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Table 12.2 Stages of general anesthesia. Anesthetic techniques: GenerAl, sedAtion, MAc ● 163 stage 1 – Amnesia Patients should follow commands; respiration pattern typically regular stage 2 – delirium Period of uninhibited excitation; Patients at risk for laryngospasm; Pupils often divergent; respirations often irregular stage 3 – surgical anesthesia target depth for anesthesia during surgery; respiration pattern typically regular stage 4 – overdosage Patients at risk for hypotension and cardiovascular collapse use to ensure that a patient is ready for extubation. If a patient is going to be extubated awake, he/she should be following commands, able to oxygenate and ventilate without assistance, and able to protect his/her airway. The four stages of general anesthesia are outlined in the Table 12.2. Taxi to the Terminal The taxi to the terminal and the post flight check list is analogous to the trip from the operating room to the post anesthesia recovery area (PACU). The anesthesia provider should be at the head of the bed continuously evaluating the patient and ready to support the airway if necessary. Once in the PACU, the anesthesiologist will give a report to the PACU nurse and turn the care of the patient over to the PACU staff. Orders should be written to prepare for potential postoperative problems, such as pain, post operative nausea and vomiting, hypoxia, and blood pressure and heart rate perturbations (see Chap. 27, Postoperative Care Unit and Common Postoperative Problems) (Table 12.3). Anesthetic Techniques Having outlined the basic sequence of a general anesthetic (Table 12.3), we will now turn to the different types of anesthetic techniques available to take a patient safely through surgery (also see Chap. 13, Regional Anesthesia). Keep in mind that there is no absolutely correct technique for any given procedure. The type of anesthesia administered will depend on the anesthesia provider, surgeon, and patient’s preferences and may be dictated by the type of surgery and/or patient co-morbidities. Some surgeries are minimally invasive and cause the patients little pain or psychological discomfort. In such cases, a surgeon may request to have an anesthesia provider present to monitor the patient and administer sedation while the procedure is being performed. This is called Monitored Anesthetic Care (MAC).
164 ● AnesthesiA student survivAl Guide Table 12.3 Action sequence of a general anesthetic. Air plane analogy Anesthesia tasks Important points Preflight check − operating room setup − Preoperative patient evaluation − Preoperative medications Takeoff − Patient monitoring − induction of anesthesia − Airway management Cruising altitude − Maintenance of anesthesia − Maintenance of homeostasis Landing − Antagonism of neuromuscular blockade − emergence/extubation Taxi to the terminal − safe transfer to PAcu − PAcu orders and discharge − M.s.M.A.i.d.s − Assessment of medical history − confirm nPo status − obtain informed consent − obtain i.v. access − Administer appropriate preoperative medications and/or anxiolysis − Place and confirm appropriate monitors − Position patient and pad pressure points − Preoxygenate − Administer induction agent − Place endotracheal tube or other advanced airway device − Protect patient eyes − Monitor vital signs and maintain appropriate blood pressure − ensure amnesia and anesthesia − Monitor blood loss and administer appropriate fluids − “reversal” of neuromuscular blockade − turn off anesthetic agents − ensure patient is awake, following commands, protecting airway and can ventilate and oxygenate adequately prior to extubation − confirm stable vital signs − Monitor airway − Maintain oxygenation − confirm stable vital signs − Write appropriate order to treat pain, nausea, vomiting and hyper or hypotension − Give report to PAcu staff Monitored Anesthesia Care (MAC)/Anesthesia Sedation Monitored Anesthesia Care or MAC is not a technique of anesthesia but rather a descriptive term for an anesthetic service in which an anesthesiologist is requested to be present at a surgical or diagnostic procedure to monitor the patient and administer medications for anxiolysis, analgesia, or sedation. It may or may not involve sedation of the patient. It is appropriate here to discuss
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Anesthesia Student Survival Guide
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Editors Jesse M. Ehrenfeld, MD, MPH
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Foreword As anesthesiologists and H
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Contents Case Studies xvii Section
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ContEntS ● xi 19 Physiology and A
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Contributors Basem Abdelmalak, MD S
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David C. Lai, MD Partner, Allenmore
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CASE STUDIES In order to focus your
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CASE StUDIES ● xix inhalation ane
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CASE StUDIES ● xxi around the job
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CASE StUDIES ● xxiii ● Although
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CASE StUDIES ● xxv ● You plan a
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CASE StUDIES ● xxvii ● What oth
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CASE StUDIES ● xxix Chapter 23 Ca
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CASE StUDIES ● xxxi of her left h
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CASE StUDIES ● xxxiii speechless.
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CASE StUDIES ● xxxv things go ver
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How to Be a “Star” Student, Car
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hOw tO Be A “stAr” student, CAr
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Pre-Op Holding Area Preoperative Ev
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History of Anesthesia and Introduct
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history of AnesthesiA And introduct
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Pharmacology Section II
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30 ● AnesthesiA student survivAl
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The Preoperative Patient Evaluation
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THe PreoPerATIve PATIenT evAluATIon
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Therapy-based indications radiation
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Table 8.5 Formulation an anesthetic
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Table 14.11 Transfusion of bloodpro
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Chapter 15 IV, Gastric Tube, Arteri
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iv, GAstric tube, ArteriAl & centrA
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Common Intraoperative Problems Fran
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Pneumothorax Uncommon, but may spon
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COMMON INTRAOPERATIVE PROBLEMS ●
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Table 16.3 Common intraoperative dy
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Table 16.3 (continued) Problem Diff
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Systems Physiology and Anesthetic S
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Chapter 20 Physiology and Anesthesi
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PhysioloGy And AnesthesiA for Gener
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Anesthesia for Urological Surgery P
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AnesthesiA for uroloGicAl surGery
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Physiology and Anesthesia for Pedia
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PhysioloGy And AnesthesiA for PediA
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Table 22.6 Common pediatric emergen
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Physiology and Anesthesia for Elder
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PhysioloGy And AnesthesiA for elder
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Chapter 24 Ambulatory Surgery and O
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AmbulAtOry Surgery ANd Out-Of-Or (O
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Perioperative Acute and Chronic Pai
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PerioPerAtive ACute And ChroniC PAi
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Chapter 27 Postoperative Anesthesia
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POstOPerAtive AnesthesiA CAre unit
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Introduction to Critical Care Bever
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introduction to criticAl cAre ● 4
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SVR = [(MAP - CVP)/CO] ´ 80 introd
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● ● ● ● ● introduction to
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Chapter 29 Professionalism, Safety,
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ProfessionAlism, sAfety, And teAmwo
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Chapter 30 Quality Assurance, Patie
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QuAlity AssurAnce, PAtient And Prov
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Chapter 32 Clinical Simulation in A
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Table 32.1 Matrix of categories of
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CliniCAl simulAtion in AnesthesiA e
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ASA Difficult Airway Algorithm Appe
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518 ● ANESTHESIA STUDENT SURVIVAL
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