Anesthesia

DR.MUHAMMAD ASIM BAJWA

ASISSTANT PROFESSOR
DEPT.OF ANESTHESIA AND ICU
UNIVERSITY OF LAHORE

Anesthesia

From Greek anaisthesis means not sensation

Listed in Baileys English Dictionary 1721.
When the effect of ether was discoveredanesthesia
used as a name for the new phenomenon.

Basic Principles of Anesthesia

Anesthesia defined as the abolition of sensation

Analgesia defined as the abolition of pain
Triad of General Anesthesia
need for unconsciousness
need for analgesia
need for muscle relaxation

History of Anesthesia

History of Anesthesia
Ether

synthesized in 1540 by Cordus

Ether used as anesthetic in 1842 by Dr.
Crawford W. Long
Ether publicized as anesthetic in 1846 by
Dr. William Morton
Chloroform used as anesthetic in 1853 by
Dr. John Snow

History of Anesthesia
Endotracheal

tube discovered in 1878

Local anesthesia with cocaine in 1885
Thiopental first used in 1934
Curare first used in 1942 - opened the Age
of Anesthesia

Anesthesiologists care for the surgical patient in the

preoperative, intraoperative, and postoperative
period . Important patient care decisions reflect the
preoperative evaluation, creating the anesthesia
plan, preparing the operating room, and managing
the intraoperative anesthetic.

Preoperative Evaluation
The goals of preoperative evaluation include assessing the
risk of coexisting diseases, modifying risks, addressing
patients' concerns, and discussing options for anesthesia
care.

What is the indication for the proposed surgery? It is elective

or an emergency?
The indication for surgery may have particular anesthetic
implications. For example, a patient requiring esophageal
fundoplication will likely have severe gastroesophageal
reflux disease, which may require modification of the
anesthesia plan (e.g., preoperative non particulate antacid,
intraoperative rapid sequence induction of anesthesia).

What are the inherent risk of this surgery?

Surgical procedures have different inherent risks. For
example, a patient undergoing coronary artery
bypass graft has a significant risk of problems
such as death, stroke, or myocardial infarction.
A patient undergoing cataract extraction has a low
risk of major organ damage.

Does the patient have coexisting medical problems?

Does the surgery or anesthesia care plan need to
be modified because of them?

Has the patient had anesthesia before? Were there

Complication such as difficult airway management?
Does the patient have risk factor for difficult
airway management?

Creating the Anesthesia Plan

After the preoperative evaluation, the anesthesia plan can
be completed. The plan should list drug choices and doses
in detail, as well as anticipated problems .Many variations on
a given plan may be acceptable, but the trainee and the
supervising anesthesiologist should agree in advance on
the details.

Preparing the Operating Room

After determining the anesthesia plan, the
trainee must prepare the operating room .

Anesthesia Providers
Anesthesiologist

( aphysician with 4 or more yearsof

speciality training in anesthesiology after medical
school)
Certified registered nurse anesthetist (CRNA),
working under the direction and supervision of an
anesthesiologist or a physician
CRNA must have 2 years of training in anesthesia

Patient Safety

Patient risk and safety are concerns during surgery and

anesthesia .
Data from a number of studies of death caused by anesthesia
indicate a death rate ranging from 1 per 20,000-35,000.
A fourfoulded decline over the last 30 years even though
surgical procedures are undertaken on increasingly sicker
and much higher risk patients than in the past.
Awareness of potential problems and constant vigilance (the
process of paying close and continuous attention) are
crucial to good patient care.

Preoperative preparation patient

evaluation
Anaesthesiologist:

reviews the patients chart,

evaluate the laboratory data and diagnostic studies such

as electrocardiogram and chest x-ray,

verify the surgical procedure,
examins the patient,
discuss the options for anesthesia and the attendant risks
and
ordered premedication if appropriate

The physical status classification

Developed by the American Society of Anesthesiologist (ASA) to

provide uniform guidelines for anesthesiologists.
It is an evaluation of anesthetic morbidity and mortality related to the
extent of systemic diseases, physiological dysfunction, and anatomic
abnormalities.
Intraoperative difficulties occur more frequently with patients who
have a poor physical status classification.

