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AN INTRODUCTION TO ANESTHESIA
 1 Preface | 4
2 Anesthesia - a branch of critical care medicine | 5
3 Anesthesia - a brief overview | 9
4 Patient assessment and preparations | 14
5 Managing the airways | 17
6 Anesthesiological methods and pharmaceuticals | 21
7 Keeping a record | 39
8 The anesthesia machine | 42
9 Different breathing circuits | 49
10 Monitoring | 55
11 Low flow anesthesia | 61
12 Safety considerations | 64
13 Special applications | 69
14 Glossary and abbreviations | 77
15 References | 83

Infologic 1.13 3
| 1 | Preface |

1 PREFACE
This booklet is designed as a basic introduction to the field of anesthesia for a variety of
interested professional groups. These include healthcare and auxiliary staff, technicians,
salespeople, service engineers, cleaners, instructors, and anyone else wishing to learn about
the fundamentals of anesthesiology. It is partly based on previous Maquet training material
that has been revised and updated.

The information is intended to be simple and accessible to many different user groups and
includes diagrams, tables and graphs to illustrate the text and provide a better overview. The
presentation is deliberately straightforward and readers interested in the more advanced
aspects of anesthesia should refer to specialized textbooks, some of which are listed under
"References".

No previous knowledge of anesthesia is required to understand this booklet, which is designed

to serve as a useful key to a field that may sometimes appear bewildering to outsiders. Some
familiarity with clinical concepts and environments is however an advantage since medical
terms are often used in the descriptions. As in many other specialized areas, the use of medical
jargon and abbreviations may confuse newcomers. A conscious effort has therefore been
made to avoid complex terminology and "insider" shorthand. Readers will also find many
specialized words and acronyms explained in the "Glossary" at the end of this booklet. These
terms are highlighted in bold the first time they appear in the text.

After two brief introductory chapters, the next five chapters focus on what happens to the
patient during anesthesia. The perspective is more technical in remaining chapters where the
focus is on the machinery and equipment used. Optimal patient care requires familiarity with
all these aspects, although different professional categories may wish to concentrate on the
areas most relevant to their interests.

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2 ANESTHESIA - A BRANCH OF CRITICAL CARE MEDICINE

The specialized field of anesthesiology focuses OR, however, remains the most important
on keeping patients (who may be seriously ill environment for the anesthesiologist and some
or traumatized) stable and pain-free during familiarity with its layout is therefore
surgery - a form of continuous intensive care. necessary.
Traditionally, anesthesiologists have been at
the forefront of critical care medicine. Their 2.1 SURGICAL WORKPLACES
work thus involves much more than simply
putting patients to sleep. Surgical workplaces will of course differ in
layout from one hospital to the next,
There is a considerable lack of consensus depending on the specific uses to which they
when it comes to how to refer to the various are put. Some knowledge of concepts and
personnel groups involved in anesthesia. The functions routinely used in most such
problem is that both anesthesia and intensive workplaces is however required.
care services are organized differently in
different countries. So while it is the Surgical workplaces can roughly be divided
anesthetist/anesthesiologist who handles all into three areas depending on the level of
patient care in some countries, in others the cleanliness:
nurse anesthetist may play a central role in
A general access area that is open to all
uncomplicated anesthesia procedures. To
personnel groups and often includes a
avoid confusion, the terms "anesthetist" and
central reception desk or nursing station,
"anesthesiologist" are used somewhat loosely
along with a waiting area. Ordinary clothes
and interchangeably in the text below to refer
are permitted here.
to the person in charge of the anesthesia
procedure, whatever that person's A "clean" area with more restrictive dress,
professional title, gender or role. requiring special clothes, including
headgear, not worn outside the area.
Anesthesia is generally associated with the
Routines nowadays generally also require
hospital environment, particularly the operating
the removal of all jewelry and watches,
room. It is however useful to remember that
since they are known to be a potential
anesthesia is nowadays also used in the
source of infection. The area includes
radiology department and the emergency
corridors and storage areas, as well as the
room, as well as during childbirth or MRI
anesthesiologist's workplace in the OR,
examinations, for outpatients and on hospital
where a surgical mask is generally
wards. Meanwhile, hospitalization times are
recommended.
also decreasing steadily all the time. In
addition, anesthesia is used for dental surgery, A "sterile" area that includes a large part of
in cosmetic surgery clinics and psychiatric the operating room and its contents, in
units, as well as on the sites of accidents. The which a surgical mask must always be

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| 2 | Anesthesia - a branch of critical care medicine |

worn. Surgeons and their assistants will also anesthetist. Hospitals are therefore always on
put on sterile robes ("scrubs") and gloves the lookout for equipment that will save space
after the routine scrubbing-up and as well as money. It should also be easy to
disinfection procedures. handle and ergonomically designed.

Individual operating rooms or theaters may

also vary in design and layout depending on
practicalities and preferences.

The main components will however be

recognizable almost anywhere and will
generally include the following:

an operating table for the patient

an anesthesia machine

a stand or cart with work surface for

anesthetic equipment and drugs
2.2 HISTORICAL OUTLINE
a pole for intravenous fluids
The following is a brief historical overview of
a suction device for removing mucus from the last two centuries of developments in the
the airways and clearing the stomach world of anesthesia. It should of course be
remembered that efforts to reduce and control
surveillance monitors
pain naturally predate this summarized outline.
stands for surgical instruments Examples include the use in many ancient
civilizations of methods such as acupuncture,
a stand for compresses, etc. and plant or herbal extracts such as
mandragora, to relieve pain or induce sleep.
a stand for surgical samples and specimens
1799 - The analgesic effects of nitrous oxide
a surgical suction device
were discovered.
a diathermy or surgical cautery unit
1818 - The anesthetic effect of ether vapor
TV monitor/X-ray equipment was discovered.

PC/laptop. 1831 - Chloroform was discovered.

1842 - Dr C. W. Long first used diethyl ether

As is obvious from this list and the illustration for surgical anesthesia.
below, the operating room is often very
crowded and freedom of movement may be 1844 - Dr H. Wells used nitrous oxide for
extremely restricted, particularly for the dental analgesia.

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 | Anesthesia - a branch of critical care medicine | 2 |

1846 - Dr W.T. Morton made the first public 1985 - Mallampati suggested a special
use of ether for anesthesia. method for assessing intubation difficulty.

1853 - Dr J. Snow used chloroform on

Queen Victoria during the birth of Prince
Leopold.

1884 - Cocaine was first used for local

analgesia.

1917 - The face mask was introduced.

1920 - Tracheal tubes were introduced by

Magill to deliver inhaled anesthetics.

1920 - Guedel published data on signs and

depths of ether anesthesia.

1930 - The circle system and CO2 absorber

were described by Dr Sword.

1934 - Thiopenthal induction was first used

by Dr Lundy.

1938 - A positive pressure respirator was

used during surgery.

1942 - Tubocurarine was used for surgical

muscle relaxation.

1949 - Succinylcholine was used for muscle

relaxation.

1956 - Halothane was used clinically by

Johnson.

1960 - Xenon was introduced for

anesthesia.

1972 - Enflurane was introduced in clinical

use.

1981 - Isoflurane was used clinically.

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| 2 | Anesthesia - a branch of critical care medicine |

1986 - The American Society of

Anesthesiologists, ASA, approved the first
standards of basic anesthesia monitoring.

1989 - Propofol came into clinical use.

1990 - Pulse oximetry was added to ASA

standards.

1992 - Desflurane was introduced in clinical

use.

1994 - Sevoflurane came into clinical use.

1996 - etCO2 (end tidal carbon dioxide)

monitoring was added to ASA standards,
complementing existing requirements
concerning oxygen monitoring.

2005 - New ASA Standards for Basic

Anesthetic Monitoring were published in
the same year in which ASA also celebrated
100 years as a professional organization for
anesthesiologists.

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 | Anesthesia - a brief overview | 3 |

3 ANESTHESIA - A BRIEF OVERVIEW

has been treated by a dentist. Like regional
3.1 BASIC INFORMATION anesthesia, discussed below, it may also serve
as a useful complement to other forms of
The word anesthesia comes from a Greek anesthesia.
term meaning "without feeling", implying that
the patient is not sensitive to external stimuli 3.1.2 REGIONAL ANESTHESIA
such as pain. General anesthesia means that
the whole body is anesthetized and involves Local anesthetic agents are injected/infused
sleep or unconsciousness (hypnosis), to achieve a regional effect. Examples include
painlessness (analgesia), reduced or spinal and epidural anesthesia, as well as
abolished reflexes and muscular relaxation. In peripheral nerve blocks. Once again, the
fact, the three concepts are sometimes advantage is that the patient can be fully
referred to as "the triad of anesthesia". conscious but feels no pain. Different agents
may be used and the anesthetic drugs are
Another important component of general sometimes complemented with opioids
anesthesia is amnesia, which means that the administered epidurally or intrathecally.
patient should have no recollection of any Regional anesthesia can be used either alone
events after consciousness was lost. or in combination with other forms of
anesthesia to provide excellent operating
Anesthesia is generally subdivided into three
conditions and prolonged pain relief.
types described under the headings below.

3.1.3 GENERAL ANESTHESIA

3.1.1 LOCAL ANESTHESIA
This involves a condition generally
As the name implies, agents are administered
characterized by
topically as creams, sprays or gels, or by
injection, to achieve a purely local effect. The sleep or unconsciousness
patient is fully conscious, though sometimes
mildly sedated by a suitable drug, generally painlessness
administered orally.
reduced or abolished reflexes and
Traditions may vary from one country to the subsequent amnesia
next and a variety of related substances may
be used. These include procaine (one of the when necessary, reduced muscular tonus.
earliest local anesthetics), lidocaine,
etidocaine, prilocaine, mepivacaine and General anesthesia is in turn subdivided into
bupivacaine, as well as more recent additions several types depending on how the
such as ropivacaine and levobupivacaine. anesthetic agents are administered:
Local anesthesia will be familiar to anyone who
inhalation anesthesia, where the agent is
administered via inhalation;

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| 3 | Anesthesia - a brief overview |

intravenous anesthesia, where the agent is 3.2 GENERAL ANESTHESIA

given by intravenous injection or infusion; ROUTINES
balanced or combined anesthesia, where Although every patient case is unique and
both of the above methods are used. This individual hospitals and doctors have different
offers an opportunity of combining the best local routines, it is possible to identify a pattern
qualities of different agents, enabling common to most forms of general anesthesia.
dosages to be adjusted and potential The section below outlines the various stages
savings to be made, while also allowing involved, while coming chapters will focus
anesthetic methods to be adapted to more on some of their details.
specific needs.
3.2.1 PREOPERATIVE ASSESSMENT
Since the patient under general anesthetic is
This is a chance for the anesthetist to meet
unconscious, it is imperative for the anesthetist
the patient, inform him/her about the planned
to monitor a number of vital parameters with
procedures, perform a physical examination
great care. All life-sustaining care revolves
and discuss any questions. General health
around the airways, breathing and circulation.
status, laboratory values, drug therapy and
In the context of anesthesia, this may involve
planned type of surgery are all taken into
the use of intubation to ensure free airways,
account in selecting the anesthesia method.
manual or machine assisted ventilation to help
the patient breathe, and infusion fluids to
ensure patient hydration, as well as carefully
selected drugs to optimize circulation.

In addition, the anesthetist must monitor and

control the level of the patient's consciousness
and ensure that he/she remains insensitive to
pain with the help of intravenous or volatile,
i.e. inhalation, pharmaceuticals. These aspects
are of course interrelated and have an impact
on each other as well on patient status.
Anesthesia is thus a complex and specialized
branch of medicine, and different patients
require the anesthetist to focus on different
aspects. Each procedure therefore needs to
be tailored to suit individual needs and
prevailing conditions.

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3.2.2 PREANESTHETIC PREPARATIONS

Preparations may vary depending on local

tradition. Fasting is often recommended,
although patients in some countries are now
allowed clear liquids up to 2 hours before
planned surgery. Sometimes, carbohydrate
drinks may even be given up to 2 hours before
induction to prevent post-operative insulin
resistance. There are also variations in
premedication routines. These involve
administering drugs for sedation and anxiety
relief either before or after transportation to
the operating room (OR). In the OR or a
preparatory room, the patient is greeted by
the anesthesiologist or anesthetist nurse, who
checks lab values and ID. The patient is then
moved to the operating table and carefully
positioned to avoid discomfort or injury during
surgery. For some types of surgery it may be
necessary to reposition the patient after he/she
has been put to sleep (see chapter 12).

3.2.3 MINUTES BEFORE ANESTHESIA

Routines for the order in which the various

steps are taken may vary from one clinic to
the next. As a general rule, however, all
watches and jewelry should have been
removed before the patient arrives in the OR,
although it is a good idea always to check that
this has been done. (These days, it may also
be a good idea to ask about any piercings.) If
an intravenous line is not already present, one
should be arranged. Oxygen (usually 80-100%)
is given via a face mask to increase the
amount of oxygen in the lungs before
induction (preoxygenation). The anesthetist
will also attempt to reassure nervous patients
and help them to relax.

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| 3 | Anesthesia - a brief overview |

3.2.4 INDUCTION

To put the patient to sleep, a short-acting

hypnotic agent is given intravenously,
although sleep is sometimes also induced by
inhalation of an anesthetic agent via a face
mask. Whichever method is preferred, a face
mask is used to assist patient breathing and
a check is made to ensure patent airways. If
muscle relaxation is needed for surgery or
intubation, muscle relaxants are given. In this
case, some form of analgesia (generally an
opioid) may also be given to avoid pain during
intubation. A laryngeal mask or an
endotracheal tube is fitted to administer a
mixture of oxygen (30-40%) and nitrous oxide
(60-70%), although medical air may also be
used for ventilation.

3.2.5 MAINTENANCE

Anesthesia is maintained by continuously

supplying the patient with anesthetic agent
via inhalation or intravenous infusion. The
dosage is adapted to individual needs. Careful
monitoring and/or observation are essential.
The parameters generally include ventilation,
gas concentration, circulation (pulse, blood
pressure, ECG), temperature (continuous or
intermittent), degree of muscle relaxation, fluid
balance (fluids given and lost), metabolism
(blood glucose, acid-base balance), and
sometimes depth of anesthesia. Sophisticated
equipment is not always necessary. A great
deal of information can be obtained through
careful observation and alertness to changes
in status.

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3.2.6 ELIMINATION

Anesthetic agents are eliminated via the lungs

or broken down by the body and removed as
metabolites. Antidotes may be given to
counteract specific agents, although this is
not common. Once the patient is awake, the
laryngeal mask or endotracheal tube is
removed (extubation) and pure oxygen is
generally given via nasal prongs.

3.2.7 RECOVERY

The patient is taken to the recovery room or

postoperative ward for recovery and
monitoring of vital functions. Once the
patient's condition is stable, he/she is
transported back to the ward or possibly even
sent home, depending on the type and extent
of the surgery performed.

In principle, all procedures involving general anesthesia will follow a pattern similar to the one
described above.

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| 4 | Patient assessment and preparations |

4 PATIENT ASSESSMENT AND PREPARATIONS

Anesthetic procedures are nowadays endocrine disease, neurological or cardiac
commonplace, safe and relatively simple as disorders, hypertension, lung disease and
long as appropriate training has been hereditary disorders, such as a predisposition
provided. In fact, the level of risk associated to develop malignant hyperthermia.
with modern anesthesia is now so low (when
the patient's only medical problem is what 4.1.2 PATIENT INTERVIEW AND
brought him or her to surgery in the first place) EXAMINATION
that it is virtually impossible to perform
randomized studies to evaluate the risks The interview is an opportunity for the
associated with new procedures or equipment. anesthetist to ask questions and for the patient
This is due largely to developments over the to find out more about the planned
last twenty years, particularly the introduction procedures. The assessment should include
of reliable equipment and careful monitoring general state of health, degree of mobility
by qualified personnel. (particularly mouth and neck), blood pressure,
functional heart and lung status, assessment
4.1 THE PATIENT'S CONDITION of potential intubation difficulties (see
BEFORE ANESTHESIA "Endotracheal intubation" in chapter 5), dental
status, body height and weight.
Thorough knowledge of the patient's case
history, current health status, drug therapy, Depending on the patient and the intended
laboratory values and indications for surgery surgery, it may be necessary to obtain an ECG
help prevent unnecessary problems and select and a laboratory status. The latter will generally
the best anesthetic method. Preoperative includes hemoglobin, serum electrolytes and
assessment should be part of hospital routines serum creatinine, although it may be extended
for all patient categories. The extent and level to cover liver status, coagulation and
of detail will however vary depending on the hemostasis status and blood glucose. It is
patient's health status, clinical condition, important to discuss current drug therapy,
intended surgery and prevailing particularly drugs used to treat heart disease,
circumstances. The most important element anticoagulants, vasoactive agents,
is the taking of a careful case history. psychotherapeutic drugs and steroids. Alcohol
or drug abuse may have adverse effects on
anesthesia and the anesthetist should ask
4.1.1 PATIENT RECORDS
about such problems and bear them in mind,
The case history provides details of the even if patient answers may sometimes be
patient's medical history, including surgical unreliable. Inquiries should also be made
operations and types of anesthesia, as well about bleeding disorders, both hereditary and
as allergic tendencies, coagulation disorders, acquired. The patient's blood group should
pregnancy, muscular disorders, rheumatic or also be routinely ascertained or checked
ahead of major surgery.

