A Practical Approach to Anesthesia for Emergency Surgery

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  1. A Practical Approach to Anesthesia for Emergency Surgery : Manju N. Gandhi :
  3. for Emergency Surgery

Sorry, you have reached the available quantity for this item to purchase. Sorry, you have already added the maximum available quantity of this item in the cart. A Practical Approach to Anesthesia for Emergency Surgery is a comprehensive guide to the use of anesthesia in different medical emergencies. Beginning with the general principles of anesthesia, each chapter focuses on a different condition and the use of anesthesia in that emergency situation.

Assisted by well-illustrated images and diagrams, this book fills a gap created by the lack of texts focusing on emergency anesthesia. Please provide your details and we will inform you on receiving the stock. Please provide the details which you feel are incorrect. Don't worry! Just fill in the details and we will try our best to get back to you as soon as possible.

It gives an idea about glucose glucose as there is always a risk of development of control over last 8 to 12 weeks. A level of less than 7 hypoglycemia. Hypoglycemia often undergoes percent implies good control. If patients often have coronary artery disease. Though in diabetes, there is hyper- Choice of Anesthetic Technique glycemia, the cells are unable to utilize glucose. This The choice of anesthesia can affect the outcome by is facilitated by continuously providing a substrate modulating the secretion of the catabolic hormones and in the form of glucose along with insulin.

It prevents stress response to of potassium. Blood glucose levels are repeated any symptoms of hypoglycemia can be immediately every hourly till patient stabilizes. This prevents detected. It improves peripheral circulation therefore lipolysis and proteolysis by providing continuous there are decreased chances of thromboembolism. The supply of glucose to the cells. DK should period by reducing the level of the stress hormones. Its presence should warn the and finally coma. The urine will test positive for anesthesiologist about the likelihood of cardiovascular ketones.

The treatment of this condition consists of: instability upon institution of the block, especially the 1. Correction of dehydration: The total deficit may high level required for abdominal surgery. In the important to rule out peripheral neuropathy. There is a possibility of exaggeration of neuropathy postanesthesia. One is also apprehensive venous pressure and the urine output.

Serum electrolyte estimation is the anesthetic implication of autonomic neuropathy. Subsequently 0. General Anesthesia 2. Correction of hyperglycemia: Separate insulin infusion, preferably in an infusion pump is Diabetes per se would not dictate administration of a particular class of anesthetic agent. It is the end organ for Considerations. Once the blood glucose level drops to less disease, hypertension and autonomic neuropathy than mg percent, dextrose saline is added to should prompt the anesthesiologist to choose the drugs prevent precipitous hypoglycemia.

There is no carefully. Prior aspiration prophylaxis is mandatory. Midazolam and fentanyl appear to be safe. They role of subcutaneous insulin in this setting. Correction of potassium level: The usual Carefully titrated doses of thiopentone or propofol or General. Ketamine is avoided infusion in these patients. The disadvantage of Table 2. Alternatively, they may present for major stimulation. These patients are considered as potentially abdominal operations or coronary artery bypass full stomach and therefore mandate rapid sequence grafting. Critically ill patients presenting to the induction and intubation.

The possibility of difficult operating room may have acute kidney injury. In such cases, use of difficult airway gadgets plan accordingly. If there is extensive peripheral are at least partly dependent on renal excretion for neuropathy causing skeletal muscle wasting, then elimination. In the presence of renal impairment, dosage succinylcholine is best avoided.

Injection rocuronium modifications may be required to prevent accumulation may be used instead. Anesthetic agents also affect the glucose homeostasis Moreover, the systemic effects of azotemia can in the perioperative period. Benzodiazepines and potentiate the pharmacological actions of many drugs. Halothane, enflurane and CRF refers to a decline in the glomerular filtration rate isoflurane cause dose dependent and reversible inhibi- GFR caused by a variety of diseases, such as diabetes, tion of insulin secretion in response to glucose load.

