Translated Copy of Anesthesia Basics Role of The Nurse Anesthetist - Jassin M. Jouria

DASAR ANESTESIA:
PERAN ATAS
ANESTETIS PERAWAT
Jassin M. Jouria,
MD
Jassin M. Jouria adalah seorang dokter medis,

profesor kedokteran akademis, dan
penulis medis. Dia lulus dari Ross
Fakultas Kedokteran Universitas dan telah menyelesaikan
pelatihan kepaniteraan klinisnya di berbagai rumah sakit
pendidikan di seluruh New York, termasuk Rumah Sakit King's
County Center dan Brookdale Medical Center, antara lain. Dr.
Jouria telah melewati segalanya Ujian dewan medis USMLE, dan
telah bertindak sebagai tutor dan instruktur persiapan ujian
Kaplan. Dia telah mengembangkan beberapa kursus dan
kurikulum medis untuk berbagai macam lembaga pendidikan. Dr.
Jouria juga melayani di berbagai tingkatan di bidang akademik
bidang termasuk anggota fakultas dan Ketua Departemen. Dr.
Jouria terus melayani sebagai Ahli Subjek untuk beberapa
organisasi pendidikan berkelanjutan yang meliputi berbagai ilmu
kedokteran dasar. Dia juga mengembangkan beberapa
pengobatan lanjutan kursus pendidikan yang mencakup berbagai
topik dalam kedokteran klinis. Baru-baru ini, Dr. Jouria telah
dikontrak oleh University of Miami / Jackson Memorial Hospital's
Departemen Bedah akan mengembangkan seri pelatihan e-modul
untuk pasien trauma pengelolaan. Dr. Jouria saat ini sedang menulis buku teks akademis
tentang Manusia Anatomi & Fisiologi.
Abstrak
Pertumbuhan pesat perawat anestesi dalam bidang bedah dan

kesehatan lainnya pengaturan telah membantu meningkatkan layanan
yang tersedia dan hemat biaya untuk pasien. Perawat anestesi
memiliki peran penting dalam pengelolaan pasien perioperatif serta
dalam penyediaan dukungan klinis layanan di luar ruang operasi.
Seperti anestesi yang dialami dokter, mereka dapat membantu dalam
pendidikan dan pelatihan baru perawat dan staf medis dalam
penyediaan perawatan yang aman dan tepat selama berbagai
prosedur anestesi, termasuksebelum dan sesudah
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perawatan anestesi. Dengan tanggung jawab yang begitu luas,
perawat ahli anestesi harus memiliki pengetahuan klinis yang
luas. Kebijakan Pernyataan
Kegiatan ini telah direncanakan dan dilaksanakan sesuai dengan

kebijakan NurseCe4Less.com dan persyaratan pendidikan keperawatan
berkelanjutan dari Komisi Akreditasi Pusat Kredensial Perawat Amerika
untuk perawat terdaftar. Merupakan kebijakan NurseCe4Less.com
untuk memastikan objektivitas, transparansi, dan praktik terbaik dalam
pendidikan klinis untuk semua kegiatan pendidikan keperawatan
berkelanjutan (CNE).
Penunjukan Kredit Pendidikan Berkelanjutan
Kegiatan pendidikan ini diberikan selama 4,5 jam. Perawat hanya

dapat mengklaim kredit yang sepadan dengan kredit yang diberikan
untuk penyelesaian kegiatan kursus ini. Isi farmakologi adalah 1
jam.
Pernyataan Kebutuhan Pembelajaran
Perawat anestesi perlu mengetahui peran dan tanggung jawab mereka

dalam manajemen pasien yang menerima berbagai jenis anestesi.
Yang penting, sebagai anggota tim anestesi, mereka aktif terlibat
dalam perawatan pasien sebelum dan sesudah operasi yang berkaitan
dengan tahap persiapan dan perencanaan, administrasi dan pemulihan
anestesi yang mengharuskan mereka untuk terus memperbarui
miliknya pengetahuan sebagai praktisi klinis dan sebagai pemimpin
klinis dan pendidik praktik anestesi di berbagai pengaturan, termasuk
Perawatan Intensif Unit, Unit Perawatan Paliatif, dan beragam rawat
inap dan layanan bedah rawat jalan.
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Tujuan Kursus
Memberikan pembelajaran lanjutan bagi dokter yang tertarik pada

peran dan praktik perawat anestesi.
Target Audiens
Praktik Tingkat Lanjut Perawat Terdaftar dan Perawat Terdaftar

(Anggota Tim Kesehatan Interdisipliner, termasuk Perawat Kejuruan
dan Asisten Medis dapat memperoleh Sertifikat Penyelesaian)
Penulis Kursus & Tim Perencanaan Pengungkapan Konflik
Kepentingan Jassin M. Jouria, MD, William S. Cook, PhD , Douglas
Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC - semua tidak
memiliki pengungkapan.
Pengakuan Dukungan Komersial
Tidak ada dukungan komersial untuk kursus ini.

Harap luangkan waktu untuk menyelesaikan penilaian diri
atas pengetahuan, di halaman 4, contoh pertanyaan sebelum
membaca artikel.
Kesempatan untuk menyelesaikan penilaian diri atas

pengetahuan yang dipelajari akan diberikan di akhir
kursus.
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1. _____________ digunakan untuk membius suatu area tubuh.
Sebuah. Anestesi lokal

b. Anestesi umum
c. Sedasi
d. Anestesi regional
2. Benar atau Salah: Istilah "tertidur" digunakan ketika dokter

anestesi berbicara tentang pasien yang dibius karena anestesi
umum mirip dengan tidur dalam istilah fisiologis.
Sebuah. Benar
b. Salah
3. Model triad anestesi berarti bahwa _______________

diperlukan untuk menghasilkan ketiga efek anestesi yang
diinginkan: narkosis, analgesia, dan relaksasi otot.
Sebuah. obat penenang adalah

b. tim perawatan anestesi
c. banyak agen
d. hanya satu agen adalah
4. Manakah dari berikut ini yang merupakan karakteristik

aktivitas listrik otak pada subjek yang dibius tetapi tidak
pada individu yang sedang tidur?
Sebuah. Rapid eye movement (REM) tidur

b. Tidur non-REM
c. Penindasan meledak
d. Periode Aniso-elektrik
5. Sinyal nyeri berubah menjadi nyeri yang dirasakan

pada saat sinyal nyeri sensorik tiba di
a. thalamus.
b. korteks.
c. nosiseptor.
d. saraf tepi ke sumsum tulang belakang.
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Pendahuluan
Tim perawatan anestesi bekerja sama dengan semua anggota tim

bedah untuk memberikan rencana yang disesuaikan dengan setiap
pasien dalam hal dukungan hidup intraoperatif, sedasi, pengendalian
nyeri , dan manajemen pasca operasi, untuk memastikan pemulihan
yang lancar
dari prosedur bedah atau darurat lainnya. Di luar ruang operasi, ahli
anestesi medis dan keperawatan terlibat dengan unit gawat darurat
yang menyediakan pemantauan, perawatan, dan dukungan selama
investigasi diagnostik. Mereka sering melakukan intervensi di unit
perawatan intensif, unit radiologi, unit nyeri akut, dan di luar
pengaturan rumah sakit, seperti memberikan perawatan untuk pasien
terminal (yaitu, kanker) dan psikiatri (yaitu, terapi elektrokonvulsif).
Di Amerika Serikat, jumlah otonomi yang dimiliki oleh perawat
anestesi bervariasi. Saat ini, perawat anestesi terdaftar (CRNA)
bersertifikat dapat berpraktik tanpa pengawasan dokter di 17 negara
bagian Amerika Serikat.3
Gambaran Umum Anestesi Dan Konsep Umum
Karena perkembangan mutakhir alat bedah dan eksplorasi dalam

bedah umum dan peningkatan tajam subspesialisasi dalam Telinga,
Hidung, dan Tenggorokan (THT), Oftalmologi, Bedah plastik, dan
Kosmetik, di antara prosedur bedah lainnya, anestesi menjadi
spesialisasi medis rumah sakit terbesar di banyak negara.
Diperkirakan 234 juta prosedur pembedahan dilakukan setiap tahun
yang memerlukan penggunaan anestesi.1 Proporsi kasus anestesi
ruang non operasi (NORA) meningkat dari 28,3% di
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2010 menjadi 35,9% pada 2014. Ada juga tren peningkatan volume
perawatan NORA di Amerika Serikat.2
Anestesi melibatkan pengobatan yang diberikan untuk menghilangkan

