45 - Goldman Index

In 1977 Goldman, et al., developed the first cardiac risk index for patients above 40 years of age about to be operated by looking at nine variables, which increased the risk of perioperative cardiac complications.

These variables are :

1. Preoperative third heart sound or jugular venous distention
2. Myocardial infarction in the preceding six months
3. More than five premature ventricular contractions per minute documented at any time before operation
4. Cardiac rhythm other than sinus rhythm or presence of premature atrial contractions on preoperative electrocardiogram
5. Age over 70 years
6. Intraperitoneal, intrathoracic or aortic operation
7. Emergency operation
8. Important aortic valvular stenosis
9. Poor general medical condition

Since 1977, multiple cardiac risk indices and guidelines for preoperative cardiac evaluation have been developed.

44 - Stages of Anaesthesia

The four stages of anaesthesia were described in 1937 by Guedel. Guedel's staging of anaesthesia was given for ether. Despite newer anaesthetic agents and delivery techniques, which have led to more rapid onset and recovery from anaesthesia, with greater safety margins, the principles remain.

Stage 1 :
Stage 1 anaesthesia, also known as the "induction", is the period between the initial administration of the induction medications and loss of consciousness. During this stage, the patient progresses from analgesia without amnesia to analgesia with amnesia. Patients can carry on a conversation at this time.

Stage 2 :
Stage 2 anaesthesia, also known as the "excitement stage", is the period following loss of consciousness and marked by excited and delirious activity. During this stage, respirations and heart rate may become irregular. In addition, there may be uncontrolled movements, vomiting, breath holding, and pupillary dilation. Since the combination of spastic movements, vomiting, and irregular respirations may lead to airway compromise, rapidly acting drugs are used to minimize time in this stage and reach stage 3 as fast as possible.

Stage 3 :
Stage 3, "surgical anesthesia". During this stage, the skeletal muscles relax, and the patient's breathing becomes regular. Eye movements slow, then stop, and surgery can begin.

It has been divided into 4 planes:
*rolling eye balls, ending with fixed eyeballs
*loss of corneal and laryngeal reflexes
*pupils dilate and loss of light reflex
*intercostal paralysis, shallow abdominal respiration, dilated pupils

Stage 4 :
Stage 4 anesthesia, also known as "overdose", is the stage where too much medication has been given and the patient has severe brain stem or medullary depression. This results in a cessation of respiration and potential cardiovascular collapse. This stage is lethal without cardiovascular and respiratory support.