Medical
and nursing records and the complementary
diagnostic exams should be sent with the
patient.3,8-10
For contacting the tertiary hospital, a
proposed checklist is given in Table 16.1.
Figure 16.1 Transport triangle
Responsibility of Interhospital
CCTT Personnel
RESPONSIBILITIES OF THE
The CCTT vary widely in composition, training
TRANSPORT TRIANGLE
and experience.11 The needs of the patient
Once the decision of transporting a patient is are the deciding factor in the composition of
taken, it should be done as soon as possible. transfer team, the commonality being that they
should have experience in the unique transport
environment and should have the ability to
Responsibility of Referring Doctors
evaluate and initiate appropriate treatment
It is the responsibility of the referring doctors promptly in critical patients. It is mandatory
to ensure that all the required resources for the that they should be trained in basic life support,
treatment are available at the choice place of advanced cardiac life support and advanced
transfer before the transfer of the patient. Family trauma life support.4,8,10-13

TABLE 16.1 Proposed checklist prior to interhospital transfer

Information to the Patient’s name and a detailed information of the medical situation and the predictable
receiving hospital therapy procedures required by the patient
• Names and contacts of the participants in the process of transfer should be recorded
• Requestor’s name and hospital
• Pickup location, if required
• Mode of transportation required, e.g. wheelchair, stretcher
• Time patient must be at destination
• Whether the patient’s chart or other items will also be transported (e.g. whether an
IV or O2 is in place)
• Whether any additional assistance or security is needed
• Isolation precautions, if any
Stability of the • Airway: Airway safe and secured by intubation, tracheal tube position confirmed
patient • Ventilation: Paralyzed, sedated and ventilated, ventilation established on transport
ventilator, adequate gas exchange confirmed by arterial blood gas analysis
• Circulation: Heart rate and blood pressure stable, any obvious blood loss controlled,
circulating blood volume restored, hemoglobin adequate, minimum two intravenous
access, arterial line and central venous pressure monitoring line appropriate
• Disability: Seizures controlled, raised Intracranial pressure managed
• Trauma: Cervical spine protected, pneumothorax drained, intrathoracic and intra-
abdominal bleeding controlled, and bones and pelvic fractures stabilized
• Metabolic: Blood glucose controlled, potassium level checked, ionized calcium, and
acid-base status checked
• Monitoring: ECG, noninvasive blood pressure, capnography, pulse oximetery and
temperature monitoring
 Interhospital Transfer of Critically Ill Patients 115

The CCTT should consist of a doctor Standard documentation should be done (see
(Intensivist, Anesthesiologist, Pulmonologists, later).
in that order as per the stability of the patient),
Critical care nurse and a respiratory therapist.
Responsibility of Receiving Physician
As with doctors, the training of nurses and
respiratory therapists assigned responsibility The receiving hospital cannot refuse to accept
for inter-hospital transport varies widely but it the transfer of a patient who is unstable or
is mandatory that they should have completed has an emergency medical condition if they
a competency-based orientation and has met have the capability and ability to care for the
previously described standards for critical care patient.2,17
nursing.8,10
The CCTT should ideally be a minimum TYPES OF INTERHOSPITAL
of two people or if there are multiple patients,
TRANSPORTATION TEAMS
a formula of n+1 (n = number of critical care
patients) has been suggested. This team is to A vehicle dispatched directly from the referring
prepare the patient for transport, accompany hospital to the receiving hospital constitutes
the patient en-route, monitor and intervene if a one-way transport. When the transport
required. This team does not routinely provide and medical team is sent from the receiving
primary stabilization and also does not replace hospital it is called a two-way transport. When
the medical team capabilities of the referring a third party provides the vehicle and team
and receiving hospitals.11,12 As with many critical from a location other than the receiving or
work situations, all members of the CCTT referring hospital, it is described as a three-
should pass the “I’M SAFE” test as for pilots legged transport. CCTTs can also be of different
before being actively involved (Table 16.2).14 types. A Retrieval CCTT is one who is centrally
Since there will almost certainly be situations located at tertiary referral center. On receiving
when a specialized team is not available for a call, the hospital dispatches these teams. The
inter-hospital transport, each referring and obvious problem is the time delay in arrival
tertiary institution must develop contingency at the site of the patient. A Regional CCTT is
plans using locally available resources for those affiliated to an individual critical care network.
instances when the referring facility cannot On receiving a call, the nearest team proceeds to
perform the transport.15 the site of the patient and, depending upon the
While transportation, special care should condition of the patient, takes him/her to the
be taken to secure patients fully with five point nearest affiliated hospital. Most hospitals have
harness care. All equipment should be fixed. a Hospital CCTT dispatched by the hospital on
The vehicle speed of the ground transport receiving a call and which brings the patient
ambulances (GTAs) should be controlled.4,11,16 back to the same hospital.3,7,9,11,12,14,15,17,18

TABLE 16.2 I’M Safe test for critical care transport team
Illness? Do I have any symptoms?
Medication? Am I using any kind of prescription or drugs?
Stress? Am I under psychological pressure from the job or home?
Have I any worries about financial, health or family problems?
Alcohol? Have I been drinking within eight hours? Within 24 hours?
Fatigue? Am I tired and not adequately rested?
Eating? Have I been eating and drinking adequately?
116 Practice Guidelines in Anesthesia

Specialized transport teams characteris- 500 to 2000 feet. Special rescue helicopters
tically receive consistent and high levels of can go upto 15,000 to 20,000 feet under the
training and experience in the transportation right conditions and for > 30 minutes provided
of critically ill patients, compared with teams additional oxygen is available for all the
assembled ad hoc. occupants. Modern helicopters routinely used
in medical missions are capable of sustained
speed in excess of 150 mph. Moreover, vertical
CHOICE OF VEHICLE
take-off and landing capabilities permit
Choice of transport vehicle is influenced by evacuation of patients from areas inaccessible
numerous factors. These include the nature of to other transport vehicles. Fixed wing aircraft
illness, possible clinical impact of the transport have the advantage of having a greater range
environment, urgency of intervention, and being faster but this is somewhat offset
location of patient, distances involved, by the need for a secondary road transfer at
number of retrieval personnel and volume of either end. There is reduced noise whilst in
accompanying equipment, road transport times flight compared to most helicopters and more
and road conditions, range and speed of vehicle, space to provide in flight quality intensive care.
weather conditions and aviation restrictions for Fixed wing aircraft are also capable of flying in
airborne transport as well as aircraft landing a greater range of weather conditions. Piston-
facilities.18-20 powered unpressurised aircrafts (PPUAs) have
Evacuating the patient can be done by both low cruising altitudes of 8,000-11,000 feet.
Ground Transport Ambulances (GTAs) and These are often noisier and subject to more
Aero-Medical Transfer (AMT). Advantages of turbulence at lower levels. There may be higher
GTAs include a door-to-door service with no route restriction due to weather or terrain. The
requirement of additional transport vehicles. patient’s oxygen status needs more monitoring.
There is ease of personnel training with few On the plus side, PPUAs need less runway for
weather restrictions. Moreover, civilian family take-off and landing and can be flown from
members can accompany the patient (Table unpaved surface. These are ideal for small
16.3). Practical problems while using the hops during which there is less time to climb
currently available GTAs for transfer of patients to higher altitude. Pressurized transport aircraft
are given in Table 16.4. have a cruising altitude of 25,000 to 35,000 feet
AMT use rotary or fixed wing aircrafts. with a cabin altitude maintained between 5,000
The latter may be either pressurized or to 8,000 ft. The absolute lowest cabin altitude is
unpressurized. Helicopters typically cruise at in Emivest SJ30 Business jet (12,000 ft) At 8,000

TABLE 16.3 Advantages of ground transport ambulances

• Readily available
• Adequate operational safety
• Capable of securely carrying at least one stretcher and intensive care equipment
• Safe seating for full team, ideally with access to the head and side of the patient with enough access for
observations and simple procedures
• Equipped with adequate oxygen/other gases for duration of transport
• Fitted with medical power supply with appropriate voltage and current capacity
• Appropriate speed (coupled with) comfortable ride, without undue exposure to accelerations in any axis
• Acceptable noise and vibration levels
• Adequate cabin lighting, ventilation and climate control
• Fitted with overhead IV hooks and sharps/biohazard waste receptacles
• Straightforward embarkation and disembarkation of patient and team
• Fitted with appropriate radios and mobile communications
 Interhospital Transfer of Critically Ill Patients 117

TABLE 16.4 Practical problems while using currently available ground transport ambulances
• T here is limited patient access. The height of the stretcher on which the patient lies is very low and cannot
be adjusted. Also the space behind does not allow for optimum airway management if required.
• GTAs are usually provided with a generator through which all the electromedical equipment and climate
control runs. Most ambulances do not have a vent for the generator leading to fume built-up in the cabin. In
case there is no generator, there is a need to carry additional batteries/AC converters
• Monitoring may be compromised by vibration, motion artifacts and limited visibility
• The motion of the vehicle makes any intervention difficult while the vehicle is moving because of
translational forces both on the patient and CCT.
• Training of the Critical Care Paramedic needs periodic updates in training. Also, frequent moves may hamper
the familiarization of the personel with the equipment.

TABLE 16.5 Tentative list of drugs to accompany critically Ill patients during transfer
Adenosine Adrenaline
Aminophylline Amiodarone
Atropine / Glycopyrrolate Sodium Bicarbonate
Dexamethasone / Methylprednisolone Diazepam / Midazolam
Isosorbide Dinitrate Dobutamine / Dopamine
Dopamine Phenobarbital
Flumazenil Furosemide
Calcium Gluconate Fentanil / Morphine
Mannitol Naloxone
Noradrenaline Paracetamol
Nitroglycerin or Glyceryl Trinitrate Metoprolol / Esmolol
Thiopental Sodium / Propofol Succinylcholine / Vecuronium Bromide
2% Lignocaine (+gel and spray) Ondensetron

ft, while the partial pressure of inspired oxygen accompanies the basic agents or is available
(FiO2) is around 108 mm Hg which is adequate from supplies (“Crash Carts”) located along the
to maintain oxygen saturation (SpO2) of over transport route and at the receiving location. An
90% in a healthy individual, a critically ill patient ample supply of appropriate intravenous fluids
with respiratory compromise could suffer from and continuous drip medications (regulated
hypoxemia.7,18,19,21-23 by battery-operated infusion pumps) has
In India, Air Ambulance Services is provided to be ensured. Supplemental medications,
by companies like EMSOS, Saras, Helping Point such as sedatives and narcotic analgesics, are
and Vibha Life savers to name a few. considered in each specific case. A proposed list
is given in Table 16.5.
ACCOMPANYING MEDICATIONS
ACCOMPANYING EQUIPMENT
Basic resuscitation drugs, including
epinephrine and anti-arrhythmic agents, are The equipment used during interhospital
transported with each patient in the event of transport vary widely. The principle is that
sudden cardiac arrest or arrhythmia. A more all critically ill patients undergoing transport
complete array of pharmacologic agents either should receive the same level of basic physiologic
118 Practice Guidelines in Anesthesia

monitoring during transport as they had in the oxygen concentration of 100% generally is
ICU. This includes, at a minimum, continuous used. However, oxygen concentration must be
ECG monitoring, continuous pulse oximetry precisely regulated for neonates and for those
and periodic measurement of blood pressure, patients with congenital heart disease who have
pulse rate, and respiratory rate. Monitors should single ventricle physiology or are dependent on
be portable, light weight, battery powered. It a right-to-left shunt to maintain systemic blood
is desirable that these should be compatible at flow.2,5,15,22,23,25
destination unit. When available, a memory- Appropriately sized apparatus for each
capable monitor with the capacity for storing patient for airway management which includes
and reproducing patient bedside data will allow laryngoscopes, masks, and endotracheal tubes
review of data collected during the procedure (ETT), has to be transported with each patient.
and transport. ETT position is noted and secured before
In ventilated patients, both monitoring of transport, and the adequacy of oxygenation and
inspired oxygen (FiO2) and end-tidal carbon ventilation is reconfirmed. For practical reasons,
dioxide (ETCO2) monitoring is mandatory. bag-valve ventilation is most commonly
Polarographic oxygen analyzers are less employed during short inter-hospital transfers.
susceptible to electromechanical interference Portable mechanical ventilators are more
and consume less power than paramagnetic appropriate gaining increasing popularity in
analyzers. However, these measure the partial this arena, as they administer prescribed minute
pressure of oxygen and derive the saturation ventilation and desired oxygen concentrations
(SpO2). This has a special consideration for more reliably. Ventilators must be small, light
aero-medical transfers as FiO2 is affected by and robust and economical on gas consumption
altitude. Therefore, either barometric pressure whilst being able to work independently of an
compensation should be in-built, a correction external power source. These must have alarms
factor applied or a manual calibration may to indicate disconnection and excessively high
be required with changing altitudes. While airway pressures and must have a backup
ETCO2 monitoring is independent of altitude, battery power supply Volume preset ventilators
mainstream analyzers are preferred to side- deliver less than set tidal volume (V T). Transport
stream ones; the former is heavy, while the ventilators are a compromise between
latter uses more power and is susceptible to portability and features.1,3,14,15,23,25
water condensation in the sampling tubes.19,21,24 For AMT, gas-driven constant-flow
Critical care patients often have multiple ventilators are less susceptible to altitude
drug infusions running. Infusions must be changes but the V T and minute ventilation
rationalized before transferring patients by may be affected. Increasing altitude can cause
either combining drugs or resorting to boluses an increase in V T in pneumatically controlled
as required. Compact, lightweight syringe driver ventilators, necessitating setting changes in
type pumps can be utilized for low volume flight. Newer ventilators compensate for the
infusions. It is particularly important that these changes in gas density and viscosity in higher
devices be compatible with all types of syringes. altitudes. The extent of the other features
Fluid pressure bags should be available to needed is determined by the level of care
maintain IV flow rates as only minimal elevation required by the patient. Noninvasive ventilation
of fluid bags is possible in most vehicles.17,25 has a limited role in AMT as most systems
An oxygen source with ample supply to have extremely high gas consumption and are
provide for projected needs plus a 30-min impractical except for very short flights.24-26
reserve should be catered for. The amount of It is important that all medical equipment
oxygen in each cylinder should also be checked. used for transfer replicate standards of a
Failure in oxygen supply can have disastrous hospital ICU while functioning in the transfer
consequences. In adults and children, a default environment without endangering patient or
 Interhospital Transfer of Critically Ill Patients 119

vehicular safety. General characteristics of 16.7). One also has to consider the effects of
equipment are given in Table 16.6. low ambient pressure on critical equipment.
In many hospitals, pediatric patients share One has to remember that both the human
diagnostic and procedural facilities with physiological processes and calibration of
adult patients. Under these circumstances, all life support and monitoring equipment is
a complete set of pediatric resuscitation adapted for life at or near sea level and changes
equipment and medications will accompany in pressure with increasing altitude affect both.
infants and children during transport and also An increase in altitude will result in a
will be available in the diagnostic or procedure reduction in partial pressure of oxygen in
area. accordance with Dalton’s law. Increasing
IEC 60601 Standards are accepted by the altitude will also increase gas volume or where
Bureau of Indian Standards as the National volume is restricted there will be a relative
Standard with no National deviation for increase in pressure in accordance with
supporting regulatory regulations and approvals. Boyle’s law. The temperature also decreases by
As per these standards, aeromedical equipment approximately 2°C for every 300 m of altitude
should pass the shock drop and topple tests, gained and the partial pressure of water also
operate correctly at 10,000 feet between falls reducing the humidity of the air. Whereas
temperature ranges of –15 to +50°C and at a hypoxia can be detected with pulse oximetry
relative humidity of 95% and electro-magnetic and mitigated with supplemental oxygen and
emissions should not interfere with flight deck positive end expiratory pressure (PEEP), the
instruments. These tests are also required consequences of gas expansion are difficult to
to obtain the compulsory CE “Conformité recognize and reverse aboard an aircraft.1,15,19,28
Européenne/Communauté Européenne” mark. Gas expansion accounts for the majority
The drop test is for hand-held or hand-guided of contraindications to AMT. Contrary to
devices and three samples are dropped from a common belief, cabin pressurization does not
height of 1.22 m (4 feet) three times on a tile- eliminate this concern. A change from sea level
covered concrete surface. The IEC 60601-1 drop to 8000 feet of altitude will expand the volume
test is a modification in which only one sample of trapped gas (inside body cavities, or air in
is dropped three times from a height of 1 m. The splints or cuff of ETT by approximately 35%. In
ball-impact test is conducted on the top, sides vulnerable patients, this can provoke a tension
and front surfaces of the device under test with pneumothorax, dehiscence of surgical wounds,
an impact of 6.78N-m or 5 ft-lb.2,19, 22, 25,27 intracranial hemorrhage and irreversible ocular
damage. Expansion of air in the cuff of ETTs at
altitude can provoke ischemic tracheal mucosal
AEROMEDICAL CONSIDERATIONS
necrosis and collapse of the cuff during descent
AMT is overwhelmingly dominated by few could cause a loss of V T as well as aspiration.
issues, an increase in altitude and exposure to This problem can be circumvented by replacing
forces of acceleration, noise, vibration (Table air with saline in the ETT cuff. Ventilators may