rasa sakit dan sensasi selama prosedur medis seperti selama operasi.
Sedasi digunakan untuk membuat pasien tenang atau mengantuk dan
sedasi juga dapat digunakan sebagai bagian dari proses anestesi.
Dalam anestesi regional, ahli anestesi membuat suntikan di dekat
sekelompok saraf untuk mematikan area tersebut tubuh yang
membutuhkan pembedahan.
Ada tiga jenis anestesi yang perlu dipertimbangkan: 1) anestesi lokal

yang dilakukan biasanya di lokasi sayatan bedah, 2) anestesi regional
yang digunakan untuk membius suatu area tubuh (digunakan sendiri
atau dikombinasikan dengan anestesi umum), dan 3) anestesi umum
anestesi di mana pasien dibuat sama sekali tidak responsif terhadap
rasa sakit, dalam hal ini pasien memerlukan bantuan ventilasi dan
pemantauan ketat terhadap status fisiologisnya.
Sedasi adalah bidang keterampilan penting lainnya dari staf medis

dan perawat anestesi. Seringkali sedasi digunakan dalam kombinasi
dengan anestesi lokal dalam prosedur ringan yang melibatkan kulit
atau jaringan subkutan, biopsi minor, dan operasi bagian perifer
tubuh yang dapat dengan mudah dibius dengan suntikan regional.
Ada beberapa tingkatan sedasi. Dosis yang ringan memungkinkan

pasien untuk tetap terjaga atau dalam keadaan mengantuk tetapi
mudah terangsang, seperti ketika pasien mendengar namanya
dipanggil. Saat sedasi semakin dalam dengan peningkatan dosis, ahli
anestesi mungkin perlu menjaga jalan napas tetap terbuka dengan
dukungan dan membantu ventilasi pasien. Dalam
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level terdalam, sedasi menjadi anestesi umum yang disebut anestesi
intravena total (TIVA), dan untuk alasan ini harus dimasukkan dalam
diskusi tentang jenis anestesi.1,4
Anestesi Umum dan Model Triad
Meskipun istilah tertidur digunakan ketika dokter anestesi berbicara

tentang pasien yang dibius, anestesi umum sangat berbeda dengan
tidur dalam istilah fisiologis. Lantas, apa itu anestesi umum? Pertama,
anestesi umum adalah istilah yang mengacu pada keadaan tidak sadar
yang sengaja dihasilkan oleh tindakan obat pada pasien. Keadaan ini
pada dasarnya dapat dibalik. Pada masa pertumbuhan, anestesi
diperkenalkan dengan tujuan menghilangkan rasa sakit dan biasanya
diberikan oleh satu agen eter atau kloroform.
Pada tahun 1926, John Lundy memperkenalkan istilah "anestesi

seimbang" untuk menggambarkan penggunaan beberapa obat
penenang sebagai premedikasi bersama dengan anestesi umum
untuk meningkatkan hasil. Kemudian, pada tahun 1950-an, Gordon
Jackson Rees dan Cecil Gray mengusulkan tiga serangkai anestesi
yang terdiri dari narkosis (ketidaksadaran), analgesia, dan relaksasi
otot; semua direpresentasikan dalam diagram segitiga. Model triad
berarti bahwa satu agen tidak lagi ditemukan cukup untuk
menghasilkan narkosis, analgesia, dan relaksasi otot. Model triad
masih diajarkan dan digunakan dengan beberapa penyempurnaan. 1,4
Anestesi Bukan 'Tidur'
Pemahaman mengapa anestesi tidak sama dengan tidur dapat dicapai

melalui pengamatan aktivitas listrik otak melalui
electroencephalography (EEG). Menggunakan analisis EEG, tidur
dicirikan sebagai dua fase. Salah satu fase ini adalah tidur gerakan
mata cepat (REM) saat mimpi yang jelas terjadi dan tidur REM
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menyumbang 10% hingga 20% waktu tidur. Yang lainnya adalah
tidur non-REM. Kedua jenis tidur ini membentuk pola yang
berlangsung sekitar 90 menit, yaitu siklus tidur. 4
Aktivitas listrik yang intens terjadi selama siklus tidur, terutama

selama fase REM, yang menyerupai aktivitas EEG pada subjek
yang terjaga. Berbeda dengan apa yang terjadi saat terjaga dan
tidur, pada subjek yang dibius, frekuensi gelombang otak
melambat dan
amplitudo keseluruhannya berkurang. Selama anestesi umum,
pasien bahkan mungkin mengalami peredaman singkat yang
disebut penekanan meledak. Oleh karena itu, rekaman EEG
memberikan bukti bahwa anestesi berbeda dengan tidur.
Analgesia Selama Anestesi
Tujuan dari analgesia adalah untuk menghilangkan sensasi nyeri

yang dialami oleh pasien selama operasi dan juga pada fase
perioperatif. American Society of Regional Anesthesia and Pain
Medicine (ASRA) mendefinisikan nyeri sebagai "stimulus yang tidak
menyenangkan, yang menimbulkan reaksi tidak menyenangkan
pada penerima".4 Definisi ini menggabungkan komponen nyeri
subyektif dan obyektif; persepsi individu dan efek terukur obyektif
yang ditimbulkan oleh stimulus.
Dirangkum secara singkat, neurofisiologi nyeri telah terbukti terdiri
dari langkah-langkah berikut. Pertama, deteksi stimulus nyeri
(nosisepsi) karena adanya nosiseptor yang terletak di kulit dan organ
lain, yang setelah distimulasi akan menghasilkan sinyal listrik; kedua,
sinyal akan dikirim melalui saraf tepi ke sumsum tulang belakang, dan
kemudian ke talamus yang bertanggung jawab untuk
mengintegrasikan sinyal sensorik; Akhirnya,
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muncul
dari thalamus akan bergerak ke korteks di mana sinyal rasa sakit
berubah menjadi persepsi sadar, dan pada saat ini saja, rasa sakit
sedang dirasakan.
Pengalaman nyeri memicu respons emosional pada pasien, termasuk
rasa takut, marah, dan cemas, yang berusaha dihindari oleh tim
anestesi selama operasi. Tetapi prosesnya tidak berakhir di situ. Nyeri
dialami di bagian bawah sadar otak, dan memicu respons fisiologis,
mengaktifkan sistem simpatis dan dengan demikian memproduksi
adrenalin, yang bertanggung jawab atas pucat, berkeringat, detak
jantung dan pernapasan yang cepat, serta peningkatan tekanan
darah. Meskipun pasien tidak merespon secara lahiriah terhadap nyeri
bedah saat dibius, dia akan berada di bawah tekanan hormonal, yang
mengubah proses penyembuhan (dengan memobilisasi penyimpanan
energi alih-alih mengaktifkan mekanisme perbaikan) dan
menyebabkan pasien tidak nyaman terbangun.
Kondisi optimal untuk anestesi umum memerlukan kombinasi

anestesi umum untuk menghasilkan ketidaksadaran dan analgesik
untuk menekan respons stres.
Relaksasi Otot Relaksasi

otot adalah komponen terakhir dari model triad. Pembagian otot
dinding perut misalnya menyebabkan refleks kejang otot, yang
membuat pembedahan perut lebih sulit dilakukan. Selain itu,
menempatkan selang di trakea hanya dapat dilakukan dengan
anestesi yang dalam. Untuk menghindari hambatan ini, pelemas otot
diperlukan untuk memudahkan akses ke lokasi operasi dan intubasi.
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Jenis Anestesi
Sistem saraf diatur secara hierarkis. Otak dan sumsum tulang

belakang merupakan sistem saraf pusat (SSP), dan berfungsi untuk
mengintegrasikan berbagai masukan sensorik, masukan proses, dan
memperoleh perintah ke organ. Di sekitar SSP adalah sistem saraf
tepi, terbuat dari saraf tepi yang menyampaikan informasi dari
berbagai bagian tubuh ke SSP, dan menyampaikan sinyal dari SSP
kembali ke tubuh. Bagian ini menyoroti jenis obat anestesi dan situs
target di tubuh tempat efeknya terjadi.1,4-8
Saraf tepi terbuat dari campuran beberapa jenis serabut dan setiap
jenis memiliki fungsi tertentu. Untuk setiap saraf tertentu, sinyal
mungkin menuju ke SSP, yang dikenal sebagai sinyal aferen (juga
disebut naik), atau menjauh dari SSP dan dikenal sebagai sinyal
eferen (juga disebut descending).
Sinyal naik hampir semuanya bersifat sensorik, yang meliputi nyeri,

