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ANESTHETIC RISK / PREMEDICATION / CHOICE

David J. Stone, M.D.

Professor of Anesthesiology and Neurosurgery
UVa Health System

Risks:

Overall risk of mortality from anesthesia is very hard to evaluate in

current practice; factors include patient, procedure, equipment,
doctors, circumstances, etc. It may be difficult to dissect out
anesthetic-related death from death due to surgical or combined
problems.

The individual patient should be informed that there is a risk to

anesthesia with any questions answered as part of 'informed consent'.
Particular risks should be pointed out as appropriate; for example, we
make a point of notifying the patient (and documenting in our note)
the risk of dental injury if there are underlying dental problems that will
predispose to this common problem. On the other hand, it may not be
appropriate to terrify each patient with all the possible risks of their
anesthetic.

If the patient wants to be informed about the risk of death from

anesthesia, it is probably somewhere between 1 in 1000 and 1 in
100,000 depending on the factors noted above. Infants less than 1
and patients older than 70 appear to have a higher risk. Unlike the
choice of whether to get onto the airplane or not, there is no choice as
to whether to have an anesthetic or not in most cases. On occasion,
local anesthesia is an option that should be considered with the
patient and surgeons.

Causes of morbidity/mortality are heavily linked to the respiratory

system and include inability to mask ventilate or intubate with
resultant hypoxemia and undetected esophageal intubation- these
problems have been addressed by the specialty in recent years and
may have been improved by better monitors (pulse oximeter,
capnography) and backup airway management techniques (see
airway lecture); complications also include laryngospasm,
bronchospasm, aspiration, intubation injury (teeth, lips, pharynx,
esophagus, larynx, trachea), pulmonary edema, respiratory arrest.

Other systems include Cardiovascular- myocardial

ischemia/infarction, cardiac failure, cardiac arrest (which may be
secondary to a respiratory problem), emboli from clots, air, or
orthopedic stimuli, hypotension due to undetected hypovolemia,
massive hemorrhage, anaphylaxis (also respiratory component), drug
overdose. Other problems include malignant hyperthermia, machine
malfunction, liver or kidney injury, stroke.

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While we will never achieve zero morbidity/mortality, the specialty has

done incredibly well in identifying and solving clinical problems.
Ironically, this makes a major complication even less acceptable at
present.

It is critical to evaluate the patient as thoroughly as appears to be

required -- it is important to move efficiently but not with undue haste
unless the problem is comparably urgent; to completely check the
equipment to be used and make sure all possibly necessary items
(extra laryngoscope blades, smaller ET tubes, etc) are available; to be
careful, vigilant and thoughtful during the entire course of the
anesthetic -- try to anticipate the possible problems of this particular
anesthetic and thereby avoid them or at least to detect them early and
minimize their impact. Especially in the early training period, ask
questions and call for help early when in doubt. It is important to learn
how to recognize when a problem is present, exactly what the
problem is, how to deal with it, and when to call for help.

See the excellent chapter by Ross and Tinker in the latest edition of
Miller's Anesthesia

ASA Physical Status

I Healthy patient
II Mild systemic disease, no functional limitations- eg hypertension,
smoker, mild asthma,
III Severe systemic disease- definite functional limitation eg coronary
disease, COPD, DM, CHF, renal failure
IV Severe systemic disease that is a constant threat to life- eg
unstable angina for emergency carotid endarterectomy, burn with
septic shock
V Moribund patient not expected to survive 24 hours with or without
operation- eg patient with extensive bowel infarction, massive head
trauma

Premedication Goals:

sedation/anxiolysis
analgesia
reduce airway secretions/heart rate control
prevent bronchospasm
hemodynamic stability
prevent and/or minimize the impact of aspiration
decrease post-op nausea/vomiting

Not every patient needs premedication- each drug has problems including
cost, side effects, hypersensitivity, prolonged sedation, drug
intereactions,etc; Use special care in the sickest patients eg mod to severe
CHF or COPD, critically ill

SEDATION/ANXIOLYSIS- pre-op visit by practitioner very effective,

outpatient practice of today, most patients are somewhat anxious but
very few are unreasonably so;

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Benzodiazepines are logical drugs for this purpose, the latest favorite
is midazolam generally given in 1 mg iv increments; for oral use,
diazepam is still used in doses of 5-10 mg po with a sip of water, for a
longer effect, lorazepam can be given 1-4 mg po the night before
surgery.

Benzodiazepines raise the seizure threshold and may be used for this
purpose before regional anesthesia to decrease local anesthetic
toxicity, others may argue that seizures are a useful marker of
reversible neurotoxicity before complete cardiovascular collapse
ensues, avoid these drugs if epilepsy surgery with recordings is
planned.

Decrease doses in elderly, ill, anticipate cardiorepsiratory depression

with narcotics.

Slow recovery from anesthesia.