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 | Patient assessment and preparations | 4 |

4.1.3 THE ASA SYSTEM ASA Class 5: Severe illness in a patient

running a substantial risk of death within 24
Patients undergoing surgery and anesthesia hours with or without surgery, although it is
may differ tremendously in terms of age, considered "best to try".
constitution and health status. It is therefore
useful to assess and categorize them in a The E designation: Emergency status. In
standardized manner so as to avoid addition to indicating underlying ASA status
misunderstandings and improve patient (1-5 above), any patient undergoing an
outcome. emergency procedure is given the suffix
"E". A fundamentally healthy patient, for
When assessing patient status prior to example, undergoing emergency surgery
anesthesia, the anesthetist interviews patients such as an appendectomy is thus classified
and generally groups them in accordance with as 1-E. The E designation is not used when
the globally accepted ASA (American Society surgery is planned.
of Anesthesiologists) classification outlines
below. ASA Class 6: Organ donors who have
already been pronounced clinically dead
ASA Class 1: No systemic or psychiatric but are waiting for surgery to be performed.
disease, the patient is healthy and normal.

ASA Class 2: Moderate systemic disease This information may be included in the
that does not limit the patient's activities anesthesia record chart under preoperative
and is often under good medical control, assessment (see chapter 7).
e.g. a patient with well controlled
hypertension or diabetes without medical 4.2 PREANESTHETIC
complications. PREPARATIONS
ASA Class 3: Moderate or severe systemic Different hospitals and anesthetists have their
disease that does limit the patient's own routines although these tend more or less
activities and may be under incomplete to follow the outline below.
medical control, e.g. stable angina
pectoris, diabetes with medical 4.2.1 INFORMATION
complications, previous myocardial
infarction or emphysema. Most patients are unnerved at the prospect of
anesthesia and surgery, although anxiety
ASA Class 4: One or more severe systemic levels may vary considerably. It is therefore a
diseases that are life-threatening. e.g. good idea to inform the patient thoroughly
severe congestive heart failure, advanced about the procedure and what to expect.
renal insufficiency, liver or lung disease,
recent myocardial infarction.

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| 4 | Patient assessment and preparations |

4.2.2 ENSURING THAT THE STOMACH IS 4.2.4 PREMEDICATION

EMPTY
If premedication is given, its purpose is
The traditional view is that the stomach should generally fourfold:
be empty before anesthesia and surgery, since
vomiting is a complication which may be to raise the pain threshold
life-threatening if aspiration to the lungs
to sedate the patient and relieve anxiety
occurs. Fasting (both food and drink) is
therefore often recommended for 4-5 hours to reduce reflex central nervous activity
before anesthesia, or longer if patients are
pregnant or overweight. Variations in this to counteract any side effects of anesthesia
routine do however occur, particularly with and surgery.
regard to fluid intake (see under "Preanesthetic
preparations" in chapter 3 above). In case of
emergency that precludes fasting, a rapid
sequence induction (RSI) is used.

Fasting may cause dehydration, which is why

a preoperative infusion is often given. Attitudes
to the use of larger quantities of ínfusion fluids
have however recently become more
restrictive.

4.2.3 DRUG THERAPY

The patient's normal drug therapy may require

changes due to surgery and anesthesia. Some
drugs, such as peroral anticoagulants and
aspirin, should be avoided before all types of
surgery.

Others, such as insulin treatment,

corticosteroids, epilepsy medication and
hypertension and heart medication, must be
carefully assessed and sometimes adjusted.

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5 MANAGING THE AIRWAYS

Airway management is crucial in all forms of Previously, only short operations were
general anesthesia, and both the agents and performed with the patient breathing
the equipment used for this purpose are kept spontaneously. Recent developments, such
close to the patient. Even when patients are as the laryngeal mask, however, now enable
breathing spontaneously, the anesthetist must spontaneous breathing during longer
always be ready to take control of ventilation. procedures as well.
Ensuring free airways and adequate ventilation
is essential to safe anesthesia. 5.1.2 LARYNGEAL MASK

5.1 FREE AIRWAYS AND ASSISTED The LMA (for laryngeal mask airway) is
BREATHING becoming increasingly popular as an
alternative to the face mask, since it frees the
5.1.1 FACE MASK anesthetist's hands and simplifies the job of
ensuring free airways.
When surgery is elective and requires general
anesthesia, the patient is generally ventilated The laryngeal mask is also widely used as an
via a face mask during induction and alternative to endotracheal intubation, since
sometimes after extubation. During the the latter may sometimes give rise to
procedure, the patient may either breathe complications and problems.
spontaneously or with the anesthetist's
assistance in the form of manual or controlled
ventilation. For emergency procedures,
routines are somewhat different.

The mask is positioned so that the tip covers

the upper esophageal sphincter, ensuring free
passage of air to the trachea. Once the mask
is in place, the rim is inflated

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| 5 | Managing the airways |

with different accessories. Some have also

been adapted to allow for the insertion of a
gastric tube. These developments contribute
to their increasing popularity.

It is primarily used during spontaneous or

supported breathing, but is also gaining more
widespread acceptance for use in combination
with controlled breathing modes.

There is now a growing range of LMAs, both

for one-time use and re-use, available in the
market in a variety of sizes and designs and

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5.1.3 ENDOTRACHEAL INTUBATION

Certain types of surgery or specific patient

positions on the operating table may make it
necessary to intubate the patient.

This is done with the help of a laryngoscope,

which enables the intubator to visualize the
As mentioned in connection with preanesthetic
larynx. The blades of this instrument are
evaluation, potential difficulties associated
available in different sizes to suit a range of
with intubating patients should be assessed
patients.
before the procedure. This generally involves
The endotracheal tube (ETT) is then inserted assessment of mouth opening and neck
and positioned so that the tube's cuff is below extension, as well as vocal cord visualization.
the vocal cords. The cuff is then inflated to Sometimes a special classification system is
prevent aspiration and leakage. The tube is used, the most widely accepted of which is
also available in a variety of sizes and may be the Mallampati system.
inserted via either the nose or the mouth. It is
In cases where major difficulties are
almost always disposable.
envisaged, it may sometimes be necessary to
resort to a fiber optic bronchoscope (FOB).
All intubation is of course only performed by
trained medical personnel and care is always
taken not to damage the teeth, mucous
membranes, vocal cords or surrounding
tissues.

When intubating infants, no cuff is used on

the endotracheal tube due to the sensitivity of
their mucous membranes, since any swelling

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| 5 | Managing the airways |

may lead to serious breathing problems after patient tubing

extubation. Allowances must therefore be
made in pediatric anesthesia for leakage fresh gas inlet
around the tube.
bag for manual ventilation

5.2 PATIENT VENTILATION ventilator

The following is a brief outline of gas unidirectional valves and/or pop-off or relief
administration and breathing systems. For a valves
more detailed description of various breathing
circuits and of the anesthesia machine as a CO2 absorbent canister when rebreathing
whole, the reader is referred to chapters 8 and systems are used.
9.
Developments have led to substitutions and
5.2.1 GAS ADMINISTRATION additions to this basic breathing apparatus.
These are also described in greater detail in
Oxygen, nitrous oxide and medical air are chapter 9.
provided via pipes from cylinders or the
hospital's central supply. Gas pressure is
5.3 MANUAL VENTILATION
reduced for medical purposes. The flow rate
and concentration of the gases are individually It must always be possible for the anesthetist
set and altered during anesthesia. to support patient ventilation or control it
Traditionally, the anesthesia machine's completely. On most machines, access to a
flowmeters allow the anesthetist to set the bag for manual ventilation is therefore
dosage. standard. It should be checked at regular
intervals to ensure that it is fully functional.
The gases then pass through a vaporizer,
when used, containing a volatile agent used Both bags and tubing come in a variety of
for inhalation anesthesia. If such a vaporizer sizes for different patients and uses.
is not in use, the gas mixture is supplied
straight to the breathing system.
5.4 MECHANICAL VENTILATION

5.2.2 BREATHING SYSTEMS In general, the ventilator on the anesthesia

machine is used when surgery necessitates
Inhalation agents are given via the breathing muscle relaxation or is due to last an hour or
system, which may differ from one machine more. However, a certain amount of flexibility
to the next with regard to level of is often necessary depending on the patient,
sophistication and the degree to which it the surgery to be performed and local routines
incorporates rebreathing. At the rudimentary and preferences. Mechanical ventilation is
level, most systems will include the following: discussed in chapter 8.

patient mask

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 | Anesthesiological methods and pharmaceuticals | 6 |

6 ANESTHESIOLOGICAL METHODS AND PHARMACEUTICALS

The preoperative assessment helps the anesthetic in the cerebrospinal fluid, which is
anesthetist select the appropriate method to in turn governed largely by the dose
use based on the patient's health status and administered. This method is common during
wishes, the type of surgery to be undertaken operations performed below the waist and
or environment in which it takes place and the lasting less than two hours, for example hip
examination results, etc. The following surgery and elective caesarean section.
provides a brief guide to the most common
anesthetic methods in use today. 6.1.2 EPIDURAL ANESTHESIA

6.1 REGIONAL ANESTHESIA Again, a local anesthetic is injected in the

lumbar (or thoracic) region, but the needle
There are several forms of regional anesthesia stops in the epidural space surrounding the
(see chapter 3), of which those involving a membrane (or dura) around the cerebrospinal
central block of the spinal cord or the nerves fluid. Normally, a fine catheter is left in place
leaving it are perhaps the most widely known which can be used for post-operative pain
and used. They may be used alone or in relief (epidural analgesia). The anesthetic
combination with other forms of anesthesia blocks the nerves that pass through the
and are briefly described below. epidural space as they leave the spinal cord.

6.1.1 SPINAL ANESTHESIA

The anesthetic is injected into the

cerebrospinal fluid (CSF) that bathes the spinal
cord and brain. The needle is generally
inserted just below the intervertebral space
between the first and second lumbar
vertebrae, known as the L1-L2 level, although
this may vary with the type of surgery. Epidural analgesia is perhaps best known for
its use during childbirth, although it does have
other areas of application, such as for
analgesia after major abdominal surgery.

6.1.3 CONTRAINDICATIONS

The main contraindications for regional

anesthesia used alone are as follows:

A combination of a local anesthetic and an allergy to local anesthetics

opioid is often used. The extent of the block
patient choice
depends on the level reached by the

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| 6 | Anesthesiological methods and pharmaceuticals |

uncooperative or restless patients METABOLISM AND ELIMINATION

bleeding disorders The elimination of intravenous agents depends

mainly on liver metabolism and renal function
ongoing anticoagulant therapy and generally takes longer than that of inhaled
agents. Remifentanil, however, which is a
topical infections.
relatively recently developed fast-acting opiod,
is metabolized by blood and tissue enzymes.
6.2 GENERAL ANESTHESIA so its elimination is not dependent on the liver
and kidneys.
This common form of anesthesia is generally
divided into the following categories: FREQUENCY OF USE

intravenous anesthesia Total intravenous anesthesia (TIVA) is less

common than combined anesthesia, in which
inhalation anesthesia
several administration routes are used
combined (or balanced) anesthesia. simultaneously. It is however preferred in some
parts of the world or for special purposes, and
some experts see a trend towards increasing
6.2.1 INTRAVENOUS ANESTHESIA use.

Anesthetic agents that are given intravenously 6.2.2 INHALATION ANESTHESIA

are rapidly distributed. Their actions and
possible side-effects are immediate in patients Inhalation anesthesia is a popular method
with normal circulation. With inhalation because the gases and agents used are easy
anesthesia, however, it can take several to measure and control, with the lungs acting
minutes to achieve a specific anesthesia level as a kind of "buffer". Less appealing is the fact
that only takes seconds to achieve that we still do not know exactly how inhaled
intravenously. anesthetic agents work.

These agents are volatile liquids that are

DOSAGE
vaporized and administered to the patient in
By combining different drugs, the specific a gas mixture, generally oxygen-nitrous oxide
benefits of each can be utilized to tailor or oxygen-air. General laws governing gas
anesthesia to the individual patient. Effective pressure, volume, temperature, flow and
analgesics can be carefully dosed and concentration are thus applicable here. It has
combined with sleep inducing drugs to been suggested that the agents act on the
anesthetize the patient. proteins in the cell's lipid membrane and their
potency is thus related to their solubility in
fat. This also makes sense when one
considers that their target organ, the brain, is
largely composed of fat.

22
 | Anesthesiological methods and pharmaceuticals | 6 |

It also explains why halothane, which used to agent is used, the MAC values are additive.
be a very popular anesthetic agent and is Thus, 0.6 MAC of nitrous oxide combined with
highly lipid soluble, is the most potent of the 0.4 MAC of isoflurane is equivalent to 1.0 MAC
anesthetic agents, while nitrous oxide, which of isoflurane. Two volatile agents, such as
is comparatively insoluble in fat, has the lowest sevoflurane and desflurane, will also have
potency of the agents in clinical use. additive effects. Several other concepts are
occasionally used in relation to MAC, such as
Lipid solubility is represented by the oil/gas "MAC 95%", "MAC awake" and "MAC aware".
partition coefficient (OGPC), although in They refer to different MAC levels ("MAC
clinical practice, potency is generally aware", for example, is about 0.3 MAC).
associated with the Minimum Alveolar
Concentration (MAC). The pharmacokinetics
UPTAKE OF INHALATION AGENTS
of the agent (how fast it reaches and leaves
the brain) must also be considered when During inhalation anesthesia, it is crucial to
discussing inhalation anesthesia. The ensure a rapid and adequate concentration of
important factors are the concentration of anesthetic agent in the brain. Since the agent's
anesthetic agent in the inspired gas mixture, partial pressure in all tissues eventually
the choice of gas mixture, alveolar ventilation, approaches that in the alveoli, the alveolar
the blood flow to the lungs (or cardiac output), partial pressure at steady state reflects the
the gradient between venous and arterial partial pressure in the brain. It should however
blood and agent solubility in blood and other be noted that anesthetists (and anesthesia
tissues. These aspects are all discussed in machines) generally measure end-tidal
more detail below. concentrations as volume fractions in percent,
rather than as partial pressures, since MAC is
MAC - MINIMUM ALVEOLAR also a percentage value.
CONCENTRATION
A high fresh gas flow and high agent
MAC is an index of the anesthetic potency and concentration in the gas mixture enable the
thus the pharmacological effect of an anesthetist to increase the agent's alveolar
inhalation agent. It is defined as the agent's partial pressure rapidly. These two factors are
alveolar concentration (in percent), as reflected thus the major determinants of how rapidly
by the expired end-tidal concentration, at the agent is delivered to the brain.
which 50% of patients will not move in
response to a surgical stimulus (skin incision). Agent uptake is best described by the rate at
1.3-1.4 MAC is the alveolar concentration which alveolar concentration (FA) rises in
needed for surgical anesthesia. relation to inspired concentration (FI). If
cardiac output is constant, the increase in
It should be noted that MAC is higher in infants the FA/FI ratio over time reflects the degree
and lower in the elderly, and that both opioids of solubility of the agent in blood.
and premedication allow surgery to be
performed at a lower MAC. Another important
aspect is that if more than one anesthetic

23
| 6 | Anesthesiological methods and pharmaceuticals |

FA/FI
N2O
1.0
Desflurane
Sevoflurane

0.8
Isoflurane
Enflurane

0.6 Halothane

0.4 Ether

0 10 20 30
Minutes

Wash-in curve for inhalation agents (rate of vapor uptake)

the same experiment as above is conducted)