suhu, sentuhan, getaran, dan proprioception (sensasi posisi sendi). Di
satu sisi, sentuhan, getaran, dan proprioception berjalan melalui serat
tipe A, yang memiliki lapisan mielin, lipid yang meningkatkan
kecepatan konduksi saraf. Ketika mencapai sumsum tulang belakang,
sinyal naik dalam struktur yang disebut kolom punggung, di sisi yang
sama dari tubuh tempat sinyal itu berasal. Di sisi lain, sinyal nyeri dan
suhu bergerak dalam serat tipe C; serat-serat ini memiliki diameter
yang lebih kecil dan kekurangan mielin, sehingga kecepatan konduksi
mereka lebih lambat. Sinyal-sinyal ini berjalan di saluran spino-
thalamic di sisi tubuh yang berlawanan dari sinyal.
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Sinyaldigunakan untuk menghasilkan gerakan otot; mereka juga
disebut sinyal motor dan bergerak melalui serat tipe A. Selain itu,
sinyal turun lainnya yang mengatur
fungsi organ dalam seperti
pernapasan, pencernaan, detak
jantung,
kontrol kandung kemih, berada di
bawah
kesadaran dan bergantung
pada sistem otonom dengan
dua komponennya - jalur simpatis
dan parasimpatis.
Sel saraf atau neuron terdiri dari

badan sel ("soma") yang darinya
muncul ekstensi atauseperti benang
yang
prosesdisebut dendrit dan
akson, yang panjang dan ramping
proyeksi neuron, atau proses yang
menghantarkan impuls listrik jauh
dari soma neuron. Panjang akson
bisa mencapai 1 meter. Serabut
saraf terbuat dari akson sel saraf, yang dapat bermielin atau tidak
bermielin.
Saraf individu mentransmisikan sinyalnya di sepanjang akson dengan

muatan listrik yang merambat sendiri yang disebut potensial aksi.
Bagian dalam akson kaya akan ion kalium sedangkan bagian luarnya
kaya akan ion natrium. Keadaan ini terus dipertahankan oleh pompa
ion yang terletak di permukaan membran akson dan
ketidakseimbangan inilah yang menciptakan energi potensial.
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Membuka saluran ion di membran memungkinkan natrium dan kalium
berpindah tempat yang mengarah ke depolarisasi yang berlangsung
beberapa milidetik. Menanggapi depolarisasi ini saluran lain yang
disebut saluran gerbang tegangan diaktifkan untuk repolarisasi
membran sel di lokasi ini. Suksesi depolarisasi dan repolarisasi
memungkinkan penyebaran impuls untuk menyebar di sepanjang
akson, yang disebut potensial aksi. Potensial aksi kemudian diteruskan
dari neuron ke neuron di persimpangan sinaptik di mana ia memicu
pelepasan bahan kimia atau neurotransmiter. Pada tingkat ini,
potensial aksi lain yang dimediasi oleh pengikatan neurotransmitter ke
situs dendritik sinaps akan dimulai dan seterusnya.
Beberapa zat yang ditemukan di alam diketahui mengganggu

penyebaran potensi aksi. Senyawa yang paling banyak diketahui
yang mengganggu konduksi saraf dengan memblokir saluran
natrium gerbang tegangan adalah kokain, obat anestesi pertama.
Kokain dan Produk Farmakologi
Turunannya Kokain adalah alkaloid yang ditemukan di daun tanaman

koka (erythroxylum coca) asli Amerika Selatan. Orang Spanyol
membawa tanaman itu ke Eropa pada abad ke-16 dan kokain untuk
pertama kalinya diisolasi pada tahun 1855 oleh Friedrich Gaedcke.
Belakangan, itu bahkan dimasukkan ke dalam minuman tonik seperti
Coca-Cola pada tahun 1866. Kokain bekerja pada dua tingkat sistem
saraf. Pertama, ia memblokir saluran natrium dengan gerbang
tegangan di neuron perifer sehingga menjadikannya agen anestesi
lokal yang efisien. Kedua, kokain bekerja pada sistem saraf pusat
dengan menghalangi pengambilan kembali neurotransmitter stimulasi
seperti dopamin, serotonin dan noradrenalin di sinapsis.
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Biasanya, neurotransmitter stimulasi didaur ulang kembali ke neuron
transmisi oleh transporter protein khusus; jika kokain ada di dalam
tubuh, ia menempel pada dopamin, serotonin atau noradrenalin
pengangkutdan menghalangi proses daur ulang normal,
mengakibatkan penumpukan neurotransmiter stimulasi ini di
sinapsis. Ini memiliki efek meningkatkan tindakan mereka. Tindakan
kedua inilah yang bertanggung jawab atas stimulan kokain dan sifat
adiktif.
Pada tahun 1904 di Institut Pasteur, Ernest Fourneau berhasil

mensintesis amilokain dan berhasil menyelesaikan pencarian obat lain
yang memiliki sifat anestesi serupa tanpa efek samping adiktif. Sejak
itu, hampir semua obat anestesi lokal menggunakan sufiks - caine.
Amilokain dan penerusnya memiliki karakteristik biokimia yang sama.
Mereka memiliki struktur berbentuk cincin yang digabungkan dengan
hubungan pendek yang larut dalam air. Jika mata rantai penghubung
adalah gugus ester maka obat akan dihidrolisis dalam plasma oleh
pseudocholinesterase; dan, jika kaitannya adalah ikatan amida,
hidrolisis akan terjadi di hati. Semakin panjang gugus amino
penghubung, semakin besar potensi dan toksisitas anestesi lokal.
Amilokain dan prokain memiliki hubungan ester, yang dapat dipecah

dalam aliran darah sehingga kedua obat ini dikenal karena durasi
kerjanya yang sangat singkat. Mereka juga dikaitkan dengan
insiden reaksi alergi yang lebih tinggi karena salah satu
metabolitnya, asam para-amino benzoat (PABA). Akhirnya, ikatan
amida diganti dengan ester, membuat molekul lebih stabil dan
dengan durasi kerja yang lebih lama. Desain terakhir ini mengarah
pada sintesis lidokain (tahun 1943), bupivakain (tahun 1963), dan
ropivacaine (tahun 1993).
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Obat yang Digunakan Dalam Anestesi Lokal
Karena agen anestesi lokal bekerja dengan memblokir konduksi saraf

sensorik dan motorik, mereka menghasilkan hilangnya sensasi
sementara tanpa kehilangan kesadaran atau depresi sistem saraf
pusat . Terlepas dari kenyataan bahwa kokain adalah anestesi lokal
yang pertama kali diidentifikasi, efeknya pada sistem saraf pusat,
ditambah dengan potensi kecanduannya, telah mengakibatkan
penurunan yang signifikan dari penggunaan klinisnya. Bagian ini
merangkum karakteristik obat yang lebih baru dikembangkan, yang
saat ini digunakan dalam anestesi lokal dan regional. Obat tersebut
adalah procaine, tetracaine, lidocaine, bupivacaine dan ropivacaine. 1,4-7
Procaine
Procaine memiliki durasi kerja yang singkat, menyebabkan toksisitas
sistemik minimal dan tidak menimbulkan iritasi lokal. Kombinasi
prokain epinefrin menurunkan laju penyerapannya dalam aliran darah
dan menggandakan durasi kerjanya. Larutan 1% -2% digunakan
untuk pemblokiran saraf pada anestesi regional dan anestesi infiltrasi,
dan 5% - 20% diperlukan untuk anestesi spinal. Procaine tidak efisien
untuk penggunaan topikal.
Tetracaine
Tetracaine kira-kira 10 kali lebih kuat dan lebih beracun daripada

prokain. Onset kerjanya sekitar 5 menit dan efeknya berlangsung
antara 2 dan 3 jam. Larutan tetrakain 2% digunakan secara topikal
pada selaput lendir.
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Lidocaine
Lidocaine juga dikenal dengan nama xylocaine cepat diserap, memiliki