Most common risk factors were arrhythmia, glucose insulin potassium drip. Anesthesiologists often care for patients with renal The precise mechanism heralding the transition from insufficiency or renal failure. Acute tubular dysfunction leading to an increase in bleeding necrosis accounts for nearly 90 percent of the cases of tendencies. Perhaps one reason for our inability to prevent renal failure is a shift in medical Principle of Anesthesia Management populations to older and more critically ill patients.

The whole process In extremely low blood flow states, reduced RBF becomes trickier when these patients are to be taken up decreases filtration, which lowers urine output further for emergency surgery. In a large clinical study, intra-abdominal pressure IAP has been shown to be an independent cause of Preoperative Preparation renal impairment, and it ranks in importance after Proper preoperative management of patients with renal hypotension, sepsis, and age older than 60 years. The protecting strategies include recent Section I.

A Practical Approach to Anesthesia for Emergency Surgery

Perhaps IAP measurement delivery, suppress renovascular constriction, produce Neurosurgical Procedures. Trauma patients exhibit two and peripheral vascular disease; GI dysfunction for Considerations. When multiorgan failure develops, mortality left ventricular hypertrophy is common finding. Impairment in the synthetic function results hemodialyzed. Blood volume status may be in a decrease in the production of erythropoietin estimated by comparing body weight before and causing anemia and active vitamin D-3 causing after hemodialysis and monitoring of vital signs hypocalcemia, secondary hyperparathyroidism, hyper- orthostatic hypotension, tachycardia and phosphatemia, and renal osteodystrophy.

Avoid heavy premedication in Pneumonia and sepsis are the most common serious severely debilitated patients. Hypokalemia is sometimes followed concomitantly with hypomagnesemia. Hyponatremia may is the goal of managing these patients. Hemodynamic occur from hypotonic fluids or inappropriate monitoring and fluid management can be challenging in secretion of antidiuretic hormone. This can be treated with dialysis. Anesthetic technique must minimize changes clearance; loading dose unaltered, but maintenance in renal blood flow Renal blood flow: 25 percent of dose should be drastically reduced; frequently used normal cardiac output.

They usually resolve rapidly with cardiovascular drugs e. Although the for better outcome. Decreased cardiac output codone. Oxycodone should not be used in dialysis secondary to insufficient preload can lead to end- patients, and others should be avoided at all times organ including renal failure. Unchecked fluid e. Also by observing the increased significantly in patients with end-stage urine output by giving fluid challenge, at least twice renal failure compared to that of healthy controls given half an hour apart to ml for 10 min per and was prolonged according to the duration of dose.

Mannitol is an osmotic diuretic and has time basis thereby preventing the overloading and been used in various situations to improve urine pulmonary edema. Functional residual capacity and should be started early. Sudden increase in systemic vascular therapy, replace only sequestration or overt losses Section 1: Anaesthesia.

Temperature monitoring and urgent attention urine output hourly should be measured. Since critically ill patients are usually crine, neurogenic, pregnancy related, pharmacologic, intravascularly depleted, further insult from post-HD central nervous system trauma, autoimmune disor-. Section I hypotension can cause ischemic damage to many ders. A variety Hypertension HTN is a common medical disease and of abnormalities including heredity, fetal under- patient with this condition is frequently encountered nutrition, abnormal sympathetic nervous system by the anesthesiologists.

It is a heterogeneous disorder activity, cell membrane defects, renal retention of excess resulting from either a specific cause secondary salt, microcirculatory alterations, endothelial cell hypertension or some unknown cause primary or dysfunction, hyperinsulinemia secondary to insulin essential hypertension. It is frequently associated with resistance, vascular hypertrophy and altered renin- other comorbid conditions. Ischemic heart disease is the angiotensin system regulation are implicated.

The others being, heart failure, renal insuffi- elastic tissue and replacement with fibrin, athero- ciency, and cerebrovascular disease. The organs most involved are of action heart, kidneys, brain and retina. The disease is usually symptomless but if Hydralazine 5—20 mg IV Vasodilator 3—6 hours untreated, hypertension may result in heart enlarge- Nifedipine 10 mg ment and failure, renal dysfunction and cerebrovascular sublingual or oral Calcium channel blocker 2—5 hours accidents.