TABLE 16.6 General characteristics of equipments used for interhospital transfer

•  uggedness
R
• High reliability and validated
• Sufficient internal power with additional capacity for unexpected delays. If battery life is limited, the batteries
should be replaceable with no interruption of the device’s function
• Should be capable of using multiple power supplies (vehicle supplies, invertors, external batteries)
• The devices should be restrained appropriately with suitable lie-down systems, straps or clamps to override
vibrations or gravitational forces
• Use of space-saving rucksacks
120 Practice Guidelines in Anesthesia

TABLE 16.7 Considerations in aeromedical evacuation

Environmental • H ypoxia and its effects on hemodynamics (tachycardia and hypertension)
conditions • Swelling of limbs beneath plaster casts with resulting neurovascular compromise
• Increased volume of air filled endotracheal tube cuffs and body cavities
(pneumothorax)
• Nausea, vomiting because of motion sickness and/or abdominal distention with
possible aspiration in patients with impaired level of consciousness
• In mechanically ventilated patients increased incidence of ventilator induced lung
injury and ventilator associated pneumonia following changes in the delivered tidal
volumes at low barometric pressures
• Acceleration during take off and landing may cause blood pooling
• Decreased humidity with altitude causes drying of mucous membranes, skin, eyes,
bronchopulmonary surfaces and leads to mucus plug formation in ventilated
patients
• Vibration can cause loss of venous access, stress and fatigue on patient and staff,
fracture displacement, bleeding from wounds, effects on equipment, loosen
attachments
• Noise causes crew and patient stress, interferes with vital signs and physical exam
• Hypothermia-temperature drops with altitude, can aggravate acidosis and
coagulopathy
• Third-space loss: Lower ambient pressure results in leakage of fluid from intra-vascular
to extravascular space results in edema, dehydration and hypovolemia
Problems in • D ifficulty in manual check of pulse rate and blood pressure due to noise/ vibration
monitoring • Inaccurate reading of automatic noninvasive blood pressure (under reads systolic
and over reads diastolic)
• Electromagnetic interference between aircraft avionics and electromedical
equipment, can result in equipment malfunction and can compromise flight safety
• Difficulty in hearing audio alarms
• Inaccurate delivery of tidal volume in mechanically ventilated patients
Miscellaneous • E xhaustion of oxygen and power supply
• Difficulty in performing procedure (CPR, endotracheal intubation)
• Disposal of patient body fluids and excreta

also deliver less than the set V T with ascent and output and blood pressure. A patient with a
the reverse with descent leading to volutrauma head injury could have raised intracranial
(see here) Therefore, V T delivered should be tension during ‘take-off’ if positioned feet first.
checked with spirometer.2,8,19,22,23,26-29 The G forces will act in the opposite direction
Acceleration and deceleration is a vector while landing.21,22,26,28
quantity, having both magnitude and direction. The noise level in many of the currently
For this reason, proper positioning of the used transport aircraft including helicopters
patient to limit stresses induced by sustained approaches 90 dB which is approximately
acceleration should be accomplished. In a 2000 times louder than heart/breath sounds.30
supine patient, gravitational forces (G forces) The most basic of monitoring skills require
during acceleration as in ‘take-off’ will act in nothing more than a stethoscope and a
a horizontal axis and will result in pooling of sphygmomanometer. In a flight environment,
blood in the lower extremities if loaded head noise significantly limits the ability of the
first. Healthy humans will be able to mount a caregiver to use these simple tools to assess
compensatory sympathetic response. Patients blood pressure and heart/ breath sounds. Noise
with labile hemodynamics and/or impaired also precludes appreciation of auditory alarms
autonomic function could have a fall in cardiac of ventilators and monitors necessitating
 Interhospital Transfer of Critically Ill Patients 121

continuous eye on the patient and equipment. resolution when patient preparation (Tables
Noise and vibration apart from causing fatigue, 16.9 and 16.10) has been inadequate.
anxiety and contributing to motion sickness
and interfering with communication can LEGAL ISSUES1,16,30,31
also seriously jeopardize monitoring of vital
parameters. Vibration can interfere with graphic • Majority of the doctors were worried in
displays of ECG, pulse oximetry and curves and transporting the accident victims for fear of
loops of ventilatory parameters. Decreased the legal process. But in the strictest sense,
humidity causes respiratory secretions to dry up the law requires the accident victims to
resulting in atelectasis and blockage of tracheal be transported even by the non-medical
tubes.19,23,26 public and if not, it amounts to negligence.
There are no absolute contraindications to (“Negligence is the omission to do something
AMT; level of preparation has to match with which a reasonable man would do, or do
patient requirement. Relative contraindications something which a prudent and reasonable
are listed in Table 16.8. Patient problems man would not do”. Alderson B in Blyth v
during aeromedical evacuation generally defy Birmingham Co (1856)11. Exch (781-784).
• The transport could be accomplished with
medicos or even with paramedical people.
Relative contraindications to Even if the patient dies during transport, the
TABLE 16.8 aeromedical evacuation law just requires the matter to be informed to
• Pneumothorax, unless reduced by chest tube the police personnel.
with underwater seal drainage in place • In Supreme Court criminal writ petition
• Decompression sickness no 270 of 1988 it is held that “It is the duty
• Air embolism (arterial or venous)
of the medical men to render all the help to
• Bowel obstruction from any source (commonly
postoperative)
the patient which he could and also see that
• Unreduced incarcerated hernia the person reaches the proper expert as early
• Volvulus / Intussusception as possible”. So it is the duty of the doctor
• Laparotomy or thoracotomy within previous 7 to render all possible help first and then
days transfer the patient.
• Eye surgery within previous 7–14 days • Before the initiation of any type of transport,
• Gas gangrene the patient or his/her legal representative
• Hemorrhagic cerebrovascular accident within should be informed of the fact and an
previous 7 days
explanation of the situation, reason for
• Severe uncorrected anemia (haemoglobin
< 7.0 g/dL) transport, name of referral hospital should
• Acute blood loss with hematocrit below 30% be given and when necessary his/her
• Uncontrolled dysrhythmia agreement. A summary of risks and benefits
• Irreversible myocardial infarction may be given to the patient or his next-of-kin.
• Congestive heart failure with acute pulmonary • In writ petition no 796 of 1992 the Supreme
edema Court held that before transfer, three
• Acute phase of chronic obstructive pulmonary obligations are imposed:
disease
– Screening the patient
• Acute exacerbation of bronchial asthma
• Acute psychosis
– Stabilizing the patient’s condition
• Spinal injury unless immobilized or traction in – Transfer or discharge of the patient for
place in Stryker frame better treatment.
• Pacemaker (must be prepared to adjust en route • Hospitals cannot transfer the patient unless
with a magnet) the transfer is “appropriate”. The patient
• Beyond 34th week of pregnancy unless medically consents to transfer after being informed
necessary of the risks of transfer and the referring
122 Practice Guidelines in Anesthesia

TABLE 16.9 Goals and checklist of patient preparation

Head injuries •  void intracranial hypertension
A
– Position head end of patient towards nose end of aircraft to avoid acceleration-
induced rise in intracranial pressure
– Altitude restriction should be considered if raised intracranial pressure as low
partial pressure of oxygen can increase intracranial pressure.
• Prevention of secondary brain injury by avoiding
– Hypoxia (keep SpO2 > 92–94%)
– Shock (keep MAP > 70 mm Hg; CVP > 5 mm Hg)
– PaCO2 around 35–40 mm Hg in first 24 hours of flight)
– Blood glucose <150 mg/dL
– Serum osmolarity 280 and 320 mOsm
– Serum sodium between 130 and 150 mEq/L
– Avoid hypothermia, anemia, coagulopathy
• Patients with a Glasgow Coma Scale ≤ 12 should be intubated and sedated with
continuous infusion of propofol before air evacuation
• Antiepileptic medication should be administered
Fascio-maxillary • I f patient has wired jaws keep a wire cutters ready
injuries • In a patient with eye injuries, altitude restriction is recommended
• Premedicate with antiemetics before boarding especially if prone to motion
sickness
Chest injuries •  onitor chest lift and SpO2
M
• Maintain adequate oxygenation and ventilation (FiO2 ~ 40% with tidal volumes
6–8 mL/kg)
• Be prepared for needle thoracostomy and/or chest tube placement
• Keep ICD open and functional throughout the flight
• Tracheotomy tubes should be changed before flight and an extra tube should be
sent with the patient
Abdominal injuries •  heck for occult and frank hemorrhage
C
• Avoid hypothermia, acidosis, coagulopathy, sepsis
• Monitor for abdominal compartment syndrome (urinary output, bladder pressures
and peak airway pressures)
• Patients prone to paralytic ileus from any cause should have nasogastric tube in
place. Patient with colostomy, an extra colostomy bag should accompany these
patients as drainage is more profuse because of gas expansion
Neurological injuries • Nasogastric tube should be inserted in patient with quadriplegia, paraplegia and
left to gravity drain
• Free swinging weights for traction are unacceptable for flight, cervical traction via a
Collins traction device should be applied
Orthopedic injuries • E nsure optimal stability of the fracture segments
• Watch for hemorrhage
• Monitor for fat embolism, compartment syndrome, neurovascular injuries,
rhabdomyolysis
• Consider deep vein prophylaxis
• Avoid use of pneumatic splints as during hypobaria in splint-pressure will increase
Hemorrhagic shock • E nsure minimum hemoglobin of 7.0 g/dL
• Patients with shock are likely to have increased intravenous fluid requirements in
flight; so keep pressure bags rapid for rapid infusion

(Contd...)
 Interhospital Transfer of Critically Ill Patients 123

(Contd...)
Burn injuries • Ensure escharotomies for full thickness circumferential burns before emplaning
Airway management •  se saline for filling cuff of endotracheal / tracheostomy tube
U
• Use tube fixator for better fixing of endotracheal tube
• Give supplemental oxygen to maintain oxygen saturation(SpO2) > 90%
Cardiac Patients • Evacuation should be undertaken 10 days post MI or 5 days pain free period and
should receive supplemental oxygen en-route
General points • Patient should be stable enough to tolerate a trip of 6–8 hours with a high
probability of not developing any complications en-route’
• Use of eye pads / ointment / artificial tears in unconscious patient
• Ensure all drainage tubes are unclamped and left to gravity drain

TABLE 16.10 Sample preflight checklist – The receiving facility must have available
•  onfirm there are no contraindications to air
C space and qualified personnel and agree
evacuation to accept the transfer.
• Complete trauma survey – The inter-facility transport must be made
– Perform chest radiography to rule out by qualified personnel with the necessary
pneumothorax equipment.
– Perform radiography or CT of facial or skull • State Commission of Kerala No. 19 of 1990
trauma and West Bengal No. 101/0/1997 held that
• Check all medical equipment is present and transfer in a car is not negligent if all possible
functioning
assistance were given to the patient while
• Check battery status of ventilator, monitors and
oxygen requirement including reserves transportation.
• Secure all lines, tubes and drains • A receiving hospital cannot refuse to accept
• Remove or deflate air splints the transfer of a patient who is unstable or
• Deflate air balloons, ETT cuff and fill with saline has an emergency medical condition if they
• Confirm ground ambulance for departure and have the capability and ability to care for the
destination airfields patient.
• Carry all medical records, lab reports and imaging • A standard documentation should be
reports
developed across the network and be used
• Liaison with the air-crew for:
– Requirement of cabin altitude restriction for both intrahospital and interhospital
(CAR) if any, as per clinical condition of patient transport. This should include a core data
– Weather en-route set for audit purposed and CCT should able
– Time to diversionary airfields to retain a duplicate for such purposes.
– Contingency plans, including diversion Document should include transfer details,
options a medical summary, a nursing summary of
the patient during transfer and audit data
including reasons for transfer, urgency of
physician certifies that the medical benefits transfer, time taken from time of requesting
expected from the transfer outweigh the for the ambulance to completion, any
risks. Appropriate transfers must meet the adverse events/critical incidents en-route.
following criteria: • Precise, complete and detailed
– The transferring hospital must provide documentation is essential not only for good
care and stabilization within its ability. patient care but also adequate legal defense
– Copies of medical records and imaging if charges arise later. If documentation is
studies must accompany the patient. appropriate, the burden of establishing
124 Practice Guidelines in Anesthesia

negligence rests on plaintiff. To prove are sentimentally exposed to a dead body being
negligence, the plaintiff has to prove both cut up. In fact generally autopsy is resisted.
a breach of duty on the part of the doctor In the US, there is a statute called Emergency
which resulted in damage to the patient. Medical Treatment and Active Labor Act
• However, if the documentation is (EMTALA) which was enacted by introducing it
incomplete/lost, “spoliation” comes into in 1986 into the Consolidated Omnibus Budget
play. Spoliation means “lost for a reason”. In Reconciliation Act, 1985 (COBRA). This Act is
this case, the plaintiff no longer required to also known as the Patient Anti-Dumping Act.
prove negligence. The onus of responsibility The basic principles include:
rests on the defendant to prove that the • Hospitals have to provide a medical screening
documentation was inadvertently lost and examination for all patients seeking medical
not “misplaced” as a means of concealing his attention in order to determine if a medical
true actions. emergency situation exists.
• While recording the Accident Register, • A patient may not be transferred to another
utmost care has to be exercised, as it would facility if they are at risk to deteriorate from
be the valid legal document in the court of or during transfer with the caveat that ‘Unless
law. The conscious status of the patient is to the current hospital cannot meet the needs of
be mentioned in an undoubted way as the the patient’.
court decides the reliability of the statement • The patient may not be transferred if he/she
only on that score. The person from whom is unstable and remain at risk of deterioration
the history is elicited is to be very clearly unless the sending physician certifies in
stated as the version from the person other writing that the benefits to be obtained at the
than the patient is a statement whereas from receiving hospital justify the risks of transfer.
the dying patient it is the Dying declaration. • The patient must be accepted by the
• As per the Dec 2013 Supreme Court (SLP receiving hospital prior to transfer.
No(C) No.25237/2010) ruling, GTAs can use • The receiving hospital must accept the
red lights of the blinker type with a purple patient if it has the space and the skills
glass. The ruling has upheld the use of multi- necessary to care for the patient.
toned horns as per rule 119(3) of the 1989 • The patient or a legally responsible person
Motor Acts Rules though one should use the must request the transfer after being advised
siren only if the patient is instable. of the risks and benefits of transfer.
• In trauma cases, postmortem is Compulsory. • The sending hospital must provide whatever
– The state commission of Gujarat (No. 77 treatment is within its capabilities to ensure
of 1993) held that “It is the duty of the that the patient is stabilized prior to transfer.
medical officers to prove or rule out the
cause of death for which they are allegedly
CONCLUSION
responsible. Only avenue open to them
was postmortem. It is no valid excuse to Choice of aircraft or ground ambulance depends
say that the relatives declined postmortem upon patient care issues. The Commission on
or they signed their unwillingness”. Accreditation of Medical Transport Systems
– In petition No. 84 of 1991 “National (CAMTS), recently published Accreditation
Commission observed”, when the cause Standards states that “Any in-service aircraft/
of death is not in doubt there was no ambulance can be configured in such a way
occasion for the hospital authorities to that the medical transport personnel can
suggest autopsy. provide patient care consistent with the mission
It may be noted that according to Indian statement and scope of care of the Medical
Cultural beliefs and cremation practices, people Transport Service”.
 Interhospital Transfer of Critically Ill Patients 125