Barbiturates once used extensively for this purpose are hardly used at
all except for pedes cardiac cases, consider benadryl in frail or elderly
patients.

ANALGESIA- If pt has painful condition or painful procedure to be

performed before the induction of GA such as internal jugular
puncture with major cardiovascular surgery planned.

IM-Morphine- .05-.15 mg/kg or Fentanyl .5-2 micrograms/kg

IV- Fentanyl- 1-4 micrograms/kg with subsequent supervision

These drugs may cause or increase nausea that is already

present, decrease gastric motility, cause biliary spasm

Respiratory depression especially with benzodiazepines

Can be given in OR just before induction to modify the

hemodynamic response to laryngoscopy and intubation but
then are really more a part of induction than a pre-med,
occasionally cause chest wall rigidity that can make mask
ventilation difficult and be confused with upper airway
obstruction or laryngospasm

AIRWAY SECRETIONS/HEART RATE- Anticholinergics are not

necessary for reduction of secretions in every case but are very useful
if prolonged use of mask is anticipated, difficult airway, with ketamine,
in smokers, procedures requiring instrumentation or examination of
the upper airway,

Glycopyrrolate- .2 mg IM or IV in adults; for children .01 mg/kg

IM or IV, .05mg/kg po- this drug provides better drying with less
tachycardia than atropine

Atropine- .4 mg IM or IV in adults- generally not used for this

purpose in adults because of tachycardia, children- .01 mg/kg
IV, .02 mg/kg IM or po

Scopolamine- .3 mg IM or IV in adults; .01 mg/kg IM or IV in

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children

Note IM premeds not generally used in children outside of

cardiac rooms where they are generally heavily premedicated,
in fact, IM premeds not often used in anyone any more

Glycopyrrolate does not enter CNS so little or no possibility of

anticholinergic CNS toxicity

Scopolamine is long acting with major CNS effect- used for

cardiac anesthesia with narcotic, sometimes employed as
amnesic during trauma case when little anesthetic can be
given for hemodynamic reasons

Children under 1 year of age generally receive atropine before

or during induction to reduce the incidence of bradycardia;
some practitioners use it in older children for the same purpose

PREVENTION OF BRONCHOSPASM- In patients with known

bronchospasm, the following may be considered:
Anticholinergics- Continue inhaled pre-op if patient taking these
meds;

Glycopyrrolate- .4-1.0 mg IV in adults is effecitive at blunting

the reflex bronchoconstriction that may occur with airway
instrumentation. Note need for higher dose than to just
decrease secretions, part of dose may be given IV with
remainder given intratracheally to diminish systemic effects of
the drug

Atropine .8-2.0 mg also works well but may cause significant

tachycardia, also can be given intracheally during
laryngoscopy, both of these drugs can also be nebulized in 2-3
cc saline and inhaled preoperatively

Continuation of oral and inhaled (beta-2 agonists- oral drugs

should be given with a sip of water pre-op and inhaled drugs
continued right up to the time of surgery, an extra puff or two
during the last dose may be a good idea; may also institute this
therapy at this time if patient not already on inhaler

Theophylline- not a local favorite as the feeling is that its

toxicity outweighs its efficacy, would hold on day of surgery to
decrease likelihood of toxicity

Continuation/administration of inhaled and oral steroids- as per beta-

2's; strongly consider increased single dose of steroid pre-op
including a dose at bedtime before the day of surgery if possible, can
use po prednisone, also consider dose of steroid even if patient
currently not on the drug- this is not generally of concern to the
surgeon re wound healing, etc but make diabetes more difficult to
control

HEMODYNAMIC STABILITY- Drugs may be administered to facilitate

the administration of hypotensive anesthesia including clonidine .05
mg/kg po, captopril 3 mg/kg po or varying doses of beta-blockers.

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Clonidine has sedative/anesthetic actions while captopril and beta-

blockers do not although beta-blockers may be effective as anti-
anxiety drugs, at least so far as the sympathetic manifestations are
concerned.

Antihypertensives are generally continued up to and including the day

of surgery; the continuation of digoxin and diuretics is a clinical
decision based on volume status, severity of myocardial dysfunction,
propensity for toxicity and likelihood of dysrhythmias. For urgent or
emergent surgery in patients with poorly controlled hypertension,
labetalol in small but increasing increments that are slowly titrated in
is very useful. Currently, there is some question about periop
continuation of ACE inhibitors.