SOLUBILITY OF INHALATION AGENTS IN passing into the blood. Its alveolar partial
BLOOD pressure thus remains high, which means that
the partial pressure in the brain will also be
The solubility of an inhalation anesthetic high, as explained above. This results in a
determines how fast it both works and wears short induction time.
off. The less soluble the drug, the faster it
works. The term also denotes the amount of GRADIENT BETWEEN VENOUS AND
agent that dissolves in the blood in relation to ARTERIAL BLOOD
the amount present in the alveolar gas at the
same partial pressure. Thus if one liter of blood The gradient between mixed venous blood
is exposed to one atmosphere of isoflurane, and arterial blood depends on the uptake in
then 1.4 liters of the agent will have entered different tissues. Anesthetic agents have
the blood once steady state is reached. different partition coefficients in different
tissues and this naturally affects their uptake.
The solubility of an agent is specified by its Potent agents (those with low MAC values)
blood/gas partition coefficient (BGPC). that have a high solubility in fat dissolve to a
greater extent in fat-rich tissues.
A highly soluble anesthetic, such as ether, will
thus dissolve to a far greater extent in the There will thus be a larger partial pressure
blood, thereby successively decreasing the gradient between venous and arterial blood
amount in the alveoli (if no further agent is in fat-rich tissues, such as the brain. The main
supplied). Nitrous oxide, on the other hand, is coefficient of interest here is the oil/gas
highly insoluble. It will therefore remain in the partition coefficient. An agent with a high
alveoli, with only a small amount (0.47 liters if coefficient, such as halothane, will have
24
 | Anesthesiological methods and pharmaceuticals | 6 |

greater potency at the site of action than an The alveolar partial pressure of any
agent with a low coefficient, such as accompanying gas will also rise more quickly,
desflurane. In addition, organs with a high rate which means that induction with an inhalation
of perfusion (such as the brain, kidneys, liver anesthetic is more rapid in the presence of
and heart) equilibrate more rapidly with the nitrous oxide. This is known as the second
alveolar partial pressure than organs with a gas effect.
lower rate of perfusion.
6.2.3 PRACTICAL EXAMPLE
CARDIAC OUTPUT
The main steps involved in anesthetizing a
Higher cardiac output means higher pulmonary patient with the help of inhalation agents are
blood flow. The agent is therefore more rapidly described below. As noted previously,
distributed from the alveoli, reducing alveolar combined or balanced anesthesia, in which
partial pressure. Reduced cardiac output, on intravenous agents are used together with
the other hand, means decreased uptake of volatile inhalation agents, remains the most
the agent and the alveolar concentration may widely used method.
then be much higher than the concentration
in the inspired gas mixture. The net effect INDUCTION
depends on the agent used and its solubility,
as explained above. INHALATION INDUCTION

This method makes use of a face mask

THE CONCENTRATION AND SECOND GAS
through which a mix of oxygen and nitrous
EFFECTS
oxide or oxygen and air is initially given, after
If a gas with a low potency (or high MAC), such which an inhalation anesthetic, such as
as nitrous oxide, is part of the inspired gas sevoflurane, is introduced by the anesthetist.
mixture, two phenomena known as the An alternative is the single-breath technique
concentration effect and the second gas effect for patients able to cooperate, which gives
will occur. These are explained below. rapid induction within 20-30 seconds.
Inhalation induction is used for young children
Since the required concentration of nitrous and patients with upper and lower airway
oxide is high, its uptake into the blood will be obstruction.
rapid. The expired nitrous oxide volume will
be lower than the inspired volume, which INTRAVENOUS INDUCTION
means that the oxygen and any second
anesthetic agent will be diluted in a smaller A drug such as propofol or a fast-acting
volume, leading to the alveolar concentration barbiturate is often used during induction to
that the effect is named after. put the patient to sleep. It is administered
intravenously while oxygen is given via the
mask. This is the most common induction
method and is especially appropriate for
patients undergoing emergency surgery where

25
| 6 | Anesthesiological methods and pharmaceuticals |

there is a risk of regurgitation.The method is During the first part of induction, large
then referred to as "rapid sequence induction" amounts of the agent are taken up by the
(RSI) and is described below (see under circulation until steady state is reached. Much
"Anesthesia in emergency conditions" in higher concentrations are therefore used for
chapter 13). this phase of induction than for maintenance.

RAPID SEQUENCE INDUCTION MAINTENANCE

Tilt the table and ensure that suction is The concentration of the gas is then lowered
ready. A trained assistant must be present to the desired level for anesthesia
and IV access must be secured. maintenance.
Sometimes, gastric volume is first
minimized via a nasogastric tube and ELIMINATION AND RECOVERY
occasionally gastric acidity is reduced
pharmacologically. Modern inhalation agents are mainly
eliminated via the lungs since they are only
Preoxygenate the patient for about 3 metabolized to a very limited extent. Toxicity
minutes, if possible. is largely dependent on the amount
metabolized. Agents that are metabolized to
Give an appropriate sleep dose of the
a lesser extent are eliminated almost solely
induction agent.
via the lungs.
Apply cricoid pressure (this involves
Recovery times are similar to induction times,
pressing against the cricoid cartilage to
in that less soluble agents have quicker
push it backwards, compressing the
recovery times. It should however be noted
esophagus. Moderate pressure may be
that lengthy periods of anesthesia require
applied before loss of consciousness, and
much longer recovery due to the accumulation
firmer pressure maintained until the cuff of
of anesthetic agent in fat-rich tissues.
the tracheal tube is inflated.)

Give suxamethonium, 1 mg/kg, and

proceed with intubation, checking the
position of the tube before releasing the
cricoid. Secure the tube.

INHALATION TO STEADY STATE

Regardless of induction method, an inhalation

agent is now added in fairly high
concentrations to an oxygen-nitrous
oxide/oxygen-air mixture until steady state is
achieved.

26
 | Anesthesiological methods and pharmaceuticals | 6 |

One example of the process described above

is illustrated in the simplified four-part drawing
below.

Induction (IV), sleep

O2 + air + drug

Induction to
steady state
O2 + N2O +
inhalational agent

Maintenance
O2 + N2O +
inhalational agent

Elimination and
recovery
O2 + air

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| 6 | Anesthesiological methods and pharmaceuticals |

6.2.4 NITROUS OXIDE, N2O CARDIAC AND CIRCULATORY EFFECTS

NITROUS OXIDE, N2O In experiments, nitrous oxide decreases the

Color code (cylinder) Light blue contractility of the myocardium, although
Blood/gas coefficient 0.47 mean arterial pressure is in practice usually
Oil/gas coefficient 1.4 well maintained by a reflex increase in
Smell Weak, sweet
peripheral vascular resistance. For patients
1.0 MAC in
who are unable to increase their sympathetic
* 100% O2 (105 = theoretical value)
drive, however, the direct myocardial
* 30% O2 + 70% N2O -
depressant effects may reduce cardiac output.
% metabolized -
Nitrous oxide does not sensitize the heart to
The low solubility of this gas means that it
catecholamines.
provides rapid analgesia, although relatively
high concentrations are required. It thus serves
as a useful complement to other anesthetic METABOLISM AND ELIMINATION
agents.
Due to its low solubility in blood and tissues,
During the first minute of induction, uptake is nitrous oxide is only minimally metabolized. It
around 1-1.5 liters when the inspired fraction is eliminated via the lungs.
(or FI) is 70%, after which it falls quickly to
reach around 100 ml after an hour. CONTRAINDICATIONS

The high concentrations of nitrous oxide N2O should not be used for patients with
required affect the uptake of other agents bowel obstruction, pneumothorax or middle
given at the same time (concentration and ear and sinus disease. Some clinicians
second gas effects), although only during the maintain that nitrous oxide use should be
initial rapid uptake phase. restricted during pregnancy because of effects
on DNA production and evidence of unwanted
EFFECT ON BREATHING reproductive outcomes, but its use remains
very popular.
N2O is non-irritant and does not cause
bronchospasm. It slightly decreases tidal Severe vitamin B12 and folic acid deficiencies
volume, although this is offset by an increase also constitute contraindications for nitrous
in respiratory rate. It may cause diffusion oxide use, and anesthesiologists therefore
hypoxia at the end of surgery. It expands also need to consider the nutritional status of
air-filled cavities because it is 40 times as vegans.
soluble as nitrogen, passing from the blood
On the whole, there is a slow downward trend
into the cavity faster than nitrogen can diffuse
in the use of nitrous oxide, although prevailing
out. This can double the size of a
routines, traditions and preferences may differ
pneumothorax in 10 minutes at a
from place to place. Among the negative
concentration of 70%.
effects of nitrous oxide, frequent reference is
made to post-operative nausea, while its
effects on the environment, both in general
28
 | Anesthesiological methods and pharmaceuticals | 6 |

and at work, are also increasingly cited. It is CARDIAC AND CIRCULATORY EFFECTS
however still a reliable and useful drug that is
relatively inexpensive and has few side-effects. Sevoflurane causes a decrease in myocardial
It therefore remains widely used. contractility and mean arterial pressure. It has
little effect on the heart rate and does not
sensitize the myocardium to circulating
6.2.5 SEVOFLURANE
catecholamines. It does not cause ‘coronary
SEVOFLURANE steal’ although dose-related hypotension has
Universal color code Yellow been noted. For patients undergoing cardiac
(bottle and adapter on
filling system)
surgery, recent research suggests that
Blood/gas coefficient 0.6 sevoflurane (and desflurane) even has a
Oil/gas coefficient 47 cardioprotective effect and could help prevent
Smell Weak myocardial infarction.
1.0 MAC in
* 100% O2 METABOLISM AND ELIMINATION
Adults 2.05
Infants & children 2.4-3.3 Elimination is rapid due to low solubility. Over
* 30% O2 + 70% N2O 95% is eliminated via the lungs, predominantly
Adults 0.66 unchanged, while less than 5% is metabolized.
Infants & children unknown - 2 Sevoflurane is however unstable in the
% metabolized <5 presence of soda lime, producing small
Sevoflurane's solubility in blood is quite low, amounts of a a degradation product known
making it a rapidly acting agent that is easy as "Compound A". In rats, this has been
to adjust during administration. shown to damage the kidneys. In humans,
however, no effect on renal function has been
EFFECT ON BREATHING seen. Low flows, high temperatures,
desiccated absorbent containers and
Sevoflurane produces dose-related respiratory
potassium based absorbents increase the
depression, although recovery from such
production of Compound A.
depression is generally rapid due to
sevoflurane's elimination characteristics. It
CONTRAINDICATIONS
causes an increase in respiratory rate,
although minute volume remains unchanged, Sevoflurane, like isoflurane, is a trigger agent
and a decreased response to hypoxia and for malignant hyperthermia. No inhalation
hypercapnia. It relaxes bronchial smooth agent should be used on patients with a
muscle and does not irritate the airways, and known or suspected genetic tendency to
its effects are very rapid. These aspects make develop malignant hyperthermia.
it ideally suited to inhalation induction and
anesthesia maintenance in adults and children.
On the other hand, sevoflurane also
potentiates the action of depolarizing and
non-depolarizing muscle relaxants to a greater
extent than either enflurane or halothane
29
| 6 | Anesthesiological methods and pharmaceuticals |

DOSAGE CARDIAC AND CIRCULATORY EFFECTS

Dosage is age-related. For children, the Arrhythmias are uncommon with isoflurane,
dosage during induction is higher than that although blood pressure may decrease in a
generally given to adults. The concentration dose-related manner and a reflex tachycardia
generally required for maintenance is between may occur. Isoflurane has a mild negative
0.5-0.8 and 3%. effect on the heart and circulation, causing
vascular resistance to decrease and mean
6.2.6 ISOFLURANE arterial pressure to fall. It has been suggested
that it causes ‘coronary steal’.
ISOFLURANE
Universal color code Purple
(bottle and adapter on METABOLISM AND ELIMINATION
filling system)
Blood/gas coefficient 1.4 Isoflurane is mainly eliminated via the lungs
Oil/gas coefficient 98 (95%), with only approximately 0.2% being
Smell Weak metabolized.
1.0 MAC in
* 100% O2 1.15
CONTRAINDICATIONS
* 30% O2 + 70% N2O 0.56
% metabolized 0.2 Isoflurane, like sevoflurane, is a trigger agent
The effects of isoflurane are very similar to for malignant hyperthermia. No inhalation
those of enflurane. Nowadays, sevoflurane is agent should be used on patients with a
often preferred to isoflurane because of its known or suspected genetic tendency to
lower solubility, which makes both induction develop malignant hyperthermia.
and recovery quicker.
DOSAGE
EFFECT ON BREATHING
Dosage is age-related (see MAC explanation
An increased incidence of "airway problems" above and values in table). During the first part
has been reported during induction with of induction, the required isoflurane
isoflurane compared with sevoflurane. concentration is around 3-4%, while for
Isoflurane is a respiratory depressant and maintenance, it is between 0.5 and 3%.
decreases tidal volume, while having little
effect on respiratory rate. It causes a
decreased response to hypoxia and
hypercapnia and is very irritant to the
respiratory tract. It also causes
bronchodilation.

30
 | Anesthesiological methods and pharmaceuticals | 6 |

6.2.7 DESFLURANE effect, generally when agent concentration is

increased. This makes the physiological
DESFLURANE
response to this agent somewhat different
Universal color code Blue
(bottle and adapter on from reactions to other anesthetic agents.
filling system)
Blood/gas coefficient 0.42 METABOLISM AND ELIMINATION
Oil/gas coefficient 19
Smell Sweet Desflurane is hardly metabolized at all (only
1.0 MAC in 0.02%).
* 100% O2
Adults 5.75-7.25
CONTRAINDICATIONS
Infants & children 7.20-10.65
* 30% O2 + 70% N2O
Desflurane is a trigger agent for malignant
Adults 1.75-4.25
hyperthermia. No inhalation agent should be
Infants & children 5.15-7.75
used on patients with a known or suspected
% metabolized 0.02
genetic tendency to develop malignant
Desflurane's solubility in blood is very low,
hyperthermia. In addition, desflurane is not
making it a very rapidly acting agent that is
suitable for induction due to an increased
easy to adjust during administration. It is fairly
tendency towards airway instability and
expensive but is often the preferred drug when
laryngospasm during induction.
anesthetizing patients with a high BMI, since
it has a low oil/gas coefficient. It does however
require a special vaporizer (see section on DOSAGE
vaporizers in chapter 8).
Dosage is age-related. The concentration
usually required for maintenance is between
EFFECT ON BREATHING 2 and 6%.
Airway problems may occur during induction
and an intravenous agent is therefore 6.2.8 ENFLURANE
recommended to put the patient to sleep. A
ENFLURANE
dose-related reduction in breathing has been Universal color code Orange
reported for desflurane. (bottle and adapter on
filling system)
Blood/gas coefficient 1.9
CARDIAC AND CIRCULATORY EFFECTS 98
Oil/gas coefficient
Smell Ether-like
Desflurane causes a decrease in myocardial
1.0 MAC in
contractility, although sympathetic tone is
* 100% O2 1.8
preserved. It does not sensitize the heart to
* 30% O2 + 70% N2O 0.57
circulating catecholamines or cause 'coronary % metabolized 2.4
steal'. A dose-related decrease in blood
pressure has been noted, as well as
tachycardia caused by an indirect autonomic

31
| 6 | Anesthesiological methods and pharmaceuticals |

The effects of enflurane are very similar to DOSAGE

those of isoflurane (see above). Enflurane is
however more soluble, resulting in slower Enflurane is not used for gas induction. In an
induction and recovery. oxygen and nitrous oxide mixture (30-40%:
60-70%), the maintenance concentration is
usually between 0.6 and 3%.
EFFECT ON BREATHING

Breathing is affected even during the early 6.2.9 HALOTHANE

stages of enflurane anesthesia. The breathing
HALOTHANE
pattern typically displays small tidal volumes
Universal color code Red
and high breathing frequency. (bottle and adapter on
filling system)
CARDIAC AND CIRCULATORY EFFECTS Blood/gas coefficient 2.4
Oil/gas coefficient 225
Enflurane is characterized by peripheral Smell Sweet
vasodilation and a tendency to bradycardia, 1.0 MAC in
* 100% O2 0.75
leading to a drop in blood pressure. The
* 30% O2 + 70% N2O 0.29
deeper the anesthesia, the more pronounced
% metabolized 15-20
the effect.
Halothane is a very potent hypnotic agent
(see MAC values) although it has a much
METABOLISM AND ELIMINATION
weaker analgesic effect. It is one of the early
Enflurane is metabolized to a lesser degree inhalation anesthetics and is not widely used
than halothane. 2.4% is metabolized in the today due to its serious side-effects and the
liver and eliminated in the urine, while the rest development of new and better agents. In
is eliminated via the lungs. some countries, it is not even registered for
sale.
CONTRAINDICATIONS
EFFECT ON BREATHING
No inhalation agent should be given to patients
with a known or suspected genetic tendency Similar to the effect of enflurane.
to develop malignant hyperthermia.
CARDIAC AND CIRCULATORY EFFECT
EEG changes may occur when higher
concentrations of enflurane are used. It is Similar to the effects of enflurane, although
therefore not used on patients with epilepsy. halothane causes more arrhythmias.
The metabolites of enflurane may cause renal
damage in higher concentrations. Enflurane
is therefore not used on patients with known
or suspected renal insufficiency.