Choice of anesthesia

The patients understanding and wishes regarding the type of

anesthesia that could be used
The type and duration of the surgical procedure
The patientss physiologic status and stability
The presence and severity of coexisting disease
The patients mental and psychologic status
The postoperative recovery from various kinds of anesthesia
Options for management of postoperative pain
Any particular requiremets of the surgeon
There is major and minor surgery but only major anesthesia

Types of anesthesia care

General Anesthesia
Reversible,

unconscious state is characterised

by amnesia (sleep, hypnosis or basal
narcosis), analgesia (freedom from pain)
depression of reflexes, muscle relaxation
Put to sleep

Types of anesthesia care

Regional Anesthesia

A local anethetic is injected to block or ansthetize a

nerve or nerve fibers
Implies a major nerve block administered by an
anesthesiologist (such as spinal, epidural, caudal, or
major peripheral block)

Types of anesthesia care

monitered anesthesia care
Infiltration

of the surgical site with a local

anesthesia is performed by the surgeon
The anasthesiologist may supplement the local
anesthesia with intravenous drugs that provide
systemic analgesia and sedation and depress
the response of the patients autonomic
nervous system

Types of anesthesia care

local anesthesia
Employed

for minor procedures in which the

surgical site is infiltrated with a local anesthetic such
as lidocaine or bupivacaine
A perioperative nurse usually monitors the patients
vital signs
May inject intravenous sedatives or analgesic drugs

Premedication

Purpose: to sedate the patient and reduce anxiety

Classified as sedatives and hypnotics, tranquilizers, analgesic or narcotics and
anticholinergics
Antiacid or an H2receptor-blockingdrug such as cimitidine (tagamet) or ranitidine
(Zantac) to decrease gastric acid production and make the gastric contents less
acidic
If aspiration occur this premedication decreases the resultant pulmonary damage
Given 60-90 minutes before surgery, or may be given i.v. After the pat. arrives in the
surgical suite
NPO for a minimum of 6 hours before elective surgery
Not given to elderly people or ambulatory patients because residual effects of the
drugs are present long after the pat. have been discharged and gone home

Perioperative monitoring
Undergeneral anesthesia: monitoring
Inspired oxygen analyzer(FiO2) which calibrated to room air and 100% oxygen on a daily basis
Low pressure disconnect alarm, which senses pressure in the expiratory limb of the patient circuit
Inspiratory pressure
Respirometer (these four devices are an integral part of most modern anesthesia machine
ECG
BP-automated unit
Heart rate
Precordial or esophagel stethoscope
Temp

Perioperative monitoring

Pulse oximeters
End tidal carbon dioxide (ECO2)
Peripheral nerve stimulator if muscle relaxants are used
Foly catheter
For selected patint with a potential risk of venous air
embolism a doppler probe may placed over the right atrium
Invasive: arterial pressure mesurements, central venous
pressure
Pulmonary artery catheter and continous mixed venous
oxygen saturation measured

Perioperative monitoring
For

special conditions other monitors as

transesophageal echocardiography
Electroencephalogram
Cereral or neurological may be used

Inhalational Anesthetic Agents

Inhalational

anesthesia refers to the delivery

of gases or vapors from the respiratory
system to produce anesthesia
Pharmacokinetics--uptake, distribution, and
elimination from the body
Pharmacodyamics-- MAC value

Regional Anesthesia
Defined

as a reversible loss of sensation in

a specific area of the body
Spinal anesthesia
Epidural anesthesia
IV Regional Blocks
Peripheral Nerve Blocks

Spinal Anesthesia
A local

anesthetic agent (lidocaine, tetracaine

or bupivacaine) is injected into the
subarachnoid space
Spinal anesthesia is also known as a

subarachnoid block

Blocks

sensory and motor nerves, producing

loss of sensation and temporary paralysis

Possible Complications of Spinal

Anesthesia

Hypotension

Post-dural puncture headache (Spinal headache) caused by

leakage of spinal fluid through the puncture hole in the duracan be treated by blood patch

High Spinal- can cause temporary paralysis of respiratory

muscles. Patient will need ventilator support until block wears
off

Epidural Anesthesia
Local

anesthetic agent is injected through an

intervertebral space into the epidural space.