onset kerja yang cepat, dan menyebabkan iritasi lokal minimal. Ini
lebih kuat dan memiliki durasi kerja yang lebih lama daripada prokain.
Larutan 0,5% digunakan untuk anestesi infiltratif, sedangkan larutan
1% -2% diperlukan untuk anestesi blok saraf dan mukosa topikal.
Lidokain juga tersedia sebagai salep, jeli dan krim.
Bupivacaine
Bupivacaine digunakan terutama untuk anestesi regional dalam

konsentrasi yang berkisar antara 0,25% -0,75%. Toksisitasnya mirip
dengan tetrakain. Efek yang tidak diinginkan termasuk hipotensi,
bradikardia, dan gangguan motorik dalam waktu lama, kardiotoksisitas,
dan toksisitas sistem saraf pusat, yang dapat berakibat fatal. Efek
samping yang parah ini terjadi setelah overdosis atau suntikan
intravaskular yang tidak disengaja.
Ropivacaine
Ropivacaine hampir identik dengan bupivacaine dalam hal onset,

kualitas dan durasi blok sensorik, tetapi menghasilkan durasi
blokade motorik yang lebih rendah dan memiliki profil keamanan
yang lebih baik.
Efek Merugikan Anestesi Lokal
Efek merugikan sistemik dari anestesi lokal diakibatkan oleh masuknya

sejumlah toksik anestesi lokal ke dalam aliran darah. Akibatnya,
epinefrin diresepkan sebagai tambahan anestesi lokal bila
memungkinkan untuk mengurangi laju absorpsi sistemik dan dengan
demikian toksisitas sistemik. Meskipun jarang, reaksi alergi terhadap
anestesi lokal telah diamati. Anestesi lokal tertentu, seperti
15
nursece4less.com nursece4less.com nursece4less.com nursece4less.comtetracaine
procaine dan, dikaitkan dengan insiden reaksi alergi yang lebih
tinggi karena metabolit para-amino benzoic acid (PABA).
Anestesi Lokal: Topikal dan Subkutan
Anestesi lokal kurang baik menembus kulit yang sehat. Oleh karena
itu, mengaplikasikannya sebagai krim atau gel bukanlah cara yang
paling efektif untuk memberikan anestesi lokal. Namun, ada preparat
seperti tetracaine atau lidocaine / prilocaine, yang digunakan untuk
membius kulit dalam keadaan tertentu; misalnya, sebelum
pengambilan sampel darah pada populasi anak.
Berbeda dengan kulit, selaput lendir menyerap anestesi topikal dengan

baik. Sebagai contoh, penggunaan anestesi topikal efektif dalam
prosedur atau operasi mata. Tetracaine tetes mata dapat memberikan
anestesi kornea yang efektif sebelum ekstraksi benda asing dari mata,
atau bahkan selama operasi mata berkepanjangan yang melibatkan
otot ekstra-okuler. Akhirnya, anestesi infiltratif adalah teknik lain
untuk anestesi lokal. Di sini anestesi disuntikkan secara subkutan.
Prosedur ini sangat cocok untuk operasi kecil seperti menjahit luka
yang dangkal.
Anestesi Regional Anestesi
regional diperoleh dengan cara memblokir saraf, sehingga kulit,

struktur yang lebih dalam, dan otot-otot yang disuplai saraf menjadi
lumpuh. Hasil anestesi regional di ketidakmampuan untuk
memindahkan
16
otot atau nyeri akal. Anestesi regional mempengaruhi suhu di area
saraf yang terkena.
Ada dua kategori utama blok saraf. Blok neuraksial pertama yang
disebut melibatkan tulang belakang dan dapat dibagi lagi menjadi
blok tulang belakang, epidural dan ekor. Yang kedua disebut blok
perifer mungkin melibatkan mata, payudara, batang tubuh,
ekstremitas atas dan ekstremitas bawah. Blok perifer dapat
digunakan sendiri atau dikombinasikan dengan anestesi neuraksial
atau anestesi umum.
Teknik alternatif lain dari anestesi regional terdiri dari injeksi anestesi
intravena ke anggota tubuh, yang diisolasi dari sirkulasi dengan
menggunakan tourniquet dan disebut blok Bier.
Keuntungan Anestesi Regional
Selain mengontrol nyeri, anestesi regional memiliki sejumlah

keuntungan. Hal ini memungkinkan pasien untuk bernapas secara
mandiri tanpa dukungan jalan napas, mengurangi mual dan
muntah pasca operasi, memblokir
respons inflamasi akibat stres terhadap trauma bedah, dan
menghindari manipulasi jalan napas dalam kasus yang sulit. Karena
anestesi regional disertai dengan pelebaran pembuluh darah dan
tekanan yang lebih rendah di dalam pembuluh yang melebar, akan
ada lebih sedikit kehilangan darah dan lebih sedikit kebutuhan untuk
transfusi darah. Selain itu, anestesi regional memungkinkan pemulihan
fungsi usus lebih awal serta rehabilitasi lebih awal dan keluar dari
rumah sakit.
Teknik Umum Teknik
anestesi regional melibatkan memasukkan jarum cukup dekat ke saraf

untuk menyimpan agen anestesi tanpa melukai
17
sarafnursece4less.com nursece4less.com nursece4less.com nursece4less.com
itu sendiri. Untuk ini, dimungkinkan untuk mengandalkan penanda
anatomi untuk menemukan lokasi saraf, tetapi penanda anatomi
mungkin berbeda dari satu individu ke individu lainnya. Saat ini, saraf
ditemukan menggunakan bantuan stimulator saraf elektronik, yang
lebih akurat dan menghemat waktu. Arus listrik kecil dialirkan ke jarum
dan, saat saraf mendekat, arus tersebut menyebabkan otot yang
dipersarafi oleh saraf berkedut. Ini memberi sinyal kepada operator
bahwa ujung jarum cukup dekat dengan saraf.
Cara lain untuk menghindari cedera saraf dan pembuluh darah besar
selama injeksi adalah penggunaan pemindai ultrasonik portabel,
yang memungkinkan blok saraf terpandu di bawah visualisasi
langsung dari struktur di sekitarnya saat jarum mendekati targetnya.
Kedua teknik ini saling melengkapi karena memberikan informasi
penting tentang fungsi dan anatomi saraf. Oleh karena itu, obat ini
digunakan dalam kombinasi oleh banyak tim anestesi.
Sebelum prosedur anestesi regional dimulai, pasien diposisikan dan

dihubungkan ke monitor standar untuk tindak lanjut tanda-tanda vital
sama seperti jika pasien menerima anestesi umum. Pasien dibius
dalam dosis kecil untuk menjaga kenyamanan pasien tetapi menjaga
kesadaran pasien karena kemampuan pasien untuk berkomunikasi
selama operasi penting untuk menjaga keamanan blok. Untuk
prosedur yang lama, kateter plastik dapat dimasukkan dan dibiarkan
in situ, sehingga suntikan berulang, atau infus anestesi dapat
diberikan.
Blokade regional terjadi secara perlahan, dan mungkin memerlukan

waktu hingga 30 menit setelah injeksi agar efektif sepenuhnya.
Anestesi regional tidak selalu
18
dapat diandalkan dalam memberikan analgesia lengkap selama
operasi. Oleh karena itu, untuk beberapa jenis operasi, blokade
regional dilakukan sebagai tambahan pada anestesi umum. Dalam
kasus ini, blok regional ditempatkan pertama diikuti dengan induksi
anestesi umum. Blok ini juga dapat meredakan nyeri setelah
pembedahan jika kateter saraf dibiarkan terpasang untuk injeksi
setelah pasien pulih dari anestesi umum. Prosedur Blok Neuraksial
Blok
neuraksial juga dikenal sebagai blok tulang belakang, blok

subarachnoid, blok intradural atau blok intratekal. 12-15 Sumsum tulang
belakang adalah struktur yang sangat halus. Itu ditutupi oleh lapisan
mikroskopis yang disebut pia mater, dan tersuspensi dalam cairan
berair jernih, cairan serebrospinal, yang bersirkulasi di sekitarnya.
Cairan serebrospinal diapit oleh membran rapuh lainnya, arachnoid,
yang pada gilirannya tertutup dalam membran keras yang disebut
dura mater.
Pada anestesi spinal, anestesi lokal disuntikkan ke dalam ruang