32
 | Anesthesiological methods and pharmaceuticals | 6 |

METABOLISM AND ELIMINATION locally for helium (brown) and oxygen (e.g.
white in Sweden, green in the USA), or as
15-20% is metabolized in the liver and 100% helium in brown cylinders. Helium has
eliminated in the urine.The metabolites are a lower density than oxygen, nitrogen and air.
immunologically active and may cause a fatal During turbulent flow, velocity is higher when
form of hepatitis. Halothane has therefore Heliox is used. This reduces work of breathing
been withdrawn from most markets. in patients with upper airway obstruction, such
as a tumor. Its use has also been proposed in
CONTRAINDICATIONS patients with severe asthma and other lower
airway disease. For anesthesia purposes,
When and if halothane is still used (see above),
Heliox may in future improve gas flow in
it should be avoided when patients suffer from
patients with chronic obstructive pulmonary
liver disease or have previously been exposed
disease (COPD), pulmonary hypertension or
to halothane and afterwards shown signs of
severe hypoxia.
abnormal liver function (tiredness, fever,
icterus, known jointly as "halothane hepatitis").
6.3 COMBINED ANESTHESIA
As always, no inhalation agent should be given
This is a common form of anesthesia in which
to patients with a known or suspected genetic
both inhalational and intravenous anesthetic
tendency to develop malignant hyperthermia.
agents are administered in an attempt to
combine the best qualities of different agents
6.2.10 OTHER AGENTS
to anesthetize and relax the patient. The
XENON component agents are selected to suit the
specific patient's status and the surgery to be
Xenon is a noble (or inert) gas with even lower performed.
solubility than nitrous oxide and high potency
(MAC = 71%). With no major depressant 6.4 MUSCLE RELAXANTS
effects on the cardiovascular system or irritant
effects on the airways, it has great appeal as Muscle relaxants affect only the skeletal
an anesthetic agent. It is however extremely muscles and have no anesthetic or analgesic
expensive and relatively complicated for the effect. They are used only when the patient is
anesthetist to control. It is not currently used asleep. They paralyze the respiratory muscles,
in the US, so most data comes from Europe, so the anesthetist must be able to ventilate
where it is believed that it will be increasingly the patient before administering them.
used in the future despite its high costs.
Muscle relaxants are frequently given to
facilitate endotracheal intubation. In addition,
HELIUM AND OXYGEN/HELIUM MIXTURES
abdominal surgeons often require muscle
Helium is a light noble gas present in air and relaxation in their patients to enable them to
natural gas from which it is extracted. It is
supplied either as Heliox (21% O2, 79% He)
in cylinders marked with the colors used
33
| 6 | Anesthesiological methods and pharmaceuticals |

operate. Deep anesthesia will generally ensure central nervous system. All non-depolarizing
muscle relaxation, but it is most common to drugs should be used with care in patients
use muscle relaxants to avoid any risks this suspected to be suffering from myasthenia
might entail. gravis (a neuromuscular disease) or
myasthenic syndrome, since these patients
There are two different kinds of muscle are extremely sensitive to their effects.
relaxants:
A large number of non-depolarizing agents
non-depolarizing. have been developed in recent decades based
on the earliest drug, pancuronium. They
depolarizing
include vecuronium and rocuronium, as well
as atracurium and its more recent derivatives,
In simple terms, the depolarizing agents mimic with their slightly modified effect profiles.
the appearance and effect of the body's
normal neurotransmitter, acetylcholine, binding They are initially used in fairly large doses
to its receptors at the neuromuscular junction supplemented as and when necessary with
and causing prolonged depolarization of the smaller maintenance doses. Cardiovascular
muscle, thereby making it unreceptive to new effects are minimal, although some may render
impulses. The muscle is effectively paralyzed. the patient vulnerable to bradycardia during
anaesthesia.
The most common depolarizing agent is
succinylcholine (suxamethonium) and it is To assess the degree of neuromuscular block,
mainly used prior to intubation. a number of monitoring tools are
recommended. These are discussed later (see
Its most common side-effect (apart from chapter 10).
post-operative muscular pain caused by initial
muscular contraction) is bradycardia, 6.5 OUTLINE OF A TYPICAL
especially if more than one dose is given. This ANESTHESIA PROCEDURE
can be prevented by the prior administration
of atropine. Children develop this complication There are certain basic steps that are the same
more commonly than adults. It may also cause in all anesthesia procedures. They are briefly
raised potassium levels and may even trigger outlined in the text and diagrams below.
the onset of malignant hyperthermia in patients
with this genetic disorder. 6.5.1 PREOXYGENATION

Non-depolarizing agents, meanwhile, are A face mask is used to give the patient
similar in appearance to acetylcholine, but not 80-100% oxygen for a few minutes before
in effect. They block its receptors at the induction to ensure high oxygen saturation
neuromuscular synapse and prevent any and prevent complications.
depolarization and subsequent muscle
contraction. They are water soluble, polar
molecules and thus do not cross the
blood-brain barrier and have no effect on the

34
 | Anesthesiological methods and pharmaceuticals | 6 |

6.5.2 INDUCTION Once the patient is breathing normally, it is

time for transport to the recovery
For IV induction, a drug such as propofol or room/post-operative ward.
thiopental is given intravenously to put the
patient to sleep. The alternative is inhalation
6.6 EFFECTS OF ANESTHESIA
induction (see discussion under section 6.2.3).
Both breathing and circulation are always
A check is performed to ensure free airways
affected by general anesthesia. In some cases,
and make sure that manual ventilation is
regional anesthesia, particularly when it is
possible. Once deep sleep is achieved, muscle
"high", may also cause a blood pressure drop,
relaxants are given if required.
as well as affecting breathing.
Intubation is then performed, if necessary, or
a laryngeal mask is fitted. Analgesics and/or 6.6.1 BREATHING
inhalation agents are administered via the
NORMAL REGULATION OF BREATHING
tube/mask. Careful observation and monitoring
are important throughout the procedure. The volume and frequency of breathing are
controlled by impulses from a cluster of nerves
6.5.3 MAINTENANCE in the brain stem called the respiratory center.
These impulses are governed by information
The gas mixture is administered as needed,
from different receptors in the body: central
and adjustments are made using inhalation
receptors close to the respiratory center and
agents and/or intravenous injections.
peripheral receptors in the carotid arteries.
Careful monitoring is crucial to ensure patient
safety, but the value of clinical observation
should not be underestimated. Changes in the
patient's condition are generally perceptible
to an alert anesthetist or nurse. The respiratory
center and
When surgery has been completed, the central receptors
anesthetic agent ceases to be given and
extubation is performed when the patient is Peripheral
awake and breathing spontaneously and the receptors
muscle relaxant wears off or is reversed.

The impulses from the central receptors

6.5.4 RECOVERY depend mainly on the carbon dioxide level in
the blood, which also affects the pH value in
Oxygen is given via a mask to prevent
the fluid surrounding the brain and spinal cord
complications. Nasal prongs can also be
(cerebrospinal fluid, CSF).
positioned to supply the patient with oxygen.

35
| 6 | Anesthesiological methods and pharmaceuticals |

The pH value of the cerebrospinal fluid has a All apparatus naturally contributes to
direct effect on the respiratory center, since a increasing total dead space: a face mask may
low pH (high CO2 level) stimulates breathing, double it, for example (more apparatus dead
and a high pH (low CO2 level) causes a space), while endotracheal intubation causes
decrease in breathing activity. a smaller increase. Dead space is an important
aspect to consider when assessing patient
The peripheral receptors are also affected by ventilation and is also described in more detail
the pH value of the blood, since low blood pH in chapter 8.
stimulates breathing.
COMPLIANCE
The Physiology of Respiration (Training
Material Workbook) provides a simple General anesthesia may alter the elasticity of
summary of respiratory anatomy and a the chest, reducing functional compliance in
somewhat more detailed summary of proportion to the depth of anesthesia. Drugs,
respiratory physiology. type of surgery and body position on the
operating table all affect functional compliance
CHANGES IN BREATHING and breathing.

Certain inhalation agents may cause a

6.6.2 CIRCULATION
decrease in breathing, leading to alveolar
hypoventilation. Blood pressure drops are common when many
anesthetic agents are administered. To
COMPRESSIBLE VOLUME counteract such falls, fluids are infused and
sometimes vasoactive drugs may also be used
Controlled ventilation always entails a certain
to normalize patient blood pressure.
volume of gas being compressed in the
apparatus and patient tubing, etc.
VAGAL REFLEXES
Compressible volume should therefore be
calculated and added to minute volume if it During general anesthesia, pressure from the
has not already been automatically surgeon on certain abdominal organs or
compensated for by the machine. stimulation of the airways may cause vagal
Compressible volume is described in more reflexes, slowing the heart rate, reducing
detail in chapter 8. blood pressure and causing a drop in stroke
volume.
DEAD SPACE
ARRHYTHMIA
Dead space is defined as the volume in which
no gas exchange takes place. It is generally Some inhalation agents affect the heart rate
divided into anatomic, physiological and although arrhythmia may also be the result of
apparatus dead space. hypo- or hypervolemia.

36
 | Anesthesiological methods and pharmaceuticals | 6 |

BRADYCARDIA

This is caused by many drugs, especially

succinylcholine, fentanyl, alfentanil and
remifentanil.

TACHYCARDIA

Combined with an increase in blood pressure,

this may be a sign of poor pain control,
insufficient depth of anesthesia or even
awareness.

Tachycardia and low blood pressure, on the

other hand, indicate blood loss or incipient
shock.

BLOOD LOSS

This is monitored by the anesthetist on an

ongoing basis and compensated when
necessary with transfusions. Significant losses
are signalled by tachycardia, low blood
pressure and peripheral coldness. If untreated,
there may be a further fall in blood pressure.
Such losses must be compensated to prevent
the development of shock.

37
| 6 | Anesthesiological methods and pharmaceuticals |

Agents used in general anesthesia

Sedation/amnesia: benzodiazepines, propofol

Hypnosis during induction: propofol, thiopenthal.

Analgesia: opiods, both traditional (fentanyl) and new faster-acting drugs (alfentanil, remifentabil,
sufentanil)

Muscle relaxation: non-depolarizing/depolarizing agents

Amnesia, hypnosis, analgesia (+ some muscle relaxation): inhalation agents

Effects on essential anesthesia parameters ("the triad of anesthesia") of drugs routinely used during
balanced anesthesia

Hypnosis Analgesia Relaxation

Nitrous oxide ++ ++ 0

Volatile inhalation +++ ++ +

agents

IV barbiturates +++ 0 0

Muscle relaxants 0 0 +++

Opioids + +++ 0

38
 | Keeping a record | 7 |

7 KEEPING A RECORD
A record is kept of each patient case on an anesthesia record chart. This documents everything
that has happened to the patient in the OR.

Records are still by and large paper-based, although computerized systems are now being
introduced. They have not yet however gained general acceptance. The latest ASA poll (2006)
showed that they were not used in more than around 20% of cases in the USA.

The layout of the patient record may differ from one hospital and country to the next, but the
chart generally includes the following points:

patient details ventilatory status (etCO2, respiratory rate,

tidal volume)
date
temperature monitoring
preoperative assessment (including ASA
classification)

(premedication and preoperative fluids, if

any)

(certain laboratory values)

position of patient on table

peripheral cannulation

choice of airway management

record of gases used

breathing system used

ventilator used

drugs administered

infusion fluids and blood transfusions

blood pressure (BP) every 5 minutes

pulse rate and oxygen saturation every five

minutes

neuromuscular transmission

39
| 7 | Keeping a record |

clinical notes, such as excessive bleeding,

allergic reactions, etc.

estimated fluid loss

estimated blood loss

time of anesthesia induction

time at which surgery began

time at which surgery ended

time of anesthesia termination

prescriptions.

40
| Keeping a record | 7 |

41
| 8 | The anesthesia machine |

8 THE ANESTHESIA MACHINE

Anesthesia machines may differ in in different countries (such as the FDA in the
appearance, size and degree of sophistication US and the relevant regulatory authorities in
but generally speaking, they consist of the EU) and the routines of different hospitals
sections for and healthcare institutions.

ventilation

- source of gases (pipes and/or cylinders)

- flowmeters/mixer for gas dosage

- vaporizers for storing and dosing

inhalation agents

- patient breathing system

- manual ventilation bag and ventilator

- suction device

- gas evacuation

space for monitoring equipment

accessories

storage space

worktop.

It is extremely important to test the anesthesia

machine every time it is used. This involves
testing many of the individual parts before
each use, as well as the functioning of the
system as a whole before connection to the
patient.

Different manufacturers issue different

recommendations concerning checkout
procedures, both prior to use and between
patients. The same applies to the authorities

42
 | The anesthesia machine | 8 |

It is therefore crucial for personnel to

familiarize themselves with the requisite
procedures in their own workplaces.

There is a great deal of information for the

anesthetist/nurse to monitor throughout
anesthesia, including oxygenation, ventilation,
blood pressure, heart rate, muscle relaxation,
fluid status, acid-base balance, anesthesia
depth, etc.
Oxygen is stored in cylinders as a compressed
8.1 CART OR COLUMN gas at a pressure of 20000 kPa. The volume
of decompressed oxygen is therefore
The cart or column should preferably be proportional to the pressure indicated on the
tailored to the environment of the OR. This pressure gauge. Nitrous oxide, on the other
may involve making it mobile, ceiling-mounted hand, is a liquid that is stored at a pressure
or wall-mounted and equipping it to suit level of around 5170 kPa or 750 psi, so that it
specific anesthetist or hospital requirements. vaporizes in the cylinder. This means that the
Space is restricted and it is also an advantage pressure level indicated on the pressure gauge
if the machine is lightweight and easy to is not relevant to the amount of gas left in the
handle. On the other hand, the anesthetist cylinder.
requires a comfortable and ergonomically
adapted workplace with space for all the Because of the high internal pressure,
equipment needed. The design therefore pressure regulating valves have to be used on
involves striking a balance between what is the cylinders.
desirable and what is practically feasible.
8.2.1 IDENTIFICATION OF GASES
8.2 SOURCE OF GASES Correct identification of the gas being supplied
The various gases used (oxygen, nitrous oxide to the anesthesia machine is clearly vital if
and medical air) may be piped via the wall potentially lethal accidents are to be avoided.
from central storage cylinders or come from A number of different measures are taken to
smaller cylinders in the OR or on the cart itself. ensure this:
There may also be extra cylinders on the cart
Color coding of cylinders provides a rapid
in case of failure of the usual source.
means of identifying their contents.
However, the definitive indicator of the
contents is always the label.

43
| 8 | The anesthesia machine |

The gas tubing and connectors are color made in the gas connections. In addition to
coded and the connectors are usually using a gas analyzer, it is recommended to
design coded (see below) for specific gases use pulse oximetry to monitor the patient's
to avoid any confusion or incorrect oxygen saturation levels.
connection.
8.3 FLOWMETERS
A gas-specific pin-index system is provided
on small cylinders: pins on the yoke of the The flowmeter allows the operator to control
machine mate with holes drilled in specific and know the flow rate of each gas, usually in
positions on the valve of the cylinder to liters or subunits of liters per minute.
provide a mechanical means of preventing
incorrect connection. Especially when small Traditionally, the flow rate and concentration
individual cylinders are used, these of the gases are individually set for each
precautions should be included in the patient and are often altered during
design of the flowmeters and/or the anesthesia.
ventilator.
The conventional flowmeter is a vertical glass
Gas-specific connectors are used on large tube that is wider at the top and contains a
cylinders that make it impossible to attach light float. Each is calibrated for a specific gas.
a regulator or fitting to the wrong cylinder.

