DOCUMENTATION:

Documentation is important for both quality assurance and medicolegal

purposes. Adequate documentation is essential for the defense of a malpractice action.

The Preoperative Note:

-The preoperative note should be written in the patient's chart and should
describe all aspects of the preoperative assessment, including the medical history,
anesthetic history, medication history, physical examination, laboratory results, ASA
classification, and recommendations of any consultants.

-It also describes the anesthetic plan and includes the informed consent. The
plan should be as detailed as possible and should include the use of specific
procedures such as tracheal intubation, invasive monitoring, and regional or
hypotensive techniques.

-Documentation of informed consent usually takes the form of a narrative in the

chart indicating that the plan, alternative plans, and their advantages and disadvantages
, including the risk of complications were presented, understood, and agreed to by the
patient.
Con..
should include the use of specific procedures such as tracheal
intubation, invasive monitoring, and regional or hypotensive
techniques.

-Documentation of informed consent usually takes the form of

a narrative in the chart indicating that the plan, alternative plans, and
their advantages and disadvantages , including the risk of
complications were presented, understood, and agreed to by the
patient.
Preoperative Physical Status Classification of Patients
According to the American Society of Anesthesiologists:

Class Definition
P1- A normal healthy patient
P2- A patient with mild systemic disease (no functional
limitations)
P3- A patient with severe systemic disease (some functional
limitations)
P4- A patient with severe systemic disease that is a constant threat
to life (functionality incapacitated)
P5- A moribund patient who is not expected to survive without the
operation .
P6 -A brain-dead patient whose organs are being removed for
donor purposes
> > E- If the procedure is an emergency, the physical status is
followed by "E"
The Intraoperative Anesthesia Record:
The intraoperative anesthesia record serves many purposes. It
functions as a useful intraoperative monitor, a reference for future
anesthetics for that patient, and a tool for quality assurance. It should
document all aspects of anesthetic care in the operating room,
including the following:

-A preoperative check of the anesthesia machine and other

equipment.

-A review or re evaluation of the patient immediately prior to

induction of anesthesia.

-A review of the chart for new laboratory results or consultations.

.
 -A review of the anesthesia and surgical consents.

-The time of administration, dosage, and route of intraoperative

drugs

-All intraoperative monitoring (including laboratory

measurements, blood loss, and urinary output).

-Intravenous fluid administration and blood product

transfusions.

-All procedures (such as intubation, placement of a nasogastric

tube, or placement of invasive monitors).

-Routine and special techniques such as mechanical ventilation

Con..

-The timing and course of important events such as induction,

positioning, surgical incision

-The condition of the patient at the end of the procedure.

 Point to be noted-
>Vital signs are recorded graphically at least every 5
min. Other monitoring data are also usually entered
graphically.
>Automated recordkeeping systems are available, but
their use is still not widespread
>Critical incidents, such as a cardiac arrest- In such
cases, a separate note in the patient's chart may be
necessary.
>Inaccurate or illegible records by physicians
malpractice will be a unjustified legal liabil.
The Postoperative Notes:
-The anesthesiologist's immediate responsibility to the patient
does not end until the patient has completely recovered from the
effects of the anesthetic.
-The anesthesiologist should remain with the patient until
normal vital signs have been established and the patient's condition
will stable.
-Prior to discharge from the post operative unit, a discharge
note should be written by the anesthesiologist to document the
patient's recovery from anesthesia, any apparent anesthesia-related
complications, the immediate postoperative condition of the patient,
and the patient's disposition.
-Inpatients should be seen again at least once within 48 h
after discharge. Postoperative notes should document the general
condition of the patient, the presence or absence of any anesthesia-
related complications, and any measures undertaken to treat such
complications.
Delivery of Medical Gases:
-Medical gases are delivered from their central supply source to the operating
room through a piping network.
-Pipes are sized such that the pressure drop across the whole system never exceeds
5 psig. seamless copper tubing using a special welding technique.
-Internal contamination of the pipelines with dust, grease, or water must be
avoided.
-The hospital's gas delivery system appears in the operating room as hose drops,
gas columns, or elaborate articulating arms .
-Operating room equipment, including the anesthesia machine, interfaces with
these pipeline system outlets by color-coded hoses.
-Quick-coupler mechanisms, connect one end of the hose to the appropriate gas
outlet. The other end connects to the anesthesia machine through a non
interchangeable diameter index safety system fitting that prevents incorrect
hose attachment.
Typical examples of (A) gas columns, (B) ceiling
hose drops, (C) articulating arms
Medical Gas Systems:

- The medical gases commonly used in operating rooms are

oxygen, nitrous oxide, air, and nitrogen. Although vacuum exhaust for
waste anesthetic gas disposal and surgical suction must also be
provided and is considered an integral part of the medical gas system.
- Patients are endangered if medical gas systems, particularly
oxygen, malfunction.
- The anesthesiologist must understand both these elements to
prevent and detect medical gas depletion or supply line misconnection
Sources of Medical Gases:
Oxygen-
-A reliable supply of oxygen is a critical requirement in any surgical
area. Medical grade oxygen (99% or 99.5% pure) is manufactured by
fractional distillation of liquefied air.
 -Oxygen is stored as a compressed gas at room temperature or
refrigerated as a liquid.
-Most hospitals store oxygen in two separate banks of high-
pressure cylinders connected by a manifold. Only one bank is utilized
at one time.