Diazoxide 30 mg boluses IV max mg Vasodilator 4—12 hours Treatment Drugs used for emergency control of hypertension Table 2. Classification of drugs used in the management of Mechanism of Examples Relevance to action anesthesia hypertension is shown in Table 2. Neurosurgical Procedures. Adrenergic neuron Guanethidine Sensitive to When dealing with hypertensive patients the blockers vasopressors.

Another very important alpha also Cause bradycardias factor is the presence of left ventricular hypertrophy as for Considerations. Phentolamine Calcium channel Nifedipine Vasodilator. So efforts should be made to control the BP before induction. Treat pain and anxiety with appropriate Investigations medication. The drugs listed in Table 2.

It is important be premedicated with benzodiazepines prior to surgery to assess the degree of blood pressure control as this will help to allay anxiety. Atropine should be avoided myocardial infarction, left ventricular failure, because of its tendency to cause tachycardia. Preoperative and renal failure. Section I pressure during anesthesia, blood loss or pain. They Adequate monitoring should be started prior to may undergo a profound fall in arterial pressure in induction of anesthesia.

Continuous pulse measurement response to induction and maintenance of and frequent arterial pressure assessment are anesthesia. They also exhibit an exaggerated important. An ECG is useful to detect ischemia and hypertensive response to stimuli such as dysrhythmias; pulse oximeter, end-tidal CO2 analyzer laryngoscopy and intubation.

They are prone to are used. For major surgery, central venous pressure develop cardiac dysrhythmias and ischemia during monitoring and measurement of urine output may be anesthesia. General Considerations Adequate control of hypertension, smooth The choice of anesthesia depends on the control of anesthesia, selection of appropriate anesthesia and blood pressure and the level of analgesia required.

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However, while conducting pressure is under control and the surgical level is not emergency surgery, there is limited time available to very high, i. Epidural anesthesia proves achieve this control. The treatment that the patient is better than subarachnoid block as the resultant already on should be continued as their discontinuation hypotension is well compensated. Minimum possible would result in rebound hypertension and tachycardia.

They pose problems because of their without causing catastrophic fall in BP. Local blocks, mode of action, i. Rarely continuous infusion response to laryngoscopy and intubation. Thiopentone of nitroglycerine or nitroprusside is needed to control may be used provided it is given slowly, and titrated hypertension during anesthesia. Similarly, propofol also would result Hypotension should be vigorously treated by in drop in blood pressure, sometime more extensively reducing the depth of anesthesia if it is excessive , and than thiopentone.

Good BP control usually does not correcting any hypovolemia. Bradycardia should be cause any major swings in blood pressure. Ketamine, treated using intravenous atropine. Occasionally, a which raises the arterial pressure and heart rate, is best small dose of a vasopressor such as ephedrine or avoided. The than 25 percent of original BP is considered severe duration of laryngoscopy should be kept to less than 15 hypotension and should be treated with fluid and seconds. Normal intravenous fluid replacement should be Maintenance given. During emergency surgery in untreated The use of opioids, which have minimal cardiovascular hypertensives, it is important to maintain careful fluid effects, will reduce the amount of volatile anesthetic replacement.

One must be cautious, that a moderately agents required. High concentrations of volatile low BP in a normal patient e. These patients tolerate hypovolemia Section I. Nitrous oxide can be safely used. The poorly. Opioids given during on their own or to supplement general anesthesia. Hypertension may Cardiostable muscle relaxant like vecuronium bromide develop during the recovery phase. Hypoxia or is preferred. It is logical to for Considerations. The specific monitoring should include; electrocar- use antihypertensive agents instead of anesthetic agents diogram for heart rate, rhythm and ischemic changes.