GTAs are generally used. Advancements 10. Bérubé M, Bernard F, Marion H, et al.
in the field of aviation (tilt-rotor aircraft) Impact of a preventive programme on the
and medical technology (user friendly, occurrence of incidents during the transport of
sophisticated, miniature monitoring and life critically ill patients. Intensive Crit Care Nurs.
2013;29(1):9-19.
support equipment, point of care testing)
11. Droogh JM, Smit M, Hut J, et al. Inter-hospital
can create an “ICU in the sky” which can offer transport of critically ill patients; expect
state-of-the-art critical care to critically-ill surprises. Crit Care. 2012;16(1):R26.
patients right from the place of injury to tertiary 12. Grisson TE, Farmer JC. The provision of
care centers. However these technological sophisticated critical care beyond the hospital.
advancements need to be backed with properly Lessons from physiology and military
trained medical teams who are well versed experiences that apply to civil disaster medical
with important aspects unique to aero-medical response. Crit Care Med. 2005;33:S13-S21.
evacuation including the effects of flight 13. Kupas DF, Wang HE. Critical care paramedics
physiology on medical conditions, oxygen -a missing component for safe interfacility
transport in the United States. Ann Emerg Med.
limitations, and distinctive medication and
2014;64(1):17-8.
equipment requirements.
14. US. Federal Aviation Administration-H-8083-25.
“The Pilot’s Handbook of Aeronautical
REFERENCES Knowledge” CFR Part 91 Sec. 91.103 - Preflight
Action page 16-6.
1. Ira J Blumen, Frank Thomas, David Williams. 15. Ramnarayan P. Measuring the performance of an
Transportation of the critically ill patients. In: inter-hospital transport service. Arch Dis Child.
Jesse B Hall, Gregory A Schmidt, Lawrence DH 2009;94(6):414-6.
Wood (Eds). Principles of critical care. 3rd edn. 16. Pontecorvo C, Minerva M, Vitali F, et al. Inter-
McGraw-Hill Medical Publishing Division. 2005. hospital transport of the critical patient. Minerva
pp.79-91. Anestesiol. 1991;57(12):1819-20.
2. Papson JP, Russell KL, Taylor DM. Unexpected 17. Kumari S, Kumar S. Patient safety and prevention
events during the intrahospital transport
of unexpected events occurring during the intra-
of critically ill patients. Acad Emerg Med.
hospital transport of critically ill ICU patients.
2007;14(6):574-7.
Indian J Crit Care Med. 2014;18(9):636.
3. Warren J, Fromm RE Jr, Orr RA, et al. Guidelines for
18. Grisson TE, Farmer JC. The provision of
the inter- and intrahospital transport of critically
sophisticated critical care beyond the hospital.
ill patients. Crit Care Med. 2004;32(1):256-62.
Lessons from physiology and military
4. Koppenberg J, Taeger K. Interhospital transport:
experiences that apply to civil disaster medical
transport of critically ill patients. Curr Opin
response. Crit Care Med. 2005;33:S13-S21.
Anaesthesiol. 2002;15(2):211-5.
5. SIAARTI Study Group for Safety in Anesthesia 19. Milligan JE, Jones N, Helm DR. et al. The
and Intensive Care. Recommendations on principles of aeromedical retrieval of the
the transport of critically ill patient. Minerva critically ill. Trends in Anaesthesia and Critical
Anestesiol. 2006;72(10):XXXVII-LVII. Care. 2011;1:22-6.
6. Berlac PA, Wammen S, Giebner M, et al. 20. Calland V. Extrication of the seriously injured
Ambulance transportation Guidelines. Ugeskr road crash victim. Emerg Med J. 2005;22:817-21.
Laeger. 2010;26;172(17):1300-3. 21. Thomas SH, Brown KM, Oliver ZJ, et al. An
7. Sethi D, Subramanian S. When place and Evidence-based Guideline for the air medical
time matter: How to conduct safe inter- transportation of prehospital trauma patients.
hospital transfer of patients. Saudi J Anaesth. Prehosp Emerg Care. 2014;18 (Suppl 1):35-44.
2014;8(1):104-13. 22. Liu X, Liu Y, Zhang L, et al. Mass aeromedical
8. Blakeman TC, Branson RD. Inter- and intra- evacuation of patients in an emergency:
hospital transport of the critically ill. Respir Care. experience following the 2010 Yushu earthquake.
2013;58(6):1008-23. J Emerg Med. 2013;45(6):865-71.
9. Rice DH, Kotti G, Beninati W. Clinical review: 23. Cornelius M. Care in the air: bringing the
critical care transport and austere critical care. wounded closer to home. Plast Surg Nurs.
Crit Care. 2008;12(2):207-11. 2009;29(3):165-8.
126 Practice Guidelines in Anesthesia

24. Helm M, Schuster R, Hauke J, et al. Tight control of of Polish Medical Air Rescue. Anestezjol Intens
prehospital ventilation by capnography in major Ter. 2010;42(3):174-8.
trauma victims. Br J Anaesth. 2003;90(3):327-32. 29. Lubillo S, Burillo-Putze G, Alonso E, et al.
25. McGuire NM. Monitoring in the field. Br J Helicopter emergency medical service in Canary
Anaesth. 2006;97(1):46-56. Islands, Spain. Eur J Emerg Med. 2000;7(1):55-9.
26. Blakeman T, Britton T, Rodriquez D Jr, et al. 30. Meenakshi Sundaram AL, HonJustice S
Performance of portable ventilators at altitude. Nagamuthu. Medico Legal Aspects in Trauma
J Trauma Acute Care Surg. 2014;77 (3 Suppl Anesthesia. Ind J Trauma. Anaesth Crit Care.
2):S151-5. 2007; 8 (2): 627-31.
27. Stevenson A, Fiddler C, Craig M, et al. Emergency 31. Law Commission of India 201st Report on
department organization of critical care transfers “Medical Treatment after Accidents and During
in the UK. Emerg Med J. 2005;22(11):795-8. Emergency Medical Condition and Women in
28. Gałazkowski R. New possibilities in emergency Labour”.; [Link]. 6(3)125/2006-LC(LS) 31st August,
medical transportation and emergency services 2006.
 CHAPTER 17
Practice Guidelines for
Management of the Difficult Airway
SK Malhotra

The guidelines for difficult airway management • When it is difficult to ventilate using
are recommendations that can be changed facemask or supraglottic device. It may
and altered as per the resources and clinical be due to leak or resistance in the circuit
requirement of an institute. Guidelines may not and may be detected as inadequate chest
take place of a hospital protocol and therefore inflation, decreased breath sounds, signs of
should not be called absolute standards that obstruction, desaturation as well as features
can bring definite results. From time to time, due to hypoxia or hypercarbia such as
the guidelines undergo amendments as the rhythm disturbances.
medical skills and know-how develops. The • There is problem in insertion of supraglottic
suggestions given in guidelines are based on device owing to anatomical abnormality.
existing literature and data which has clinical • Routine laryngoscopy does not allow
practicability and skill in the field. Task Force visualization of larynx, partially or completely
on Difficult Airway Management has given the in spite of several attempts.
guidelines that have been accepted by ASA. • Difficulty in intubation of trachea due to
anatomical or pathological causes.
• Not possible to intubate trachea at all,
Definitions
despite numerous attempts.
An ideal definition to describe difficult airway is Goal of the airway guidelines is to accomplish
not there in the scientific literature. However, it the security of airway and to decrease the
can be defined as a “clinical situation in which complications such as trauma to teeth and
a conventionally trained anesthesiologist airway, need for surgery to achieve airway,
experiences difficulty with facemask ventilation cerebral hypoxia and even cardiac or respiratory
of the upper airway, difficulty with tracheal arrest. The major aim of guidelines is to secure
intubation, or both”.1 Various factors affecting airway during anesthesia under the control of
this situation are condition of the patient, an anesthesiologist at different locations and in
resources available and experience of the all age groups.
anesthesiologist. The Task Force recommends The guidelines were first prepared in 2002 by
that anesthesiologists should employ clear Task Force comprising of ten anesthesiologists
descriptions of the difficult airway. Some of the appointed by ASA. They reviewed and evaluated
descriptions advocated are as follows: the difficult airway literature from indexed
128 Practice Guidelines in Anesthesia

journals. From all the material, a consensus oxygen throughout the procedure to avoid
was made and guidelines finalized. In 2011, the hypoxia.7 The facemask, nasal cannulae,
guidelines were evaluated again after reviewing supraglottic device or simple insufflation
the literature and various recommendations may be employed for this purpose. The
were made. pediatric patients may not cooperate during
preoxygenation.
The presence of “Difficult airway
Assessment of Airway
management cart” is of great value and should
The past medical records and history must be contain the essential items (Table 17.2).
evaluated for a difficult airway before taking the
patient for anesthesia. This helps in identifying
Plan for Difficult Airway Intubation
anesthetic and medical aspects that may
influence the airway. Various factors affecting The strategy to manage difficult airway
airway management include age, obesity, may be guided by ASA algorithm for airway
obstructive sleep apnea, history of difficult management (Fig. 17.1). The plan depends on
laryngoscopy or intubation.2,3 the kind of surgery, patient’s condition and the
A thorough physical examination may help choice of anesthetist.
in detecting anatomical abnormalities in the Following points must be considered to plan
upper airway.4-6 Various features to assess a difficult airway:
airway are recognized (Table 17.1). • Patient’s consent is vital and so is his will to
cooperate. One may find it hard to ventilate
by mask. The insertion of supraglottic device
Preparation of Airway Management
may be difficult. Successful laryngoscopy
The availability of difficult airway devices in and intubation as well as surgical airway may
the form of “Airway management cart” must be difficult.
be assured. The patient with difficult airway • Anesthesiologist should consider various
should be explained beforehand about the choices, such as, (a) consideration of GA
risks and complications involved. An assistant versus awake technique for intubation.8,9
should be ready in case difficult airway has to (b) Percutaneous or surgical access
be handled. The role of preoxygenation is vital for airway. (c) Intubation while
to buy precious time as well as supplementing maintaining spontaneous ventilation.
(d) Use of videolaryngoscope as primary
approach.10,11
TABLE 17.1 Features of airway assessment
1. Any protruding teeth
2. Mouth opening ( < 3 cm) TABLE 17.2 Difficult airway management cart

3. Uvula–its visibility (Mallampati class > 2) 1. Various kinds and sizes of laryngoscopic blades

4. Length/thickness of neck 2. Tracheal tubes-appropriate size

5. Thyromental distance ( < 6 cm) 3. Fiberoptic bronchoscope

6. Neck extension/flexion 4. Videolaryngoscope

7. Jaw protrusion (Relationship of maxillary and 5. Stylets, light wands

mandibular incisors) 6. Bougie, tube changer
8. Upper lip biting test 7. Supraglottic devices (LMA/Intubating LMA)
9. Shape of palate (high arched palate) 8. Devices to secure emergency surgical airway
 Practice Guidelines for Management of the Difficult Airway 129

Figure 17.1 Difficult Airway Algorithm (Courtesy: American Society of Anesthesiologists).

130 Practice Guidelines in Anesthesia

• Assess whether the patient can be ventilated Documentation should include the
or there is a critical “cannot ventilate, cannot following:
intubate” situation.12 • The details of the difficulties faced during
mask ventilation as well as intubation.
• The mention of various devices and
Alternative Approaches for
techniques used to secure airway.
Difficult Ventilation
• The role and advantages of the devices used
If ventilation with facemask fails, other devices in the process.
that may be employed are, supraglottic airway, The patient should be apprised of the airway
oral/nasal airway, rigid bronchoscope, two difficulty involved and how the intubation
person ventilation with mask or transtracheal was secured. This would help in appropriate
invasive ventilation.13,14 management in future. A detailed report about
airway management must be written in the
patient record. The concerned surgeon or
Alternative Approaches for
caregiver should also be informed. The aftercare
Difficult Intubation of the expected complications following difficult
In case initial approach to ventilate is not airway is a must, such as, laryngeal edema,20
successful, some alternative plans may be damage to trachea, pulmonary aspiration21
considered. Among these, awake intubation and pneumothorax.22 If any features of these
is commonly considered. Other approaches complications appear, like pain in the throat,
may be blind intubation,15 use of bougie/ swelling or tenderness of the face and neck,
light wand,16 changing laryngoscope blade, problem in swallowing or pain in the chest must
videolaryngoscope or fiberoptic intubation.17 be communicated immediately.

Plan for Extubation Key Points

There should be an appropriate plan for • Always carry out a thorough and detailed
extubation keeping in mind the kind of surgery airway assessment during preanesthesia
and clinical aspects of the patient.18 check-up.
• The effect of extubation on ventilation must • If indicated by evaluation, anticipate the
be considered. probability of encountering a difficult airway.
• A strategy should be thought regarding steps • If severe difficulty expected, try to secure
to be taken if patient cannot maintain proper airway using awake technique.
ventilation after extubation. • In case the initial plan fails, have backup
• Stylet may be left in the trachea that would plan(s) to secure the airway successfully.
help in case reintubation is required.
• Similarly, LMA or intubating LMA may be left REFERENCES
in place to ensure satisfactory re-intubation. 1. Apfelbaum JL, Hagberg CA, Caplan RA, et al.
Practice guidelines for management of the
Postoperative Care and difficult airway: An updated report by the
American Society of Anesthesiologists Task
Documentation Force on Management of the Difficult Airway.
A proper documentation should be made Anesthesiology. 2013;118:251-70.
2. Ezri T, Medalion B, Weisenberg M, et al. Increased
about the difficulties encountered in securing
body mass index per se is not a predictor of
airway.19 This will help in undertaking proper difficult laryngoscopy. Can J Anaesth. 2003;
management in the future. 50:179-83.
 Practice Guidelines for Management of the Difficult Airway 131

3. Heinrich S, Birkholz T, Ihmsen H, et al. Incidence 12. Das B, Nasreen F, Haleem S, et al. A “cannot
and predictors of difficult laryngoscopy in ventilate, cannot intubate” situation in a patient
11,219 pediatric anesthesia procedures. Paediatr posted for emergency surgery for acute intestinal
Anaesth. 2012; 22:729-36. obstruction. Anesth Essays Res. 2013;7:140-1.
4. Rose DK, Cohen MM. The airway: Problems and 13. Cook T, Howes B. Supraglottic airway devices:
predictions in 18,500 patients. Can J Anaesth. recent advances Contin Educ Anaesth Crit Care
1994;41(5 Pt 1):372-83. Pain. 2011;11(2):56-61.
5. Tremblay MH, Williams S, Robitaille A, et al. 14. Davidovic L, LaCovey D, Pitetti RD. Comparison
Poor visualization during direct laryngoscopy of 1- versus 2-person bag-valve-mask techniques
and high upper lip bite test score are predictors for manikin ventilation of infants and children.
of difficult intubation with the GlideScope Ann Emerg Med. 2005;46(1):37-42.
videolaryngoscope. Anesth Analg. 2008; 15. Holzapfel L. Nasal vs oral intubation. Minerva
106:1495-500. Anesthesiol. 2003;69(5):348-52.
6. Wilson ME, Spiegelhalter D, Robertson JA, et 16. Kim JH, Kim KW, Park J, et al. Use of light wand
al. Predicting difficult intubation. Br J Anaesth. as an adjunct during intubation of patient with
1988;61:211-6. large epiglottic cyst. Korean J Anesthesiol.
7. Xue FS, Tong SY, Wang XL, et al. Study of the 2013;65(6 Suppl):S21-2.
optimal duration of preoxygenation in children. 17. Collins SR, Blank RS. Fiberoptic intubation:
J Clin Anesth. 1995;7:93-6. an overview and update. Respir Care. 2014;
8. Dimitriou VK, Zogogiannis ID, Liotiri DG. 59(6):865-78.
Awake tracheal intubation using the Airtraq 18. Cavallone LF, Vannucci A. Extubation of the
laryngoscope: A case series. Acta Anaesthesiol difficult airway and extubation failure. Anesth
Scand. 2009;53:964-7. Analg. 2013;116(2):368-83.
9. Suzuki A, Toyama Y, Iwasaki H, et al. Airtraq for 19. Haigh FP, Swinton FW, Dalgleish DJ.
awake tracheal intubation. Anaesthesia. 2007; Documentation and communication of the
62:746-7. ‘difficult airway’. Anaesthesia 2006;61(8):817.
10. Koh JC, Lee JS, Lee YW, et al. Comparison of the 20. Divatia J, Bhowmick KV. Complications of
laryngeal view during intubation using Airtraq endotracheal intubation and other airway
and Macintosh laryngoscopes in patients with management procedures. Indian J Anaesth.
cervical spine immobilization and mouth opening 2005;49(4):308-18.
limitation. Korean J Anesthesiol. 2010; 59:314-8. 21. Cook TM, MacDougall-Davis SR. Complications
11. Aziz MF, Healy D, Kheterpal S, et al. Routine and failure of airway management. Br J Anaesth
clinical practice effectiveness of the Glidescope 2012;109:(suppl 1): i68-i85.
in difficult airway management: An analysis of 22. Rashid AM, Williams C, Noble J, et al.
2,004 Glidescope intubations, complications, and Pneumothorax, an underappreciated
failures from two institutions. Anesthesiology. complication with an airway exchange catheter.
2011;114:34-41. J Thorac Dis. 2012; 4(6):659-68.
 CHAPTER 18
Practice Guidelines in
Obstetric Anesthesia
Sunanda Gupta, Seema Partani

These guidelines are recommendations to count is not necessary in the healthy parturient.
enhance the quality of obstetric anesthesia, It should be individualized and based on a
reduce the incidence and severity of patient’s history, physical examination and
complications and help in the provision of clinical signs. Similarly a blood type and
safe and adequate anesthesia. These are not screen or cross match should only be done, on
standard or absolute requirements but can be anticipation of hemorrhagic complications.
modified according to local or individual needs Specific investigations like recent blood glucose
and constraints. in diabetics on insulin, recent CBC in sickle cell
disease, platelets, PT, PTT, fibrinogen in HELLP
and Intrauterine fetal demise of unknown
Preanesthetic Requirements
etiology will be required.
History and Physical Examination
The antepartum screening in all high-risk Perianesthetic Recording of
parturients referred for anesthesia consultation Fetal Heart Rate
should include a complete maternal medical, Fetal heart rate should be monitored before
obstetric and anesthetic history, baseline vitals, and after initiation of neuraxial analgesia
height and weight, head and neck, airway, for labor. There is no need of continuous
heart, lung and back examination along with electronic monitoring of fetal heart rate in the
categorization into ASA physical status (I-V). perianesthetic period.
Recognition of any anesthetic or obstetric risk
factors should encourage a communication
between the anesthesiologist, obstetrician and/ Informed Consent
or members of the multidisciplinary team. It should be taken by the anesthesiologist before
any procedure according to the hospital or
Laboratory Investigations institution protocol.