Nitrous Oxide-
-Nitrous oxide, a most commonly used anesthetic gas, is
manufactured by heating ammonium nitrate (thermal decomposition).
It is almost always stored by hospitals in large H-cylinders connected
by a manifold with an automatic crossover feature.
-The critical temperature of nitrous oxide (36.5°C) is above room
temperature, it can be kept liquefied without an elaborate refrigeration
system. If the liquefied nitrous oxide rises above its critical
temperature, it will revert to its gaseous phase.
Air-
-The use of air is becoming more frequent in anesthesiology as
the potential effect of nitrous oxide and high concentrations of oxygen
receive increasing hazards.
- Cylinder air is medical grade and is obtained by blending
oxygen and nitrogen.
- Dehumidified air is provided to the hospital pipeline system by
compression pumps. The critical temperature of air is –140.6°C.

Vacuum-
A central hospital vacuum system usually consists of two
independent suction pumps, each capable of handling peak
requirements. Traps at every user location prevent contamination of the
system with foreign matter.
 Temperature:
- The temperature in most operating rooms seems uncomfortably
cold to many conscious patients and, at times, to anesthesiologists.
- As a general principle, the comfort of operating room personnel
must be reconciled with patient needs. For example, for small children
and patients with large exposed surfaces (eg, those with thermal
burns) the operating room temperature should be 24°C or higher, since
these patients lose heat rapidly and have a limited ability to
compensate.

- Hypothermia has been associated with an increased incidence of

wound infection, greater intraoperative blood loss, and prolonged
hospitalization.
- On the other hand, intraoperative hypothermia may offer a
degree of neurological protection during some intracranial or
cardiopulmonary bypass surgeries.
 Humidity:
- A relative humidity of at least 50% is recommended.
- Routine compliance with this requirement is no longer important
in the modern era of nonflammable anesthetic agents.
- However, static sparks can still damage sensitive electrical
equipment or lead to Risk of Electrocution.
.
Ventilation:
- A high rate of operating room airflow decreases contamination
of the surgical site.
- These flow rates are usually achieved by blending of air with
fresh air. Therefore, a separate anesthetic gas scavenging system
must always supplement with operating room ventilation.
- Extreme rates of flow have been proposed for procedures with
particularly high risks of infection.
Noise:

Multiple studies have demonstrated that exposure to noise can

have a detrimental effect on multiple human cognitive functions.
Operating room noise has been measured at 70–80 dB with frequent
sound peaks exceeding 80 dB.

The Risk of Electrocution:

The use of electronic medical equipment ,patients and hospital

personnel has the risk of electrocution. Anesthesiologists must have at
least a basic understanding of electrical hazards and their prevention.
For example- a grounded person need contact only one live conductor
to complete a circuit and receive a shock. A circuit is now complete
between the power line through the victim and back to the ground. The
physiological effect of electrical current depends on the location,
duration, frequency, and magnitude of the shock.
Anaesthetic machine:

In an anesthetic machine, Circle breathing circuiting system is, the

flow of gases is directed by two unidirectional valves, one in an
expiratory and one in an inspiratory tube.
The rebreathing bag and the canister of CO2 absorption are located
between the two tubes.

BREATHING SYSTEM:
DEFINITION-
“A breathing system is defined as an assembly of components which
connects the patient’s airway to the anaesthetic machine, creating an
artificial atmosphere, from and into which the patient breathes”.
 -The Breathing systems provide the final pathway for the delivery
of anesthetic gases to the patient. Breathing circuits link a patient to an
anesthesia machine. Many modifications in circuit design have been
developed, each with varying degrees of efficiency, convenience, and
complexity.

It primarily consists of :
a) A fresh gas entry port/delivery tube through which the gases are
delivered from the machine to the systems;
b) A port to connect it to the patient’s airway.
c) A reservoir for gas, in the form of a bag or a corrugated tube to
meet the peak inspiratory flow requirements.
d) An expiratory port/valve through which the expired gas is vented to
the atmosphere,
e) A carbon dioxide absorber if total rebreathing is to be allowed,
Classification of breathing system:

Breathing system without co2 absorption –

1.Unidirectional flow
-non rebreathing system
-circle system
2.Bi-directional flow:
- Afferent reservoir systems.
Mapleson
- Lack’s system.
- Enclosed afferent reservoir systems
Miller’s
- Efferent reservoir systems
- Bain’s system
- Combined systems
BREATHING SYSTEMS WITH CO2 ABSORPTION

1.Unidirectional flow
Circle system with absorber.

2.Bi-directional flow
To and Fro system.