If during extubation and emergence to awaken the patient possible two leads should be monitored simultaneously. Lower doses of lidocaine, Blood pressure should be monitored either manually or esmolol or labetalol can be given 2 minutes before noninvasively. In extremely high-risk patient for major extubation. If the hypertension is due to bladder surgery, even invasive anesthetic BP can be considered. If it is caused Central venous pressure can be monitored depending by inadequately treated pain, analgesics should be on the need of surgery.

The patient General. Anesthesia for patients with preexisting cardiac disease Hypertension during anesthesia may reflect undergoing emergency surgery is an interesting inadequate depth of anesthesia, pain or hypercarbia challenge. Most common cause of perioperative raised blood carbon dioxide level due to inadequate morbidity and mortality in cardiac patients is ischemic ventilation. These factors should be corrected before heart disease IHD. This stress such as labetalol or nifedipine.

Risk variables Points myocardial ischemia and infarction MI , arrhythmias, congestive heart failure and multiple organ failure 1. S3 gallop or raised jugular venous pessure 11 secondary to low cardiac output. If the different 2. Recent Myocardial infarction 10 mechanisms involved in different cardiac disease states 3. Non-sinus rhythm, paroxysmal atrial contractions PAC 7 are understood, then the most suitable anesthetic can be 4.

More than 5 ventricular premature beats VPC 7 given. The skill with which the anesthetic agents are 5. Emergency surgery 4 used. Care of these patients requires identification of 7. Poor general medical condition 3 8.

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Intrathoracic, intraperitoneal surgery 3 risk factors, preoperative evaluation and optimization, 9. Aortic stenosis 3 medical therapy, vigilant monitoring and the choice of appropriate anesthetic technique and drugs. The latest guidelines on perioperative cardio- Lee et al wherein six independent risk correlates vascular evaluation and care for noncardiac surgery in were identified. This revised cardiac risk AHA , and published in the year ,44 and modified index has become one of the most widely used indices in Section I Ischemic heart disease is the result of the build-up in The guidelines are elaborate regarding preoperative larger coronary arteries of plaques of atheroma— risk assessment of these patients.

The document consisting of cholesterol and other lipids. This causes considers effect of type of surgery, functional capacity narrowing of the vessels, restricting coronary blood and the clinical presentation of the patient for flow. There may be insufficient myocardial blood preoperative risk assessment and further workup supply during times of high demand, e. The aim is to identify the patients at risk leading to the effort related chest pain of stable angina.

General Considerations rest and myocardial infarction are thought to be due to Since elaborate work-up is not possible during rupture of the atheromatous plaques causing total emergency, the stress is on knowing the severity of the obstruction as well as due to vasoconstriction of the symptoms, the functional capacity and the invasiveness coronary vessels. Silent ischemia also can occur in of surgery. Depending on the results of evaluation, the diabetic patient. There are several factors in the risk stratification of the patient is done and perioperative period which precipitate such events: interventions if any are prescribed.

Several risk indices have been developed over the past 25 years based on multivariable analysis derived from In addition, the patient should also be asked about: history, physical examination or ECG review. Family history of CAD Diabetes Indications for preoperative noninvasive cardiac Stress Obesity testing have been limited to the group in whom coronary revascularization may be beneficial, independent of noncardiac surgery.

Ask about coronary interventions in the past not possible but information obtained from the above and in case of PCI, whether the patient is on any noninvasive and biochemical investigations is sufficient anticoagulants or platelet inhibitors. It can be classified as shown in oxygen balance Table 2. It is Neurosurgical Procedures. The investigations during emergency can not be elaborate, however, following investigations can be Table 2. The procedures included in each group are death by 30 percent. Rather, acute and recent MI i.

As the emergency surgery cannot be deferred, the risk reduction strategies are adopted. If PCI is necessary, then maintaining hemodynamic stability. If the noncardiac surgery is urgent or emergent, then weighed against each other. In fact, premature with the noncardiac surgery could be considered. Several reports of drug-eluting stent DES Table 2. The postponement of myocardial ischemia. Ketamine is best avoided as it surgery by more than eight weeks could increase the causes tachycardia and hypertension.