ASPIRATION- Predisposing factors include uncertainty re NPO

status, obesity, pregnancy, gastric or esophageal disorders, drugs,
esophageal reflux; NPO issue under re-evaluation but probably best
to avoid solids 8 hrs as traditionally if possible, the traditional issues
are gastric volume and pH but particulate matter is at least as
important; clear liquids are OK up to 2 hours preop in small quantities
and may even improve gastric emptying, see pediatric lectures for
rules in kids. The following agents may be considered in the patient at
risk:

Non-particulate anatacids- designed to avoid the pneumonitis

that may occur when normal, particulate antacids are
aspirated, local favorite is Bicitra- (sodium citrate with citric
acid) tastes terrible, comes in 30 ml bottle, usually warn the
patient about the taste and advise them to swallow as much as
possible as quickly as possible, (taste a little for yourself), if it
precipitates vomiting, so much the better, can use sodium
bicarbonate via the NG tube, if present- very low volumes may
be effective in increasing pH

Metoclopramide-peripherally, acts as a cholinergic agonist to

increase lower esophageal spincter pressure and improve
gastric emptying, 10 mg iv or po, may decrease postop nausea
a little, efficacy; acts centrally as dopamine antagonist so
contraindicated with parkinson's or history of dystonia,
malignant neuroleptic syndrome, may also inhibit
pseudocholinesterase and prolong succinylcholine duration
which is critical if patient can not be ventilated or intubated, has
definitely fallen out of favor

H2 antagonists- also probably not used as much currently as in

past years, note that these drugs will not act on acid already in
the stomach as bicitra will, they do have some effect on
decreasing volume but less so than on pH, cimetidine may
affect metabolism of other drugs

Cimetidine- 300mg hs and in AM po (children 7.5 mg/kg

as liquid)

Ranitidine - 150 mg hs and in AM po, 50-100 mg IV-

longer lasting and preferred

Omeprazole- inhibits acid secretion, little data with

mixed results perop

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NAUSEA/VOMITING- difficult to prevent especially in predisposed

patient- eye and ear surgery, laparoscopic procedures previous
nausea, propensity car/seasickness

General measures- strongly consider propofol for induction,

avoid nitrous. minimize narcotic use, preop ginger ale as clear
liquid, slow movements postop

Ondansetron- best available agent- 4 mg dose in adults iv as

prophylaxis or treatment, minimal side effects, cost-$36 to pt @
Uva, use prophylactically if predisposed ie sd&e, tonsils,
strabismus

Other drugs of questionable efficacy

droperidol- may slow recovery, dystonia plus other side
effects, doses .25-1.25 for nausea- .625-1.25 for gyn
and ortho surgery, transdermal scopolamine,
metoclopramide- 10-20 mg iv. see above ; low-dose
propofol

CHOICE OF ANESTHESIA:

General vs Regional- regional will be discussed in detail by Dr. DiFazio

appropriate for pt, operation- consent, personality, surgeon, site &

length of surgery
contraindications- coagulation, neuro disease, infection, volume
status, ICP
avoids many problems of GA when successful ie airway
management, myocardial and respiratory depression but consider
possible need to convert to GA if fails, inadequate, can't be re-dosed;
still need consent for GA and inform pt of possible need for GA unless
anesthesia can be provided by local supplementation and iv sedation
rare neurological complications- hematoma, infection, trauma, toxicity
of agent
other problems- hypotension, intraoperative cardiorespiratory arrest,
discomfort in areas that are not blocked,
consider combined technique if appropriate- medically compromised
pt or predictably painful procedure- need to do lumbar epidurals
before thoracic

Method of Induction-

Generally, IV and will be discussed by Dr Durieux, may be mask or

rectal or IM induction in children
Agent and dose along with supplementary drugs determined by
concomitant medical problems such as CHF, coronary disease,
volume status, neurologic problems, bronchospasm, NPO status,
allergies, malignant hyperthermia hx, hyperkalemia from sux

Maintenance-

Primarily inhalational- isoflurane current favorite- not cheap but not

extremely expensive, especially at low flows, issues of brain
protection and myocardial steal have fallen from the medical stage,

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primary advantage is lack of toxicity and relative cardiovascular

stability; enflurane-more expensive, more hypotension, seizures with
hypocapnia so avoided in neuro, not a local favorite.; halothane-still
used in children and for rare mask inductions in adults- hepatitits in
older patients- 1/40,000 with half fatal, most potent, great
bronchodilator, all these agents provide for rapid induction and
recovery so use of newer agents, desflurane coming, sevoflurane
especially good for mask inductions

Nitrous oxide- used by most but avoided entirely by a few, not potent
but very rapid induction and wake-up with hemodynamic stability,
problems include inability to give high 02 if required, expansion of
closed spaces (pleural, intestinal, eye, middle ear, intracranial,
venous air embolus), special problems in neuroanesthesia

Can be provided entirely with intravenous agents eg propofol and

sufentanil but not done too commonly, intravenous agents primarily
used to supplement inhaled gases

Narcotics- can be used in low doses to blunt hemodynamic impact of

laryngoscopy and intubation, then used to reduce inhalational
anesthetic requirement and prevent/treat postop pain

Other intravenous agents lidocaine -contributes to anesthesia,treats

bronchospasm, ketamine-can be used for maintenance as well as
induction, barbiturates- may be used as sole anesthetic in severe
head trauma

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