8.2.2 OTHER SAFETY ASPECTS

Built-in safety systems that automatically shut

down the nitrous oxide supply in case of low
oxygen levels or total oxygen failure are
crucial. They are known as hypoxia guards
and are designed to prevent hypoxic gas
mixtures from ever being administered to the
patient even in the unlikely event of the
anesthetist mistakenly setting a fresh gas flow
When the gas is turned on, the float stabilizes
of, for example, 100% nitrous oxide.
and rotates at a height inside the tube where
the force of the gas flow is equal to the weight
8.2.3 GAS ANALYZER/OXYGEN of the float. The gases from each flowmeter
MEASUREMENT are then mixed.

It is now mandatory for the anesthesia Newer flowmeter units have built-in safety
machine to provide the anesthetist with a features, including shutting down the N2O
means of sampling the oxygen administered supply and sounding an alarm if the oxygen
to the patient. This is the most reliable method
of ensuring that the patient has an adequate
oxygen supply and that no errors have been
44
 | The anesthesia machine | 8 |

supply should fail (see above). Many also have design. Generally speaking, there are
a preset minimum oxygen concentration which traditional simple vaporizers, often of the
varies from one manufacturer to another, drawover type, and more modern precision
although it never falls below 21%. vaporizers. The latter are common in
developed countries and are generally flow
Flowmeters are typically pneumatic, but and temperature compensated, as well as
electromagnetic digital flowmeters are now being unaffected by positive pressure
gaining popularity. ventilation. Drawover vaporizers are basic and
robust, have a low resistance to flow and so
8.4 VAPORIZERS FOR INHALATION do not require pressurized gases. Because
AGENTS their performance is variable, accurate
calibration is more or less impossible. They
A vapor formed from the volatile liquid
are common in countries that have fewer
anesthetic agent is added to the gas mixture
resources to invest in equipment.
by the anesthesia machine's vaporizer, whose
function is to deliver a safe, reliable Precision vaporizers have developed in recent
concentration of volatile agent to the patient. years and newer vaporizer designs enable
The output of older vaporizers is affected by control of the vaporizer by a central processing
the flow rate, the ambient temperature and unit in the machine. The concentration of
the amount of inhalation agent, although more vapor is then monitored on an ongoing basis
modern vaporizers compensate automatically and adjusted by altering the fresh gas flow
for variations in these parameters. through the vaporizer. Some of the different
types on offer now include:
In terms of safety, there are unique color
codes for each agent, a special key filling the plenum vaporizer, where the incoming
system with specific design coded adapters gas is accurately split into two streams. One
to prevent the vaporizer from being filled with passes straight through the vaporizer in the
the wrong liquid, and anti-spill mechanisms. bypass channel, while the other is diverted
into the vaporizing chamber. Gas in the
The vaporizers also undergo regular overhauls
vaporizing chamber becomes fully saturated
to ensure that the set concentrations do not
with volatile anesthetic vapor. This gas is
vary, although in more traditional types of
then mixed with the gas in the bypass
equipment, the concentrations delivered may
channel before leaving the vaporizer.
vary at low fresh gas flows. Nowadays, the
Modern vaporizers of this type are not
monitoring of anesthetic agent concentration
sensitive to variations in temperature and
in the patient breathing system is therefore
pressure;
standard, especially during low flow
anesthesia. the injection principle vaporizer, where the
gas flow is throttled, causing a pressure
It is useful to have some understanding of the
difference between the liquid reservoir and
basic principles of anesthetic vaporizers,
vaporizer outlet. The difference is
including the principles that affect vaporizer
proportional to the degree of throttle and is
output and how they influence vaporizer

45
| 8 | The anesthesia machine |

used to inject the desired amount of agent 8.5 USING A VENTILATOR

into the gas flow. The use of the injection
principle allows accuracy to be maintained Traditional ventilators used for anesthesia have
regardless of patient tidal volume; generally been simple, since they were only
used to replace manual ventilation when the
the electronic vaporizer, where electronically anesthetist needed his/her hands free. Surgery
controlled valves ensure higher accuracy. is rapidly becoming more complex and
growing numbers of patients, who are both
older and more severely ill than ever before,
There is also an agent-specific vaporizer
are now eligible for surgical interventions. The
constructed for use with desflurane. Because
need for more advanced anesthesia machines
of its unique physical properties, desflurane
with ventilators that offer additional and more
requires a special vaporizer in which the agent
sophisticated ventilation modes has therefore
is heated, pressurized and added directly to
increased.
the gas stream.
Ventilators are generally pressure, flow and
Below is a diagram of one recent development
time (cycle) regulated. This refers to the
- an electronic vaporizer with injector system.
mechanism used to switch from inhalation to
exhalation.

The text and figure below have been adapted

from a number of relevant articles listed under
Filter
"References".

Most recent ventilators used for anesthesia

include specific design characteristics that
have been more or less standard for all across
manufacturers (see figure below). They have
a bellows that delivers inspiratory gas when
pressurized by an external gas source
(bag-in-bottle design). Exhalation is passive
and there is a circuit to reuse variable amounts
of exhaled gas in the inspiratory limb. A fresh
gas flow (FGF) also contributes to the flow
delivered to the patient, while a CO2 absorber
is used to remove CO2 from the gas delivered
to the patient.

This design has remained the same for many

years, although anesthesia ventilators are now
changing to meet new demands (see chapter
9).

46
 | The anesthesia machine | 8 |

Fresh gas flow compressible volume should be calculated

and added to the minute volume if the
Drive ventilator does not compensate automatically
Inspiratory gas
limb for it.

8.5.2 DEAD SPACE

CO2 Dead space is by definition the volume in the
airways where no gas exchange takes place.
The alveolar ventilation volume is thus tidal
Expiratory volume minus dead space.
limb
Anatomic dead space is proportional to the
Ventilator size of the patient and includes the volume
from nostrils and mouth down to the upper
bronchioles. It is generally around 2 ml/kg of
In terms of safety and alarms, a minimum body weight and is decreased by endotracheal
requirement for all simple ventilators is that intubation and tracheostomy.
they should alert the user in case of
Apparatus dead space includes many of the
disconnection or if the upper pressure limit is
accessories associated with the Y-piece that
reached. It should be noted that for infants
are necessary to ventilate a sleeping patient,
and children, special equipment is used.
such as a Y-piece, connection tubes and the
humidifier unit. It is often around 50 ml.
8.5.1 COMPRESSIBLE VOLUME
Physiological dead space (which is alveolar
Part of the inspiratory minute volume is
plus anatomic dead space) is a dynamic
needed to compress the gas in the apparatus
concept and depends on the efficiency of gas
and tubing and thus fails to reach the patient.
exchange. Poor diffusion capacity increases
This means that the choice of breathing
physiological dead space, as do some forms
system, tubing and ventilator affects the
of controlled ventilation and some pathological
compressible volume. If the tubing,
processes.
connectors, valves and canister have a large
internal volume, a higher fresh gas flow will be
required.
8.6 MONITORING
The monitoring systems used to follow the
To lower the compressible volume, it is a good
patient's vital signs and inspired and expired
idea, at the machine design level, to position
gas concentrations are described more fully
the manual ventilation bag or ventilator as
in a separate chapter below.
close to the patient as possible. The

47
| 8 | The anesthesia machine |

8.7 GAS EVACUATION OR patient may be serious. The suction device

SCAVENGING SYSTEM forms an integral part of the equipment
needed to ensure free airways and manage
From the point of view of both ecology and the patient safely.
the work environment, gas evacuation is an
important standard feature of most anesthesia The device must therefore have both high
machines. capacity in case of vomiting or regurgitation,
and offer lower capacity for simply clearing
In the diagram below, the green arrow shows the airways. Like all other parts of the
gas coming from the patient (left)and moving equipment, it must be carefully checked before
towards the gas evacuation system (right), use on each new patient.
while the orange arrow (right) shows the inflow
of room air when needed.

There are passive through-the-wall systems

or active systems with a central vacuum or
active ducts. The systems also include built-in
protections against subjecting the patient to
negative pressure.

8.8 SUCTION DEVICE

The suction device is a crucial part of the
equipment, since all anesthesia entails a risk
of aspiration and the consequences for the

48
 | Different breathing circuits | 9 |

9 DIFFERENT BREATHING CIRCUITS

The function of a breathing circuit is to deliver semi-open and semi-closed. The list below is
oxygen and anesthetic agent to the patient based on this old-fashioned and now
while at the same time removing carbon redundant nomenclature, dividing breathing
dioxide from the circuit. systems as follows:

There are several ways of classifying the Open systems in which the anesthetic is
breathing circuits or systems used in given via the atmosphere (through a mask
anesthesia machines. Over time, a wide range and/or cloth). This was the first method
of names has been used to describe them. In used to anesthetize patients.
order to understand the often confusing
nomenclature surrounding these systems, a Inhaled Exhaled

short review of the historical background is

appropriate. Many of the older classifications
are no longer adequate, particularly now that
gas analyzers have become an essential
feature of the anesthesia machine. This
historical review will be followed by a
suggestion for a more suitable practical
classification of breathing systems.
The classic if somewhat outdated example
The selection of a specific system naturally
is ether administered via a cloth inserted
involves assessing the clinical situation (type
into an open mask. Totally open systems
of surgery and anesthesia), although it is also
are thus primarily of historical interest.
inevitably connected with personal
preferences, financial priorities and potential Closed systems in which the anesthetic gas
benefits. This chapter focuses less on these is given via tubing from a reservoir. The
aspects than on classifying the systems in carbon dioxide in the system is eliminated
practical and functional terms. chemically and only the amount of oxygen
and anesthetic agent that is actually
9.1 OLDER CLASSIFICATION consumed is supplied. Such a system is
reminiscent of the breathing circuits used
Historically speaking, breathing systems have
by certain military divers, for example.
been classified in terms of their degree of
openness to the surrounding atmosphere. This Finally, the terms semi-open and
means that they are in principle either open or semi-closed, described by Moyers in 1953,
closed, with systems in between that are tend to confuse rather than clarify the issue
variously and often confusingly described as and are therefore best avoided. Moyers
himself referred to a system with a reservoir
but without rebreathing as semi-open, while

49
| 9 | Different breathing circuits |

a circuit with a reservoir and partial flow to be minimized without jeopardizing

rebreathing was semi-closed. Different patient safety. This has resulted in more
authors, however, have meant different widespread use of low flow anesthesia
things when using these terms. (see chapter 11), which is as close as one
gets in clinical practice to a closed
Due to this lack of consistency, this system (although it is now in fact possible
classification will not be applied to the to construct a truly closed circle system
presentation below. In the modern circle as well).
systems presented there, it is the fresh gas
flow that determines the degree of openness.
The various systems are described and
illustrated in the breathing system survey in
9.2 FUNCTIONAL CLASSIFICATION
section 9.3 below.
A more practical classification divides
anesthetic breathing systems as follows: 9.3 BRIEF SURVEY OF
CONTEMPORARY BREATHING
non-rebreathing systems, the classic CIRCUITS
example of which is the breathing circuit of
an ICU ventilator (see survey below) 9.3.1 NON-REBREATHING SYSTEMS

rebreathing systems, which are in turn In these systems, only fresh gas is supplied
divided into: to the patient and no gas or anesthetic agent
is recycled. Valves are used to prevent exhaled
- partial rebreathing systems without CO2 gas from entering the inspiratory limb and
absorption, where the fresh gas flow mixing with inhaled gas. The gas mixture given
regulates the elimination of carbon to the patient usually needs to be heated and
dioxide humidified to prevent damage to the airways.

- circle systems with CO2 absorption,

which are by far the most widely used
systems in clinical practice today.
Fresh gas
Normally, a circle system is a partial
rebreathing system with CO2 absorption.
The fresh gas flow generally plays no part
in the elimination of carbon dioxide. It
does, however, determine the degree of Exhaled gas
rebreathing of oxygen and anesthetic
agent. It should be noted that a very high A traditional ICU ventilator is one example of
fresh gas flow (higher than the inspiratory a non-rebreathing system. Anesthesia
peak flow) will transform the circle machines using non-rebreathing circuits of
system into a non-rebreathing system.
On the other hand, modern gas analyzer
technology has enabled the fresh gas

50
 | Different breathing circuits | 9 |

this type have a "fresh gas flow" equal to the

minute volume. This means a high
Fresh gas
consumption of anesthetic agents since
nothing is recycled
Re-used
On the other hand, the ventilation performance gas
of these systems is often good and they may
therefore be preferred when anesthetizing
Excess gas
patients with severe pulmonary disease and
children, where the fresh gas flow per se is One Mapleson variant that is still used is the
low. Bain system shown below, which is a
modification with an inner tube for fresh gas,
The inspired gas is heated by and mixed with
exhaled gas close to the mask or tube.
Although somewhat old-fashioned and not
particularly sophisticated, the Bain system has
remained popular in many parts of the world
largely because of its simplicity and ease of
use, and because the patient receives the
same gas mixture (of fresh and recycled gas)
during spontaneous and controlled ventilation.
9.3.2 REBREATHING SYSTEMS - PARTIAL
Excess gas
REBREATHING WITHOUT CO2
Re-used gas
ABSORPTION

These systems use both fresh and recycled

gas. Exhaled gas heats and humidifies the
inspired gas. The systems have a surplus valve
and are generally referred to as Mapleson
systems, where each variant has a different Fresh gas
letter (Mapleson A to F) depending on the
There is also the very simple Ayre's T-piece
position of the valve and the fresh gas inlet.
system shown below, where the fresh gas flow
These systems require relatively high fresh gas once again determines the level of rebreathing.
flows, which generally entails a high This system is mainly used to ventilate smaller
consumption of anesthetic agents. infants.

51
| 9 | Different breathing circuits |

Fresh gas Excess gas A circle system reuses a specific amount of

exhaled gas, passing it through a CO2
absorbent. This eliminates the carbon dioxide
and simultaneously heats and humidifies the
gas. The latter still contains nitrous oxide and
Re-used
gas anesthetic agent not taken up by the patient
and is mixed with fresh gas as it returns to the
patient.
Another example of partial rebreathing without Fresh gas
CO2 absorption is the modification of the
Non return
Ayre's T-piece, the Jackson-Rees system. It valve
uses a reservoir bag for gas and requires a Absorber
fresh gas flow that is 3-5 times higher than the Excess
minute volume. gas

Fresh gas Excess gas

Re-used
Relief gas
valve
Manual
ventilation

Re-used As mentioned above, the circle system can in

gas fact be used not only as a partial rebreathing
system, but also as a non-rebreathing or total
rebreathing system. The amount of rebreathing
9.3.3 REBREATHING SYSTEMS - CIRCLE depends on the fresh gas flow, although at
SYSTEMS WITH CO2 ABSORPTION rates above 4 liters/minute, most of the
economic advantages of the system are lost.
These systems were designed to use a low
fresh gas flow to economize on the use of Using low flows in a circle system does
agents and avoiding side-effects. As leakage however mean that it takes a while for the
lessened due to more sophisticated altered settings to take effect. When rapid
equipment, anesthetists were quick to see the changes in fresh gas or inhalation agent
benefits of lower flows. The systems use two concentrations are required, a high fresh gas
unidirectional valves, a relief valve, a CO2 flow or a significant increase in anesthetic
absorber, a manual ventilation bag and tubing agent concentration is needed.
to connect all the parts, resulting in a simple
As mentioned above, the circle system can
circle system that is not totally closed to the
also be used for total rebreathing, which
surrounding environment. One example is the
minimizes the amount of exhaled gas that
circle system with a fresh gas flow higher than
escapes from the system. This maximizes
the patient's needs. Benefits relate to both
recycling of unused gas and inhalation agent
and automatic gas humidification and heating
52
 | Different breathing circuits | 9 |

efficiency with regard to use of gases and 9.4 THE CARBON DIOXIDE
volatile agents, since once steady state is ABSORBER
reached, the amounts of fresh gas required
are very low (see chapter 11). A canister is used to hold the absorbent
substance, often a mixture known as soda
lime. The CO2 reacts with the absorbent,
Re-used gas producing both heat and water to humidify
Fresh gas
and warm the rebreathing gas.

There is also an indicator that changes color

as the soda lime becomes depleted. The
Absorber
carbon dioxide absorbent canister is illustrated
below.