In general, all risk of restenosis. It is strongly The choice of anesthesia would depend on the left recommended to continue treatment with aspirin, at the ventricular function. Patients with good ventricular very least during emergency surgery. The surgical risk function tolerate inhalational anesthesia better. Whereas of excessive bleeding is manageable with platelet patients with poor LV function require titrated doses of transfusions, fresh frozen plasma and blood if required.

Use of high-dose opioid based anesthesia was Withdrawal of therapy may precipitate major adverse previously popular due to its apparent hemodynamic cardiac events. However, it can be associated with the need for postoperative mechanical ventilation. Anesthetic Goals and Technique Irrespective of the surgery and patient profile the Intubation anesthetic goals in such a patient are to maintain the Laryngoscopy is a powerful stressor, causing hyper- balance between myocardial oxygen demand and tension and tachycardia.

This can be avoided with a supply so as to prevent myocardial ischemia. In case supplemental dose of intravenous induction agent or ischemia or infarction does develop, it should be opioid, e. Other detected and treated as soon as possible. The essential requirements of general anesthesia for IHD are avoiding agents like lignocaine or esmolol can be given intravenously to achieve the same effect. Overall volatile agents are ment plan. All anesthetic techniques and drugs are cardioprotective. The indicators of cardioprotection known to have effects that should be considered in the shown include decrease in troponin level, preservation for Considerations.

There is very little evidence to of early LV function, decreased ICU stay, as well as support an advantage of any one technique or agent decreased late cardiac events. The mechanism of over the other per se. The choice of anesthetic technique cardioprotection with volatile agents is the postulated does not matter more than the maintenance of preconditioning and postconditioning of the heart hemodynamics.


A Practical Approach to Anesthesia for Emergency Surgery : Manju N. Gandhi :

Premedication A nervous patient may have tachycardia and require an Monitoring General. Beta-blockers also reduce Online ST-segment monitoring, if done appropriately in tachycardia, and prevent perioperative myocardial Section 1: Anaesthesia. In a similar fashion, alpha2-agonist drugs ischemia. They should such as clonidine reduce noradrenaline release from be monitored for any ischemic changes. All intravenous anesthetic agents except ketamine have There is no study to clearly demonstrate a change in a direct depressant action on the myocardium, and may outcome from routine use of pulmonary artery catheter, also reduce vascular tone.

This causes hypotension ST-segment monitor, transesophageal echocardio- especially in the hypovolemic patient , often with a graphy or intravenous NTG.


Cardiac biomarkers for perioperative MI are — If patient is hemodynamically unstable— reserved for those patients in whom severe Support with ionotropes, use of intraoperative hemodynamic perturbations occur and there is clinical balloon pump may be necessary.

Urgent or ECG signs of ventricular dysfunction. Postoperative Management Reversal and Recovery The postoperative goal in such patients is also the same, Reversal of muscle relaxation with a combined anti- i. Postoperatively, MI cardia, and extubation in itself is a stressor. Problems in may often be painless, making its management even the recovery phase which can cause ischemia include; more difficult. Although most cardiac events occur hypoxia, tachycardia, pain, hypothermia, shivering, and within first 48 hours, delayed cardiac events within anemia should be treated in the immediate post- first 30 days still happen and could be the result of operative period.

The use of supplemental oxygen in the secondary stress. Pain costs postoperative preventing myocardial ischemia. Section I once it occurs the mortality is high to the tune of 40 advantages. Epidural anesthesia reduces preload and percent. In a patient with IHD, local anesthetic techniques. General Considerations postoperative myocardial ischemia, which is often such as brachial plexus block should be encouraged in silent.

Postoperative myocardial ischemia predicts order that the hemodynamic responses to general adverse in-hospital and long-term cardiac events. It anesthesia are avoided. However, even under local should be identified, evaluated, and managed anesthesia, the patient will be subject to the stresses of aggressively, preferably in consultation with a the surgical procedure itself, which can have marked cardiologist.

