ASA Physical Status Classification

The ASA (American Society of Anesthesiologists) physical status classification has been
shown to generally correlate with the perioperative mortality rate (mortality rates given below).

ASA 1: a normal healthy patient (0.06-0.08%).

ASA 2: a patient with a mild systemic disease (mild diabetes, controlled hypertension, obesity
[0.27-0.4%]).

ASA 3: a patient with a severe systemic disease that limits activity (angina, COPD, prior
myocardial infarction [1.8-4.3%]).

ASA 4: a patient with an incapacitating disease that is a constant threat to life (CHF, renal
failure [7.8-23%]).

ASA 5: a moribund patient not expected to survive 24 hours (ruptured aneurysm [9.4-51%]).

ASA 6: brain-dead patient whose organs are being harvested.

For emergent operations, add the letter ‘E’ after the classification.

ASA standards for basic anesthetic monitoring*

Standard 1: Qualified anesthesia personnel shall be present in the room
throughout the conduct of all general anesthetics, regional anesthetics and
monitored anesthesia care
Standard 2: During all anesthetics, the patient’s oxygenation, ventilation,
circulation, and temperature shall be continually* evaluated
Oxygenation:
Oxygen analyzer for inspired gases
Observation of the patient
Pulse oximetry
Ventilation:
Auscultation of breath sounds
Observation of the patient
Observation of the reservoir bag
Capnography (Carbon dioxide monitoring)
Circulation:
Continuous* ECG display
Heart rate and BP recorded every 5 minutes
Evaluation of circulation
Auscultation of heart sounds
Palpation of pulse
Pulse plethysmography
Pulse oximetry
Intraarterial pressure tracing
Temperature:
Monitor temperature when changes are intended, anticipated, or suspected
* The term “continuous” means prolonged without interruption; "continually"
means repeated regularly and frequently. ECG indicates electrocardiography;
 ASA minimal requirement for basic anaesthesia monitoring
During all anesthetics, the patient’s oxygenation, ventilation,
circulation, and temperature shall be continually* evaluated

1. E.C.G. monitoring
2. Pulse oximetery monitoring
3. Capnography monitoring
4. Temperature monitoring
5. BP (NIBP or arterial line) monitoring

Preoperative Fasting Guidelines

Recommendations (applies to all ages)
Ingested Material Minimum Fasting Period (hrs)
Clear liquids 2
Breast milk 4
Infant formula 6
Non-human milk 6
Light solid foods 6
Clear liquids include water, sugar-water, apple juice, non-carbonated soda, pulp-free juices, clear tea, black coffee.

Recommendations apply to healthy patients exclusive of parturients undergoing elective

surgery; following these recommendations does not guarantee gastric emptying has occurred.
For emergency patients and all obstetric patients
Perioperative fasting should be for at least 4 hours (unless surgery cannot safely be delayed for
this period) and the anaesthetic technique used should be suitable for a patient with a full
stomach.
All parturients are considered “full stomach” regardless of their NPO status.

Spinal Anaesthesia for Cesarean Delivery

I. Contraindications:

Absolute

• Patient refusal
• Inadequate resuscitation drugs and equipment
• Coagulopathy and Therapeutic anticoagulation (Thrombocytopenia: platelet count
below of 100,000/mm3 or INR <1.5)
• Skin infection at injection site.
• Raised intracranial pressure.
• Hypovolaemia.
• Septicaemia.

Relative

• Uncooperative patients
• Pre-existing neurological disorders
• Fixed cardiac output states.. This includes aortic stenosis, hypertrophic obstructive
cardiomyopathy (HOCM), mitral stenosis and complete heart block. Patients with these
cardiovascular abnormalities are unable to increase their cardiac output in response to the
 peripheral vasodilatation caused by subarachnoidal blockade, and may develop profound
circulatory collapse which is very difficult to treat.
• Anatomical abnormalities of vertebral column

II. Preoperative

• BP,HR, Temperature, Hb, platelets

• Skin test for sensitivity to LA
• NPO status
• Premedication at least 30min before operation:
- Medigel 30 ml P.O.
- Metoclopramide 10mg IVI start
• Antibiotic prophylaxis

- Ampicillin 1.0 IVI start

• Correctly filled consent form

III. Intraoperative

• Prepare everything for General Anaesthesia and Resuscitation

• 4 Medicines (MEAN) must be readily to use:

M – Maxolon, E – Ephedrine, A – Atropine, N - Naloxone

• Fluid preload 15-20 ml/kg via IV canule G20-G18 (0.9%NaCl, R-L or Plasmalyte B
avoid glucose-containing fluids)
• Standard monitoring ( BP every 1min over10, every 2min for the next 10min then
within 5min interval, Ps,SaO2,ECG -continuously)
• Lumbal puncture L2-L3; L3-L4 Use a small needle (27-gauge Quincke or 25-gauge
Whitacre)
• Drugs and Doses Bupivacain5-10mg or Lignocain 20-40mg +/- Pethidine12.5-25mg or
Fentanyl 12.5-25 mcg in 7.5% (5-10%) Dextrose. All medicines should be withdrawn
from ampoules but not flacons
• Supine position with left uterine displacement ( 150 tilted to left operation table or
wedge under right hip)
• Skin sensation test before incision
• Prompt treatment of bradycardia and hypotension with left uterus displacement,
bolus infusion of crystalloid, increments of ephedrine, 5 to 10 mg intravenously as
needed or other vasopressors at a time if necessary and M-cholinomimetics.
• Oxytocin 10 IU IVI when baby has been delivered
• Transfer to recovery room when haemodynamically stable

IV Postoperatively

• Record BP,HR,SaO2,T0C,PV bleeding, motor functions recovery

1st hour every 15 min

2nd hour every 30 min

From 3-ed hour - hourly

 • Patient can start with ice cube 2hours, drink 4 hours and take soft food (yogurts) 6
hours post operative, if no objections from obstetrician. Don’t restrict patient in oral
fluid intake (3-5L/day). It is strongly recommended to take caffeine –contained fluid
among others: coffee 2-3 cups per day,” gas-free”(shaked) “Coca-cola” 4-6 cups per day
for 3 days.
• Analgesia, antibiotics, IV fluids est. - according to obstetrician’s protocol.

POST OPERATIVE CARE FOR STATE PATIENTS AFTER CASERIAN SECTION

UNDER SPINAL
ANAESTHESIA [FIRST 24 HOURS]
Activity Hours after operation
- nd
1 Hr 2 Hr 3rd Hr 4th Hr 5-6 7-SHrs
Hrs
1. Record BP; Ps; SaO2; PV Every Every 30 Once Once According to
bleeding 15 min min p/hour p/hour the ward
protocol
2. Assess and record recovering of Every Every 30 Once Once According to
motor functions. Inform Dr in 15 min min p/hour p/hour the ward
charge in case of deterioration. protocol
3. Oral fluid intake. Start 4 hrs Sips of Water As much as patient can
after Operation, if no objection water 100ml 1 take (3-5L per OS per day)
from Obstetrician. It is strongly P.R.N; times with for the next 3 days.
recommended to give caffeine- Ice interval 30
contained fluid among others; cube min.
(Coffee 3 cups/day; "Gas free" tolerance
Coca-Cola, 4-6 cups) for the next test
3 days: To prevent post-puncture
headache.
4. Soft food (Yoghurts, Omaere); 1/2 -1 +
start 6 hrs after operation, if no cup
objection from Obstetrician. Avoid
traditional drinks for the first days
(Oshikundu etc.)
5. Mobilization with nurses Turn in the Can sit To sit Stay
assistance. (There is no connection bed (Pt's in the in the and
between post-puncture headache self) bed. bed. walk.
and mobilization has been
established)
6. IV fluids, analgetics, antibiotics
and other medicines according to
Obstetrician prescriptions.
 POST PUNCTURE HEADACHE PREVENTION BY NURSING STAFF

1. Well hydration with IV fluids.

2. Early oral intake (4 Hours after operation). If no objections by Obstetrician.
Do not restrict patient in taken oral fluids. Start takes fluid orally 4 hours postoperative. Continue
for the next 3 days. It is strongly advised to drink caffeine-contained fluid among others. Coffee
3 cups per day. "Gas free" Coca-Cola (shake Coca-Cola before use to take gas out) 4-6 cups per
day for five days.
3. Strict bed rest doesn't prevent headache.

TREATMENT

1. Monitor vital signs BP; HR; RR; Temperature

2. Strict bed rest for 3-5 days.
3. Inform Dr in charge.
4. Increase oral intake as much as patient can tolerate. Coffee and caffeine contained fluids
strongly recommended.
5. Usually patients benefit from:-
• Increased IV fluids about 3L/day
• Aminophyllin 250mg IV bd
• Non-steroid antiflamatory drugs. (Panado, Indocid, Brufen)
• Epidural blood patch

ANAESTHETIC TEAM IHO