Interest in these systems has grown due to

improvements in the accuracy of gas
concentration measurement and dosage, the
elimination of leakage, the increasing costs of
gases and anesthetic agents and growing
environmental awareness. On the other hand,
there are certain safety concerns with a closed
system. These relate to smaller safety margins
and potential risks connected with the
production of Compound A (see discussion
of sevoflurane in chapter 6). 9.5 RECENT MODIFICATIONS AND
INNOVATIONS
Fresh gas
9.5.1 ADVANCED VENTILATORS WITH
Non return
valve BREATHING SYSTEMS
Absorber
Modern anesthesia machines have improved
considerably in terms of their usability in both
outpatient and intensive care. They have also
become increasingly sophisticated. Much of
the discussion below is based on the relevant
Manual
Re-used articles listed in the "References".
gas
ventilation
Today's anesthesia machine ventilators are in
fact approaching the performance of
ventilators used in the ICU. Anesthesia
machines need to deliver a gas mixture of

53
| 9 | Different breathing circuits |

known composition and now also recirculate stored and recycled. It is based on a very
exhaled gases into the system. Most therefore simple idea that is similar to a bellows, and it
include a CO2 absorber and a bellows-style enables rebreathing of all gases, including
or piston driven ventilator. nitrous oxide.

This design implies a large internal volume, The idea of reflector systems is to economize
which leads to progressive decreases in tidal on the use of expensive agents and enhance
volume delivery when airway pressures the efficiency of the anesthesia process.
increase. Modern ICU ventilators, on the other
hand have much smaller internal volumes.
They are thus less vulnerable to high airway
pressure. Accordingly, new anesthesia
machines are now being designed to offer
better performance to suit critically ill patients.
The reduction in internal volume has also
enabled more precise ventilation of infants and
children. These technological advances have
led to greater flexibility in perioperative care.

These advances also extend the range of

patients that can be supported by an
anesthesia machine and make new ventilation
modes available to the anesthetist. These
combine patient- and ventilator-initiated
breaths and may enable spontaneous
breathing techniques to be used for longer
periods and facilitate rapid changes in
anesthetic depth.

9.5.2 REFLECTOR SYSTEMS

Another new concept is to use a reflector

system, which may allow the anesthetic agent
to be reused more efficiently. Different types
of reflector system are mentioned in these
discussions.

One example of such an agent conserving

device is the volume reflector. It uses a
reservoir tube in which the anesthetic agent
contained in the exhaled gas is temporarily

54
 | Monitoring | 10 |

10 MONITORING
During anesthesia, it is obligatory to monitor galvanic fuel cell (inspired O2) or on magnetic
a number of parameters and vital functions to or magnetoacoustic technology to monitor
ensure patient safety. The type of surgery to oxygen levels. The sampled air is passed
be performed and the health status of the through a sensor before being returned to the
patient determine how sophisticated the circuit. Special care should be taken with
monitoring needs to be. Technological infants and small children, since the analyzer
advances have also increased the number of "steals" a large part of the tidal volume from
variables that can be monitored and the patient.
anesthesia machines therefore offer a more
or less extensive range of possibilities. The 10.1.2 PULSE OXIMETRY
crucial aspect here is to provide the
anesthetist/nurse with the information he/she This non-invasive method of monitoring
requires, presented in a clear and reliable way. oxygen saturation is now standard almost
everywhere. Normal SpO2 values are between
It is however important to stress that the 95 and 100% in adults, but lower for neonates
no-tech or low-tech approach should never and the elderly.
be forgotten: observe the patient, feel the
pulse, watch and listen for signs of distress or A sensor is applied to the finger, for example,
other clues to status, even if you have access sending pulses of red and infrared light
to highly sophisticated apparatus. through the tissue. This enables the calculation
of the percentage of oxygen-carrying
hemoglobin molecules, known as oxygen
saturation. The oximeter will also display a
pulse curve known as a plethysmograph,
where the amplitude reflects peripheral
perfusion and the pulse rate can also be
displayed.

10.1 OXYGENATION
10.1.1 MONITORING INSPIRED OXYGEN
LEVELS IN THE BREATHING CIRCUIT

A sample of the contents of the breathing

Other suitable sites for application of a sensor
tubes is drawn sidestream into a gas analyzer,
include the ear lobe and foot.
which uses O2 sensors based either on a

55
| 10 | Monitoring |

The reliability of the oximeter is limited in and the tubing). In the sidestream method
patients with poor peripheral circulation (e.g. described above, on the other hand, the
patients with hypothermia or heart disease), sampled air is removed and passed through
while carbon monoxide poisoning may lead a sensor before being returned to the circuit.
to falsely high values.
10.2.2 RESPIRATORY RATE
10.2 VENTILATION
When the patient is breathing spontaneously,
10.2.1 CAPNOGRAPHY the respiratory rate is used to estimate both
(ETCO2)/CAPNOMETRY ventilation efficiency and depth of anesthesia,
with a slower rate indicating deeper
Capnometry enables a number of important anesthesia.
parameters, such as end-tidal carbon dioxide
levels, inspired CO2 levels and respiration rate, There are various techniques for measuring
to be monitored. Capnography reflects a respiration rate. Impedance pneumography is
slightly delayed or real-time CO2 wave form, an older method used in conjunction with ECG
while the capnometer presents only values. monitoring. The newer method used in
CO2 levels are affected by both ventilation and conjunction with capnography (see above)
metabolism, making capnography a useful calculates the rate on the basis of the
method of following the respiratory process. capnogram wave form and is less prone to
artifact-induced error caused by movements.
Capnography/capnometry is an important tool
when intubating patients, since any carbon 10.3 BLOOD PRESSURE AND
dioxide response detected shows that the tube PULSE
is correctly positioned in the trachea.
10.3.1 NIBP (NON-INVASIVE BLOOD
The most common method is based on the PRESSURE)
use of infrared sensors that detect infrared
light that is passed through a sample of airway This is the traditional method of checking a
gas. An example of a normal capnogram is patient's blood pressure. It is routine to
provided below. monitor it during anesthesia, generally via a
cuff on the arm. Normal systolic blood
Exhalation Inspiration Exhalation pressure is between 90 and 150 mm Hg, while
diastolic is between 60 and 80 mm Hg. Mean
BP should be in the interval 70-90 mm Hg. In
addition to the standard manual systems,
there are automatic systems for measuring BP
with the help of oscillometry.

The sample may be taken using either

mainstream or sidestream technique. The
former uses a sensor placed in line with the
ventilator tubing (e.g. between the Y-piece
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 | Monitoring | 10 |

10.3.2 IBP (INVASIVE BLOOD PRESSURE) The events recorded by the ECG are the de-
and repolarization of the heart. First the
This is common during lengthy surgery or electrical stimulation originating from the
when the patient's health is poor. It is more sinoatrial node in the right atrium spreads
rapid than NIBP. It is often used on patients through the atria, causing them to contract
with heart disease, as well as on critically ill or (the P wave), then through the ventricles
hemodynamically unstable patients. (whose contraction is reflected in the QRS
wave). This is followed by the repolarization
The measurements are obtained from a
process (reflected in the final T-wave).
catheter positioned in the patient's vascular
system, e.g. the radial artery in the wrist for
monitoring peripheral arterial blood pressure.
Central venous pressure may be monitored
as well (mainly as a reflection of volume
status), although it is nowadays often used in
combination with other information.

10.3.3 SPO2 AND ECG 10.4.1 S-T MONITORING

Pulse oximetry, discussed above, is also a The S-T segment of the ECG represents the
useful method of following the patient's pulse, phase in the cardiac cycle between the end
as is the electrocardiogram, discussed below.. of depolarization (i.e. contraction of the
ventricles) and repolarization (i.e. relaxation
and refilling of the ventricles).
10.4 ECG
The segment is monitored to detect elevations
The electrocardiogram provides information
or depression, since these may be early signs
about the electrical activity of the heart and is
of myocardial ischemia (insufficient blood
mainly used to identify various types of
supply).
arrhythmia. It is the oldest monitoring
parameter and is a standard feature of most
anesthesia machines, although its contribution 10.4.2 TEE (TRANS-ESOPHAGEAL
to minimizing morbidity during anesthesia is ECHOCARDIOGRAPHY)
relatively small.
This is a method used to monitor cardiac
function, particularly contractility and filling.
By following the movements and volume of
the various chambers of the heart, it enables
the clinician to treat the patient before any
serious problems arise. In many situations, it
has replaced the use of the more invasive
pulmonary artery catheter.

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10.5 MULTIGAS 10.7 NEUROMUSCULAR

ANALYZER/ANESTHESIA GASES TRANSMISSION (NMT)/MUSCULAR
RELAXATION
The gas monitoring system measures inspired
and expired values of oxygen, carbon dioxide, The monitoring of neuromuscular transmission,
nitrous oxide and the most common NMT, is particularly important when
anesthetic agents (see section on methods administering and titrating muscle relaxants
and agents above). and reversing their effects.

A sample of the contents of the breathing The degree of muscle relaxation is an

tubes is drawn using the sidestream technique important parameter and there are several
(see above). It is then fed into the gas analyzer, methods available nowadays for monitoring
which uses infrared light of different it.
wavelengths to determine the levels of CO2,
NO2 and inhalation agents. O2, on the other The method most commonly used is Train of
Four, or TOF, monitoring, in which the
hand, is monitored using O2 sensors (see
magnitude and type of neuromuscular
10.1.1 above).
blockade are measured. Four electrical
The development of accurate gas monitoring currents are applied for 2 seconds to a
systems has enabled safe and widespread peripheral motor nerve and the ratio of the
use of low flow anesthesia (see chapter 11). amplitude of the fourth evoked mechanical
response to the first one is observed. If the
10.6 BODY TEMPERATURE response decreases over time, the patient is
still under the influence of muscle relaxants.
The maintenance of normal body temperature
is important in many patients, since it has been 10.8 BIS/ENTROPY/AUDITORY
shown to have a positive effect on coagulation EVOKED POTENTIAL (AEP)
and diminish the risk of wound infections.
Close monitoring of body temperature is Electroencephalography (EEG) measures
particularly important in children and patients cortical activity in the brain and the patterns
where there is reason to suspect a risk of change during sleep and anesthesia. It can
either hypothermia or malignant hyperthermia. therefore be used as an indicator of the depth
of anesthesia.
It is best measured in highly perfused tissues
(oral, rectal, in the ear) since this is more Several methods can also be used to process
reliable than measurements taken at the skin the information obtained from an EEG so as
surface. Recent technical innovations also to make interpretation easier, the most
allow temperature to be measured either in successful of which is described below.
the bladder via a specially adapted catheter,
The bispectral index (BIS) monitor provides a
or in the esophagus.
dimensionless number obtained from
automatic analysis of EEG waveforms. This
number ranges from 0 (EEG silence) to 100

58
 | Monitoring | 10 |

(fully awake adult), while numbers between 40 vena cava. This type of catheter is increasingly
and 60 are expected during general used in place of a pulmonary artery catheter,
anesthesia. BIS monitors the depth of since the pressures measured using both
anesthesia, enabling the appropriate titration methods are considered to be approximately
of anesthetic drugs. This makes for faster equal.
wake-ups and better recovery, and reduces
intraoperative awareness. 10.10 CARDIAC OUTPUT (CO AND
100
Consciousness to Unconsciousness
CCO)
Unconsciousness to Consciousness
80
This is a measure of the amount of blood
60
pumped by the heart and is generally stated
40
BIS

20
in liters per minute. Normal values lie between
0
4 and 8 liters per minute for healthy adults and
Time are affected by vascular resistance, heart rate
and contractility.
BIS measurements can help healthcare
professionals tailor the type and dosage of Thermodilution is the method generally used
anesthetic or sedative medication to the needs to measure cardiac output with the help of a
of each patient. The method is however not pulmonary artery catheter, often in conjunction
yet widely used. There are several sources of with SvO2. It results in a curve from which the
error and the BIS monitor follows trends rather desired volume may be calculated. A more
than absolute values. recent technique measures the output
continuously (CCO).
10.9 SVO2
Non-invasive and less invasive methods of
SvO2 is a form of invasive pulmonary artery monitoring cardiac output and other
oximetry that measures venous oxygen hemodynamic parameters by using special
content, or saturation, in the blood returning algorithms have now been developed to avoid
to the heart. This gives an indication of oxygen insertion of a Swan-Ganz catheter in the
demand and consumption, with normal values pulmonary artery.
between 60 and 80%.
10.11 URINE OUTPUT
To obtain these measurements, a very fine
(Swan-Ganz) catheter is inserted into a central Urine output is measured to help monitor fluid
vein and led into the pulmonary artery. balance and circulation status. This may
Spectrophotometry is used to estimate the involve the insertion of a catheter. Urine
oxygen content in the blood. This method also volume is the most important parameter to
provides an opportunity to monitor cardiac note. Ultrasound is now also a common
output (see below). method of monitoring residual urine volume
in many recovery rooms.
ScvO2 (where "c" stands for cava) is a form of
invasive central venous oximetry that involves
using a central venous catheter placed in the
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| 10 | Monitoring |

10.12 BLOOD LOSS

This may be either measured or estimated and
may be actively compensated with the help
of transfusions, if necessary, to raise blood
pressure, enhance oxygenation and prevent
vascular collapse. Even small losses are
generally compensated in children, although
the attitude to compensation is nowadays
somewhat more restrictive in adults.

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11 LOW FLOW ANESTHESIA

Low flow anesthesia has gained ground in When uptake falls, the concentration at the
recent years and has become increasingly vaporizer may be lowered to ensure that the
accepted as the preferred mode of anesthesia. exhaled amount does not rise. One alternative
It requires a reliable gas monitoring system here is to allow the concentration difference
and a rebreathing system with a CO2 absorber. between inspired and expired gas to decrease
It is as close as one can get in clinical practice the fresh gas flow. The exhaled gas is used
to a closed system. Although the extent of for rebreathing once it has passed a CO2
rebreathing and the fresh gas flow used may absorber. This means that both fresh gas flow
vary (low flow, minimal flow and closed system and the quantities of volatile agents used can
anesthesia), the basic principle remains the be decreased.
same.
Accurate monitoring is essential to avoid
The benefits of low flow anesthesia are both complications and help the anesthetist tailor
financial (cutting costs of increasingly the anesthesia to the needs of the patient.
expensive anesthetic agents) and
environmental. During low flow anesthesia, it 11.2 LOW FLOW TECHNIQUE
is crucial to analyze the oxygen, carbon
dioxide and anesthetic agent in the breathing While there are no general rules for
system. Now that reliable gas analyzers are administering low flow anesthesia, one
available, low flow anesthesia is as safe as possible procedure is outlined below.
anesthesia using a non-rebreathing system.
11.2.1 PREOXYGENATION
11.1 PRINCIPLES OF LOW FLOW
Extra oxygen is administered for some 3-5
ANESTHESIA
minutes, usually via a face mask. Thorough
Low flow anesthesia involves the use of both oxygenation is still the best safeguard against
intravenous and volatile agents. The precise complications. The patient is generally put to
limits of low flow anesthesia are not clearly sleep with an intravenous agent during this
defined, but a fresh gas flow below 2 liters is phase and if necessary intubated.
generally considered low flow in the US, while
in the EU, low flow is generally below 1 liter. 11.2.2 HIGH FLOW - INDUCTION TO
STEADY STATE
The technique is based on the patient's
physiological needs. The proportion of A fresh gas flow using standard flows of
rebreathing and desired fresh gas flow setting oxygen and nitrous oxide/air is given for some
are adjusted to the patient's status (oxygen 6-10 minutes. Nitrogen from the body's own
consumption and CO2 production, etc.) nitrogen stores is gradually eliminated from

The uptake of N2O and other inhalation agents

is high in the first few minutes of anesthesia,
falling once the tissues become saturated.
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| 11 | Low flow anesthesia |

the body and replaced by nitrous oxide. Induction - high flow

Although nitrous oxide is still used relatively
often, the current trend is pointing towards a
decline in its use.

11.2.3 MAINTENANCE

When the uptake of gases stabilizes and the

patient is comfortably asleep, oxygen is always
administered as required by the patient.

The nitrous oxide flow depends on uptake and

the inspired oxygen fraction, as shown
continuously on the monitor. Steady state - high flow

With regard to inhalation agents, the vaporizer

is initially used in the traditional manner (i.e.
high flow) for 6-10 minutes. As the patient's
volatile agent requirement decreases, the flow
can be set to a lower value for maintenance
purposes.

The patient is carefully monitored throughout

anesthesia, and the various values can be
adjusted to suit changing patient needs.

Maintenance - low flow

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11.2.4 ELIMINATION AND RECOVERY

High flow and increased oxygen

concentrations are once again administered
for 5-10 minutes to eliminate the anesthetic
agent. The nitrous oxide has already been
turned off and the extra oxygen supply should
be maintained for at least 5-10 minutes after
recovery to avoid diffusion hypoxia.