subarachnoid yang terletak di antara pia mater dan arachnoid,
menggunakan jarum halus, biasanya sepanjang 9 cm (3,5 in).
Anestesi spinal memberikan blok padat dari semua fungsi sumsum
tulang belakang di bawah level blok. Ini termasuk hilangnya fungsi
motorik dan sensitif serta hilangnya refleks otomatis yang mengontrol
tekanan darah dan detak jantung tergantung pada tingkat
penyumbatan. Kepala dan tubuh tidak terpengaruh dan pasien tetap
terjaga.
Ketinggian atau ketinggian blok tergantung pada tempat suntikan,

yang biasanya dilakukan di daerah pinggang, tetapi juga pada difusi
larutan anestesi di cairan serebrospinal (CSF). Untuk mencegah
penyebaran obat anestesi yang lebih tinggi dari yang dimaksudkan,
beberapa solusi untuk anestesi spinal diformulasikan dengan
dekstrosa 8%, menjadikannya
19
lebih padat (larutan hiperbarik)(larutan hiperbarik) daripada CSF.
Setelah injeksi, pasien akan diposisikan sesuai dengan gravitasi untuk
mengontrol ketinggian balok.
Peta Dermatom
Ada delapan saraf serviks, dua belas saraf toraks, lima saraf lumbal
dan lima saraf sakral. Masing-masing saraf ini menyampaikan sensasi
dari wilayah tertentu ke otak. Dermatom adalah area kulit yang
disuplai oleh serabut sensorik saraf tulang belakang. Di kepala dan
bagasi, setiap segmen ditempatkan secara horizontal, kecuali C1, yang
tidak memiliki komponen sensorik.8
Penilaian Tingkat Blokade Neuraksial
Pengetahuan tentang tingkat dermatom adalah kunci yang

memungkinkan ahli anestesi untuk menilai tingkat blokade. Saraf
tulang belakang mengandung jalur sensorik dan motorik, serta serat
otonom. Secara umum, serat bermielin kecil lebih rentan terhadap
blokade daripada serat tak bermielin yang lebih besar. Selain itu,
dengan blok neuraksial ada perbedaan antara tingkat blok simpatis,
sensorik dan motorik. Tingkat simpatis umumnya dua sampai enam
tingkat dermatom lebih tinggi dari tingkat sensorik. Tingkat sensorik
kira-kira dua tingkat dermatom lebih tinggi dari tingkat motorik. 9
Contraindications
Contraindications should include patient refusal, infection, abnormal

coagulation, and cardiac disease. The use of neuraxial anesthesia in
20
patients with pre-existing neurologic disorders, such as multiple
sclerosis is not recommended unless it is absolutely necessary.
Indications of Spinal Anesthesia
Spinal anesthesia is used for almost any procedure of the lower half of
the body, including orthopedics, obstetrics, and prostate surgery. The
use of spinal anesthesia has also been described for surgeries in the
head and neck where punctures performed between the 1st and 2nd
thoracic vertebrae resulted in good analgesia. Laparoscopic surgeries
such as laparoscopic cholecystectomy performed under spinal
anesthesia require very small incisions, produce less pain and result in
shorter hospital stays. They are particularly advantageous to use in
older and high-risk patients for general anesthesia. 10 In the same
manner, spinal anesthesia has been associated with a lower
postoperative mortality risk in elective total joint replacement
surgery.11
Spinal anesthesia is generally preferred over a general anesthesia in

the obstetric population, as long as it is not contraindicated. The dose
of local anesthetic is often reduced to one-third due to changes in the
intra-abdominal pressure and effects of hormones, which increase
sensitivity.
Drugs and Associated Factors Influencing Effect
The level and duration of spinal anesthesia are primarily determined

by 1) baricity (the density of the drug as compared to the density of
human cerebrospinal fluid), 2) contour of the spinal canal, and 3)
patient position in the first few minutes after injection. To optimize
lordosis, a pillow is placed under the patient's knees; the other option
21
is to place the patient in the lateral position. Isobaric solutions
undergo less spread than hyperbaric solutions, and both of these
solutions are suited for perineal or lower extremity surgery. Hypobaric
solutions (sterile water or normal saline) are rarely used due the
osmotic stress they might cause.
Short Duration Procedure
Lidocaine, with duration 60-90 minutes, provides good sensory and

motor block. The dose of lidocaine used is between 60-75 mg.
Lidocaine has been linked to transient neurologic symptoms in up to
one-third of patients. Lidocaine gives less vasodilation.
Longer Duration Procedure
Bupivacaine is the most commonly used local anesthetic. It decreases

spinal and dural blood flow, and 2 to 3 ml of 0.5% in the cerebrospinal
fluid provides about 2 hours of surgical anesthesia. It is administered
at similar dose and duration as tetracaine (5-20 mg with duration of
90-120 minutes). However, bupivacaine gives a slightly more intense
sensory anesthesia (and less motor blockade) than tetracaine.
Tetracaine provides slightly more motor blockade (although less

sensory anesthesia) than bupivacaine. Its duration of action is more
variable than bupivacaine. And since tetracaine is accompanied by
important vasodilation, it is more profoundly affected by
vasoconstrictors.
Spread of anesthesia is affected by the addition of vasoconstrictors; so

the addition of epinephrine (usually 0.1 – 0.2 mg of epinephrine, ie.,
22
0.2 to 0.5 cc of 1:1000, or 2 – 5 mg phenylephrine) may be
considered to prolong and/or improve the quality of the block.
Opioids (usually fentanyl 25 µcg) and morphine (0.1 – 0.5 mg) can be
added to provide 24 hours of relief, but unlike fentanyl, morphine
requires in-hospital monitoring for respiratory depression.
Technique
Spinal anesthesia is one of the oldest techniques in anesthesia. Its use

to produce surgical anesthesia dates back to 1899, and was reported
in a classic paper by a German surgeon Augustus Bier.
Spinal anesthesia is considered as a routine part of any anesthetist

skills. The technique of administering spinal anesthesia can be
described as the “4 P's”: preparation, position, projection, and
puncture. The use of a rigorous aseptic technique during both the
preparation and the procedure itself must be the rule, as reviewed
further below.12-15
Preparation
Preparation refers to the preparation of the material necessary for the

procedure based on the type of planned surgery and patient's
characteristics (general status, associated pathologies).12 The
anesthetist will then be able to choose the appropriate anesthetic drug
and formulation (hypobaric, hyperbaric, or isobaric), to match the
proposed length of the surgical procedure.
23
Prepackaged spinal kits are normally used or can be custom made. If a
prepackaged spinal kit is not available, the following equipment needs
to be assembled:
• Sterile towels
• Sterile gloves
• Sterile spinal needle
• An introducer needle if using a small gauge needle (this can be a
sterile 19 gauge disposable needle)
• Sterile filter needle to draw up medications
• Sterile 5 ml syringe for the spinal solution
• Sterile 2 ml syringe with a small gauge needle to localize the
skin prior initiation of the spinal anesthetic
• Antiseptics for the skin (such as betadine, chlorhexidine, methyl
alcohol)
• Sterile gauze for skin cleansing and to wipe off excess antiseptic
at needle puncture site
• Single use preservative free local anesthetic ampoule made
specifically for spinal anesthesia
Local anesthetics from multi-dose vials or those that contain

preservatives should never be used for spinal anesthesia. Prior to
initiating a spinal block, the clinician's hands must be carefully washed.
The patient should be attached to standard monitors including
electrocardiogram, blood pressure, and pulse oximetry, and an initial
set of vital signs should be recorded. Access to an intravenous route
should be ensured.
Positioning of the Patient
Proper positioning of the patient is essential for a successful block. 24

