Choice of anesthetic technique

miller
The anesthesia care provider has several options available
including (1) general anesthetic, (2) regional anesthetic
(see Chapter 17), (3) peripheral nerve block (see Chapter 18),
or (4) monitored anesthetic care (MAC). The choice of
anesthetic technique (or combination of techniques)
should be based on surgical and patient considerations;
frequently, more than one anesthetic technique is appropriate.

Patient safety (see Chapter 47),

the ability of the surgeon to perform the procedure, and
patient comfort during and after the procedure are important
issues. Intraoperative and postoperative monitoring
(see Chapter 20) considerations may influence the
choice of anesthetic technique. For example, if a rapid postoperative neurologic evaluation is needed, a general
anesthetic with short-acting anesthetic drugs or a regional
anesthetic may be selected. Conversely, if intraoperative
transesophageal echocardiography is required, a general
endotracheal anesthetic will probably be preferred. There
are few circumstances in which a specific anesthetic technique
may be safer or more efficacious than another technique.
2,3

An ideal anesthetic technique would incorporate optimal

patient safety and satisfaction, provide excellent
operating conditions for the surgeon, allow rapid recovery,
and avoid postoperative side effects

In addition, the chosen technique would be low in cost, allow early

transfer or discharge from the postanesthesia care unit
(see Chapter 39), optimize postoperative pain control
(see Chapter 40), and permit optimal operating room efficiency,
including turnover times.
Regardless of the anesthetic technique selected, the
provider should verify that the anesthesia machine is
present and functional (in certain circumstances such as
anesthesia for cardioversion, a breathing circuit may suffice)
and that specific drugs and equipment are always
immediately available (see Table 14-4), including suctioning
capability, adequate monitoring (systemic blood
pressure, electrocardiography, pulse oximetry, capnography,
body temperature), airway equipment (appropriately
sized face mask, oral airway, nasal airway, LMA, laryngoscope
with appropriate functional blades), materials
for venous access, and drugs appropriate for emergency
intravenous induction and resuscitation (induction drugs,
neuromuscular blocking drugs, vasopressors, including
ephedrine and phenylephrine).

General Anesthetic
General anesthesia may be initiated by the administration
of intravenous drugs or inhalation of a volatile anesthetic
with or without nitrous oxide

General anesthesia is usually induced in adult patients by

the intravenous administration of an anesthetic (propofol,
thiopental, or etomidate) that produces rapid onset
of unconsciousness

Administration of oxygen (preoxygenation) is intended to replace nitrogen

(denitrogenation) in the patient’s functional residual
capacity (about 2500 mL of 21% oxygen) with oxygen, this is to increase the safe apnoea time. In healthy awake
patients, the increase in arterial hemoglobin oxygen
saturation achieved with eight vital capacity breaths of
100% oxygen over a period of 60 seconds is similar to
that achieved by breathing 100% oxygen for 3 minutes
at normal tidal volumes.9 Four vital capacity breaths over
a 30-second period also increases arterial oxygenation,
but the time until hemoglobin desaturation is shorter
than in patients breathing oxygen for 3 minutes or taking
eight deep breaths.

Rapid sequence induction

A typical rapid-sequence induction of anesthesia
includes preoxygenation and subsequently cricoid pressure
may be applied by an assistant just before the onset
of drug-induced unconsciousness and loss of protective
upper airway reflexes. An opioid (e.g., fentanyl, 1 to
2 mg/kg IV or its equivalent) is often given 1 to 3 minutes
before administration of a drug to induce anesthesia. The
opioid is intended to blunt the subsequent hypertensive
and heart rate responses to direct laryngoscopy and
tracheal intubation and also to initiate possible preemptive
analgesia. Because remifentanil and alfentanil
undergo more rapid blood-brain equilibration than fentanyl
these opioids may be more reliable in blunting the
sympathetic nervous system responses evoked by direct
laryngoscopy and tracheal intubation.

With the onset of unconsciousness, the patient’s head

is positioned to provide optimal patency of the upper airway.
Positive-pressure inflation of the patient’s lungs
with oxygen is then instituted. Direct laryngoscopy for
tracheal intubation is initiated only after the onset of
skeletal muscle paralysis (often verified by a peripheral
nerve stimulator), which is typically 45 to 120 seconds
after the intravenous administration of sucinylcholine,
1.0 to 1.5 mg/kg, or rocuronium, 0.6 to 1.2 mg/kg. Rocuronium,
0.6 mg/kg, has slower onset time than succinylcholine. Increasing the dose of rocuronium to 1.0 to 1.2
mg/kg creates an onset time similar to that of succinylcholine, After tracheal intubation,
a gastric tube may be inserted through the mouth to
decompress the stomach and remove any easily accessible
fluid. This orogastric tube should be removed at the
conclusion of anesthesia. When gastric suction is needed
postoperatively, normally the tube should be inserted
through the nares rather than the mouth.

INHALED INDUCTION OF ANESTHESIA

An alternative to rapid-sequence induction of anesthesia
is the inhalation of sevoflurane (nonpungent) with or
without nitrous oxide.16 Prior administration of a “sleep
dose” of an anesthetic (e.g., propofol) may be used if an
intravenous catheter is in place. Desflurane produces a
rapid onset of effect but is not often selected for an
inhaled induction of anesthesia because of its airway irritant
effects. Inhaled or “mask induction” of anesthesia is
most often selected for pediatric patients when prior
insertion of a venous catheter is not practical. Sevoflurane may also be useful when difficult
airway management is anticipated because of the absence
of salivation and preservation of spontaneous breathing.