For a normal healthy parturient undergoing

Ideal Requirements
cesarean section (CS) or postpartum tubal
ligation (PPTL), a hematocrit and Complete Obstetric operating theaters, both in the
Blood Count will suffice. A routine platelet delivery suite and main operation theaters
 Practice Guidelines in Obstetric Anesthesia 133

should have comparable basic monitoring For Labor Epidural

facilities which include ECG, noninvasive blood
Every parturient does not require anesthetic
pressure, pulse oximeter and ETCO2 monitor
care during pain relief for labor and delivery.
along with support personnel. Resources for the
There are many options, with neuraxial
treatment of potential complications (e.g., failed
analgesia as one of the available techniques. If
intubation, inadequate analgesia, hypotension,
there is adequate trained staff and resources,
respiratory depression, pruritus, vomiting) neuraxial analgesia should be offered based
should be available in the operating suites. on the anesthetic and obstetric risk factors,
Recovery room should have monitoring for patient preferences and progress of labor. All
noninvasive blood pressure, ECG and oxygen these patients should have a patent intravenous
saturation. A high dependency unit should be line, along with resources to treat complications
available for high-risk parturients in the vicinity like hypotension, systemic toxicity, high spinal
of the obstetric unit along with access to the ICU and opioid related side effects like respiratory
if need arises. depression, pruritus, nausea, etc. No preloading
with fluids is required before initiation of
Aspiration prophylaxis neuraxial analgesia. Basic monitoring facilities
should include ECG, noninvasive blood
Oral intake of clear liquids, in small quantities, pressure monitoring, heart rate and oxygen
like water, fruit juices without pulp, carbonated saturation.
beverages, clear tea and black coffee, should be Neuraxial analgesia should not be withheld
encouraged in normal parturients, up to 2 hours till an arbitrary cervical dilatation is achieved.
before induction of anesthesia, as it increases Early initiation of neuraxial analgesia does not
maternal satisfaction. However, oral intake affect the maternal or neonatal outcome, nor
should be further restricted on an individual does it increase the incidence of CS. In patients,
basis, in patients who are at risk of aspiration attempting vaginal birth after a previous CS, an
(morbidly obese, diabetes, difficult airway) early epidural catheter placement can be used
or who are at risk for cesarean delivery due to for labor analgesia or for subsequent operative
nonreassuring fetal heart rate pattern. A fasting delivery. Similarly in the high-risk parturient,
period for solids (especially fatty food) of 6 to 8 an early placement of the catheter (even before
hours should be followed in all patients posted labor starts) can help in avoiding GA in an
for elective surgery (CS-Cesarean section or emergency.
PPTL-postpartum tubal ligation). Solid food Regional analgesia should only be initiated
should be avoided during labor. Non-particulate and maintained in locations where appropriate
antacids, H2 receptor antagonists and/or resuscitation equipment and drugs are
Metoclopramide should be given timely before immediately available. Informed consent
anesthetic induction in elective surgery. should be obtained and documented in the
medical record. Intravenous access must be
established before initiating regional analgesia.
Guidelines for regional The intravenous access should be maintained
anesthesia in Obstetrics as long as regional analgesia is administered.
The anesthesiologist should be immediately
Absolute Contraindication for available until analgesia is established and the
Regional Anesthesia patient’s vital signs are stable.
• Uncorrected maternal hypovolemia
• Documented coagulopathy (PT>1.5 times Single Injection Spinal Opioids with or
normal) without Local Anesthetics
• Sepsis at local site Single spinal injection of opioids with or
• Patient refusal or inability to cooperate. without local anesthetics may be used to
134 Practice Guidelines in Anesthesia

provide effective, although time-limited includes epidural, spinal combined spinal

analgesia for spontaneous vaginal delivery. If epidural and general anesthesia. Choice of
labor is expected to last longer or if operative technique depends on anesthetic, obstetric or
delivery is expected then a catheter technique fetal risk factors (e.g., elective vs emergency),
instead of a single shot technique should be the preferences of the patient, and judgment
used. To improve the quality and duration of of anesthesiologist. Neuraxial anesthesia is
analgesia, local anesthetics should be added the preferred technique for operative delivery
to the intrathecal opioids. The single injection in majority of the cases. Onset of anesthesia
spinal technique for labor analgesia are more through an indwelling epidural catheter or
advantageous in cases where rapid onset of initiation of spinal anesthesia, are considered
analgesia is required, e.g. in advanced labor. equivalent, for urgent caesarean delivery.
General anesthesia may be an ideal choice
Continuous Infusion Epidural Analgesia in specific situations like profound fetal
bradycardia, ruptured uterus, massive obstetric
Opioids when added to local anesthetics in hemorrhage with hemodynamic disturbances,
CIE has the added advantage of reducing the or severe placental abruption. Irrespective of
dose of local anesthetics, improve the quality of the anesthetic technique used, a left uterine
analgesia and minimize motor block. Adequate displacement should be maintained until the
analgesia for labor should aim at producing delivery of the fetus.
minimal motor block with lowest possible
concentration of local anesthetics which
Type of Spinal Needles
provides adequate analgesia as well as maternal
satisfaction. In most patients a dilution of To minimize the risk of postdural puncture
0.125% of local anesthetics is adequate to headache the pencil point needles should
provide analgesia. be used rather than the cutting bevel spinal
needles.
Patient–controlled Epidural Analgesia
Intravenous Fluid Preloading
For maintenance of epidural analgesia, PCEA
provides a flexible and effective approach. It may be used to reduce the incidence of
Comparison with fixed-rate CIE has proved hypotension following spinal anesthesia for
that PCEA with a background infusion, requires caesarean delivery. However, initiation of spinal
fewer doses of local anesthetics, improves anesthesia should not be delayed to infuse a
analgesia and also reduces frequency of fixed volume of fluids.
anesthetist interventions.
Requirement of Vasopressors
Combined Spinal Epidural Analgesia
Intravenous ephedrine and phenylephrine
Combined Spinal Epidural (CSE) with local are both acceptable drugs to treat maternal
anesthetics and opioids provides effective and hypotension. In the absence of maternal
rapid analgesia as compared to epidural local bradycardia, phenylephrine may be preferable
anesthetics and opioids, with better patient as it improves fetal acid-base status in
satisfaction. uncomplicated pregnancies.

Anesthesia for For Postoperative Analgesia

Cesarean delivery
For postoperative analgesia, after neuraxial
Various techniques are available to provide anesthesia following cesarean delivery,
anesthesia for operative delivery, which neuraxial opioids are a preferred choice
 Practice Guidelines in Obstetric Anesthesia 135

as compared to parentral opioids as they on patient preferences, anesthetic and obstetric

improve analgesia and maternal satisfaction. risk factors.
Nonsteroidal anti-inflammatory drugs like
Dicofenac and analgesics like Paracetamol can Management of Obstetric and
be used per rectal/IV/oral in the postoperative
Anesthetic emergencies
period, if there are no known contraindications.
Resources for Management of
Removal of Retained Placenta Hemorrhagic Emergencies
All resources required for management of
Anesthetic Technique
massive obstetric hemorrhage like: equipment
There is no preferred technique for the removal for rapid blood and fluid infusion, fluid warmer,
of retained placenta. If there is an existing warming blanket or forced air warmer and
epidural catheter in place and the patient large bore iv catheter should be available.
is hemodynamically stable then epidural Blood should be sent for blood grouping/
anesthesia is preferable. If the patient is not cross matching, complete blood count and
hemodynamically stable and if there is major coagulation studies. In an emergency, type
maternal hemorrhage, then general anesthesia specific or group O RhD negative blood can
with endotracheal tube should be the preferred be administered. A minimum of 6 whole units
option as compared to regional anesthesia. of blood should be ordered. Once surgical
Before initiating neuraxial or general anesthesia, hemostasis is achieved, continued oozing
hemodynamic status should be assessed and should be managed with blood products. In
aspiration prophylaxis should be initiated. cases where banked blood is not available, or
the patient refuses banked blood, intraoperative
Uterine Relaxation cell salvage should be considered. A pressure
bag system for rapid fluid infusion is mandatory
General endotracheal anesthesia with as also a high flow warming blanket to keep the
halogenated agents or terbutaline sulfate or patient warm and reduce coagulation problems.
Nitroglycerine can be used for uterine relaxation Consider early use of CVP monitoring and
during removal of the retained placental tissue. direct arterial pressure monitoring. Decision to
Nitroglycerine can be used as incremental doses transfer to a high dependency unit or intensive
intravenously or as a metered dose sublingually, care unit, should be taken according to the
which relaxes the uterus sufficiently to remove criticality of the patient.
the placental pieces, with less complications
like hypotension.
Central Invasive Hemodynamic
Monitoring
Postpartum Tubal Ligation
The decision to perform invasive monitoring
For Post partum tubal ligation (PPTL), fasting should be individualized as per the patient’s
guidelines and aspiration prophylaxis should clinical condition and cardiovascular risk
be strictly adhered to as for caesarean delivery. factors.
Anesthesiologists should be aware that gastric
emptying will be delayed in patients receiving
For Management of
opioids during labor, and that epidural
catheters are more likely to fail with longer
Airway Emergencies
postdelivery time intervals. The choice of All obstetric units should have trained
anesthetic technique should preferably be personnel and basic airway management
neuraxial anesthesia. However, decision for equipment available in the labor and delivery
neuraxial vs general anesthesia should be based units. In the operation theaters and labor
136 Practice Guidelines in Anesthesia

TABLE 18.1 Difficult airway management equipment

Basic intubation equipment—Basic airway equipment should be readily available at each anesthesia machine
or cart and includes:
• Masks (varying sizes)
• Oral airways (7–10 cm) +/- nasal airways
• Laryngoscopes – straight and curved blades (#3, 4), regular and short handles +/- McCoy blade
• Tracheal tubes (varying sizes)
• Stylets
• Gum elastic bougie
• Lubricating jelly
• Magill forceps
• Laryngeal mask airway (LMA) appropriate size
Standard monitoring equipment (ECG, noninvasive blood pressure, carbon dioxide [CO2] analyzer, oxygen [O2]
monitor, pulse oximeter)
• Suction device
• Self-inflating Ambu bag and mask for positive-pressure ventilation
• Medications for blood pressure support, muscle relaxation and hypnosis

TABLE 18.2 Difficult intubation equipment

Equipment for difficult intubation is specialized and should be kept in one location and checked regularly:
• Flexible fiberoptic bronchoscope
• Videolaryngoscope (e.g. Glidescope, C-Mac)
At least one device suitable for emergency nonsurgical airway ventilation, including but not limited to:
lightwand, jet ventilator, Combitube, Intubating LMA, ProSeal LMA (PLMA)
• Jet ventilation apparatus
• Cricothyrotomy kit
• Retrograde intubation equipment
• Ventilating tube exchangers
Topical anesthetics and vasoconstrictors

wards, the basic intubation kit (Table 18.1) Cardiopulmonary

along with specific difficult airway equipment Resuscitation in
(Table 18.2) should be available as a portable obstetric patients
unit, which should be accessible to both the
labor and delivery areas as well as the operation Basic and advanced life support equipment
theater. All units should have indigenously should be available in the delivery as well as
developed protocols for stepwise management operative areas. In the event of a cardiac arrest
of the difficult airway in parturients. When during pregnancy, a left uterine displacement
tracheal intubation fails, ventilation should be should be ensured, apart from other standard
maintained with a mask and cricoid pressure, resuscitative measures, since patient position
an LMA or supraglottic device like Combitube, is the most important factor in enhancing the
intubating LMA (fastrach) should be considered quality of CPR. This can be achieved initially
till delivery of the fetus, rather than repeatedly by manual left uterine displacement in the
trying to intubate the patient. If ventilation is supine position using either two-handed or
not possible, then a surgical airway should be one-handed technique from the patient’s
created. right side or left side respectively. If a wedge
 Practice Guidelines in Obstetric Anesthesia 137

is available, then a left lateral tilt of 27 to 30 2. Guidelines to the Practice of anesthesia. Revised
degrees, can be given, using a firm wedge edition 2013. Can J Anesth. 2013;60(1):60-84.
to support the pelvis. If resuscitation fails to 3. Nice Clinical Guidelines 132. Caesarean Section
2011. [Link]
produce an effective cardiac output, a timely
4. Obstetric anaesthesia services. Obstetric
decision for operative delivery should be taken Anaesthesia Association UK 2012.
within 4 minutes to save the mother and fetus. 5. Practice Guidelines for Obstetric anaesthesia: An
updated report by the ASA task force on obstetric
anaesthesia. Anesthesiology. 2007;106:843-63.
Bibliography [Link]
1. Blood transfusion and the anaesthetist. Manage­ 6. Sabai BM. Acute Management of Obstetric
ment of massive haemorrhage. London: AAGBI, Emergencies. Pub. Elsevier Health Sciences.
2010. 2011.
 CHAPTER 19
Checking Anesthesia Equipment
Susheela Taxak

Introduction Anesthesia Delivery

System Checks
The anesthetist has a primary responsibility
to understand the function of the anesthetic The following checks should be carried out
equipment and to check it prior to use. at the beginning of each operating theater
Anesthetist must not use equipment unless they session. In addition, specific checks should be
have been trained to use it and are competent to carried out before each new patient during a
do so. Failure to check the anesthesia equipment session or when there is alteration or addition
is a major contributor in many anesthetic to the breathing system, monitoring or
misadventures. These guidelines are framed so ancillary equipment. It is the responsibility of
as to assist practitioners and health facilities to an anesthetist to make sure that a these checks
minimize equipment-related risks. have been performed and have been carried
out correctly. It is essential that anesthetists
have full training and formal induction for any
Principles machines they may use.
• Responsibilities: Each facility is required to Section A: Checks self-inflating bag and
designate an individual to be responsible presence of alternate oxygen supply source:
for servicing and maintaining equipment Verify auxiliary oxygen cylinder and
and ensuring that relevant personnel self-inflating manual ventilation device are
are trained in the checking and use of available and functioning—a safety measure
often overlooked. Because equipment failure
anesthesia equipment.
with resulting inability to ventilate the patient
• Servicing of anesthesia equipment
can occur at any time, a self-inflating manual
should be performed regularly, at
ventilation device (e.g. Ambu bag) should be
specified intervals in accordance with present at every anesthetizing location for every
the manufacturer’s documented service case and should be checked for proper function.
requirements and recorded in detail. In addition, a source of oxygen separate from
• Confirmation that a secondary means the anesthesia machine and pipeline supply,
of oxygenation and positive pressure specifically an oxygen cylinder with regulator
ventilation is immediately available. and a means to open the cylinder valve, should
 Checking Anesthesia Equipment 139

be immediately available and checked. The should be closed after it has been verified
early use of alternative means of ventilation may that adequate pressure is present, unless
be life saving. the cylinder is to be the primary source of
Section B: perform the manufacturer’s oxygen (i.e. piped oxygen is not available).
machine check: Other gas supply cylinders (e.g. air, N2O)
• Power supply: Turn on anesthesia delivery need to be checked only if that gas is
system and confirm that AC power and required to provide anesthetic care.
back-up battery power is available. Visual Check the operation of flowmeters,
indicators of the power source showing where these are present, ensuring that each
the presence of both AC and battery power control valve operates smoothly and bobbin
should be checked and connection of moves freely throughout its range without
the power cord to a functional AC power sticking. Confirm anti-hypoxia device is
source should be confirmed. Verify that working by turning on the nitrous oxide flow
anesthetic machine is directly connected and ensuring that 25% oxygen also flows and
to the mains electrical supply. Multisocket on turning off oxygen flow, nitrous oxide flow
extensions leads must not be plugged into also stops. Operate the emergency oxygen
the anesthetic machine outlets or used bypass control and ensure that flow occurs
to connect the anesthetic machine to the from the gas outlet without significant
mains supply. Electrical power supply decrease in the pipeline supply pressure.
for desflurane vaporizers should also be Ensure that the emergency oxygen bypass
checked. Switch on the gas supply master control ceases to operate when released.
switch (if one is available). Turn on oxygen flow and check that oxygen
• Gas supply: Anesthesia delivery systems rely analyzer display approaches 100%. Turn off
on a supply of oxygen for various machine all flow control valves.
functions. At a minimum, the oxygen supply • Oxygen monitor: Calibrate, or verify
is used to provide oxygen to the patient. calibration of, the oxygen monitor and check
Pneumatically-powered ventilators also the low oxygen alarm. The oxygen monitor
rely on a gas supply. Identify and take note is essential for detecting adulteration of
of the gases that are being supplied by the oxygen supply. Most oxygen monitors
pipeline, confirming with a ‘tug test’ that require calibration once daily, although
each pipeline is correctly inserted into the some are self-calibrating. For self-
appropriate gas supply terminal. Check calibrating oxygen monitors, they should be
that anesthetic apparatus is connected to a verified to read 21% when sampling room
supply of oxygen and adequate supplies of air. The low oxygen concentration alarm
other gases intended for use are available. should also be checked.
Verify that all pressure gauges for pipelines • Suction: Safe anesthetic care requires the
connected to the anesthetic machine immediate availability of suction to clear
indicate 400 to 500 kPa. the airway if needed. Verify availability of
Verify that cylinders mounted on high vacuum tracheal suction with backup
machine are filled and have acceptable means of suction.
minimum pressure. Typically, an oxygen • Breathing system: Verify the whole system
cylinder will be used if the central oxygen is patent and there is no leak between
supply fails. If the cylinder is intended to be common gas outlet (CGO) and flowmeter
the primary source of oxygen (e.g. remote by performing “two bag” test. The breathing
site anesthesia), then a cylinder supply system pressure and leak test should
sufficient to last for the entire anesthetic be performed with the correct circuit
is required. The oxygen cylinder valve configuration to be used during anesthetic
140 Practice Guidelines in Anesthesia