There are three positions used for the administration of spinal
anesthesia: lateral decubitus, sitting, and prone. In lateral decubitus,
the patient is positioned with their back parallel with the side of the
operating table. Thighs are flexed up, and the neck is flexed forward in
a fetal position. The patient should be positioned to take advantage of
the baricity of the spinal local anesthetic. The seated position is used
for anesthesia of the lumbar and sacral levels required by urological or
perineal surgeries. The patient should be sitting up straight, with feet
on a stool, head flexed and arms hugging a pillow. For a lower
lumbar/sacral block, the patient is left sitting for 5 minutes before
assuming a supine position. The prone position is used when the
patient will be in this position for the surgical procedure such as rectal,
perineal, or lumbar procedures.
Approaches to Access Subarachnoid Space
There are two approaches to access the subarachnoid space: the

midline and paramedian approach. The midline approach is easiest and
passes through less sensitive structures. The patient is sitting up
straight and with proper positioning to give access to L2-L3, L3-L4, L4-
L5, and L5-S1. After identification of the top of the iliac crests, Tuffier's
line, a landmark for the placement of spinal or epidural needle, which
meets the body of L4 or L4-L5 interspace, is drawn across the iliac
crest. Whereas, the paramedian approach is better suited for narrow
interspaces or difficulty with flexion, and typically is located 1 cm from
the midline. The advantage is that by placing the needle laterally, the
anatomical limitation of the spinous process is avoided. The most
common error when attempting this technique is being too far from the
midline, which makes encountering the vertebral lamina more likely.
25
Puncture
All precautions should be taken during the step that involves spinal
puncture to preserve a sterile environment. The clinician should wash
hands, put on sterile gloves, and use sterile technique. The tray should
be prepared in a sterile fashion. The patient's back should be prepped
with an antiseptic. A skin wheal of local anesthetic is placed at the
intended spinous interspace.
Smaller gauge needles will require an introducer to stabilize the

needle. The introducer is placed firmly into the interspinous ligament.
Grasping the introducer with one hand, the anesthetist should hold the
spinal needle like a dart/pencil. Cutting needles should be inserted with
the bevel parallel to the longitudinal fibers of the dura. This helps
reduce cutting fibers and enhances tactile sensation as anatomical
structures are crossed. Anatomical structures that will be transversed
include skin, subcutaneous fat, supraspinous ligament, interspinous
ligament, ligamentum flavum, epidural space, and dura.
Monitoring During Spinal Anesthesia
After successful placement, the patient should be monitored

continuously for block progression and complications. The first 5-10
minutes are critical in terms of monitoring the cardiovascular response
as well as the level of progression of anesthesia. The patient's blood
pressure should be taken every 3 minutes, initially. The patient should
be monitored for the following:
Block Progression:
26
The anesthetist has to ensure that the block is adequate for the
surgical procedure and does not progress too high. Numbness of the
arms and hands and breathing problems may indicate that the block is
too high. High spinals are often accompanied by hypotension, nausea,
and agitation.
Hypotension can be severe enough to cause stroke so it should be

treated aggressively if blood pressure decreases by 20% or more from
baseline. Bradycardia should be treated aggressively as it may
progress to cardiac arrest. A change in the level of consciousness
“total spinal anesthesia” is accompanied by loss of consciousness.
Measures to prevent high spinal spread:
• Use “Heavy” Bupivacaine (0.5% + 8% dextrose)

• Inject slowly at L3/4 or L4/5
• Inject correct dose (≤ 2mls)
• Head elevated on pillow
• Monitor rising spinal level
Emergency treatment in case of high spinal spread:
• Raise the Blood pressure aggressively with vasopressors •

Bradycardia is treated with atropine and ephedrine, adrenaline in
severe cases
• Intravenous fluids, colloid solutions, oxygen
• Intubate and ventilate if loss of consciousness
Postoperative Care Monitoring:
Patient's recovering from a spinal anesthesia should receive the same

vigilant monitoring as the patient recovering from general anesthesia.
27
Patients may experience some level of hypotension in the
postoperative period too. Treatment includes a Trendelenburg position,
additional intravenous fluids, oxygen, and vasopressors as needed.
Urinary retention should be assessed in patients that do not have a

urinary catheter. The patient should not be discharged from the
recovery area until vital signs are stable and the spinal block is
regressing. The patient should remain in bed until full sensory and
motor function has returned. The first time a patient is ambulated, the
patient should be assisted by a medical or nursing clinician to ensure
full function has returned.
Epidural Anesthesia And Analgesia
This section provides a specific focus on the combination of epidural

anesthesia and analgesia medication for the critical management pain
control and patient cooperation during a surgical procedure. The
epidural (or extradural) space is a potential space surrounding the
outer envelope of the spine, which contains loose fat tissue and veins.
The injection of local anesthetics in the epidural space creates a less
pronounced block than a spinal injection. The anesthetics will target
the spinal nerves on their path out of the vertebral canal. Myelinated
nerve fibers (type C-fibers) are more resistant to local anesthetics.
This means that unmyelinated sensory nerve fibers, which carry pain
signals, are blocked earlier and more completely than myelinated
fibers. This explains why a moderate dose of anesthetic will produce
analgesia without impairing the motor and touch function. However, to
obtain a dense block much like a spinal, one would need a dose about
ten times greater than the dose required for a spinal.1,4-8,12-19
28
Neural Blockade
As with spinal anesthesia, a number of parameters determine how far

neural blockade will spread after epidural injection. Some variables are
intrinsic to the patient's anatomy; others depend on variations in the
techniques and the drugs given. The combination of all of these
variables can make the spread of the solution in the epidural space
unpredictable.
Epidural analgesia is commonly indicated during labor and childbirth

because it provides pain relief while still allowing the mother to push
with her pelvic muscles when needed (at this stage the anesthetist has
to simply discontinue the anesthetic infusion). Also, when labor does
not proceed as expected and a cesarean section is planned in an
emergency, the anesthetist needs only to inject a more concentrated
local anesthetic to achieve a denser anesthesia to the lower abdomen
for the surgical incision.
In addition to obstetrics indications, any lower limb procedure such as

hip replacement, knee replacement or fracture repair can benefit from
epidural anesthesia. Furthermore, epidural analgesia has proved useful
during the recovery from surgeries performed under general
anesthesia such as, upper abdominal or thoracic procedures which can
be quite painful. In this scenario, epidural anesthesia has been shown
to provide a better postoperative pain management than opioids or
morphine, in the same time it decreases postoperative ileus and
improves patient recovery. The latter advantages are particularly
important in elderly patients as well as in patients with pre-existing
pathologies.
29
Types of Epidural Anesthesia
Single-shot technique is easiest and provides the most uniform spread

of anesthetic. Always begin with a negative aspiration and a test dose
(3 ml of 1.5% lidocaine with 1:200,000 epinephrine) followed by a 3
minute waiting period. If the test dose is adequate, the total amount is
injected in fractionated aliquots of 5 ml each.
Continuous epidural techniques involve placement of a catheter 3-5 cm

beyond the needle (any longer than has the risk of penetrating into a
vein, exiting the foramen, or wrapping around a nerve root). In a
standard technique the catheter can be left in place for up to 72 hours
and the retrieval of the catheter should never be done through the
needle due to the risk of nerve transection.
Caudal blocks are epidural injections placed through the sacrococcygeal

ligament and sacral hiatus, absent in 10% of patients. The technique
consists in passing the needle through the ligament until it hits the
sacrum, and then retracting slightly before aiming cephalad (towards
the head), and then readvancing 2 cm and injecting air; if no crepitus
is felt, it is likely placement is in the caudal canal and the anesthetist
can inject. As with all neuraxial procedures, caudal block should be
executed with a rigorous aseptic technique.
Duration and Influencing Factors
Dose and volume are important for epidural anesthetics, while

concentration is not. By decreasing concentration and increasing
volume, one can obtain greater anesthetic spread.
30
In contrast to spinal anesthesia, baricity does not matter in epidurals,
but negative intrathoracic pressure does in terms of levels. Lumbar
epidurals tend to flow cephalad due to negative intrathoracic pressure,
whereas thoracic epidurals tend to stay in place. L5/S1 anesthesia is
more difficult, likely due to the large fiber size. Chlorprocaine is used
for rapid onset and short procedures. Lidocaine is intermediate, and
bupivacaine/L-bupivacaine/ropivacaine has slower onset and prolonged
duration. Tetracaine and procaine are not used because of their long
latency times.
On a practical level, for a one-shot epidural, a 20 cc dose via lumbar