Characteristics of Inhaled Induction of

Anesthesia with Sevoflurane
Loss of consciousness typically occurs within about 1 minute
when breathing 8% sevoflurane. Insertion of a LMA can
usually be achieved within 2 minutes after administering
7% sevoflurane via a face mask. The addition of nitrous
oxide to the inspired gas mixture usually does not improve
the induction of anesthesia sequence. Prior administration
of benzodiazepines may facilitate an inhaled induction of anesthesia, whereas opioids may complicate this
technique
by increasing the likelihood of apnea

A technique for induction of anesthesia with sevoflurane

includes priming the circuit (emptying the reservoir
bag and opening the adjustable pressure-limiting [“popoff”]
valve), dialing the vaporizer setting to 8% while
using a fresh gas flow of 8 L/min, and maintaining this
flow for 60 seconds before applying the face mask to the
patient. At this point a single breath from end-expiratory
volume to maximum inspiration followed by deep breathing
typically produces loss of consciousness in 1 minute.

After an inhaled induction of anesthesia, a depolarizing

or nondepolarizing neuromuscular blocking drug is
administered intravenously to provide the skeletal muscle
relaxation needed to facilitate direct laryngoscopy for
tracheal intubation. If endotracheal intubation is not
accomplished, anesthesia can be maintained by inhalation
via a facemask or LMA.

MAINTENANCE OF ANESTHESIA
The objectives duringmaintenance of general anesthesia are
amnesia, analgesia, skeletal muscle relaxation, and control
of the sympathetic nervous system responses evoked by
noxious stimulation. These objectives are achieved most
often by the use of a combination of drugs that may include
inhaled or intravenously administered drugs (or both), with
or without neuromuscular blocking drugs.

Volatile
anesthetics may provide an inadequate analgesic effect
and be associated with postoperative hepatic dysfunction.
A useful method to
decrease the cost of volatile anesthetics is the use of low
fresh gas flow (2 L/min) during maintenance of anesthesia.

Disadvantage of high flow

 Cost as the more flow the more volatile agent is used
 Loss of humidity of the upper airway
 Pollution as the more flow the more volatile agent is used this the more gas will be in the room and the
environment

Disadvantage of low flow

 Rebreathing (sevo will breakdown to compound A which is hepatotoxic when in contact with soda
lime and deso will be broken down to carbon monoxide when in contact with soda lime)
Brain function monitoring
(bispectral index, entropy, auditory evoked potentials)
may be helpful in titrating the dose of inhaled or
injected anesthetic drugs to produce the desired degree
of central nervous system depression

Regional Anesthetic

A neuraxial regional anesthetic (spinal, epidural, caudal)

is selected when maintenance of consciousness during
surgery is desirable
Spinal
anesthesia in comparison to epidural (1) takes less time to perform, (2) produces a
more rapid onset of better-quality sensory and motor
anesthesia, and (3) is associated with less pain during surgery. Unlike epidural anesthesia, a continuous spinal
technique is rarely used because of postspinal headache
and concern about the proper maintenance of the catheter
in the subarachnoid space

The principal advantages of epidural anesthesia are (1)

a lower risk for post–dural puncture headache, (2) less
systemic hypotension if epinephrine is not added to the
local anesthetic solution, (3) the ability to prolong or
extend the anesthesia through an indwelling epidural
catheter, and (4) the option of using the epidural catheter
to provide postoperative analgesia.

The only absolute contraindication to

spinal or epidural anesthesia is when a patient wishes
another form of anesthesia.

Disadvantages
of this anesthetic technique include the
occasional failure to produce sensory levels of anesthesia
that are adequate for the surgical stimulus and hypotension
that may accompany the peripheral sympathetic
nervous system blockade produced by the regional anesthetic,
particularly in the presence of hypovolemia.

Skeletal muscle relaxation

and contraction of the gastrointestinal tract are also
produced by a regional anesthetic.

Peripheral Nerve Block

A peripheral nerve block is most appropriate as a technique
of anesthesia for superficial operations on the
extremities (see Chapter 18). Advantages of peripheral
nerve blocks include maintenance of consciousness
and the continued presence of protective upper airway
reflexes A disadvantage of peripheral nerve block as an anesthetic
technique is the unpredictable attainment of adequate
sensory and motor anesthesia for performance of
the surgery. The success rate of a peripheral nerve block
is often related to the frequency with which the anesthesia
provider uses this anesthetic technique. Patients must
be cooperative for a peripheral nerve block to be effective.
For example, acutely intoxicated and agitated
patients are not ideal candidates for a peripheral nerve
block. The use of ultrasound guidance in regional anesthesia
has become a routine technique and has increased
its use for perioperative care
Initial preparation for anesthesia, regardless of the
technique of anesthesia selected, usually begins with
insertion of a catheter in a peripheral vein and application
of a blood pressure cuff. Monitors such as the pulse oximeter, electrocardiogram,
and peripheral nerve stimulator are also applied
while the patient is still awake. Immediately before
induction of anesthesia, baseline vital signs (systemic
blood pressure, heart rate, cardiac rhythm, arterial hemoglobin
oxygen saturation, breathing rate) and the
corresponding time are recorded.