delivery. If any components of the circuit • Carbon dioxide absorber: Inspect the
are changed after this test is completed, contents and connections and ensure
the test should be performed again. Ensure there is adequate supply of carbon dioxide
that there are no leaks or obstructions in absorbent. Check the color of absorbent to
the reservoir bags or breathing system and ensure that it is not exhausted.
they are not obstructed by foreign material. • Alternative breathing system: Ensure the
Perform a pressure leak test (between presence of alternative breathing circuit
20 and 60 cm of water) on the breathing (Bain’s, T-piece). Perform an occlusion test
system by occluding the patient end and on the inner tube and check the adjustable
compressing the reservoir bag. Verify that pressure limiting (APL) valve, where fitted,
gas flows properly through the breathing can be opened and closed.
circuit during both inspiration and • Correct gas outlet: Ensure that there is no
exhalation. Proper testing will demonstrate misconnection or miselection of an auxiliary
that pressure can be developed in the common gas outlet (ACGO). Whenever a
breathing system during both manual and breathing system is changed, either during
mechanical ventilation and that pressure a case or a list, its integrity and correct
can be relieved during manual ventilation configuration must be confirmed.
by opening the APL valve. • Scavenging: Verify correct connections
• Vaporizer: Ensure that vaporizer(s) for the between the scavenging system and the
required volatile agent(s) are fitted correctly anesthesia delivery system. Ensure vacuum
to the anesthetic machine. Check that the level is adequate.
locking mechanism is fully engaged and • Monitors: Verify availability of required
that the control knobs rotate fully through monitors and check alarms. The first step
the range(s). Ensure that the vaporizer is is to visually verify that the appropriate
not tilted. Tilting a vaporizer may result in monitoring supplies (BP cuffs, oximetry
delivery of dangerously high concentrations probes, etc.) are available. All monitors
of anesthetic. Turn off the vaporizer. Verify should be turned on and proper completion
that vaporizers are adequately filled and not of power-up self tests confirmed. Verifying
overfilled, if applicable, that the filler ports proper function of pulse oximetry and
are tightly closed. High and low anesthetic capnography. Ensure proper functioning
agent alarms are useful to help prevent of visual and audible alarms. Check the gas
over- or under-dosage of anaesthetic vapor. Sampling lines are properly attached and
If anesthetic vapor delivery is planned, free from obstruction or kinks. Be aware of
an adequate supply is essential to reduce the ‘default’ alarm settings if using these.
the risk of light anesthesia or recall. This • Airway equipment: Ensure the presence of
is especially true if an anesthetic agent full range of airway equipment, including
monitor with a low agent alarm is not being tracheal tubes, laryngeal mask airway,
used. appropriate laryngoscope, oropharyngeal
• Ventilator: Check that the ventilator is airway, bacterial filter and catheter
working and configured correctly. Confirm mount. Check that all these equipment are
ventilator settings and evaluate readiness to functioning properly. Equipment for the
deliver anesthesia care. When a ventilator management of anticipated or unexpected
is being used, we should check for low difficult airway must be available and
pressure or disconnect alarm. Ensure that checked regularly in accordance with
the ventilator tubing is securely attached. departmental policies.
Check that the pressure relief valve functions • An “Arrest Cart” containing emergency
correctly at the set pressure. resuscitation equipment including a manual
 Checking Anesthesia Equipment 141

resuscitator, defibrillator, appropriate Section F: Timing:

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

maintenance, and educates the anesthesia 3. Hartle A, Anderson V, Bythell V, et al. Checking
provider about equipment. anaesthetic equipment: AAGBI 2012 guidelines.
Anaesthesia. 2012;67:660-8.
Bibliography 4. International Electrotechnical Commission. IEC
60601-2-13. Medical electrical equipment. Part
1. American Society of Anesthesiologists 2-13: Particular requirements for the safety and
Recommendations for Pre-Anesthesia Checkout essential performance of anaesthetic systems.
Procedures. Sub-Committee of ASA Committee [Link]
on Equipment and Facilities (2008). http:// 13%7Bed3.1%[Link] (accessed 18/02/2012).
w w w . a s a h q . o r g / Fo r- Me m b e r s / C l i n i c a l - 5. International Standards Organization.
Information/2008-ASARecommendations- ISO860601-2-13:2011. Medical electrical
for-PreAnesthesia-Check [Link] (accessed 18 equipment. Part 2-13: Particular requirements
⁄ 02 ⁄ 2012). for basic safety and essential performance of
2. Australian and New Zealand College of an anaesthetic workstation. [Link]
Anaesthetists. Minimum Safety Requirements iso/catalogue_detail.htm?csnumber=51285
for Anaesthetic Machines for Clinical Practice (accessed 18/02/2012).
(2011). [Link] 6. Merchant R, Chartrand D, Dain S, et [Link]
professionaldocuments/documents/technical/ to the practice of anaesthesia revised edition
pdffiles/[Link] (accessed 18 ⁄ 02 ⁄ 2012). 2013. Can J Anaesth. 2013;60:60-84.
 CHAPTER 20
Perioperative Blood Transfusion
T Prabhakar, RK Tripathi

“To raise new questions, new possibilities, to regard old problems from a new angles, require creative
imagination and marks real advance in science.”
— Albert Einstein

Blood being a precious and scarce resource, perfusion to sustain normal levels. The rationale
every attempt should be made to transfuse for blood transfusion is rooted in the physiology
blood and blood products only when essential. of oxygen delivery (DO2) which depends upon
Low Hemoglobin (Hb), blood loss and the concentration of hemoglobin (Hb), the
hypovolemia are main indicators for peri- percent saturation of O2 in that hemoglobin
operative blood transfusion. Blood transfusions, (SaO2), and the cardiac output (CO):
transfusion medicine continues to be dogged by DO2 = Hb × %SaO2 × CO
controversies and a lack of conclusive evidence. Because oxygen requirement by tissues
That leaves us wondering when and to whom are increased during acute surgical stresses
to give blood perioperatively. Platelet and fresh perioperatively, it is mandatory to maintain
frozen plasma (FFP) transfusion trigger point are adequate oxygen levels for better outcome.
also not very clear. Hence in this article we have Manipulation of hemoglobin, oxygen
tried to elucidate certain important practical saturation and/or cardiac output increases
guidelines of transfusion medicine as related to oxygen delivery. However, hemoglobin is
our perioperative transfusion practice. normally almost fully saturated with oxygen,
Adverse events associated with blood and increasing cardiac output in the face
transfusions, including infections and of adequate filling pressures requires the
transfusion reactions, also have been use of ionotropic agents. Thus, augmenting
recognized. Recent publications1-2 have hemoglobin level is a beneficial strategy to
demonstrated an association between increase oxygen delivery.3
transfusions and increased morbidity and Transfusion trigger: Transfusion trigger is
mortality. hemoglobin/hematocrit at which the risks
Purpose of blood transfusion: Blood of decreased O2 carrying capacity exceed the
transfusions are given basically to increase risks of transfusion. In 1942, minimum 10 g/
the intravascular volume and oxygen carrying dL hemoglobin and 30% hematocrit levels, has
capacity. The goals should be to restore been accepted over the years as the appropriate
intravascular volume, cardiac output and organ “transfusion trigger” but recent guidelines
144 Practice Guidelines in Anesthesia

state that when a patient’s hemoglobin level mortality rate was not significantly different.
falls below six or seven grams per deciliter, a Therefore a restrictive strategy is superior, in
patient will benefit from a transfusion, and some patients, to a more liberal transfusion
that if the levels are above 10, a patient does strategy. Although in one study Herbert et al
not need a transfusion. But when blood levels also found that a postoperative hematocrit of
are in-between 7 and 10, there has been little < 28% was significantly associated with
consensus about what to do.4 increased myocardial ischemia and morbid
cardiac events. This was particularly apparent in
the setting of tachycardia. Koch et al9 concluded
Risks of Blood Transfusion
that giving erythrocytes (packed red cells) older
Blood transfusion, which introduces a foreign than 14 days was associated with an increased
substance “transplant” into the body, initiates risk of postoperative complications along with
a series of complex immune reactions. Patients reduced short-term and long-term survival in
often develop antibodies to transfused red patients undergoing coronary artery bypass
blood cells making it more difficult to find surgery. This concluded that “to the extent
a match if future transfusions are needed. possible, newer blood might be used in clinical
Transfused blood also has a suppressive effect situations that seem to call for it.10
on the immune system, which increases the In 2006, the American Society of
risk of infections, including pneumonia and Anesthesiologists (ASA) advised that blood
sepsis.5 is rarely indicated when the hemoglobin
concentration is greater than 10 g/dL and is
Cancer Recurrence almost always indicated when it is less than
6 g/dL, especially when the anemia is acute. The
A study published in the Oct. 18, 2003, issue transfusion of autologous RBCs may be more
of The Lancet about cancer progression in liberal than those for allogeneic RBCs because
advanced squamous cell carcinoma of the of lesser risks.11
oropharynx, who had initial hemoglobin levels
less than 12 g/dL. When transfusions were given
BLOOD COMPONENT THERAPY
to reach a target hemoglobin of 14 g/dL found
“a 62% increased risk of recurrence and survival In 2005 The Association of Anesthetists of
was also adversely affected. In colorectal cancer Great Britain and Ireland recommended that,
a similar recurrence was also observed by Assessment of hemostasis in the pre-operative
Amato et al in 2011.6 period can reduce perioperative blood loss
and as red cell concentrates do not contain
HOW MUCH HEMOGLOBIN coagulation factors or platelets, so the use of
blood components [fresh frozen plasma (FFP)
IS ENOUGH?
and platelets] needs to be considered early in
Various studies have been done in this field managing a patient with massive hemorrhage.
which illustrates that low levels of Hb are Thawed FFP can be stored at 4°C and can be
tolerated by healthy subjects. Carson et al7 used safely within 24 hours. Platelet transfusion
observed that surgery was safely performed in the bleeding patient, or a patient requiring
in patients with Hb levels as low as 6 g/dL, urgent surgery, is indicated at a platelet count
providing blood loss was less than 500 mL. In a < 50000/μL but in stable nonbleeding patients
study Hebert et al8 compared liberal transfusion in intensive care, a trigger of 10,000/μL is
strategy (Hb–10–12 g/dL) with a restrictive acceptable. Vitamin K +/- prothrombin complex
transfusion strategy (Hb 7–9 g/dL) and found concentrate (PCC) is recommended to reverse
mortality was significantly lower in the warfarin. FFP is indicated when there is severe
restrictive strategy group, although the 30 days bleeding or when PCC is unavailable.
 Perioperative Blood Transfusion 145

Evidence Based Guidelines for until bleeding is controlled. However, while

Blood Transfusion (Cochrane) maintaining blood pressure may prevent
shock, it may worsen bleeding. Oxygen carrying
In 2012 in an article Carson JL, et al. Transfusion capacity of transfused blood will take time
thresholds and other strategies for guiding anything between 6 and 24 hours depending
allogeneic red blood cell transfusion studied upon the age of the blood, temperature and 2,3
Nineteen trials involving a total of 6264 patients DPG level.
found that restrictive transfusion strategies
reduced the risk of receiving a RBC transfusion
by 39%. This equates to an average absolute risk Platelet-rich Plasmapheresis
reduction (ARR) of 34%. The volume of RBCs Platelet-rich plasmapheresis is a technique
transfused was reduced on average by 1.19 that involves a patient’s own blood (autologous
units. However, heterogeneity between trials whole blood) being withdrawn via an
was statistically significant for these outcomes. intravenous catheter into a device that separates
Restrictive transfusion strategies did not appear the blood by centrifugation into red blood cells,
to impact the rate of adverse events compared plasma, and a highly concentrated platelet
to liberal transfusion strategies (i.e. mortality, solution. This concentrated autologous platelet
cardiac events, myocardial infarction, stroke, solution is returned to the patient at the end of
pneumonia and thromboembolism). Restrictive the operation to optimize blood clotting and
transfusion strategies were associated with a minimize bleeding.
statistically significant reduction in hospital
mortality, but not 30 days mortality. The use of
restrictive transfusion strategies did not reduce A WORKABLE GUIDELINE
functional recovery, hospital or intensive care Indications for Red Blood Cells
length of stay. There are no trials in patients
with acute coronary syndrome.11,12 • Hb < 7 g%; although lower thresholds
may be acceptable in patients without
symptoms and where specific therapy
Other Strategies to Reduce (eg iron) is available. Hb < 7 g% during
Perioperative Blood Transfusion surgery associated with major blood loss or
Cell Salvage if evidence of impaired oxygen transport,
Hb < 8 g% for otherwise healthy patients
‘Cell salvage’ or ‘auto-transfusion’ involves for cesarean section in emergency and for
the collection of a patient’s own blood from elective Iron and Folic acid supplementation
surgical sites which can be transfused back should be given to achieve 10 g%, on a
into the same person during or after surgery, as chronic transfusion regimen or during
required. There are significant reduction in both marrow suppressive therapy, however Hb
the incidence and volume of allogeneic blood < 10 % to 12 g% recommended only for very
transfusion compared with the control. select populations, e.g. Neonates and cardiac
surgeries.
Fluid Administration
Timing and Volume Indication for Platelet Transfusion
Treatment of hemorrhagic shock involves Platelets transfusion if risk factors like
maintaining blood pressure and tissue fever, antibiotics, hemostatic failure, risk of
perfusion until bleeding is controlled. Different intracranial hemorrhage are present. Surgery/
resuscitation strategies have been used to invasive procedure platelets < 50000/μL.
maintain the blood pressure in trauma patients However, higher counts may be needed
146 Practice Guidelines in Anesthesia

in surgery with high-risk of bleeding, e.g. CONCLUSION

neurosurgery or Transfuse if there is bleeding
or high-risk of bleeding, regardless of actual Patient blood management encompasses
platelet count. In cases of bleeding/massive an evidence-based medical and surgical
transfusion maintain platelets > 50000/μL if approach that is multidisciplinary including
thrombocytopenia likely to be a contributing transfusion medicine specialists, surgeons,
factor for bleeding. Maintain platelets > 100000/ anesthesiologists, and critical care specialists
μL in the presence of DIC or CNS trauma. and multiprofessional including physicians,
nurses, perfusionists and pharmacists.
Awareness of risks and understanding of the
Indications for Fresh Frozen Plasma normal and pathological physiology must
• Warfarin effect- life-threatening bleeding in remain the guiding principle for perioperative
addition to the use of vitamin K and vitamin blood transfusion management. The data
K dependent clotting factor concentrates for available suggests that most patients can
bleeding with abnormal coagulation tolerate hemoglobin levels in the 7 to 9 g/dL
• Liver disease, if bleeding with abnormal range without suffering adverse consequences
coagulation related to the anemia while patients with acute
• Acute DIC when there is bleeding and cardiac disease may require higher hemoglobin
abnormal coagulation levels.
• Following massive transfusion or cardiac ‘Remember that, when used correctly, blood can
bypass for bleeding in the presence of be life-saving. Inappropriate use can endanger
abnormal coagulation. life and may cause a shortage of blood for
Cryoprecipitate may be indicated in Fibrinogen other patients who require it.’ World Health
deficiency, in the setting of clinical bleeding, an Organization.13
invasive procedure, trauma or DIC.
REFERENCES
Management of Transfusion
1. Hebert P, Wells G, Blajchman MA, et al.
1. A formal checking process prior to Transfusion Requirements in Critical Care
commencement of transfusion Investigators, Canadian Critical Care Trials
2. The use of correct equipment (filters, pump, Group, N Engl J Med. 1999;340:409-17.
2. Wu WC, Rathore SS, Wang Y, Radford MJ,
consideration of blood warmer)
Krumholz. Blood transfusion in elderly patients
3. Correct transfusion documentation including with acute myocardial infarction. N Engl J Med.
patient observations, start and finish times. 2001;345:1230-6.
3. Miller RD. Patient blood management:
Complications During Transfusion Transfusion therapy. In: Miller RD, editor.
Miller’s Anesthesia. 8th ed. Philadelphia,
• The most common immediate adverse PA: Churchill Livingstone/Elsevier, 2015.
reactions to transfusion are fever, chills and p.1830-67.
urticaria. The most potentially significant 4. Marshall JC. Transfusion trigger: when to
reactions include acute hemolytic transfusion transfuse? Crit Care. 2004;8:S31-3.
5. Rao SV, Jollis JG, Harrington RA, et al. Relationship
reactions, bacterial contamination of blood
of blood transfusion and clinical outcomes in
products and transfusion related acute lung patients with acute coronary syndromes. JAMA.
injury. All suspected transfusion reactions 2004;292:1555-62.
must be reported to the issuing blood bank 6. Amato A, Pescatori M. Cochrane Summaries-
immediately. Published online Feb 16, 2011.
 Perioperative Blood Transfusion 147