injection is assumed to provide a mid-thoracic level block and then the
volume is adjusted according to the desired level, for example, a
decrease in the volume if only lower dermatomes are the aim.
Bupivacaine produces a significant sensory block with minimal motor
block, as opposed to etidocaine, which has a more pronounced motor
block. Epinephrine at 1:200,000 can prolong a lidocaine block, but not
a bupivacaine block. The mechanism for the latter is unknown; a
decreased blood flow, an intrinsic analgesia provided by epinephrine,
or an increased volume of distribution has been hypothesized.
Adjuvant Medications
Epinephrine (1:200,000 or 5µcg/mL) can prolong an epidural,

especially if chlorprocaine or lidocaine is used. One has to be aware
however that the mild B-stimulation may accentuate the fall in blood
pressure that generally occurs with neuraxial anesthesia. On the other
side, other studies report that the use of epinephrine seem to be
preferable to phenylephrine at an equivalent dose as it has been
shown to preserve cardiac output in contrast to the latter.
31
The use of opioids can enhance analgesia, with the degree of side
effects largely related to lipid solubility. Morphine (hydrophilic or
lipophobic) injected epidurally stays in place or spreads rostrally
(distribution of medication within the cerebrospinal fluid), whereas
fentanyl (hydrophobic/liphophilic) will be rapidly absorbed.
Sodium bicarbonate is known to promote a more rapid onset of

epidural anesthesia.
Neuraxial Anesthesia Complications
Neuraxial techniques are generally considered safer than general

anesthesia, particularly in patients with difficult airway management,
elderly debilitated patients and even the premature newborn.
However, several studies demonstrate that the setting in which a
neuraxial block is performed, as well as the technique used, make a
difference in the risk of complications. Adverse effects of neuraxial
anesthesia may be as minimal as discomfort but may have more
serious consequences such as disability or even death.
Hypotension
Hypotension is the most frequent immediate adverse effect. It occurs

in one third of patients, initially due to decreased vascular resistance
but in severe cases it may be due to decreased venous return and
cardiac output. Risk factors for hypotension include arterial
hypertension, obesity, increased fetal weight, chronic alcohol use, and
a high level of blockade. Hypotension may cause intraoperative nausea
and vomiting. Bradycardia may also be present if the block involves
32
the heart-accelerating fibers (T1-T4 level), or from a decreased venous
return.
A slight head-down position (5-10 degrees) to increase venous return

without altering the spread of anesthetic and the maintenance of an
adequate hydration are able to correct the situation.
High Blockade or High Spinal
Due to excessive spread of the anesthetic to higher levels of the

dermatome, hemodynamic and respiratory effects are expected to
occur. It can happen both in spinal and epidural anesthesia. A total
spinal blockade is characterized by sympathetic blockade and
respiratory arrest needs immediate and aggressive treatment as
described in the section above on monitoring.
Cardiac Arrest
Cardiac arrest is most frequently seen in spinal anesthesia with an

incidence estimated at 2.73 per 10,000 patients. A high block,
dehydration, deep sedation, and inadvertent intravascular injection of
the anesthetic, are considered risk factors for this complication.
Urinary Retention
Studies have shown that the sensation of urgency to void disappears

30-60 seconds after spinal injection of anesthetic solution; as for the
detrusor muscle, contraction is completely abolished 2-5 minutes
after. Opioid administration also affects bladder function and
contributes to urinary retention.
33
Urinary retention is a complication which is more common in men older
than 50 years with a history of urologic dysfunction as well as in
anorectal surgery, inguinal hernia repair, hip surgery and gynecological
surgery. Other risk factors include perfusion of large amount of fluids,
the use of long acting anesthetics, and the site of the injection for
epidurals. A lumbar site is more often associated with urinary retention
than a thoracic site. Postoperative urinary retention causes
unnecessary pain, vomiting, bradycardia, hypotension, and can be
complicated by urinary infection. Bladder catheterization is
recommended in high-risk patients.
Adverse Effects: CNS and Technique
Central nervous system toxicity can occur whereby the initial

excitatory phase is characterized by the onset of facial numbness,
metallic taste and tinnitus followed by agitation or confusion and
seizures. A depressive phase occurs that involves respiratory
depression and coma following the above symptoms. Cardiovascular
toxicity can also occur and is initially manifested by tachycardia and
hypertension followed by hypotension and myocardial depression,
and then by vasodilation and arrhythmias.
Adverse effects due to technique are highlighted below:
Paresthesia
Paresthesia may be experienced as sharp discomfort by the patient,

during the insertion of the needle or the catheter, radiating to the
buttocks, pelvis or legs. In such case, it is recommended to stop
advancing the needle or injecting the anesthetic at the site as it may
34
result in nerve injury; in fact, this is the main reason that anesthetists
conduct spinal procedures while the patient is still alert to be able to
report such sensations.
Postdural Puncture or Spinal Headaches
Postdural puncture or spinal headaches are postural; they are due to a

leak of cerebrospinal fluid through the hole left by the needle. They are
experienced by the patient while sitting and resolve in a supine
position. They are less common now due to the availability of smaller
needles for spinal anesthetics injection.
Spinal headaches are treated most successfully with bed rest and an
increase in fluid for 24 hours. If they persist, the next therapeutic
option will be to perform an epidural blood patch, which consists in
drawing blood from the patient and injecting it in the epidural space to
help seal the hole.
Spinal or Epidural Hematoma
Spinal or epidural hematoma is a rare and potentially catastrophic

complication of neuraxial anesthesia because of the nature of the
bleeding into a fixed and noncompressible space. The incidence of
hematoma in epidural anesthesia is about 1 in 50,000 and above 1 in
200,000 in spinal procedures.
The higher incidence of epidural hematoma can be explained by the

increased vascularity of the epidural space. The clinical manifestations
are due to the compression and ischemia of the spinal cord or spinal
nerves; they may include legs or backache, motor weakness and
35
dysfunction of the rectal and bladder sphincters. In the event of spinal
hematoma, a prompt diagnosis and intervention are critical to ensure
a recovery of the patient. Spinal cord ischemia tends to be reversible
in patients who underwent laminectomy within the 8 hours of onset of
the neurologic symptoms.
Often patients who are candidates for procedures where a regional

technique would be advantageous are receiving anticoagulant or
antiplatelet therapy, for example, pregnant patients with
preeclampsia, and orthopedic patient under thromboprophylaxis. In
such cases, regional anesthesia can still be safely performed provided
there is appropriate timing of needle placement and catheter removal
relative to the timing of anticoagulant drug administration.
The patient's coagulation status should be optimized at the time of

spinal or epidural needle or catheter placement and the level of
anticoagulation must be carefully monitored during the period of
epidural catheterization. Indwelling catheters should not be removed
in the presence of therapeutic anticoagulation, as this appears to
significantly increase the risk of spinal hematoma. Vigilance is
therefore again emphasized in monitoring to allow early evaluation of
neurologic dysfunction and prompt intervention.
Although spinal anesthesia seems to be safe to perform in patients

with bleeding disorders (provided there is a platelet count between
50,000 and 80,000) the decision should be based on careful weighing
of the risk of spinal hematoma with the benefits of regional
anesthesia for a specific patient.
36
Infections
Bacterial contamination can lead to meningitis or to an epidural

abscess, which can cause spinal cord compression. Bacterial meningitis
after a neuraxial anesthesia is rare with an incidence of 0-2 cases per
10,000, and a high mortality rate of 30% even when antibiotherapy
has been applied. Meningitis may be differentiated from postdural
spinal headache based on the presence of fever accompanying the
neurological signs. Streptococcus salivarus, which is regularly present
in the skin, oral cavity, gastrointestinal and genitourinary tracts has
been found responsible of more than 90% of post spinal meningitis.
Viral contamination may also occur after neuraxial techniques though

they are less frequent and benign.
Inadvertent germ inoculation during neuraxial anesthesia can be

prevented by a rigorous preparation of the injection site with sterile
equipment, and by maintaining a sterile environment.
Failure
The incidence of failure with neuraxial anesthesia is variable and highly

dependent on institutions and patient population, among other factors.
Experienced clinicians might consider it to be around 1%, while
hospital series reported incidences reaching 47%. Block failure in
general can be attributed to one or the combination of the following
parameters: 1) the experience of the operator, 2) the technique, 3) the
spreading of the anesthetic agent, 4) the dosing of the anesthetic
solution, 5) the solution itself, which can be ineffective, and 6) possibly
related to the patient's preoperative and intraoperative management.
37
Failed Lumbar Puncture
Failed lumber puncture is the only cause that is immediately obvious.