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| 12 | Safety considerations |

12 SAFETY CONSIDERATIONS
In anesthesia, the patient is dependent on the levels. This regulatory system becomes
skill and experience of healthcare increasingly insensitive to raised carbon
professionals and on high standards of safety, dioxide levels as anesthesia deepens. This
as well as built-in precautions in the equipment may lead to carbon dioxide retention. The
they use. Here, as elsewhere, prevention of regulatory system also gradually becomes
patient injury is crucial. insensitive to lack of oxygen as depth of
anesthesia increases.
The anesthesia machine is always checked
before use, including the patient breathing External apparatus dead space must always
system and suction device. As mentioned be considered, since face masks may double
above, it is crucial for personnel to be this dead space, while intubation decreases
thoroughly familiar with the relevant routines it.
governing safety and checkout procedures.
All members of staff should be updated on the One reason for reduced compliance may be
latest developments on an ongoing basis. the use of surgical retractors and abdominal
Warnings, cautions, recommendations and packs that press the diaphragm upwards
instructions concerning intended use should during open abdominal surgery. Even the
also be followed at all times position of the patient (such as the
Trendelenburg position) may have a negative
Although incidents are rare and complications impact on breathing, as may some of the
unusual, there are a number of risks drugs used during anesthesia. The use of large
associated with anesthesia of any kind and amounts of intraabdominal carbon dioxide
both personnel and patients should be aware during laparoscopy may also affect both
of these. While every effort is made to respiration and circulation.
minimize them, anesthesia can never be totally
risk-free. 12.2 CARDIOVASCULAR
COMPLICATIONS
12.1 RESPIRATORY
COMPLICATIONS Falls in blood pressure are primarily treated
by increasing the fluids infused or tipping the
Respiratory complications may arise during patient to lower the head below the level of
the induction and recovery stages of general the rest of the body (Trendelenburg position).
anesthesia. Obstruction of the upper airways, If these procedures should fail, patient blood
laryngospasm and bronchospasm, may occur pressure may also be raised
and an assessment of the risk of airway pharmacologically.
problems should therefore be performed
before anesthesia. Vagal reflexes are most common at the
beginning and end of general anesthesia.
Anesthesia has an effect on spontaneous Sensory stimulation normally leads to an
breathing, which is normally stimulated increase in the heart rate. Vagal stimulation of
primarily by an increase in carbon dioxide various kinds may however cause bradycardia
64
 | Safety considerations | 12 |

and a lowering of stroke volume and blood the lithotomy position, with a 90 degree
pressure. Pressure on certain abdominal flexion of both hips and knees and
organs during surgery may also cause vagal abduction of the hips, mainly used for pelvic
reflex activity. and perineal surgery;

Tachycardia accompanied by high blood the prone position, which involves lying on
pressure may also be a sign of inadequate the stomach;
anesthesia.
the lateral position, with the patient lying on
Rapid changes in the concentration of either the right or the left side;
desflurane may also cause tachycardia and
during isoflurane or desflurane anesthesia, a number of more specialized positions,
tachycardia may cause coronary ischemia. including, for example, the modified sitting
position and the lumbar spinal surgery
position, sometimes modified as the
12.3 NERVE AND OTHER INJURIES
knee-elbow position, which may involve the
- THE IMPORTANCE OF PATIENT
use of a special operating table for spinal
POSITIONING
surgery.
Anesthesia depresses the autonomic nervous
system and thus the capacity to make the Safe positioning of patients involves team
physiological adaptations needed when work between anesthesiologist, surgeon and
changing body position. Nerve injuries may nurse. All aspects of positioning should be
result from pressure or strain or be due to the planned in advance and tasks assigned, and
fact that the patient has been anesthetized. the accessories needed should be checked
Anesthetists and surgeons should thus be beforehand.
aware of the effects of the most common
surgical positions, the areas vulnerable to Positions associated with major physiological
injuries, and the precautions needed to changes (like the modified sitting position)
prevent them. should be achieved in a stepwise fashion,
checking hemodynamic and other parameters
The main positions of interest are: and adjusting anesthesia depth. The position
of the endotracheal tube or laryngeal mask
the supine or horizontal position, in which
should also be checked. Padded cushions
most patients are anesthetized and then
should be kept under areas vulnerable for
repositioned if necessary;
nerve compression. Bony areas may be left in
the head-down position, including the contact with the mattress. However, if the
famous but now little-used Trendelenburg surgical time is likely to be prolonged, or if the
position with the head and body tilted patient is likely to be hypothermic or
downwards 45 degrees from horizontal. hypotensive, they also need to be well
Most head-down positions involve a tilt of padded. It is preferable to have all the joints
10-15 degrees in combination with various in the body (except the ankle) in minimal
anglings of the lower body; flexion. During anesthesia, the eyes should be

65
| 12 | Safety considerations |

kept closed and the ears may be protected communicate his or her condition. It is
with the help of ear plugs. Finally, the patient generally associated with the use of muscle
should be covered as much as possible so relaxants, while technical failures rarely cause
that heat loss is minimized, except in the case awareness.
of artificially induced hypothermia (used for
open heart surgery, for example). Inhalation anesthesia without the use of
muscle relaxants minimizes the risk of
awareness, as long as the induction phase is
12.4 VOMITING AND
adequately completed and sufficient time is
REGURGITATION
allowed for the agent to equilibrate and
Anesthetized patients always run the risk of provide full anesthetic effect.
vomiting and regurgitation, particularly during
induction if the airway is not free and gas is 12.7 MALIGNANT HYPERTHERMIA
pumped into the stomach.
Some patients have a rare genetic
Endotracheal intubation diminishes the risk of predisposition to develop malignant
aspiration, although the laryngeal mask does hyperthermia (or hyperpyrexia). When volatile
not. There is also a higher risk of vomiting after agents are used, body temperature and
anesthesia and surgery, although the patient metabolism both rise dramatically in these
is then conscious and generally able to move patients. Increased metabolism is reflected in
and communicate. higher etCO2 values. Suxamthonium may also
be implicated in malignant hyperthermia.
12.5 SHIVERING
All inhalation agents appear to produce these
Shivering may occur after all general side-effects, which may, if they go untreated,
anesthesia and is not necessarily due to heat ultimately cause death. The complication is
loss. very rare and runs in certain families.

Shivering greatly increases oxygen

12.8 GAS LEAKAGE
consumption, causing hypoxia, hypercapnia
and even acidosis. Moreover, oxygen Anesthesia machines may occasionally have
transportation often decreases during problems with leakage, which may occur from
shivering. The treatment involves vaporizers, flowmeters, patient tubing,
administration of pure oxygen and sometimes connectors or any of the other components
very small doses (10-20 mg) of pethidine are of the apparatus. All leakage should be
given intravenously with almost immediate avoided to maintain safety in the OR and
effect. ensure environmental friendliness. The use of
low flow anesthesia has been shown to reduce
12.6 AWARENESS occupational exposure to anesthetic agents.

This may occur if the patient is not fully

unconscious and hears sounds or words, or
even feels pain, without being able to
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 | Safety considerations | 12 |

By performing a checkout procedure prior to

low flow anesthesia, leakage can be detected.
Low flow anesthesia may not be used if
leakage is higher than 100 ml.

12.9 AIR POLLUTION

In theory, nitrous oxide has a negative impact
on the environment, both at the OR level via
leakage and at the global level, since it is a
potent greenhouse gas. The effect of nitrous
oxide emissions from hospitals is however
negligible when compared with emissions
caused by other human activities. There is still
insufficient research into the long-term effects
of lengthy exposure to volatile anesthetic
agents, although regulations involving very
low occupational limits are in place so as to
protect personnel from all unnecessary
exposure.

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| 12 | Safety considerations |

12.10 ELECTRICAL HAZARDS

The most common source of malfunctions
caused by electric current is surgical
diathermy, which may cause serious failures
in medical devices and interrupt their
functioning.

There is a also a general recommendation to

avoid the use of cell phones in the vicinity of
medical devices as the signals may interfere
with the way the equipment functions.
Routines may however vary from one country
or hospital to another. Modern mobile
telecommunication systems also carry a much
lower risk of interference than older systems.

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13 SPECIAL APPLICATIONS
Anesthesia is used in the OR not only for
13.1.1 AIRWAY ANATOMY
routine surgery, but also for special types of
surgery that involve special anesthesiological The mucous membranes are more sensitive
requirements. Pediatric care, neurosurgery, to trauma in children. In addition, the
transplantation and cardiovascular surgery are appearance of the larynx differs, with the
just a few examples. Anesthesia is also used narrowest point located just below the vocal
in other parts of the hospital, such as for cords rather than at their level.
sedation within intensive care (the ICU) or in
MR environments. This section presents some This means that when endotracheal tubes are
of these special applications, although readers used, the cuff is not inflated so as to avoid the
looking for more in-depth information should risk of trauma and swelling. However, this may
consult specialized works on anesthesia (see increase the risk of leakage, although this is
References). not generally a problem in practice.

13.1 PEDIATRIC ANESTHESIA 13.1.2 DEAD SPACE

It is not just in size that children and infants In relative terms, there is more dead space
differ from adults. The following sections cover when a child is anesthetized than when an
the main points to remember when adult is. The space should therefore be limited
anesthetizing children. wherever possible and compensation should
be made for it.

13.1.3 BREATHING

The breathing rate is faster in children, who

are often mouth-breathers. This must be taken
into account when using a face mask since it
may make it more difficult to maintain a free
airway.

13.1.4 HYPOVENTILATION

Children are more susceptible and sensitive

to hypoventilation. Obstruction of the airways
is quick to result in bradycardia and respiratory
acidosis.

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| 13 | Special applications |

13.1.5 COMPRESSIBLE VOLUME adequate oxygenation and CO2 elimination.

Previously, hyperventilation was used to
This should be minimized when children are lower intracranial pressure, although the
anesthetized, which makes the choice of tendency now is to strive for
breathing system and ventilator crucial. normoventilation;

13.1.6 CIRCULATION suitable intravenous infusions using agents

such as cortisone and hypertonic fluids to
Children's heart rate is faster, their blood reduce edema in the brain and thus lower
pressure lower and their cardiac output high pressure;
in relation to body weight. Even small blood
losses may be significant in children and are maintaining stable blood pressure without
therefore compensated. The aim should be to fluctuations;
avoid hypovolemia and maintain
careful patient positioning, sometimes in
normovolemic patients.
the sitting position, and the use of special
drugs and accessories to enhance
13.1.7 METABOLISM
peripheral circulation;
Children have a higher metabolic rate than
using suitable anesthetic agents and drugs
adults, which means that they break down
such as muscle relaxants to prevent the
drugs and pharmaceuticals more rapidly. The
patient from coughing or straining.
concentration of anesthetic gases thus
generally needs to be raised.
13.3 ANESTHESIA FOR
13.1.8 BODY TEMPERATURE CARDIOVASCULAR SURGERY
Children's body temperature, especially that Thoracic surgery imposes special demands
of neonates and infants, is less stable than on the anesthetist, including:
that of adults. It is therefore important to
monitor body temperature more closely. Often effective ventilation/respiration must, as
a hot air warmer is used to maintain normal during all surgery, be maintained;
body temperature.
it must be possible to ventilate the lungs
individually during lung surgery;
13.2 ANESTHESIA FOR
NEUROSURGERY equipment to counter induced hypothermia
must be at hand;
The focus here is on lowering intracranial
pressure, which means special demands on special cardiovascular drugs must be
anesthesia, including: available in case of emergency;

maintaining free airways at all times; pleural drains are almost always needed;

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 | Special applications | 13 |

it is even more important than usual for the 13.5 ANESTHESIA DURING
patient to have an adequate cough reflex ARTHROSCOPY
shortly after recovery so as to avoid
postoperative complications. The patients here are often relatively healthy
outpatients, necessitating rapid recovery from
anesthesia if regional anesthesia, often the
13.4 ANESTHESIA DURING method of choice in such cases, is not used.
LAPAROSCOPY
This in turn means that inhalation anesthesia
This type of surgery using a laparoscope is using agents eliminated via the lungs and with
increasing in popularity and more and more low solubility is generally preferred when
interventions are now performed general anesthesia is given. The idea is to
laparoscopically. avoid long stays in hospital. Short-acting IV
agents such as propofol are also popular.
The technique requires the patient to be
slightly tipped and the abdomen to be filled 13.6 ANESTHESIA DURING
with CO2. Although it requires special skills in TRANSPLANTATION
the operating surgeon, it enables relatively
complicated surgery to be performed without The special demands imposed here depend
large skin incisions. The high level of visual on the organ to be transplanted and include:
detail contributes to enhancing accuracy and
patient safety. blood flow and perfusion have to be
adequate and constant before, throughout
It may also give rise to a number of and after surgery;
physiological effects including:
total muscular relaxation is often used;
major changes in compliance
special drugs must be at hand.
CO2 retention and embolism

risk of bradycardia and arrhythmia 13.7 ANESTHESIA IN BURNS UNITS

other cardiovascular effects caused by the Burns patients are often anesthetized during
rise in intraabdominal pressure painful bandaging and may face special
complications, including:
pneumothorax.
frequent hypovolemia

serum potassium levels may increase during

anesthesia if depolarizing muscle relaxants
are used, causing large amounts of
potassium to be released from cells in
damaged tissues, with an ensuing risk of
cardiac arrest

71
| 13 | Special applications |

a high risk of respiratory distress The need for familiarity with special tubes,
gags and equipment for microlaryngoscopy,
a high risk of circulatory instability bronchoscopy´and laser surgery (e.g.
Venturi devices, ventilating bronchoscope
frequent septicemia.
and fiber optic bronchoscopy);

The use of HFO, ventilation with high

13.8 ANESTHESIA FOR EAR, NOSE frequency oscillation;
AND THROAT SURGERY
Middle ear surgery may involve special
ENT anesthesia techniques may differ from
hypotensive techniques;
those used in other specialized fields. The
most important aspects include the shared Major head and neck surgery sometimes
airway, the difficult airway, emergence and entails special positioning;
extubation, special airway equipment, apnea
and rapid case turnover. Preoperative Emergency airway management may be
assessment is crucial, particularly prediction needed, including tracheostomy;
of difficult intubation. Patients may be of all
ENT anesthesia is often pediatric
ages and include those with:
anesthesia;
stridor
ENT anesthesia often involves assessing
intubation difficulties and managing the difficult airway, including
fiber optic intubation;
sleep apnea
ENT anesthesia may also involve managing
concomitant diseases. major facial injuries.

Special points to remember include:

13.9 ANESTHESIA FOR
The use of local techniques and surface OUTPATIENTS
analgesia;
General anesthesia is frequently offered to
The special nature of ENT emergencies particularly sensitive patients who suffer from
(including croup, epiglottitis and foreign severe anxiety or are afraid of pain. In addition,
bodies); it is becoming increasingly popular to perform
surgery on outpatients who are sent home the
Frequent use of laryngoscopy and same day as surgery is performed. This
bronchoscopy; imposes special requirements including:

use of fast-acting drugs

relatively healthy patients

rapid recovery

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 | Special applications | 13 |

effective analgesia. When patients who are agitated or anxious

require sedation ahead of difficult procedures,
ICU personnel need to consider various means
13.10 ANESTHESIA IN MR of sedation and pain relief so as to meet the
ENVIRONMENTS patients' needs.

Many patients, and especially children, find The following are some of the indications for
MRI examinations difficult to cope with, since sedation in the ICU:
they have to lie still for long periods inside the
machine. As the use of MRI equipment facilitation of mechanical ventilation/airway
becomes more widespread, the need to management
anesthetize certain patients is increasing.
pain relief
This involves the same kind of requirement as
fear and/or anxiety
listed above for outpatients, but because the
MR environment is a highly specialized one, sleeping problems
it also imposes specific requirements on the
equipment used there, which must be capable amnesia during neuromuscular blockade
of withstanding the powerful magnetic fields
used. Another requirement is that such control of agitation
equipment should not affect the MR
apparatus. The drugs most commonly used include
benzodiazepines, propofol and opioids (for
13.11 ANESTHESIA IN THE ICU analgesia).

Anesthesia in the ICU focuses mainly on

13.12 ANESTHESIA AND THE
sedation and analgesia. It is often necessary
OLDER PATIENT
to sedate patients or anesthetize them while
certain procedures are performed, or even for The elderly population is growing as people
long periods while they undergo treatment. are living longer. In Europe, Japan and the
These patients are often extremely ill and USA, people over 65 represent 15% or more
require specialized anesthesiological care. of the population and many of them seek
Generally speaking, an ICU ventilator is used surgical care. The increased risk involved in
and intravenous anesthetic agents hospital care of older patients is related both
administered via a central line. to their age and to the fact that more and more
of them are seriously ill when hospitalized.
The needs of the ICU are imposing growing
requirements on the equipment used there. It Although the ageing process is highly
has been suggested that special anesthesia individual, it is often characterized by
machines could be developed with access to degeneration of organ systems and tissues
sophisticated modes of mechanical ventilation and loss of functional reserves, as well as a
and the highest levels of reliability for use in decreasing ability to cope with anesthesia and
the ICU. surgery. The systems most affected include
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| 13 | Special applications |

the respiratory, cardiovascular, renal, and

central nervous systems. It is also important
for the anesthetist to remember that patients'
skin, dental and nutritional status should be
taken into account.

