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Clinical Procedures & Support Services

Anaesthesia (General Considerations & Types)

Overview of the main objectives, general considerations, and basic types of anaesthesia used for surgical and other procedures.

Also known as: Anaesthesia Basics

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Referral and warning signs

When to refer

Complex patients or procedures requiring specialized anaesthetic techniques or monitoring should be managed by qualified Anaesthesiologists at appropriate facilities.

Red flags

  • During Anaesthesia: Severe hypotension/bradycardia, Hypoxia, Bronchospasm/Laryngospasm, Difficult airway, Suspected malignant hyperthermia, Anaphylaxis.

Signs and symptoms

  • Not applicable - Guidance topic.

Risk factors

  • Factors increasing anaesthetic risk: Extremes of age, Obesity, Emergency surgery, Co-morbidities (cardiac, respiratory, renal, liver disease, diabetes), Difficult airway anatomy, Allergies, Smoking, Alcohol abuse.

Diagnosis

Clinical assessment

  • Pre-anaesthetic assessment (history, exam, investigations) to determine patient fitness, classify risk (ASA score), and plan appropriate technique.

Investigations

  • Based on patient age, comorbidities, type of surgery (e.g., Hb, UEC, ECG, CXR).

Diagnostic criteria

  • ASA Physical Status Classification (ASA 1-6) used to stratify risk.

Management

Non-pharmacological management

  • Preparation: Ensure availability and readiness of equipment (anaesthesia machine, monitors, airway devices, suction, IV access, drugs, resuscitation gear). Qualified anaesthesia provider and assistant present.
  • Pre-operative Assessment & Optimization: Assess patient, correct deficits (fluids, electrolytes, anaemia), obtain informed consent, ensure fasting guidelines followed.
  • Monitoring (Minimum Standards): Continuous monitoring of Oxygenation (Pulse Oximetry), Ventilation (Capnography if intubated, observation), Circulation (ECG, BP, Pulse), Temperature.
  • Post-operative Care: Recovery monitoring, pain management, nausea/vomiting control, fluid balance.

Pharmacological treatment

  • Types of Anaesthesia:
  • 1. General Anaesthesia (GA): Reversible state of unconsciousness, amnesia, analgesia, +/- muscle relaxation.
  • - Induction: IV agents (Propofol, Thiopental, Ketamine) or Inhalational agents (Halothane, Sevoflurane, Isoflurane - via mask).
  • - Maintenance: Inhalational agents (+/- Nitrous Oxide) OR Total Intravenous Anaesthesia (TIVA - e.g., Propofol infusion).
  • - Airway Management: Facemask, Oropharyngeal/Nasopharyngeal airway, Laryngeal Mask Airway (LMA), Endotracheal Tube (ETT).
  • - Muscle Relaxants: (e.g., Suxamethonium - short acting; Rocuronium, Vecuronium, Atracurium - longer acting) used to facilitate intubation/surgery.
  • - Analgesia: Opioids, NSAIDs, Paracetamol, Local infiltration.
  • 2. Regional Anaesthesia: Blocking nerve conduction to a specific region, patient remains conscious (may be sedated).
  • - Spinal Anaesthesia: Local anaesthetic injected into cerebrospinal fluid (CSF) in subarachnoid space. Blocks nerves below injection level. Common for lower limb, pelvic, lower abdominal surgery (e.g., C/S).
  • - Epidural Anaesthesia: Local anaesthetic injected into epidural space. Catheter can be left for continuous infusion/top-ups. Used for surgery and labour analgesia.
  • - Peripheral Nerve Blocks: Local anaesthetic injected near specific nerves or plexuses (e.g., brachial plexus block for arm surgery, femoral nerve block for leg). Often ultrasound-guided.
  • - Intravenous Regional Anaesthesia (IVRA / Bier's Block): Local anaesthetic injected into vein of exsanguinated limb isolated by tourniquet. For short procedures on hand/forearm/foot.
  • 3. Local Anaesthesia:
  • - Topical: Applied to skin/mucous membranes (e.g., EMLA cream, Lidocaine spray).
  • - Infiltration: Injecting local anaesthetic (e.g., Lidocaine +/- Adrenaline) into tissues around surgical site.
  • - (Often combined with sedation).
  • Adjunctive Drugs: Antiemetics, Atropine (treat bradycardia), Vasopressors (treat hypotension), Reversal agents (Neostigmine for non-depolarizing muscle relaxants).

Monitoring

  • Continuous intra-operative monitoring is standard. Post-operative monitoring in recovery area.

Complications

  • Airway problems (difficult intubation, laryngospasm, aspiration).
  • Cardiovascular instability (hypotension, hypertension, arrhythmias).
  • Respiratory depression / Hypoxia.
  • Allergic reactions / Anaphylaxis.
  • Nausea and Vomiting (PONV).
  • Pain.
  • Awareness during GA (rare).
  • Malignant Hyperthermia (rare genetic disorder).
  • Complications specific to regional techniques (nerve damage, post-dural puncture headache, epidural haematoma/abscess).
  • Local anaesthetic toxicity.

Prevention

  • Thorough pre-anaesthetic assessment and planning.
  • Appropriate equipment checks.
  • Adherence to safety protocols and monitoring standards.
  • Skilled anaesthesia providers.

Patient education

  • Explanation of planned anaesthetic technique.
  • Risks and benefits.
  • Fasting instructions.
  • Post-operative expectations (pain, nausea, recovery).

Uganda-specific notes

Anaesthesia often provided by non-physician anaesthetic officers. Availability of different agents (esp. inhalational like Sevoflurane), monitors (capnography), and equipment varies greatly. Ketamine widely used due to safety profile with minimal equipment. Regional techniques (spinal) common where feasible.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 24, Section 24.3 (including 24.3.1, 24.3.1.1, 24.3.1.2, 24.3.1.3, 24.3.3, 24.1.1.1)

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