Anesthesia

Mrs.santhi
 Anesthesia
 From Greek anaisthesis means ”not sensation”
 Listed in Bailey´s English Dictionary 1721.
 When the effect of ether was discovered”anesthesia”
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 patient´s 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 patient´s understanding and wishes regarding the type of
anesthesia that could be used
 The type and duration of the surgical procedure
 The patients´s physiologic status and stability
 The presence and severity of coexisting disease
 The patient´s 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
 Infiltrationof 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 patient´s 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 patient´s
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

 Blockssensory 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 dura-
can 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
 Injectionof local anesthetic around a
peripheral nerve

 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
patient’s 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

 Pageanesthesia 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

 Pressureon 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
 Limitany discussion of patient’s medical
condition and prognosis

 Avoid discussion of other patients & limit

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