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Anesthesia 10 0 1 1 5 3
Basic Science
Authors: Ujash Sheth | Derek Moore

Anesthesia

Components of anesthesia
amnesia
anxiolysis
analgesia
akinesia
attenuation of autonomic repsonses to noxious stimuli

General Anesthesia

Pharmacologically induced, reversible loss of conciousness, irrespective of airway

management
inhalational anesthesia
by volatile liquids vaporized in a carrier gas including
isoflurane
sevoflurane
desflurane
nitrous oxide
associated with increased gaseous
abdominal distension
leads to increased difficulty with
fluoroscopic identification during pelvic and
spinal procedures
intravenous anesthesia
non-opioids
propofol
etomidate
benzodiazepines
dexmedetomidine
ketamine
opioids
fentanyl, alfentanil, sufentanil, remifentanil
morphine
hydromorphone
neuromuscular blocking agents
depolarizing agents
bind to, depolarize, and transiently block
ACh receptor
short-acting: succinylcholine
no intermediate or long-acting
agents
non-depolarizing agetns
bind to and transiently block ACh receptor,
but do not depolarize
no short-acting agents
intermediate-acting: rocuronium,
vecuronium, atracurium,
cisatracurium
long-acting: pancuronium

Local Anesthesia - Upper Extremity

Interscalene regional block

indications
commonly used for shoulder/upper arm/elbow surgery
technique
performed by injecting local anesthetic to the nerves of the
brachial plexus as it passes through the groove between the
anterior and middle scalene muscles at the level of the cricoid
cartilage
complications
sensory neuropathy is most common complication
Supraclavicular block
indications
ideal for operations involving the arm and forearm, from the lower
humerus down to the hand.
technique
targets brachial plexus superior to the clavicle
complications
nerve injury and intravascular injection
pneumothorax, dyspnea damage to the subclavian artery
Infraclavicular block
indications
ideal for operations involving the arm and forearm, from the lower
humerus down to the hand.
technique
targets brachial plexus inferior to the clavicle
Axillary block
indications
postoperative analgesia for surgery to the elbow, forearm, wrist
and hand
Bier block
indications
short (< 60 mins) operative procedures (i.e., carpal tunnel release)
in the hand and forearm
technique
Esmarch exsanguination and tourniquet inflation
inject lidocaine through a small, distal (hand) intravenous catheter
on the surgical side
deflate tourniquet after a minimum of 30 minutes to avoid venous
release of local anesthetic and potential local anesthetic systemtic
toxicity (LAST)

Local Anesthesia - Spinal

Spinal
indications
often used for knee and hip arthroplasty
technique
a single injection with a small 24 or 27-gauge needle
combination of morphine and bupivacain is often used
complications
spinal headache (decreased with small gauge needle), hematoma
and opioid side effects (nausea, vomiting, purities, respiratory
depression)

Epidural
indication
often used for knee and hip arthroplasty
technique
similar to spinal anesthesia, except an indwelling catheter is
placed
combination of opioid and local anesthetic
complications
postoperative hypotension and motor impairment
spinal headache, hematoma and opioid side effects (nausea,
vomiting, pruritus, respiratory depression)
Combined spinal epidural
indications
often used for knee and hip arthroplasty
technique
an epidural needle is placed into the epidural space and spinal
anesthesia is administered through a spinal needle followed by
placing an epidural catheter
complications
postoperative hypotension and motor impairment
spinal headache, hematoma and opioid side effects (nausea,
vomiting, purities, respiratory depression)

Local Anesthesia - Lower Extremity

Lumbar plexus/ psoas compartment nerve block

indications
surgeries involving the hip, anterior thigh and knee
a sciatic block can be given concomitantly to provide pain relief to
the entire lower extremity
technique
targets the lumbar plexus (L1 to L4 spinal nerves) which form the
obturator nerve, lateral femoral cutaneous nerve, and femoral
nerve
the injection is usually placed 3-5 cm lateral to the spinous
process of L4 and is often guided by ultrasound and nerve
stimulators
complications
nerve damage and intravascular injection
epidural diffusion, retroperitoneal hematomas, intrathecal
injections and an increased risk of falls
Femoral nerve block
indications
surgeries around the knee
concomitant sciatic nerve block can be done to increase analgesia
around the knee
technique
targets the femoral nerve (L2-L4)
the injection occurs just lateral to the femoral artery and on a line
connecting the anterior superior iliac spine to the pubic symphysis
complications
nerve damage and intravascular injection
increased risk of falls, prolonged quadriceps weakness and
infections
Sciatic nerve block
indications
surgeries involving the leg, ankle and foot
can be combined with the femoral or lumbar plexus block to
provide analgesia to the entire lower extremity
technique
targets the sciatic nerve providing analgesia to the common
peroneal and tibial nerves
multiple techniques have been described
lines are drawn between the greater trochanter and the
posterior superior iliac spine (PSIS), and the greater
trochanter and the sacral hiatus
halfway between the greater trochanter and the PSIS a
perpendicular line is drawn, and the injection is placed
where the perpendicular line crosses the line between
the greater trochanter and the sacral hiatus
complications
nerve damage and intravascular injection
vascular injury, heel ulcers and a delay in diagnosis of
nerve injuries after surgery
Obturator nerve block
indications
adductor muscle spasm, severe hip pain from osteoarthritis
adjuvant pain management for knee surgeries
technique
targets the anterior and posterior branch of the obturator nerve
blocking the anterior branch leads to decreased sensation at the
hip joint and inner thigh, where blocking the posterior branch
decreases sensation around the knee
injection site is usually 2 cm inferior and 2 cm lateral to the pubic
tubercle
complications
nerve injury and intravascular injection
damage to structures in the pelvic cavity
Popliteal nerve block
indications
used for surgery around the foot and ankle
often used in conjunction with the saphenous nerve block
technique
targets the sciatic nerve prior to its bifurcation
injection site is often 10 cm proximal to the popliteal crease
complications
nerve injury and intravascular injection
hematoma, persistent foot drop and pressure sores
Saphenous nerve block
indications
procedures around the medial aspect of the knee, leg and ankle
technique
targets the saphenous nerve
multiple different techniques, but it is often blocked behind the
sartorius muscle
complications
nerve injury and intravascular injection
hematoma and infection