13.13 ANESTHESIA AND

MATERNITY CARE
Obstetric anesthesia and analgesia constitute
the only area of anesthetic practice where two
patients are cared for simultaneously.
Pregnancy is a physiological rather than a
pathological state and patient expectations
are therefore high - the mother expects full
involvement in her choice of care.

The majority of the workload is the provision

of analgesia in labor and anesthesia for
delivery, although multidisciplinary care for
sick mothers is increasingly important.
Knowledge of techniques such as epidural
and spinal anesthesia is essential, as well as
familiarity with and planning for obstetric
emergencies, should they arise.

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 | Special applications | 13 |

13.14 ANESTHESIA IN EMERGENCY Treatment routines in case of trauma will of

CONDITIONS course differ in different countries and
hospitals, as will access to the most
Whenever there is a risk that the patient's sophisticated equipment for saving lives.
stomach may not be empty (emergency
surgery or other unforeseen situations), the
anesthetist will generally choose rapid
sequence induction (described in more detail
in Chapter 6).

Anesthetists and other healthcare

professionals may also be called to the scenes
of accidents and emergencies to take care of
patients on site. This involves familiarity with
routines that apply in the pre-hospital
environment, pre-hospital analgesia and
practical methods for rapid patient
assessment. Special drugs, equipment and
procedures may be used and multidisciplinary
trauma teams are often formed. These
specialists are often experts on advanced
airway management, intravenous and other
forms of cannulation, thoracotomy and
laparotomy.

One of the main complications among trauma

patients is shock, or acute circulatory failure,
with hypovolemia as the most common cause.

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| 13 | Special applications |

13.15 ANESTHESIA IN THE

DEVELOPING WORLD
In 1960, the per capita gross domestic product
(GDP) of the 20 richest countries was 18 times
that of the 20 poorest. By 1995, the gap
between the richest and poorest nations had
more than doubled to 37 times. Only a small
minority of the world's population have access
to a computer, and there is also a striking
disparity between rich and poor nations.
According to the International
Telecommunications Union, there were 61.1
personal computers per 100 people in North
America as compared with 6 in the East
Asia/Pacific or Latin America/Caribbean
regions in 2001. Access to qualified medical
care is likewise unevenly distributed at the
global level. Most of the sophisticated
equipment and high standards of care that we
take for granted in the western world are
unavailable to people in developing countries.

There is a great need to collaborate with

developing nations on the education of
anesthetists and to work with governments
and other agencies. In many cases,
collaboration involves assistance in the form
of advice and even of trained and experienced
specialists who can provide help where
needed. There is also a tremendous need for
training and personnel, as well as material and
equipment. Fortunately, some such efforts are
now being made as attitudes begin to change
and progress is made.

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 | Glossary and abbreviations | 14 |

14 GLOSSARY AND ABBREVIATIONS

Medical professionals often use terms and Angina pectoris - chest pain originating from
expressions that may be unfamiliar to the heart, sometimes referred to (in English)
outsiders. They also sometimes assign simply as angina. It is generally a sign of
specialised meanings to otherwise familiar myocardial ischemia (inadequate blood supply)
words and this may require explanation. As is and is a relatively common symptom,
the case with all specialist terminology, its use particularly after stress or effort, in patients
may be more justifiable in some cases than in with known heart disease.
others. As a rule, however, excessive use of
jargon is a barrier to understanding, rather Anticoagulants - pharmaceuticals designed
than an aid. to prevent, suppress or delay the clotting
process in blood.
Health professionals in general also have an
unfortunate tendency to use acronyms and ASA - American Society of Anesthesiologists.
abbreviations that occasionally make their In medical charts and case histories, the term
language obscure or difficult to interpret. may also be used to refer to acetyl salicylic
Some of these terms and abbreviations are acid, a drug generally known as aspirin.
explained below, although there are of course
Aspiration - accidental sucking in of food
local variations that are beyond the scope of
particles or fluids into the lungs.
this short glossary.
Awareness - a condition in which the patient
Acidosis - condition characterized by a low
is not fully anesthetized and may therefore be
pH (acidity) caused, in the case of respiratory
aware of some of the things that go on in the
acidosis, by accumulation of CO2 due to
OR without being able to communicate this
inadequate respiration, as opposed to
fact.
metabolic acidosis, where the excess acid is
due to metabolic processes. BGPC - blood/gas partition coefficient, a
measure of the solubility of an anesthetic
Alveoli (plural form of alveolus) - the smallest
agent in blood.
space units in the lungs formed by the terminal
air-filled sacs at the end of the bronchioles, BMI - Body Mass Index, a key index for
where gas exchange takes place. relating body weight to height and assessing
obesity. BMI is calculated by dividing a
Analgesia - originally a state of painlessness,
person's weight in kilograms (kg) by their
although it now mainly means pain relief.
height in meters (m) squared.
Analgesics are thus drugs used to relieve pain.
Bradycardia - a slower heartbeat than is
Amnesia - lack of memory.
normal, i.e. generally < 50 in adults.
Anesthesia - a state of being "without
Bronchospasm - spasmodic contraction of
feeling", insensibility to most external stimuli,
the bronchi, as in asthma.
including pain.

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| 14 | Glossary and abbreviations |

Capnometry/Capnography - monitoring of Coronary steal - the detrimental redistribution

patients' inhaled and exhaled carbon dioxide of coronary blood flow whereby blood is
levels. diverted from underperfused areas toward
better perfused areas.
Carbon dioxide retention - inadequate
elimination of carbon dioxide, CO2. Cricoid cartilage - ringshaped cartilage
forming the lower and back part of the larynx
Cardiac output (CO) - the effective volume at the level of C6.
of blood pumped out by the heart per unit of
time (l/min). CSF - cerebrospinal fluid, which surrounds
the brain and spinal cord.
Catecholamines - amines derived from a
special amino acid (tyrosine), examples of Dead space - for each breath taken, there is
which include adrenaline, noradrenaline and a part that is not involved in gas exchange.
dopamine. ´They act as hormones or There are three types of dead space -
neurotransmitters, raising blood pressure and anatomic (the trachea and bronchi, which have
heart rate, among other things. no alveoli), apparatus or external (the
endotracheal tube and other pieces of tubing
CCO - continuous cardiac output. Definition with bidirectional gas flow), and physiologic
as for "Cardiac output" above, but monitored (the apical areas of the lung with ventilation
continuously. but no perfusion).

Coagulation and hemostasis status - a panel Diathermy - the use of electrocautery for
of tests that provide information about cutting and coagulation or cauterization, as
coagulation status and bleeding tendencies. for sealing a blood vessel, resulting in local
tissue destruction. Diathermy may be either
Compliance - a measure of the elasticity of
monopolar or bipolar.
the lungs and thoracic wall, expressed as the
volume change per unit change in pressure. Edema - accumulation of fluid in serous
cavities (e.g. lungs) or connective tissue.
Compressible volume - the part of the
inspiratory minute volume needed to compress ECG - electrocardiography uses electrodes
the gas in the apparatus and tubing and placed on the body to monitor electrical
therefore not reaching the patient. activity in the heart. The ECG curve has a
characteristic appearance that also provides
COPD - chronic obstructive pulmonary
information about the condition of the heart
disease, comprising any disorder that
muscle.
persistently obstructs bronchial airflow. COPD
mainly involves two related diseases - chronic EEG - electroencephalography uses
bronchitis and emphysema. Both cause electrodes placed on the head to monitor
chronic obstruction of air flowing through the activity in the brain cortex, which is then
airways and in and out of the lungs. The graphically displayed in the form of waves.
obstruction is generally permanent and
becomes worse over time.
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 | Glossary and abbreviations | 14 |

Elective - a procedure that is planned and Hypercapnia - a condition characterized by

scheduled, as opposed to emergency a higher than normal level of carbon dioxide
procedures. in the blood.

Emphysema - a pathological increase in the Hyperpyrexia - see hyperthermia.

size of the alveoli, involving their distension or
rupture and leading to progressive loss of Hypertension - elevated arterial blood
pulmonary elasticity. It is a common pressure.
complication among smokers.
Hyperthermia - a condition, sometimes
Endocrine disease - disease involving known as pyrexia, in which body temperature
disorders of the endocrine glands and is elevated.
hormones of the body, for example, and
Hyperventilation - ventilation that exceeds
including such conditions as diabetes and
normal physiological requirements.
thyroid disease, as well as many less common
disorders. Hypnosis - although now use in a slightly
different sense, the term originally refers to a
etCO2 - end-tidal concentration of carbon
sleeplike condition.
dioxide.
Hypnotic agent - a drug that puts patients to
ETT - endotracheal tube used for endotracheal
sleep.
intubation.
Hypotension - low arterial blood pressure.
Extubation - removal of an endotracheal tube.
Hypothermia - a condition in which body
FA - alveolar concentration (or fraction) of a
temperature is lowered.
gas.
Hypoventilation - inadequate or reduced
FI - inspired concentration of a gas. ventilation that does not meet physiological
requirements.
FA/FI ratio - the change in this ratio over time
describes the wash-in curve of a gas such as Hypovolemia - decreased volume of
an anesthetic agent (and thus its solubility in circulating fluid in the body.
blood).
Hypoxia/hypoxemia - condition in which O2
FGF - fresh gas flow. levels in the blood are reduced.

FOB - fiber optic bronchoscope. a flexible Icterus - jaundice.

instrument used to view the trachea and
bronchi. Intrathecally - drugs given intrathecally are
administered into the cerebrospinal fluid
Hemoglobin - the molecule in red blood cells surrounding the spinal cord and brain.
that transports oxygen.

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| 14 | Glossary and abbreviations |

Intubation - insertion of a tube, generally Malignant hyperthermia - a genetic disorder

endotracheal. (sometimes referred to as malignant
hyperpyrexia) triggered by exposure to volatile
Laparoscopy - examination of intra-abdominal agents that causes a life-threatening condition
organs using a laparoscope. The term is now of rapidly increasing body temperature,
often used to denote surgical intervention hyperventilation and tachycardia. Early signs
during the above procedure. include high muscle tonus verging on rigidity
and an increase in etCO2. Untreated, the
Laryngoscope - a flexible, lighted tube used
condition can lead to cardiac arrest.
to look at the inside of the larynx. It is inserted
through the mouth into the upper airway. Metabolism - the range of biochemical
processes occurring within any living organism
Laryngospasm - spasm of the larynx causing
and involving the build-up and breakdown of
closure of the vocal chords and severe airway
substances. The term is commonly used to
obstruction. A complication of
refer specifically to the breakdown of food and
intubation/extubation.
its transformation into energy.
Larynx - upper part of the respiratory tract
Metabolites - breakdown products (often of
(above the trachea) containing the vocal cords.
pharmaceuticals) resulting from metabolism
Liver status - a group of laboratory values by the body.
that reflect liver function, the most important
Mixed venous blood - the blood in the
of which are the ASAT, ALAT, LD, ALP and
pulmonary artery that has returned to the right
GT (liver enzymes) and bilirubin tests.
side of the heart from all parts of the body.
LMA - laryngeal mask airway, a device used
Myocardial infarction - an infarct in part of
for maintaining a patent airway without
the heart muscle, often known as a heart
endotracheal intubation. It consists of a tube
attack.
connected to an oval inflatable cuff that seals
the larynx. Myocardium - the heart muscle.
MAC - Minimum Alveolar Concentration, an OGPC - oil/gas partition coefficient, a measure
index of the anesthetic effect and potency of of the lipid solubility of an anesthetic agent.
an inhalation agent in relation to alveolar
concentration. 1.0 MAC is the concentration Opioid - chemical substance with a
required for lack of reflex response to skin morphine-like action in the body, mainly used
incision in 50% of patients. 1.3-1.4 MAC is used for pain relief.
the concentration usually required for surgical
anesthesia. MAC values are affected by Peroral - administered through the mouth as
patient age (lower for old people and higher opposed to other administration routes,
for infants and children) and the use of other generally in relation to medication.
inhalation agents (when MAC values are
additive).

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 | Glossary and abbreviations | 14 |

Plethysmograph - curve measuring the oxygen consumption. It is therefore treated

amount of blood flowing through an organ and with pure oxygen and sometimes small doses
the organ's blood content. of pethidine given intravenously, as well as by
warming the patient and preserving body heat.
Pneumothorax - a collection of air or gas in
the pleural space of the lung, causing the lung Solubility - the ability to dissolve, generally
to collapse. It may be caused by an open measured by the amount (in ml) of a substance
chest wound allowing air to enter, by a rupture that will dissolve in another quantified
of the surface of the lung due to lung disease substance.
such as emphysema, or by a severe bout of
coughing. It may also occur spontaneously. SpO2 - the percentage of oxygen-carrying
hemoglobin molecules, or oxygen saturation,
Pop-off valve - valve used in breathing in peripheral blood as measured non-invasively
systems for releasing excess gas at a certain by pulse oximetry.
pressure.
Stridor - a harsh high-pitched crowing sound
Regurgitation - passive backward flow, e.g. during inhalation or exhalation associated
of stomach contents from the ventricle. primarily with airway obstruction.

RSI - rapid sequence induction, a variation of Stroke volume - the volume (in ml) of blood
the standard induction technique for patients pumped out by the heart with each beat.
under anesthesia. It is performed when
immediate definitive airway management SvO2 - oxygen saturation in mixed venous
through intubation is required, especially in blood (as opposed to arterial blood - SaO2, or
emergencies when there is a risk of aspiration. peripheral blood - SpO2), a spot value
measured invasively as the percentage of
Serum electrolytes - laboratory values hemoglobin occupied by oxygen.
indicating levels of important electrolytes in
the blood, The main electrolytes tested are Tachycardia - an accelerated heartbeat,
sodium and potassium. High or low levels of generally > 100 in adults.
the latter (hyper- and hypokalemia), in
particular, may have a negative impact on TIVA - total intravenous anesthesia, a form of
cardiac rhythm. general anesthesia involving the intravenous
administration of hypnotic agent, analgesic
Serum creatinine - laboratory value that drugs and muscle relaxants and excluding
provides a quantitative estimate of kidney simultaneous administration of any inhaled
function. drugs.

Shivering - a condition resulting from low TOF - train of four, a method used for
body temperature following anesthesia in measuring magnitude and type of
which metabolism increases, causing higher neuromuscular blockade. It is based on the

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| 14 | Glossary and abbreviations |

ratio of the amplitude of the fourth evoked

mechanical response to the first one, when
four electrical currents are applied for 2
seconds to a peripheral motor nerve.

Trachea - the part of the airway referred to as

the windpipe between the larynx and the
bronchi.

Trendelenburg position - position on the

operating table in which the patient is supine
with head tilted down in relation to the rest of
the body.

Vagal reflexes - reflexes relating to the vagus

nerve and causing bradycardia, reduced
stroke volume and a fall in blood pressure.

Vasoactive agent - a drug causing

constriction or dilation of blood vessels.

Vasoconstriction - narrowing of the diameter

of blood vessels resulting from contraction of
their muscular walls. This is the opposite of
vasodilation.

Vasodilation - widening of the diameter of

blood vessels resulting from relaxation of their
muscular walls. Vasodilation is the opposite
of vasoconstriction.

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15 REFERENCES
American Society of Anesthesiologists (ASA): ASA Physical Status Classification System.

Anaesthesia UK (FRCA): Resources.

Cashman, Davies: Lee's Synopsis of Anaesthesia.

Euliano, Gravenstein: Essential Anesthesia. From Science to Practice.

Food and Drug Administration (FDA): Anesthesia Apparatus Checkout Recommendations.

Halldin, Lindahl: Anestesi.

Jacobsson, Murray: Medical Devices: Use and Safety.

MAQUET Critical Care AB: Anesthesia. An Introductory Guide.

Moyers: A nomenclature for methods of inhalation anesthesia.

The Virtual Anaesthesia Textbook: The Anesthesia Gas Machine.

Tung: New Developments in Anesthesia Ventilators.

Tung: New Anesthesia Techniques.

www.medterms.com

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| 15 | References |

84
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