7.7 Management of anesthesia 

• Only emergency surgeries are performed in this level 
• Premedication: Oral sedatives such as diazepam may be used. H2 antagonists or non particulate antacids (e.g. sodium citrate) should be given if esophageal reflux is a problem. All drugs has to be titrated slowely 
• Patients with uremia and other co-morbid conditions (diabetes mellitus) are at an increased risk for aspiration of gastric contents during induction of anesthesia. The use of a rapid sequence induction of anesthesia technique may be indicated in such patients. Succinylcholine is not contraindicated unless the serum potassium increased to > 5 mEq/L. 
• Several strategies have been successfully used to achieve adequate heart rate and arterial blood pressure control during induction of anesthesia. Moderate doses of opioids such as fentanyl can blunt the response of laryngoscopy. However, systemic blood pressure is frequently more difficult to maintain after induction of anesthesia, and hypotension may require treatment with vasoconstrictors. The short-acting beta-adrenergic blocker esmolol may be used to blunt the hemodynamic response of tracheal intubation and is ideally suited for patients with an adequate ejection fraction 
• Full monitoring must be established prior to induction of anesthesia, with special attention being paid to the ECG and blood pressure. The patient should be kept well oxygenated and hemodynamically stable. Hypovolemia and hypotension worsen renal function therefore blood and other fluid losses should be carefully replaced. Input output monitering with catheter is issential 
• If spinal anesthesia is being performed fluid preloading should be kept to a minimum and vasoconstrictors used to maintain the blood pressure. Coagulation profile should be checked preoperatively. 
• Postoperative fluid balance must be maintained. 
• Oxygen (2-3 litres/minute nasally or 3-4 litres/minute via face mask) should be administered for 48 hours, and 24 hours after intermediate surgery.