When combined with an adequate Patients with valvular heart disease undergoing local anesthesia, suppress the stress response. When noncardiac surgery need thorough preoperative chosen as the anesthetic technique, it should be evaluation. The goal of evaluation is to identify the most remembered that an adequate analgesia is mandatory. The anesthetic management requires an understanding order to optimize the preoperative condition. Anesth- of the natural history and pathophysiology of the valve etic goals include control of heart rate, maintenance of disease.

This volume SV depends on adequate filling or preload, the can reduce cardiovascular depression and risk. Similarly, central Thus, stenotic lesions require the heart to force an neuraxial blocks are administered with caution in adequate volume through a small orifice; regurgitant patients with severe cardiac disease. The LV than subarachnoid block as the hypotension is not left ventricle is pressure overloaded in aortic stenosis precipitous. Also, regurgitant lesions tolerate it better and volume overloaded in aortic insufficiency and than the stenotic lesions.

It also can be instituted only for mitral regurgitation. In mitral stenosis, the LA left the purpose of postoperative analgesia. The Section I. Preoperative Evaluation Includes RV right ventricle faces progressively increasing left atrial and pulmonary artery pressure. Detailed history of symptoms of reduced forward flow, Neurosurgical Procedures. In mitral regurgitation, LA has both pressure as well increased back pressure, like angina, syncope, as volume overload. Compensatory mechanisms consist symptoms suggestive of congestive heart failure, of chamber enlargement, myocardial hypertrophy, and embolization, cardiac medications and any previous variations in vascular tone and level of sympathetic admission to the hospital, etc.

Also any rheumatic activity. These mechanisms in turn, induce secondary infection in past should be asked about. The important points are; pulse rate, rhythm-sinus Myocardial contractility is often transiently depressed or nonsinus, if other than sinus, ventricular rate, gallop but may progress to irreversible impairment even in the rhythm, heart sounds, murmurs, evidence of absence of clinical symptoms. Conversely, the patient cardiomegaly and basal crepitations. Recent ECG and 2-D echocardiography to assess left ventricle function, valve status such as Anesthetic Considerations area, calcification, regurgitation, presence of pulmonary The risk of cardiac events depends upon the severity of hypertension, chest radiograph to rule out cardiac disease and surgery specific risk.

Surgery cardiomegaly and features of pulmonary artery specific risk is further related to type of surgery itself hypertension should be reviewed. For example, those with cardiologist. The patient is given infective patients suffering from severe stenotic valvular lesions, endocarditis prophylaxis prior to shifting to the operating balloon valvotomy must be considered prior to elective room OR which should be repeated after 6 hours.

Pulmonary artery occlusion pressure PAOP may be rhythm, normal intravascular volume, normal cardiac considered in very high-risk patient. However, this is an contractility and normal systemic vascular resistance. An infusion of and associated tachycardia. Induction of anesthesia can ionotropes and a defibrillator should be kept ready be achieved with any available intravenous induction prior to induction.

Sufficient time should be given for the drug cardiologist for further management of valvular heart to reach the central circulation as the circulatory time is disease. Utmost care should be taken to prevent In this section intraoperative anesthetic management overdose of the drug. Ketamine, should be avoided for emergency surgery in patients with valvular lesions because of its propensity to increase the heart rate.

Nitrous oxide and narcotic anesthesia with low echocardiographically. Patients in sinus rhythm who develop atrial fibrillation in the perioperative period should be Mitral Stenosis cardioverted. Patients already in atrial fibrillation should have the rate controlled aggressively. Normal mitral valve area is 4 to 6 cm2. Mitral stenosis is In the postoperative period, the risk of pulmonary said to be present when the area becomes less than 2 edema and right heart failure continues, so cm2.

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  • This impairs left ventricular filling and results in cardiovascular monitoring should continue as well. General Considerations decreased cardiac output. Since, left atrial emptying is Pain and hypoventilation with subsequent respiratory decreased, it causes back pressure effect and LA acidosis and hypoxemia may be responsible for pressure increases.

