Anaesthesia guide
Anaesthesia briefing — JCI-standard process
The #1 worry of international patients: "is anaesthesia safe?" Yes — but you have the right to know how. ASA assessment, monitoring, drug choice, PONV prevention: the full process transparently shared in 6 sections.
How is anaesthesia kept safe, what monitoring is used?
JCI-standard anaesthesia uses 5 main monitors: SpO2, ECG, blood pressure, ETCO2 (capnography), body temperature. Additionally BIS (Bispectral Index 0-100, target 40-60) shows anaesthesia depth numerically; TOF measures muscle-relaxant effect. Patient is classified ASA I-VI — most rhinoplasty patients are ASA I-II. Anaesthesia type: TIVA (propofol + remifentanil) preferred for rhinoplasty (rapid emergence, 30-40% less post-op nausea) vs inhalational (sevoflurane). Malignant hyperthermia screening (1/15,000-100,000) via family history; if positive, TIVA only + dantrolene stock mandatory. PONV prevention: dexamethasone + ondansetron + scopolamine patch in high-risk patients. Surgery day timeline: 8h NPO → 2h clear water → registration + IV → 5 min pre-oxygenation → 30 sec induction → maintenance → emergence + 1-2 hours recovery. Anaesthesiologist present at every stage.
ASA assessment — how we classify you
ASA (American Society of Anesthesiologists) classification is the standard system to predict anaesthesia risk. Six classes (ASA I-VI):
ASA I: healthy patient, non-smoker, no chronic disease. Minimum risk. Most rhinoplasty patients are in this class.
ASA II: mild systemic disease (controlled hypertension, mild obesity BMI 30-35, smoking, controlled diabetes). Anaesthesia typically safe with small extra precautions.
ASA III: severe systemic disease (poorly controlled diabetes, COPD, heart failure, BMI 40+). Anaesthesia plan personalised, more frequent monitoring.
ASA IV-V: life-threatening conditions — elective rhinoplasty-type procedures are postponed; patient stabilised first.
Your ASA score is assessed during the tele-consult; ASA III+ may require additional pre-op tests (cardiac consult, echocardiography).
Anaesthesia type — TIVA vs inhalational
TIVA (Total Intravenous Anaesthesia): continuous propofol + remifentanil infusion. Advantages: rapid emergence, less post-op nausea/vomiting (PONV), better control. Preferred for rhinoplasty.
Inhalational anaesthesia: sevoflurane + nitrous oxide. Advantages: lower cost, rapid induction. Disadvantage: PONV 30-40% more frequent.
Combined: TIVA + inhalational for some cases — long operations or ASA III patients.
Sedation + local: may suffice for small septoplasty, otoplasty, or laryngeal microsurgery. Patient awake or lightly sedated. Less risk, shorter hospitalisation.
Which anaesthesia for you: anaesthesiologist decides via tele-consult questions — past anaesthesia experiences, drug allergies, family history, procedure duration all evaluated.
Intra-operative monitoring — what we watch
JCI standard: 5 main parameters continuously monitored — SpO2 (oxygen saturation), ECG (cardiac rhythm), blood pressure, ETCO2 (end-tidal CO2), body temperature.
BIS monitoring (Bispectral Index 0-100): shows anaesthesia depth numerically. Target: 40-60 (adequate depth). Too low = excessive, too high = awareness risk.
TOF (Train-of-Four): measures muscle relaxant effect. Full block / partial / return. Critical for proper relaxation during + safe reversal at end.
Capnography (ETCO2): shows breathing is adequate, airway is open, circulation is working. Anaesthesia safety signal as important as heartbeat.
Temperature monitoring: hypothermia (<35°C) slows wound healing; hyperthermia may signal malignant hyperthermia. Active warming (Bair Hugger) standard.
Post-op nausea/vomiting (PONV) — prevention
PONV rate: 20-30% across all anaesthesias. In nasal surgery (rhinoplasty), blood ingestion can raise it to 35-50% without prevention.
Risk factors: female sex, non-smoker, history of PONV/motion sickness, opioid use, long operation.
Apfel score: 4 risk factors (0-4) — high score = high PONV risk → multimodal prophylaxis.
Prophylaxis: dexamethasone (8 mg IV at induction) + ondansetron (4 mg IV at end) + droperidol or scopolamine patch (high risk).
TIVA (propofol) reduces PONV 30-40% vs inhalational.
Post-op hydration, early oral intake (liquids first), head elevation, caffeine-containing drinks all help.
Malignant hyperthermia screening — rare but critical
Malignant hyperthermia (MH): a genetic, life-threatening reaction triggered by inhalational anaesthetics or succinylcholine. Incidence 1/15,000-1/100,000.
History questions: family death during anaesthesia, unexplained fever, muscle rigidity, brown urine.
Positive family history or suspicion: TIVA (propofol only — no sevoflurane) or local anaesthesia preferred.
Clinic MH protocol: dantrolene sodium stocked in OR (intra-op use). Mandatory at JCI-standard clinic.
Known MH history: family members should consider caffeine-halothane contracture test (available in some European centres).
Anaesthesia day timeline
8 hours before: NPO. Nothing to eat or drink, including water. Stop smoking/vape.
2 hours before: clear water (300 mL) allowed. No bowel prep.
0 hour (hospital arrival): registration, anaesthesia consult (final questions + consent), IV access (usually dorsum of hand), pre-medication (anxiolytic if needed).
+15 min: transfer to OR. Monitors attached (ECG, SpO2, NIBP, BIS). Pre-oxygenation (5 min 100% O2).
+30 min: induction — IV propofol/fentanyl. Asleep in 30 seconds. Airway secured (LMA or endotracheal tube).
+30 min — operative time: maintenance anaesthesia (TIVA infusion or sevoflurane). Surgery proceeds; anaesthesiologist continuously monitors parameters.
End of surgery: drugs stopped, patient emerges (15-30 min). Transfer to recovery room. 1-2 hours observation (SpO2 normal, pain control, nausea control) → room transfer.
Frequently Asked Questions
- BIS (Bispectral Index) continuously monitors anaesthesia depth, kept at 40-60. Intra-op awareness rate is 0.1-0.2% in modern BIS-equipped clinics. Not a realistic risk — be assured.
- PONV occurs 20-30%; in rhinoplasty 35-50% due to blood ingestion (without prevention). Prophylaxis (dexamethasone + ondansetron) reduces it 50-70%. Significant nausea resolves in 4-6 hours.
- TIVA preferred for rhinoplasty — rapid emergence, less PONV, better control. Combined for ASA III or long operations. Sedation + local may suffice for some smaller procedures (otoplasty, septoplasty). Anaesthesiologist decides jointly via tele-consult.
- Must disclose during tele-consult. For suspected malignant hyperthermia: TIVA only (no sevoflurane), dantrolene stock mandatory, MH protocol ready. Family members may consider caffeine-halothane contracture test.
- 8 hours NPO (nothing including water). Clear water 300 mL allowed up to 2 hours before (Turkish Anaesthesia Society guideline). Full stomach increases aspiration risk; rule strictly applied.
- With TIVA, full awakening in 15-30 minutes. Mild confusion first 30 min (normal). 1-2 hours observation in recovery — breathing, pain, nausea check. Then transfer to patient room.
Discuss anaesthesia plan via tele-consult
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