7. Carson JL, Hill S, Carless P, et al. Transfusion 11. ASA Guideline for preoperative blood
triggers: a systematic review of the literature. transfusion-2002.
Transfusion Med Rev. 2002;16:187-99. 12. Carless PA, Henry DA, Carson JL, et al.
8. Hébert PC, Wells G, Marshall J, et al. Transfusion Transfusion thresholds and other strategies for
requirements in critical care—A pilot study. guiding allogeneic red blood cell transfusions.
JAMA. 1995; 273:1439 for the Canadian Critical Cochrane Database Syst Rev. 2010.
Care Trials Group. 13. Carson JL, Carless PA, Hebert PC. Cochrane
9. Koch CG, Li L, Sessler DI, et al. Duration of Database Syst Rev. 2012 Apr 18;4:CD002042. doi:
red-cell storage and complications after cardiac 10.1002/14651858.CD002042.pub3 -Transfusion
surgery. N Engl J Med. 2008; 358:1229-39.
thresholds and other strategies for guiding
10. Adamson JW. New blood, old blood, or no blood?
N Engl J Med. 2008; 358:1295-6. allogeneic red blood cell transfusion.
 CHAPTER 21
Infrastructure Requirements
for Operation Theater
Naresh Dua, VP Kumra

Introduction specially trained personnel to promote healing

and cure with maximum safety, comfort and
The functioning and infrastructure of operation economy.2
theaters has pivot role in any hospital’s esteem.
Nowadays, large number of surgical patients
are getting admitted for different surgeries. Utilization of
The surgical speciality and super-speciality operation theater
branches are advancing tremendously with
good results. Operation theater complexes are designed
Safer anesthetic techniques, complete aseptic and built to carry out investigative, diagnostic,
environment, sophisticated equipment and therapeutic and palliative procedures of varying
skills make the surgical outcome successful. For degrees of invasiveness. Many operation theater
all these requirements, operation theater (OT) set-ups are customized to the requirements
needs specialized planning and execution which according to a particular speciality.
is not a simple civil engineering work. A “civil-
mechanical-electrical-electronic-biomedical” Infrastructure of
combo effort driven in harmony with medical, operation theater
surgical team requirements form an ideal OT.
Anesthesiologists, by virtue of their knowledge Infrastructure starts with proper planning,
of the intricacies of physiology, physics and designing along with all the parameters and
biomedical aspects of medicine and constant ancillary units required for smooth running of
proximity to the operation theater should operation theater.
preferably be involved from the early stages of
planning of operating theaters.1 Aim of Planning
The main objectives of planning include
Definition
promotion of high standard of asepsis,
Operation theater is that specialized facility of maximum safety and proper utilization of OT
the hospital where life saving or life improving and its staff. The working conditions should
procedures are carried out under strict aseptic be optimized for patient and staff comfort to
conditions on the human body by invasive facilitate good coordinated services. There
methods in a controlled environment by should be planning with the aim to ensure
 Infrastructure Requirements for Operation Theater 149

functional separation of spaces and minimal • Intensive care unit (ICU) and post
maintenance requirement. anesthesia care unit (PACU).
• Sterile stores
2. Clean zone: Connects protective zone to
Requirements for designing
aseptic zone and has other areas also like:
Operation theaters require specialized planning • Stores and cleaner room
because surgical facilities represent a central • Equipment store room
life saving activity, they make or break the • Maintenance workshop
reputation of the hospital. The functional • Kitchenette (pantry)
efficiency of the OT governs the revenue • Firefighting device room
generation as it is a major cost consuming • Emergency exits
center in the establishment of the hospital. It • Service room for staff
is responsible for an appreciable quantum of • Close circuit TV control area
revenue in private sector. As no one plan suits 3. Aseptic zone: Includes operation rooms
all hospitals, a scientific and detailed planning (sterile)
is required while designing an OT in order 4. Disposal zone: Disposal areas from each OR
to ensure its smooth functioning, efficiency and corridor lead to disposal zone.
and effective utilization. To design the OT,
the basic fundamental asepsis environment
Accessory Working Areas
has to be maintained by keeping the outside
contaminate out by separation of clean area • Changing room: This is important with
from contaminated area within OT complex.3 respect to maintaining privacy, for changing
from street clothes to gown and to provide
lockers and lavatories for the staff.
Basic architecture of the OT
• Preanesthetic checkup (PAC) room: This
The OT complex should be located at a low area is planned for patient’s preoperative
transaction area of hospital. The OT complex evaluation and to take care of their special
should be located away from the inpatient area, needs.
often in a blind wing or on the top or bottom • Holding area: This area is planned for IV
floor. It is a scientifically planned barrier system, line in­sertion, preparation, catheter/gastric
such that it keeps the flow of traffic from the tube insertion, connection of monitors, and
clean area to dirty ones and never vice verse. shall have O2 and suction lines. Facility for
Four zones can be described in an CPR should be available in this area.
OT complex, based on varying degrees of • Induction room (anesthetic room): It
cleanliness, in which the bac­teriological count should have all facilities as in OT, but
progressively diminishes from the outer to the depends on hospital policy and space
inner zones (operating area) and is maintained availability. The anesthetic room will
by a differential decreasing positive pressure provide a more tranquil atmo­sphere to the
ventilation gradi­ent from the inner zone to the patient than the OT. It should provide space
outer zone.4 for anesthetic trolleys and equipment and
1. Protective zone: It includes: should be located with direct access to
• Changing rooms for all medical and circulation corridors and ready access
paramedical staff with conveniences to the operating room. It will also allow
• Transfer bay for patient, material and cleaning, testing and storing of anes­
equipment thesia equipment. It should contain work
• Rooms for administrative staff benches, sinks. It should have sufficient
• Stores and records power outlets and medical gas panels for
• Pre- and postoperative rooms testing of equipment.
150 Practice Guidelines in Anesthesia

• Postanesthetic recovery room: It should – Air conditioning with 10 to 12 air

be preferably adjacent to the recovery room. exchanges per hour
These should contain a medication station, – Storage of sterile drapes, sponges, gloves,
hand washing station, nurse sta­tion, storage gowns and other items ready to use.
space for stretchers, supplies and monitors/ – Option to store in the goods from one side
equipment and gas, suction outlets and and remove from other side of the room is
ventila­tor. Additionally 80 sq ft (7.43 sq m) highly preferable.
for each patient bed, clearance of 5 ft (1.5 – Proper inventory to prevent running out
m) between beds and 4 ft (1.22 m) between of stock.
patient bed sides and adjacent walls should • Scrub room: This is planned to be built
be planned. within the restricted area. Elbow operated or
• The anesthesia gas/cylinder manifold room infrared sensor operated taps / water source
and storage area: A definite area for this is ideal. It is essential to have nonslippery
should be designated. It should be in a cool, flooring in this area.
clean room that is constructed of fire resistant
materials. Conductive flooring must be laid Principles to be Taken into Consideration
but is not required if noninflammable gases
while Planning an OT (Physical/Architecture):
are stored. Adequate ventilation should be
allowed for leaking gases to escape. Safety • Location: Low rise buildings limited to two
labels should be put on each cylinder and or three storeys high are preferred because
separate space for empty and full cylinders of maximum advantage of natural light
should be allocated. and ventilation. The OT should be separate
• Offices for staff nurse and OT staff: The office from general ‘traffic’ and air movement
should allow access to both unrestricted of rest of the hospital. OT, surgical wards,
and semi-restricted areas as frequent ICU, accident and emergency department,
communica­tion with public is needed. Radiological department should be closely
• Rest rooms: Pleasant and quiet rest for staff related and access is also required to
should be arranged either as one large room sterilizing and disinfecting unit (SDU) and
for all grades of staff or as separate rooms; laboratory facilities. The location of the
both have merits. Comfortable chairs, operation complex in a multi-storey building
one writing table, a book case, etc. may be is planned either on the top floors or in the
arranged. basement to avoid traffic.5
• Seminar room: Since the OT staff cannot • Zone wise distribution of the area should be
leave the complex easily, it is better to have a done to avoid criss­cross movements of men
seminar room within the OT complex. Intra- and machines.
departmental discus­ sions, teaching and • Adequate and appropriate space should be
training sessions for staff (with audio-visual allotted as per utility of the area.
aids) may be conducted here. • Provision for emergency exit must be kept in
• Store room: This is designed to store large accessible area.
but less frequently used equipment of the • Provision for ventilation and temperature
OT. There should be storage space for special control, laminar flow, HEPA filter air
equipment after clean­ing. conditioner should be installed to minimize
• Theater sterile supply unit (TSSU): Within infection.
this area, following are desirable: • Operation rooms: The number and size can
– Temperature between 18° and 22°C, be as per the requirement of the hospital but
humidity of 40 to 50% is the aim. recommended size of OT is 6.5 m × 6.5 m ×
 Infrastructure Requirements for Operation Theater 151

3.5 m. Glass windows can be planned on one OTs and areas where patients are retained.
side only. Oxygen, gas and suction pipe to be connected
Doors: Main door to the OT complex has to with central facility and standby local facility
be of adequate width (1.2–1.5 m). The doors should also be available.
of each OT should be spring loaded flap • Provision for adequate and continuous water
type, but sliding doors are pre­ferred as no supply: Besides normal supply of available
air currents are generated. All fittings in OT water at the rate of 400 liters per bed per day,
should be flush type and made of steel. a separate reserve emergency over head tank
The surface/flooring must be slip resistant, should be provided for operation theater.
strong and impervious with minimum joints Elbow taps have to be installed 10 cm above
(e.g. mosaic with cop­per plates for antistatic wash basins.
effect) or jointless conductive tiles/ terrazzo, • Planning of proper drainage system with
linoleum, etc. The recommended minimum provision of easy repair work have to be in
conductivity is 1 m Ohm and maximum place.
10 m Ohms. Presently the need for antistatic • Preoperative area with reception with
flooring has dimin­ ished as flammable separate des­ ignated area for pediatric
anesthetic agents are no longer in use.2 patients is desirable.
Walls: Laminated polyester or smooth paint • The safety in working place is essential, and
provides seamless wall; tiles can break and fire ex­
tinguishers have to be planned in
epoxy paint can chip out. Collusion corners appropriate zone.
to be covered with steel or aluminum plates • Provision for expansion of the OT complex
or can be made round, color of paint should should be borne in mind during planning
allow reflection of light and yet soothing stages itself. So that in future if need arises,
to eyes. Light color (light blue or green) much OTs can be formulated.
washable paint will be ideal. A semi-matt
wall sur­face reflects less light than a highly
Ventilation
gloss finish and is less tiring to the eyes of OT
team. Central air conditioning should ensure
Operation table: One operation table per OT temperature range of 18 to 24°C with 50
should be the norm. to 60% humidity levels. A minimum of 20
Electric point: Adequate electric points on air changes/hour should be ensured. It is
the wall (at < 1.5 m height from the floor) preferred to have 100% fresh air. Theater to
should be present in OT. maintain positive pressure and controlling of
X-ray illuminators: There should be X-ray pressure is adhered to by providing pressure
film illu­minators preferably recessed into the release dampers at the time of opening
wall. and closing of the door. The minimum
Scrub area: It should be planned for atleast bacteriological requirements are that the air
for 2 to 3 persons in each OT. should not contain detectable Clostridium
• There has to be a preparation room in clean spores of coagulase positive Staphylococcus.
zone. During surgical operations the concentration
• The width of corridors should not be less of bacterially-contaminated airborne
than 2.85 m width for easy move­ment of staff, particles in the operating theater averaged
stretcher and machines. over any 5 minute period should not exceed
• Separate corridors be should be planned for 180 per m3 (5 per ft3), and special types
uses other than going into OT. of surgical operation, e.g. orthopedic and
• Gas and suction (control, supply and transplantation procedures, higher standards
emergency stock) should be planned for all of air cleanliness must be ensured.2
152 Practice Guidelines in Anesthesia

Pendant Services • Power line of 220 Volts should be maintained

without much fluctuation.
Two ceiling pendants for pipeline services • Suspended ceiling outlets should
should be designed; one for surgical team and have locking plugs to avoid accidental
one for anesthesiologist. Anesthetic pendant disconnection.
should be retractable and have lim­ited lateral • Insulation around ceiling electrical power
movement and provide a shelf for monitoring sources should withstand frequent bendings
equipment. It should have oxygen, nitrous and flexings. They should not develop cracks
oxide, 4 bar pressure medical compressed air, and should not damage wires. Wires inside
medical vacuum, scav­enging terminal outlets rigid or retractable ceil­ing service column
and at least four electric sockets. can help to some extent.
• Wall outlets to be installed 1.5 m above
Piped Gases in the OT ground.
• Use of explosion proof plugs is desirable.
1. Automatic/semi-automatic fail safe manifold
• Multiple outlets from different electrical line
room to be designed.
sources should be available.
2. Two outlets for O2 and suction and one for
• Electrical load calculation should be
N2O are a minimum in each OT.
based on equipment likely to be used and
3. Pipeline supply system should be able to
appropriate current car­rying capacity cords
cut off from mainline if the problem occurs
to be used.
anywhere along the delivery hosing / tubing.
• Emergency power: OT electrical networks
need to be connected to the emergency
Scavenging generators with au­ tomatic two way
The method of scavenging should be decided changeover facility.
during planning stage of OT. International
standards are available for scavenging but it is Lighting
ideal to plan the type of system (active/passive),
number and location of scav­ enging outlets General illumination is furnished by ceiling
beforehand. lights. Lighting should be evenly distributed
throughout the room. Around 300 lux light is
sufficient light for anesthesiologist to adequately
ELECTRICAL
evaluate the patient’s skin color. Electrical wiring
All electrical equipment in the OT need proper should be in concealed conduit lighting both
grounding. In the past, isolated power systems natural and artificial should be of appropriate
were preferred when explosive agents were illumination.
being used. They have the advantage of a Isolated power systems help prevent sparks
transformer using grounded electricity and from igniting flammables anesthetics and also
there is no risk to the patient or machines if a help to protect patients and personnel from
machine gets faulty. shock. Ground fault circuit interrupters (GFCIs)
The grounded systems as used at homes may be utilized which are designed to shut off
offer pro­tection from macro shock but devices the electric power within a few milliseconds
may lose power without warning. Life support of the occurrence of a ground fault, thereby
systems, if in use could be disturbed. preventing serious electric shock.
Following criteria are ideal with respect to To minimize eye fatigue, the ratio of intensity
electrical functioning in OT complex:6 of general room lighting to that at the surgical
• Use of circuit breakers/interrupters is site should not exceed 1:5, preferably 1:3. This
desirable if there is an overload or ground contrast should be maintained in corridors
fault. and scrub areas, as well as in the room itself,
 Infrastructure Requirements for Operation Theater 153

so that the surgon becomes accustomed to emergency state such as cardiac arrest or need
the light before entering the sterile field. Color for immediate assistance.
and hue of the lights also should be consistent.
The overhead operating light must have the
Catering
following feature.2,4
• An intense light, within a range of 27,000 Basic services such as preparation of beverages
to 127,000 lux is required into the incision and some snacks, use of vending machines may
site. It must be without glare on the surface. be planned, augmented by provision of hot and
The light may be equipped with an intensity cold meals from main hospital kitchen.
control.
• Provide a diameter light pattern and focus Cleaning
appropriate for size of the incision. Fixture
should provide focused depth by retracting The construction materials selected for the OT
light to illuminate both the body cavity and com­plex should aim to minimize maintenance
the general operating field. and cleaning costs. The corners have to be
• Light should be shadowless. Multiple light minimum in number and it should be rounded
sources and/or reflectors decrease shadows. to minimize dirt collection.
• The goal should be to produce the blue-
white color of daylight. Data Management
• It should enable easy cleaning.
• The installation of lights should be Customized network connections should be put
aerodynamically designed to facilitate in place or a conduit should be planned. A well
airflow. designed system such as hospital information
• Light must produce a minimum of heat. system (HIS) can provide automated records,
Halogen bulbs generate less heat than other materials management, quality improvement
types. and assessment, laboratory tracking, etc. The
Software for OT management are costly and
hospitals are generally slow to adopt to changes.
Anesthesia Equipment and Customized OT software can be designed for
Monitoring Needs individual hospital needs.7
At least one anesthesiologist should be in the
team involved in planning an OT. It is imperative Operating Theater Satellite Pharmacy
that certain mandatory considerations with
respect to the anesthetic equipment and The pharmacy should be accessible from OT
monitors be planned during the planning and areas. It should have a laminar flow hood,
design stage itself. Personal, practice and cost a refrigerator, space for drug storage locked
preferences may influence the plans.1 containers for controlled substances computer,
desk area for paper work and phar­maceutical
literature. Special kits for specific surgeries may
Communications also be arranged. The pharmacy may open for
Telephones, intercom and code warning signals 1 to 24 hours based on need but it is desirable
are desirable inside the OT. One phone per that an after hour system is planned.
OT and one exclu­sively for use of anesthesia
personnel is desirable. Inter­com to connect Statutory Regulations
to control desk, pathology and other OTs as
well as use of paging receivers (bleeps) is also The design and planning of an OT complex will
ideal. A code signal, when activated, signals an need compliance with mandatory regulations
154 Practice Guidelines in Anesthesia

related to local administration such as different diagnostic, therapeutic and surgical