    This results in left atrial enlargement increasing heart rate and pulmonary vascular and increased pulmonary artery pressures to maintain resistance. Decreased pulmonary compliance and cardiac output. These patients may develop pulmonary increased work of breathing may necessitate a period of edema and cardiac failure especially with higher heart mechanical ventilation, particularly after major thoracic rate. Atrial fibrillation may develop as a result of LA or abdominal surgery. Relief of postoperative pain with enlargement and stagnation of blood causes neuraxial opioids can be very useful.

    The main symptom of mitral stenosis is dyspnea. Patients having atrial fibrillation, experience dyspnea at rest and wake up at night with Mitral Regurgitation shortness of breath paroxysmal nocturnal dyspnea. Whenever the left ventricle contracts some of the blood Asymptomatic patients usually tolerate noncardiac flows backwards into the left atrium. The regurgitant surgery well.

    Most patients with chronic valve dilatation prior to or simultaneously with mitral regurgitation are well for many years without emergency surgery. However, the incidence is very low. Dyspnea and pulmonary The anesthesiologist should avoid myocardial edema are signs of severe mitral regurgitation. Forward depressants, tachycardia which reduces ventricular cardiac output is best when the heart is full and filling time , hypovolemia, hypotension and increased reasonably fast, and the blood pressure is low-normal pulmonary vascular resistance e.

    For induction of pain or hypercarbia. Selection of a muscle relaxant oxide and volatile anesthetic and opioids or by opioids should follow the same principles. Pancuronium alone. Performing the operation using local anesthetic produces a modest increase in heart rate, which can infiltration may be a safe method provided adequate contribute to maintenance of forward left ventricular pain relief is provided and measures taken to allay stroke volume.

    An increase in systemic vascular resistance will intravascular volume. Volatile anesthetics that do not further reduce cardiac output and a reduction in cause dysrhythmias can be administered for systemic vascular resistance may reduce coronary blood maintenance of anesthesia. Myocardial depressants must be avoided as heart Regional anesthesia particularly epidural block is is already overworked. Similarly dysrhythmias are well-tolerated. Regional anesthesia can cause dangerous fall in Aortic Stenosis systemic vascular resistance and heart rate. However, Aortic stenosis AS is a major risk factor for peri- epidural anesthesia may be tolerated if performed operative cardiac events in patients undergoing slowly with careful monitoring and treatment of blood noncardiac surgery.

    The main symptoms of aortic stenosis are Aortic Regurgitation dyspnea, angina and syncope. They occur as a result of Patients with aortic regurgitation may not have severe myocardial hypertrophy, increased intra-cavitary symptoms for many years. They may develop signs and Section I. Coronary artery symptoms of left ventricular failure. Aim is to maintain disease is commonly seen with aortic stenosis. The an adequate preload to assure filling of the Neurosurgical Procedures.

    Atrial hypertrophied, dilated LV, a high-normal heart rate to contraction is vital to maintaining adequate ventricular reduce the proportion of time spent in diastole, and low- filling. The heart rate should be on the lower side of normal systemic blood pressure to encourage forward normal. Tachycardia and bradycardia will both reduce rather than regurgitant flow. There is a high risk of myocardial Bradycardia should be prevented as this will ischemia due to increased oxygen demand and wall increase the time for backwards flow and regurgitant for Considerations.

    Thirty percent factor. Anesthetic induction and maintenance must be of patients who have aortic stenosis with normal designed to avoid these changes. Induction of coronary arteries have angina. Subendocardial ischemia anesthesia in the presence of aortic regurgitation can be may exist as coronary blood supply does not increase in achieved with standard intravenous induction drugs. Tachycardia is The ideal induction drug should not decrease the heart detrimental as it may produce ischemia because of increased demand in face of reduced supply.

    Cautious rate or increase systemic vascular resistance.

    for Emergency Surgery

    In the premedication of the anxious patient is indicated. Maintenance of diastolic blood pressure is crucial to maintain coronary perfusion. The selected anesthetic technique should maintain opioid. In patients with severe left ventricular afterload and avoid tachycardia to maintain the balance dysfunction, high-dose opioid anesthesia may be between myocardial oxygen demand and supply in the preferred.