Blood Management

Risks of transfusion
transfusion errors
allergic reaction
infection
down-modulation of immune system
Ways to reduce postop anemia and need for allogeneic transfusion
surgical
hemostasis
meticulous dissection
transfusion triggers
example of strict transfusion triggers based on hemoglobin levels
average patient, 8.1g/dl
young (<60yr) patients without co-morbidity, 6.5g/dl
compromised patients, 9.7g/dl
subcutaneous epoetin injections
used preop for patients with low Hb (10-13g/dl)
able to bring up Hb by 1.9d/dl
administer with supplementary PO iron
dosing
long interval to surgery
600IU/kg once weekly x 3wk before surgery
short interval to surgery
300IU/KG daily x 2wk
autologous blood donation (ABD) and acute normovolemic hemodilution
(ANH)
ABD
donate 1-2 units preoperatively
ANH
collect 2-3 units at 1 hour preoperatively
receive crystalloid/colloid intraoperatively
re-infuse ABD blood postoperatively
COX2 inhibitors analgesia (instead of COX1 NSAIDS)
Avoids antiplatelet effects of
anti-coagulation management
stop anticoagulation a few days preoperatively
restart just before surgery
platelet rich plasma (PRP), fibrin sealants, anti-fibrinolytics
PRP
apply PRP to wounds might reduce
capsule/subcutaneous bleeding
fibrin sealants
very low risk of infection from microbial/viral
contamination during processing
antifibrinolytics
aprotinin
tranexamic acid (TXA)
topical
IV
hypotensive epidural anesthesia (HEA)
epidural dermatomal block from T2 distal
blocks cardio-accelerator fibers of sympathetic chain
causes bradycardia which is treated with low-dose
epinephrine
lowers MAP to 50mmHg
keeps normal heart rate, CVP, stroke volume, cardiac
output
can be used in high risk patients with
hypertension
poor cardiac function
chronic kidney disease
cell saver
expensive
intraoperative
washed vs unwashed (filtered)
indications
revision surgery
high EBL
contraindications
infection
malignancy
EBL <500ml
postoperative
filtering of shed blood (trap clots and debris)
within 6h of end of surgery to avoid bacterial
contamination, febrile reaction
after 6h, converted to vacuum drain (not retransfused)

Complications

Malignant hyperthemia
rare (1:15,000 to 1:50,000) life-threatening condition
autosomal dominant transmission
abnormalities in the ryanodine receptor (RYR1) gene
triggers
volatile inhalational anesthetic agents
succinylcholine
symptoms
hypermetabolic state
increased skeletal muscle contraction and metabolism
rigidity
masseter spasm
rapid oxygen depletion
increased carbon dioxide concentration (EtCO2) and body
temperature
outcome
if untreated, leads to circulatory collapse and death
treatment
provide antidote
active cooling
antidote
dantrolene (calcium blocker)
Local anesthetic systemic toxicity (LAST)
intravascular bupivicaine
effect
CNS
seizures, coma, respiratory arrest
CVS
asystole, ventricular fibrillation, cardiac
arrest
antidote
intravenous 20% lipid emulsion
Bone cement implanation syndrome
associated with use of bone cement during joint arthroplasty procedures
symptoms
hypotension
hypoxemia
treatment
intravenous fluids
vasopressors
100% inspired oxygen

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QUESTIONS (2)

QUESTIONS
Previous Next 0%
1 of 2

(OBQ08.141) Nitrous oxide has which of the following important effects when used during orthopedic
procedures? Review Topic
QID: 527

1 Potential interaction with oral contrast material

2 Slow induction times

3 Interferes with self-passivation of titanium implants

4 Gaseous abdominal distension

5 Increases risk of metal ion release from stainless steel implants

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VIDEOS (1)

Interscalene Block 11/3/2015

Basic Science - Anesthesia - 696 views

Interscalene block done with Ultrasound. Performed …

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