Municipal Corporation, Government, Pollution interventions.
Control Board, Fire Safety Department, Water
supply and Drainage department, etc. References
1. Dorsch JA, Dorsch SE. Operating room design
Regulatory Authority and equipment selection, Understanding
Anaesthesia Equipment, 4th Edn; Williams and
The Joint Commission on Accreditation of Wilkin; [Link].1015-16.
Healthcare Organizations (JCAHO) standards 2. Gupta SK, Kant S, Chandrashekhar R.
can be used to formulate the basic infrastructure Operating unit – planning essentials and design
plans of OT. considerations. Journal of the Academy of
Hospital Vol. 17 (2):(2005-01–2005-12).
3. Harsoor SS, Bhaskar SB. Designing an ideal
Conclusion operating room complex. Indian Journal of
The operation theater is an aseptic zone Anaesthesia. 2007;51:193-199.
4. Bridgen RJ. Ch1. The operating department 2.
with controlled climatic environment for the
Organization and management 3. Electricity and
operation and perioperative care of patients electromedical equipment 4. Static electricity:
undergoing diagnostic and surgical procedures operating theratre technique, 5th edn: Churchill
under anesthesia. The robotic surgeries and Livingstone 1988; 09,10,13,16-21,27-31, 41,
other superspeciality branches has necessitated 43-45,109.
the modernization of operation theater. The 5. Sehulster LM, Chinn RYW, Arduino MJ, et al.
design of an operating theater offers a challenge Guidelines for environmental refection control in
to the planning team to optimize efficiency by health care facilities. Recommendations from CDC
and the Healthcare infection Control Practices
creating safer practice in anesthesia, asepetic
Advisory Committee (HICPAC) November 2003.
and controlled climatic conditions, realistic 6. National Fire Protection Association (NFPA).
functional traffic flow and flexibility for future Standard for Health Care Facilities. NFPA, 2002.
expansion. An update version of NFPA 99 standards.
Model operation theater specification 7. Miller Rd. Operating room information systems.
varies from hospital to hospital as per Miller’s anesthesia, 6th Edn; Elsevier – Churchill
surgeon-anesthesiologists demand for Livingstone; [Link].3131-32.
 CHAPTER 22
Preoperative Fasting Guidelines
Vinod Kalla

Introduction • Decrease the risk of dehydration and

hypoglycemia
Fasting protocols for elective surgery aim to
• Minimize perioperative morbidity.
provide a balance between safety and comfort
for the patients. Prolonged fasting time causes
patient discomfort along with physiological Fasting Protocol for Adults
alterations consequent upon fluid deprivation undergoing Elective Surgery
and caloric restriction. The full stomach patient
• Fluids: Adults can be allowed to drink clear
on the other hand makes for a poor candidate
fluids including water, pulp-free juice, black
for an elective surgical procedure because tea or coffee, carbonated drinks, coconut
of risk of pulmonary aspiration of gastric water, etc. up to 2 hours before elective
contents necessitating delay or postponement surgery. This has been seen to increase
of such cases. Publications appear in literature gastric pH and reduce the gastric volume.3
since 1950s on trials of fasting protocols • Clear carbohydrate rich drinks (ORS) can
before elective surgery.1,2 There has been a be safely given up to 2 hours preoperatively.
convergence of views over the intervening These fluids change the metabolism from
decades towards shorter fasting times. Current overnight fasted state to that of a fed state and
practices aim to minimize fluid deprivation also reduce postoperative insulin resistance
and physiological changes in the immediate without any evidence of increase in gastric
preoperative period. volume.4,5
Certain groups of patients like the obese, • Solid food: A fasting period of less than 4 hours
pregnant women not in labor, diabetics and after a light breakfast has been reported to
those suffering from gastroesophageal reflux are have equivocal finding with regard to gastric
considered to have delayed gastric emptying. volume and pH. Despite this, preoperative
However, the current evidence suggests that fasting of 6 hours is recommended after
they can also follow the same guidelines as consumption of solids. Additional fasting
healthy adults. time of 8 hours or more is recommended
The purpose of these guidelines is to: after ingestion of fried or fatty food and meat.
• Increase patient satisfaction • Chewing gum and sucking of boiled sweets
• Avoid delays and cancellations of planned can be allowed up to the time of induction of
surgeries anesthesia.
156 Practice Guidelines in Anesthesia

• Women in labor should be encouraged to 2. MW. Lincoln, Aspiration of Gastric Contents

ingest clear fluids. Ingesting of solid food under Anaesthtesia: a review & Clinical Study,
should be discouraged. Western journal of medicine. 1957;87(6): 403-7.
• Pregnant women scheduled for cesarean 3. Hutchinson A, Maltby JR, Reid CR. Gastric fluid
volume and pH in elective inpatients. Par I:
section can drink clear fluids up to 2 hours
Coffee or orange juice versus overnight fast. Can
before surgery.6,7
J Anaesth. 1988; 35;12-5.
4. Taniguchi H, Sasaki T, Fujita H, et al. Preoperative
Fating Guidelines for fluid and electrolyte management with oral
Infants and Children rehydration therapy. J Anesth. 2009; 23:222-9.
5. Kaska M, Grosmanova T. Havel E, et al. The impact
• Fluids: Clear fluids can be given to infants and safety of preoperative oral or intravenous
and children up to 2 hours preoperatively.8 carbohydrate administration versus fasting in
• Breast milk can be given up to 4 hours before colorectal surgery: a randomized controlled trial.
surgery.9 Wien Klin Wochenschr. 2010;122:23-30.
• Infant formula, cow milk and solids should 6. Porter JS, Bonellon E, Reynolds F. The influence
be withheld 6 hours preoperatively.9 of epidural administration of fentanyl infusion
• Fasting time exceeding 8 hours may result in on gastric emptying in labour. Anaesthesia. 1997;
hypoglycemia in children. 52:1151-6.
7. Wong CA, Loffredi M, Ganchiff JN, et al.
Gastric emptying of water in term pregnancy.
Pharmacological Prophylaxis
Anesthesiology. 2002;96:1395-400.
Against Pulmonary Aspiration 8. Shime N, Ono A, Chihara E, Tanaka Y. Current
• Routine preoperative use of prokinetic practice of preoperative fasting: a nationwide
(metoclopramide), H2 receptor antagonist survey in Japanese anesthesia-teaching
(ranitidine), antacids (magnesium hospitals. J Anesth. 2005;19:187-92.
trisilicate, sodium citrate) and antiemetics 9. American Society of Anesthesiologist Task Force
(ondansetron) to reduce the risk of on Preoperative Fasting. Practice guidelines for
pulmonary aspiration in patients who do not preoperative fasting and the use of pharmacologic
have increased risk for pulmonary aspiration agents to reduce the risk of pulmonary aspiration:
application to healthy patients undergoing elective
is not recommended.
procedures Anesthesiology. 1999;90:896-905.
• Parturients scheduled for elective cesarean
section should be administered oral H2
receptor antagonist (ranitidine 150 mg) or Recommended Reading
proton pump inhibitor (omeprazole 40 mg) 1. Smith I, Kranke P, Smith A, O’Sullivan G, Soreide
along with prokinetic (metoclopramide 10 E, Spies C, Veld BI. Perioperative fasting in adults
mg) at bed time and again 60 to 90 minutes and children: guidelines from the European
before induction of anesthesia. Society of Anaesthesiology. Eur J Anaesthesiol.
• In case of emergency cesarean section, 2011;28:556-69.
2. Apfelbaum JL, Caplan RA, Connis RT, Epstein
intravenous H2 antagonist (ranitidine 50
BS, Nickinovich DG, warner MA. Practice
mg) and prokinetic (metoclopramide 10 mg) guidelines for preoperative fasting and the use
should be administered at the time decision of pharmacologic agents to reduce the risk of
for surgery is taken. pulmonary aspiration: Application to healthy
patients undergoing elective procedures.
Anesthesiology. 2011;114(3):495-511.
References
3. Merchant R, Chartrand D, Dain S, Dobson G,
1. Murray FA, Erskine JP, Fielding J. Gastric Kurrek MM, Lagacé A, Stacey S, Thiessen B.
secretion in pregnancy. J Obstet Gynaecol Br Guidelines to the Practice of Anesthesia-Revised
Empire. 1957; 64:373-81. Edition 2014. Can J Anaesth. 2014;61(1):46-59.
 CHAPTER 23
Anesthetic Care for MRI
Sarla Hooda, Prashant Kumar

There is a need for an efficient and effective when nuclei resume their original alignment at
method of sedation/anaesthesia in the MRI. cessation of second magnetic field.3 Magnetic
The continuous presence of a strong magnetic field is generated by large electromagnets. The
field, small bore of magnet and restricted field strength of such electromagnets in routine
access to the patient make it a difficult place. clinical use is 1.5 Tesla to 7.0 Tesla (1 T=10000
Children and adults with movement and Gauss). One can understand the magnitude
learning disorders or claustrophobia who are of such field by knowing the fact that earths’s
unable to lie still during the long period of magnetic field is approx. 0.5 Gauss. The coils
scan necessitate the requirement of sedation wires are made superconductor by bathing wire
or general anesthesia. Even patients requiring (copper embedded with a niobium/titanium
general anesthesia are often difficult to manage, alloy) in liquid helium at 4.22 K (i.e. -269° C).
e.g. rare pediatric syndromes and critical care In this situation wires’ resistance becomes
patients. Performing anesthesia at a MRI suite is negligible and current generated in the coil
a process where things have to be well planned continues to flow indefinitely with no energy
with well trained staff to guarantee maximum input. It is important to note that electromagnet
safety to patient and all.1,2 created by this super conductor is always on,
regardless of whether we use it for scan or not.
Magnet can be turned off by allowing helium to
Basic Physics
evaporate the process called “quench”. To restart
MR imaging is a non-invasive and radiation free such magnet will involve many days with loss of
diagnostic procedure. Atomic nuclei containing lacs of rupees as cost of liquid helium.3
a positive charge (due to their protons) spin Different tissues in the body have different
on their own axis like the earth. MRI scanner, relaxation rates. “T” refers to relaxation time
generally use hydrogen nuclei (i.e. protons) to constant, and images may be T1 weighted
generate images. When protons are exposed to (generated a few milliseconds after the
a static magnetic field, the orientation of their electromagnetic field is removed) or T2
spinning axis will be aligned with that of the weighted (generated later then T1) depending
static field. If a transient magnetic field is applied on the characteristics of the tissue you wish
perpendicular to the static field it will cause the to look at. Nuclei in hydrogen take a long time
nuclei to flip orientation and rotate. This process to decay to their original position, so fluid will
consumes energy. This energy will be released appear dark (minimal signal) in a T1 weighted
158 Practice Guidelines in Anesthesia

image but white in the later T2 image as the procedure, have an important role wherever
signal appear. MRI machine is contained within available.
a radiofrequency shield called Faraday Cage.
Guidelines for Preparation of Patient
Specific Issues Remain the Same as for General
Anesthesia
Remote locations, special patient needs, limited
access to patient in tunnel, high magnetic field, Written informed consent informing the
ferromagnetic objects and their projectile effect, risk involved, adequate fasting (request of
ferromagnetic implants, specific equipment anesthesia assistance after failed attempt of
and monitoring issues, high level acoustic conscious sedation cannot be accepted if patient
noise (reaching up to 95 decible), scavenging, is not fasting), intravenous access, standard
quenching and its associated hypoxia, contrast, monitoring, ready availability of emergency
cold environment are the major concerns for equipment and presence of anesthesiologist
anesthesiologist at MRI suite. A field of more experienced in working in specific environment
than 30 Gauss is capable of erasing magnetic and equipment are required. Preoperative
strip data which are stored on computer disks assessment should include a history of
and credit cards. implanted devices4,5 (Table 23.1).

Preparation and Techniques Monitoring Equipment

Distraction can be a powerful tool for reducing All equipment to be used within scanning room
anxiety and increasing patient compliance. must be nonferromagnetic and should be MR
Techniques such as audiovisual aids are useful safe (i.e. present no safety hazard to patient or
during the scan when patients are required to lie personnel when taken into MR room provided
still in the bore. Having a point of interest (such instructions concerning its use are followed,
as a parent/relative or video screen) is helpful in however it does not guarantee its normal
maintaining the patient in one position. function and interference with imaging) or
Educational play therapists can use a range MR compatible (i.e. MR safe which function
of resources to assist children to comply with normally in MR environment)6 (Table 23.2)
the procedure without sedation or anesthesia MRI compatible monitors are commercially
by using brochures, MRI toys, story books, available. These may include a master monitor
discussions and most importantly Mock MRI and a slave monitor. The master monitor stays

TABLE 23.1 Implanted devices to be verified for compatibility with MRI

Device Reason
Metallic make-up and tattoos Can distort image or heat-up to cause burn
Cardiac pacemaker/ ICDs Switch malfunction
Metal eye splinters Can cause injury/blindness
Vascular clips, intrauterine contraceptive devices If, ferromagnetic, could move in the magnetic field, with
Interventional radiological device (coil/stents) potentially disastrous consequences.
Most modern ones are non-ferromagnetic and are safe in
MRI
Orthopedic devices (prosthetic joints, wire plates) Titanium or chromium/cobalt implants are compatible
Cochlear implants Contain a magnet which may move and cause injury
 Anesthetic Care for MRI 159

TABLE 23.2 Compatibility of other anaesthetic equipments5,7

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

in the MRI suite and the slave monitor sit in monitoring indispensible in RI procedure.
the MRI control room and receive information Long tubings needed in MRI suits may
wirelessly from the master monitor3. also be a contributory factor for waveform
• The electrocardiogram introduces problems showing a prolonged upslope. It is more
with both image degradation from wire leads important to follow trends then to look for
(ensure to avoid any loop) and inability absolute values. Use of special respiratory
of ECG monitor to discern ECG from belt which provide respiratory measurement
background static magnetic field waves. in MRI scanner is a better alternative.
High impedance graphite electrode with • Blood pressure monitoring can be
specially insulated leads placed at V5, V6 accomplished using the oscillometric
maximizes QRS and minimize artifacts are method. Invasive pressures can be monitored
clinically important using high pressure low compliance tubings
• Pulse oximetry is essentially to be used on with transducer placed beyond 50 Gauss
all anesthesiologist-administered sedation line.
or general anesthesia. Use of nonferrous • Temperature monitoring needs to be
pulse oximeter with probe placed on a distal done with temperature probes that use
extremity as far from the scan site as possible radiofrequency filters or with nonferrous
is required. skin temperature probe.
• Special note has to be taken as chest Anesthesiologist’s expertise is required in
excursions may not be observed easily and pediatric airway management as in event of
saturation might fall late after cessation of hypoventilation, the scan has to be stopped, the
breathing, especially when oxygen is being table pulled out and airway managed in odd
insufflated. Thus making end tidal CO2 environment.
160 Practice Guidelines in Anesthesia

Drugs for Sedation of 15 to 30 minutes. Analgesic component

of ketamine is usually not required for MRI
The ideal sedation agent for this type of setting procedure. Generally coadministarion
would have a rapid onset, rapid recovery, be of anticholinergics or benzodiazepines
easily titrated for varying levels of sedation, be is required. Ketamine is also associated
safe for both pediatric and adult patients, allow with hypertonicity, hypertension and
patients to remain hemodynamically stable, and re-emergence.9
have a low cost, A variety of drugs are available • Dexmedetomidine as selective alpha2 agonist.
for sedation.8 It has minimal respiratory effects. A loading
• Chloral hydrate is a sedative and hypnotic dose of 2 to 3 µ kg-1 over 10 minutes followed
drug with barbiturate like effect. In by a continuous infusion @ 1 to 2 µ kg-1 hr-1
therapeutic doses i.e. 25 to 100 mg kg-1 it has is sufficient to provide adequate sedation
onset in 15 to 30 minutes with duration of maintenance. However hemodynamic side
60 to 120 minutes. It has only a slight effect effects of low blood pressure and heart rate
on respiration and blood pressure. Nausea, may be observed. Compatibility of infusion
vomiting and long recovery time along with pump has to be taken care of as it may
high failure rates of successful MRI scan malfunction near the field.
has to be considered about this drug as cost
effective and time saving sedation option.9
• Midazolam is not a comfortable drug for Anesthesia for MRI
sedation in MRI when used alone. This is due
to its short duration of action, it is needed Where potential complications of deep sedation
to be given repeatedly or in continuous like hypoventilation, CO2 retention in head
infusion. However in combination with injury patients, apnea, airway obstruction,
fentanyl or pentobarbital or ketamine can be laryngospasm, and cardiopulmonary
used effectively. Associated risk of respiratory impairment are concern, general anesthesia is
depression has to be taken care of. often preferred for the diagnostic procedures
• Propofol is a near perfect drug due to its rather than sedation.10 Managing general
effectiveness, short recovery time and easy anesthesia for MRI procedures has advantages
titrability to the required sedation level. including; being independent of child’s
Doses of 2 to 5 mg kg-1 hr-1 are sufficient cooperation, being more predictable, better scan
to maintain sedation. Propofol has been quality because the child is immobilized and
associated with short ready to scan and scan interruptions due to sedation side-effects
discharge time. When administering are minimized. In addition, it is possible to
propofol in the MRI suite, the patient’s EKG, perform breath-holding maneuvers for images
heart rate, oxygen saturation, respirations that need complete immobilization. In principle
and blood pressure should all be monitored all types of general anesthesia techniques can be
Propofol is also compatible via a Y-site with used in MRI. If the ventilator is equipped with
Gadolinium, the contrast agent used in a vaporizer, maintenance of anesthesia using
MRI. Dosing of propofol needs to be closely inhalation agents is still standard in pediatric
controlled and possibly titrated for effect, an anesthesia. New short acting inhalation
electronic infusion pump is recommended anesthetics such as sevoflurane and desflurane
for administration. Placement of syringe have acquired widespread acceptance in
pump beyond 30 Gauss line with fixation to pediatric anesthesia because of their rapid
a base is essential safety measure.8 uptake and elimination. Sevoflurane is an ideal
• Ketamine in doses of 1 to 1.5 mg kg-1 when inhalation agent routinely used for children.
used iv or 4 to 5 mg kg-1 as intramuscular has Use of N2O in 50% Oxygen help in reducing
onset time of 1 to 5 minutes with duration inhalational concentration reduction.10 On
 Anesthetic Care for MRI 161