May

be administered as a one-time dose, or

as a continuous epidural, with a catheter
inserted into the epidural space to administer
anesthetic drug

Dr. Aidah Abu Elsoud Alkaissi

Division of Intensive Care and
Anaesthesiology University of

Complications of Epidural
Anesthesia
Hypotension
Inadvertent

dural puncture
Inadvertent injection of anesthetic into the
subarachnoid space

IV Regional Blocks
Also

known as a Bier Block

Used on surgery of the upper extremities
Patient must have an IV inserted in the
operative extremity

IV Regional Block
After

a pneumatic tourniquet is applied to

extremity, Lidocaine is injected through the
IV.

Anesthesia

lasts until the tourniquet is

deflated at the end of the case.

IV Regional Blocks
IMPORTANT- to

prevent an overdose of
lidocaine it is important not to deflate the
tourniquet quickly at the end of the
procedure.

Peripheral Nerve Blocks

Injection

nerve

of local anesthetic around a peripheral

Can

be used for anesthesia during surgery or for

post-op pain relief

Examples:

ankle block for foot surgery,

supraclavicular block for post-op pain control
after shoulder surgery

Monitored Anesthesia Care (MAC)

Generally

used for short, minor procedures

done under local anesthesia
Anesthesia provider monitors the patient and
may provide supplemental IV sedation if
indicated

Conscious Sedation

Used for short, minor procedures

Used in the OR and outlying areas

(ER, GI Lab, etc)

Patient is monitored by a nurse and receives

sedation sufficient to cause a depressed level of
consciousness, but not enough to interfere with
patients ability to maintain their airway

Inhalation Anesthetics
Nitrous

Oxide- can cause expansion of

other gases- use of N20 contraindicated in
patients who have had medical gas instilled
in their eye(s) during retinal detachment
repair surgery

Inhalation Anesthetics

Cause cerebrovascular dilation and increased cerebral

blood flow

Cause systemic vasodilation and decreased blood

pressure

Post-op N&V

All inhalation anesthetics, except N20, can trigger

malignant hyperthermia in susceptible patients

Intravenous
Induction/Maintenance Agents
Propofol

(Diprivan)- pain/burning on
injection, can cause bizarre dreams

Pentothal

(Sodium Thiopental)- can cause

laryngospasm

General Anesthesia

During induction the room should be as quiet as

possible

The circulator should be available to assist

anesthesia provider during induction & emergence

Never move/reposition an intubated patient

without coordinating the move with anesthesia
first

General Anesthesia

Laryngospasm may happen in a patient having a

procedure with general anesthesia

When laryngospasm occurs, it is usually during

intubation or emergency

Assist anesthesia provider as needed- call for

anesthesia back-up if necessary

Difficult Airway Cart

Anesthesia

maintains a Difficult Airway Cart

containing equipment & supplies for difficult
intubations

This

cart is stored in one of the anesthesia

supply rooms

Page

anesthesia tech if the cart is needed for

your room

Cricoid Pressure or Sellick Maneuver

Used

for patients at risk for aspiration

during induction, due to a full stomach or
other factors such as a history of reflux

Pressure

on the cricoid cartilage compresses

the esophagus against the cervical vertebrae
and prevents reflux

Sellick Maneuver

Cricoid pressure is maintained, as directed by

anesthesia provider, until the ETT cuff is inflated:

Regional Anesthesia
Circulator

may need to assist anesthesia

provider with positioning for spinal or
epidural anesthesia.

Patient

usually is positioned laterally for

placement of regional anesthesia, but may
be positioned sitting upright.

The Awake Patient

Patients

undergoing surgery with regional

or local anesthesia, even if sedated, may be
aware of conversation and activity in room

Post

sign on door to OR, Patient is Awake

so that staff entering room will be aware
that patient is conscious

When Patient is Awake

Limit

any discussion of patients medical

condition and prognosis

Avoid

discussion of other patients & limit

unnecessary conversation-- a sedated
patient can easily misinterpret conversation
they overhear