    Bradycardia and junctional rhythm may presence of a hypertrophied ventricle and reduced require prompt treatment with intravenous atropine. Induction agents, muscle relaxants, and While reductions in contractility are undesirable in potent inhalational anesthetic agents must be almost all valvular disease conditions, for AR the administered in such a way that the hemodynamic maintenance of adequate preload and reduced afterload compensations are not lost.

    Induction of anesthesia can are most important. Therefore, one should avoid be accomplished with an intravenous induction drug increased peripheral resistance and myocardial that does not decrease systemic vascular resistance. An depressants and aim to maintain an increased heart rate, opioid induction may be useful if left ventricular adequate intravascular volume and decreased systemic function is compromised. Maintenance of anesthesia vascular resistance. Regional anesthesia is well tolerated in patients with postoperative pulmonary complications, reversing the chronic aortic regurgitation.

    Acute Aortic Regurgitation Preoperative Evaluation and Preparation Acute onset of AR is usually secondary to diseases such The goals of preoperative evaluation in these patients as endocarditis, aortic dissection, or valve trauma, are: without having time to develop compensatory LV 1. To diagnose the presence of a respiratory disease. To identify the type of respiratory disease as requiring valve replacement.

    Maintenance of parenchymal disease, airway disease, pulmonary tachycardia and avoidance of myocardial depressants vascular disease. To check the reversibility of the disease. It has significant operative pulmonary complications. The entire process extrapulmonary effects also. This entity includes: of strict pulmonary regime requires around 6 to 8 weeks 1.

    Chronic bronchitis in which there is obstruction of for optimization and this is not possible in the small airways. Still it is possible to improve the 2. Emphysema in which there is enlargement of the condition marginally within the stipulated time. As airspaces and destruction of lung parenchyma. Section I soon as the patient is posted for emergency surgery, he causes loss of lung elasticity and obstruction of small should be quickly evaluated as mentioned below. Symptoms of respiratory disease should be asked for. Chronic Bronchitis Table 2. It is defined as presence of productive cough for more The activity level should be defined: severe dyspnea.

    General Considerations than 3 months duration for more than 2 successive may be a predictor of both poor ventilatory reserve and years. It consists of: the need for postoperative mechanical ventilation. Hypersecretion of the mucus as a result of chronic Table 2. Inflammation of the mucosa of the airways.

    Luminal narrowing. Blockade of the airway by dried mucus. The destruction of the lung parenchyma. Chest pain: site, type, relation with respiratory cycle 2. Loss of elastic recoil of the lungs. Breathlessness and wheezing: Ability to talk, effort tolerance 3. Airway collapse that occurs during exhalation Occupational history: Asbestosis, industrial lung diseases 4. Air-trapping with formation of emphysematous Smoking: Duration and quantity to find out pack years consumed bullae pressing on adjacent normal lung History of pulmonary tuberculosis in past or in family, with treatment details parenchyma.

    History of any surgery in the past for pulmonary symptoms It is very important that these patients be evaluated Drug history: For example, amiodarone, ACE inhibitors, bleomycin, thoroughly and optimized prior to surgery as they not etc. With this method very Respiratory rate, pattern Breath sounds small droplets of water and the medication are Movement of the chest Presence of ronchi, rales produced which get deposited in the airways Use of accessory muscles of respiration Stridor causing better hydration and better action using Obstructed purse lipped breathing Signs of CHF smaller doses and less systemic side effects.

    Both have different mechanisms of Expiratory time action and hence can be used complimentary to each Breathholding time other. Anesthetic Considerations in Blast and Burn Injuries. Anesthesia for Maxillofacial and Upper Airway Trauma. IX: Miscellaneous. Anesthesia for Emergency Renal Transplant. Role of Anesthesiologist in Disaster Management. About Us. New Releases. Check List. Best Sellers. Books of the Month. Subscribe Now. Gandhi, Manju N.

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