the other hand, propofol can be used for total In addition to the separate areas for patient
intravenous anesthesia. Laryngeal masks and preparation and recovery, the design of the
tracheal tubes can be used in the MRI setting. transport path to the MRI must be barrier-free.
The decision should depend on comorbidities, Placement of workstation along with fixation of
anatomy and fasting status in the individual monitors and syringe pumps be designed with
case. consideration of 50 gauss line. The nominated
Widely accepted technique with airway consultant anesthesiologist should ensure that
managed with a supraglottic device is a safe, anesthetic staff is familiar with the anesthetic
predictive and controlled method. Availability machine and monitoring equipment which are
of anesthesia machine with a vaporizer in often of a nonstandard configuration. All staff
preparation room along with all monitoring should be familiarized with local rules of the
equipment is of great help. The child can be MR department which are appropriate to their
made to sleep in parents lap using inhalational individual role.6
anesthetic with sevoflurane. As soon as child
goes to sleep iv access is secured. Airway be
Conclusion
secured with a appropriate size supraglottic
device like LMA, igel or Ambu LMA. The child The decision of sedation or anesthesia has to
can then be allowed spontaneous respiration be made on a case-by-case basis, taking into
through circuit using inhalational anesthetics. account all characteristics of the individual. A
While wheeled inside the suite the spontaneous fully equipped anesthesia workstation is strictly
respiration can be maintained with 1 MAC required for both sedation and anesthesia.
of inhalational. Addition of N2O is another Airway management and resuscitation
option to reduce high concentration of O2 equipment have to be prepared and directly
and gases. Spontaneous technique allows for available. Adequate training in pediatric airway
predictable smooth spontaneous recovery.10 and emergency management in this setting with
Use neuromuscular blockers whenever needed a restricted view of and access to the patient is
(such as in situations of controlled ventilation essential for anesthesiologists working in this
and respiratory maneuvers). environment.
General anesthesia with endotracheal
intubation may sometimes be necessary during References
MR imaging. Patients with head trauma, requiring
control of their EtCO2, children from PICU who 1. Uentrop LS, Goepfert MS. Anaesthesia or
are intubated due to underlying pathology and sedation for MRI in children. Current Opinion in
Anaesthesiology. 2010;23:513-7.
infants with history of apnea and bradycardia
2. The Association of Anaesthetists of Great Britain
are few of the examples of indications for and Ireland. Provision of anaesthetic services
endotracheal intubation. In lack of clear medical in magnetic resonance units. London UK: The
reason for tracheal intubation most instances Association of Anaesthetists of Great Britain and
spontaneous ventilation is preferred.11 Ireland ;May 2002
3. Olive D. Don’t Get Sucked in: Anaesthesia for
Magnetic Resonance Imaging in Keneally J
Planning and safety (Ed) Australian and New Zealand college of
Framework for anesthesia in the MRI Anesthetists: Melbourne; 2005. pp.85-96.
4. Teissl C, Kremser C, Hochmair ES, Hochmair-
environment is quite different from that
Desoyer IJ. Magnetic resonance imaging and
found in the operating room. Involvement of cochlear implants: compatibility and safety
experienced anesthesiologist in planning is aspects. J Magn Reson Imaging. 1999;9:26-38.
important as anaesthesia management for 5. Bresland MK, Thomas ML, Roy WL. Anesthesia
MRI does not just involve simply duplicating for offsite procedures. In: Healy TEJ, Knight PR
comparable operating room requirements. (Eds). Wylie and Churchill- Davidson’s A Practice
162 Practice Guidelines in Anesthesia

of Anesthesia 7th edn. Arnold Publishers: mechanical ventilation. A comparison of

London; 2003. propofol and midazolam. American Journal of
6. The Association of Anaesthetists of Great Britain Respiratory and Critical Care Medicine.
and Ireland. Provision of anaesthetic services 9. Krauss B, Green SM. Procedural sedation and
in magnetic resonance units. London UK: The analgesia in children. Lancet. 2006;367:766-80.
Association of Anaesthetists of Great Britain and 10. Orhan Me, Bilgin F, Kilickaya O, Atim A, Kurt E.
Ireland;May 2002. Nitrous oxide anesthesia in children for MRI: a
7. Peden CJ, Menon DK, Hall AS, Sargentoni comparison with isoflurane and halothane. Turk
J, Whitwam JG. Magnetic resonance for the J Med Sci. 2011;41:387-96.
anaesthetist. Part II: Anaesthesia and monitoring 11. Committee on Drugs: Guidelines for Monitoring
in MR units. Anaesthesia. 1992;47:508-17. and management of pediatric patients during
8. Kress JP, O’Connor MF, Pohlman AS, et and after sedation for diagnostic and therapeutic
al. Sedation of critically ill patients during procedures. Pediatrics. 1992;89:1110-5.
 Index
Page numbers followed by f refer to figure, t refer to table and b refer to box

A patient monitoring 95 suction 139

patient selection and vaporizer 140
Adrenaline 26, 110
consent 93 ventilator 140
for anaphylaxis
protocols and guidelines Anesthesia
management 26
97 depth of 51
in children 27t
risk factors 93 for MRI 160
Aero medical transfer 116
Anaphylactic reactions 23, 26t general 104
Airway management,
anesthetic technique 29 intraoperative monitoring 49
preparation of 128
associated etiologies 26t airway and ventilation 49
Airway
grading of severity of 25t circulation 50
assessment 128 neuromuscular monitor 50
features of 128t non-immunogenic 24
Anaphylaxis 23 oxygenation 49
difficult temperature 50
algorithm 129f allergic 23
definition 23 local
definition 127 CNS manifestation 110
intubation 128 non-allergic 23, 24
perioperative 24 diagnosis 110
Aldrete score 105 prevention 110
Alpha 2-adrenergic clinical features 24
monitoring 48
antagonists 80 differential diagnosis 25
monitoring standards in 45
Ambulances ground transport etiology of 23
perioperative care and
advantages of 116t investigation 27
monitoring 49
practical problems 117t management guidelines
quality assurance 60, 66
Ambulatory surgery 17 26t, 26 acute pain management 65
general anesthesia 19 management in adverse events
intraoperative care 18 children 27t reporting 66
intravenous regional risk factors for 25t drugs 61
anesthesia 19 Anesthesia equipment guidelines for obstetric
perioperative care 18 anesthesia delivery system analgesia 64
peripheral nerve block 19 checks 138 in ICU 66
postoperative recovery 20 airway equipment 140 in operating room
preoperative preparation 18 alternate oxygen supply services 61
regional anesthesia 19 source 138 intraoperative period 63
Ambulatory surgical unit 13 alternative breathing monitoring equipment 61
AMT see also aero medical system 140 post-anesthesia
transfer breathing system 139 care unit 63
Analgesia carbon dioxide preoperative checklist 63
epidural 93, 97 absorber 140 preoperative
audit and critical correct gas outlet 140 examination 62
incidents 97 gas supply 139 records maintinance 63
catheter insertion 94 monitors 140 sterilization of
complications 93 oxygen monitor 139 equipment 61
drugs for 95 power supply 139 regional 4
equipment used 95 scavenging 140 Anesthesiologist 47
in children 96 self-inflating bag 138 qualification of 61
164 Practice Guidelines in Anesthesia

Anesthetic, local, systemic D definition 79

toxicity 109 environmental risk
Dexmedetomidine 102, 160
Anxiolysis 104 factors 83
Apnea, postanesthetic 15 E grades 79
Atracurium 23 risk factors 80
Epidural abscess 96
Atropine 61 treatment of 84
Etomidate 56
active warming
B mechanisms 84
F
Benzodiazepines 80 thermal insulation
Fasting guidelines mechanisms 84
Blood transfusion
for adults 155
complications 146
evidence based guidelines
for infants and children 156 I
Femoral nerve 91
for 145 IgE assay, anaphylactic
Fentanyl 101, 102
management of 146 reaction 28
FFP see also fresh frozen
perioperative, strategies to Inadvertent perioperative
plasma
reduce 145 hypothermia /IPH 79
Flumenazil 80
purpose of 143 effect of anesthesia
Fresh frozen plasma
risks of 144 duration 82
transfusion 143
cancer recurrence 144 effect of anesthesia type 82
indications for 146
Brachial plexus 89 management
Bupivacaine 62 G intraoperative phase 85
perioperative care 84
C Glasgow coma scale/GCS postoperative phase 86
score 53, 53t preoperative phase 84
Catheter related blood stream Glucagon, for anaphylaxis in
infections/CRBSI 76, 77 risk factors 82
children 27t surgery risk factors 82, 83
CCTT 115
Interhospital transfer
Central venous catheters /CVC H aeromedical
infection control Head injury considerations 119
measures 77 classification 53 aero-medical transfer 116, 121
limitation 78 definition 53 patient preparation 122t
precautions to prevent as per WHO task force 53 relative
mechanical injury 78 severity as per glasgow coma contraindications 121t
selections of insertion site 76 scale/GCS score 54t sample preflight
Central venous pressure/ Histamine levels 28 checklist 123t
CVP 76 Hypersensitivity reactions, type checklist 114t
Cerebral edema 74 4 delayed 24 drugs to accompany
Cerebral herniation 54 Hypertension management; in critically ill
Chloral hydrate 160 post anesthesia care patients 117t
Cisatracurium 24 units 9 emergency transfer 113
Compartment syndrome 97 Hyponatremia, in children, equipment required 117
CRBSI See also catheter perioperative general characteristics
related blood stream period 73 of 119t
infections Hyponatremic ground transport
Cricothyrotomy 56 encephalopathy 73 ambulances/GTAs 116
Critical care transport team 113 Hypotension management; in legal issues 121
I’m safe test 115, 115t post anesthesia care medications required 117
Croup, postintubation 15 units 8 primary 113
CVC see also central venous Hypothermia secondary 113
catheters consequences of 83 transport triangle 113, 114f
 Index 165

Interhospital transportation capnography 105 procedure 90

teams, types of 115 cardiovascular usage 90
Intradermal tests/IDT, for system 105 ultrasound guided 87
anaphylactic communication and complications 91
reaction 28 observation 104 Neuromuscular blocking
Intravenous colloids 24 level of sedation 104 agents/NMBA 23
IPH see also Inadvertent local anesthetic over NMBA see also Neuromuscular
perioperative dosage/toxicity 105 Blocking Agents
hypothermia PACU care and Nonsteroidal anti-inflammatory
discharge 105 drugs/NSAIDs, in post
K pulse oximetry 104 operative pain 10
Ketamine 160 temperature 105
Ketorolac, in post operative practice guidelines 99 O
pain 11 preanesthetic assessment 99 OAA/S scale 104
Kounis syndrome 24 airway assessment 100 Observer assessment of
L cardiorespiratory reserve alertness/sedation
and physical scale (OAA/S scale)
LAST see also local anesthetic fitness 100 104b
systemic toxicity cognitive function 100 Obstetric anesthesia 132
Lignocaine 62 general assessment 100 aspiration prophylaxis 133
CV/CNS ratio 109 preoperative cardiopulmonary
Local anesthetic systemic
instructions 101 resuscitation 136
toxicity 109
procedure explanation, combined spinal epidural
management of 111
briefing and analgesia 134
M consent 100 continuous infusion epidural
MAC see also Monitored Morphine, in post operative analgesia 134
Anesthesia Care pain 10 emergency management
Magnesium trisilicate 156 MRI 157 airway emergencies 135
Metoclopramide 156 compatibility of anaesthetic anesthetic
Midazolam 80, 101, 160 equipments 159t emergencies 135
Mivacurium 23 compatibility of implanted for cesarean delivery 134
Modified aldrete score 3 devices 158t for labor 133
Modified postanesthetic informed consent 132
discharge scoring/
N laboratory investigations 132
PADS 105 Narcotics, for post operative neuraxial analgesia 133
for ambulatory surgery 20t pain 11 patient–controlled epidural
Monitored anesthesia care/ Nerve block analgesia 134
MAC 99 femoral 90 regional 133
ASA definitions 99 equipment 91 spinal opioids 133
commonly performed position during 91 Omeprazole 156
procedures 103 procedure 91 Operation theater
commonly used drugs for for post operative pain 11 basic architecture of 149
101 interscalene and catering 153
complications of 106 supraclavicular 89 cleaning 153
in elderly patients 102 equipment 89 data management 153
monitoring 104 position during 89 definition 148
adverse events/effects procedure 89 infrastructure of 148
secondary to deep sciatic operating theater satellite
sedation and equipment used 90 pharmacy 153
procedure 105 position during 90 piped gases in 152
166 Practice Guidelines in Anesthesia

regulatory authority 154 Platelet-rich pulmonary function

requirements for plasmapheresis 145 test 71
designing 149 Post-anesthesia care units 1 serum albumin level 71
scavenging methods 152 Complications 6 serum glucose 71
statutory regulations 153 airway obstruction 6 serum urea and
utilization of 148 atelectasis 7 electrolytes 71
ventilation 151 cardiogenic shock 8 jaundice 68
circulatory long-term steroid therapy 69
P complications 8 malignant hyperpyrexia 68
PACU bypass SCORE 4t diffusion hypoxemia 7 neurological status
PACUs see also post-anesthesia dysrhythmias 9 assessment 69
care units emergence delirium 15 parathyroid disease 68
PADS 106 hypertension 9 renal disease 68
Pain management hypotension 8 unusual bleeding 69
in childbirth 39 hypothermia 12 Prilocaine, side effects 109
in critically ill and cognitively hypoventilation 8 Propofol 101, 160
impaired patients 39 hypovolemic shock 8
side effects 102
in geriatric patients 38 hypoxemia 6
Propofol-alfentanil-nitrous
multimodal approach for 36 nausea and vomiting 11
oxide 12
multimodal approach pneumothorax 7
techniques, types postoperative pain 10 R
of 37 pulmonary edema 7 Ranitidine 156
pediatric patients 38 pulmonary embolism 7 RAPBC see also regional
perioperative respiratory
anesthesia PACU
evaluation 34 complications 6
bypass criteria
preparation 35 septic shock 8
Red blood cells, transfusion
techniques 35 factors influencing stay in 4
indications for 145
Pain pediatric 14
Regional Anesthesia PACU
acute, definition 32 standards 4
bypass criteria 3
ASA task Force’s Postanesthesia discharge score
system 13t Retained Placenta removal 135
recommendations
Postanesthesia discharge Ringer lactate 74
for 34
scoring/PADS system, Rocuronium 56
postoperative 10
modified 106b Ropivacaine, CV/CNS ratio 109
management 10
risk factors 10 Postanesthesia recovery score 3 S
Pancuronium 24 Postpartum tubal ligation 135
Salbutamol , for anaphylaxis in
Perioperative fluid Preanesthetic evaluation 68
asthma 68 children 27t
management, in
diabetes 68, 69 Sedation
children 73
evaluation of cardiovascular ASA suggested levels 104
Perioperative fluid monitoring
risk 68 deep 104
in children
central venous pressure/ hyperthyroidism 69 minimal 104
CVP monitoring 74 hypothyroidism 69 moderate 104
with burn injury 74 investigation 70 Skin Tests, for anaphylactic
with trauma 75 chest X-ray 70 reaction 28
Physostigmine 81 coagulation profile 71 Society for ambulatory
Piston-powered unpressurised echocardiography 71 anesthesia/SAMBA 17
aircrafts/PPUA) 116 electrocardiogram 70 Sodium citrate 156
Platelet infusion 143 nutritional and fluid and Spinal Needles 134
indication for 145 electrolyte status 71 Succinylcholine 23, 56
 Index 167

Surgical patient safety Thiopentone 24 brain trauma foundation/

checklist 62 Thiopentone sodium 61 BTF 54
Suxamethonium 61 Transversus abdominis plane transportation 55
block /TAP 36
T primary survey and
Traumatic brain injury/TBI 53 resuscitation 56
TBI see also traumatic brain ABC 56
injury ventilation strategy 54
criteria to refer a patient to
Temperature Tryptase 27
ED 55
methods of recording 84
esophageal devices 84
assessment at the ED 55 V
imaging 57
nasopharyngeal Vecuronium 24
devices 84 CT scan 57
pulmonary artery magnetic resonance W
devices 84 imaging/MRI 57
Warming devices, complications
rectal devices 84 management in children 55
neurologic evaluation 57 of 84
sublingual devices 84
prehospital management White and song scoring
tympanic membrane
devices 84 airway management 54 system 13