It can be caused by a blocked lumen of the needle, thus the
requirement to check the material before use, by an incorrect
positioning of the patient, or a spine anomaly. Obesity, anxiety and
pain due to the pathology presented by the patient can hamper the
positioning of the patient. Gentle, reassuring handling of the patient,
light anxiolytic premedication and systemic analgesia can prevent
movement during the procedure. Good knowledge of spinal anatomy
will be necessary to understand the different structures and potential
resistance encountered when orienting and advancing the spinal
needle.
Dosing and Spread
Spinal needle insertion followed with appearance of cerebrospinal fluid

is a prerequisite but not a guarantee of success during lumbar
puncture. The injection of the appropriate dose should be done after
verification that the connection between the needle and the syringe is
firm to prevent a leak. Similarly, unwanted anterior or posterior
displacements of the needle tip during CSF fluid aspiration (a
necessary step before injection) can result in misplaced injection
(spinal versus epidural).
Inadequate spread of the anesthetic solution can stem again from

inadequate positioning after injection, or from anatomical abnormality
such as kyphosis, scoliosis, which could have been anticipated, within
certain limits, by the preoperative examination. Another rare and not
apparent possibility, lies in the presence of septae within the
38
anatomical supportive structures of the spine, which act as barriers to
the spread of the anesthetic solution. This can result in unilateral
blocks or insufficient cephalad spread despite the appropriate baricity
of the anesthetic solution and the positioning of the patient.
Furthermore, in rare instances, a larger than usual volume of CSF
associated with dural ectasia (widening of dural sac surrounding the
spinal cord) seen in patients with connective tissue disorders, may
limit anesthesia spread.
In addition to solution density (baricity), which influences the spread
through gravity, a correct location of the site of the injection must be
carefully selected to avoid a too low block or, to the contrary, a
dangerous and unnecessary higher level spread.
Ineffective Drug versus Medical Error
A well-prepared spinal anesthesia procedure including the preparation

of the required material and the verification that it is adequate and
properly functioning should leave no room for confusion in the solution
preparation. Nonetheless, reports of failure have been attributed to the
loss of solution effectiveness due to prolonged storage or induced by
the sterilization process.
Management of Failure
If all the preventive and corrective measures described above do not

lead to a positive outcome, then the anesthetist has to accept the idea
of failure and move to a back-up plan. A back-up plan should have
been already discussed with the well-informed patient during the
preoperative evaluation. The consequences of a failed block that is
discovered in the course of the surgery have more severe implications
for the patient's safety, not to mention the medico-legal aspects.
39
Minor Adverse Effects of Regional Anesthesia
Shivering is partly related to vascular dilation and heat loss from the
skin, and possibly due also to the direct effect of anesthesia on the
thermoregulation center. Temperature regulation is a challenge in both
regional and general anesthesia.
Itching is observed when opioids are injected into the spinal fluid to
control for postoperative pain. Itching may also occur after
intravenous administration of the same drugs.
Intravenous Regional Anesthesia
Intravenous regional anesthesia (IVRA) or Bier's block is named after

the German surgeon AG Bier who described it first in 1908. The IVRA
is a highly popular procedure, versatile and useful in other settings
than the surgical suite, such as in emergency departments during
reduction of limb fractures and dislocations. It is considered safer than
general anesthesia, especially for those patients who are elderly or
carry diagnoses such as cardiac or respiratory disease. This section
briefly highlights the IVRA procedure.1,4,18,19
With this technique, anesthesia is obtained by the intravenous injection

of a local anesthetic, typically, 12-15 mL of 2% lidocaine for upper
extremities, or 30-40 mL of 0.5% lidocaine, in a previously
exsanguinated vascular space, isolated from the rest of the circulation
by two Esmarch bandages used as tourniquets. The exact mechanism
of IVRA is not completely understood. The likely mechanism is that the
local anesthetic, via the vascular bed, reaches both peripheral nerves
and nerve trunks (vasae nervorum), and nerve endings. Diffusion of
40
local anesthetic into the surrounding tissues, ischemia and
compression of the peripheral nerves at the level of the inflated cuff
may also contribute to the mechanism of IVRA.
Contraindications
Contraindications to this technique are crush injuries, skin infection,

compound fractures, allergy to local anesthetics and severe peripheral
vascular disease. Disadvantages include incomplete muscle relaxation
(where important) and lack of postoperative pain relief.
Indications
Bier's block is a widely accepted technique for short duration surgeries

such as wrist or hand surgery, carpal tunnel syndrome, Dupuytren
contractures, and reduction of fractures. Since the duration of
anesthesia depends on the length of time the tourniquet is inflated,
there is no need to use long-acting or more toxic agents. Its
application for longer surgical procedures is however impeded by the
discomfort caused by the tourniquet, which occurs typically within 30
to 45 minutes.
General Anesthesia
General anesthetics act on the central nervous system or autonomic

nervous system to produce analgesia, amnesia or hypnosis. They are
used alone, or most frequently, as we will see, in combination with
other agents to provide an optimal depth of anesthesia. General
anesthesia can be achieved by inhalation of anesthetic gases or
intravenously. Introduced around 1846, ether and nitrous oxide were
the first inhalation anesthetics to be accepted by the medical
41
community. Beginning with halothane in the 1950s, halogenated
anesthetics replaced the routine use of ether and chloroform. 20
Intravenous agents are used mostly for induction of anesthesia but

they can be used also for some other longer procedures, which are 1)
Neuroleptanesthesia, where a narcotic analgesic is combined with a
neuroleptic in association with inhalation of nitrous oxide and oxygen,
2) Dissociative anesthesia with ketamine which produces rapid
analgesia and amnesia while maintaining the laryngeal reflexes, and 3)
Preanesthetic medication (also called premedication) which includes
sedatives opioids, tranquilizers, and anticholinergic agents. 4,6
Mechanism of Action of Anesthesia Drugs
There are two levels of understanding how the anesthetic agents work.
Firstly, the molecular basis, which addresses what effect anesthetics
have at a molecular level; and, secondly, the anatomical basis, which
focuses on what part of the body they act on.
The molecular basis of anesthesia is complex and still incomplete.

Although, it seems the predominant molecular mechanism lies in a
transmembrane protein called GABAA receptor with five subunits, found
widely in the central nervous system. The five subunits are the
potential binding sites for general anesthetic agents.
The neurotransmitter GABA (gamma amino butyric acid) is inhibitory,

for example, it makes the postsynaptic cell fire less. Specific binding
sites have been identified for volatile agents as well as for intravenous
drugs such as propofol (potent GABA agonist) and etomidate. More
recently, the intervention of the two pore-domain potassium channels,
42
which are also widely distributed in the mammalian central nervous
system, have been described. Experimental studies with halothane,
isoflurane sevoflurane, and desflurane have shown an enhancement of
potassium channels leading to hyperpolarization of the neuronal
plasma membrane.1,4,20
As for the mechanism of action of other anesthetics, such as Nitrous

oxide, xenon and ketamine, they are likely mediated by N-methyl-D
aspartate (NMDA) receptors. Moreover, apart from its well accepted
NMDA blockade, ketamine has been reported to interact with a wide
range of other intracellular neuronal processes. It seems likely that its
hypnotic effects are caused by a combination of immediate channel
blockade of NMDA and HCN1 channels.21
With regard to the anatomic basis of anesthesia action, the

macroscopic level of the neuroanatomy must be considered.
Immobility induced by inhalational anesthetics is produced in the
spinal cord, precisely it is due to a decreased transmission of afferent
noxious information to the cerebral cortex via the thalamus; in
addition, there is an inhibition of the spinal motor response which
explains the reduction of the withdrawal movement. On the other
hand, amnesia and hypnosis (the two other end points of anesthesia)
are mediated by the brain. Inhalational agents have been shown to
depress cerebral blood flow and glucose metabolism.
Amnesia probably involves among other structures, the hippocampus,

amygdala, and the mediotemporal lobe. Hypnosis or unconsciousness
concerns the cerebral cortex, thalamus and reticular formation. 1,4,20
43
Inhalation Agents
Current volatile anesthetic agents are colorless liquids that evaporate

into a vapor, which produces general anesthesia when inhaled. They
are chemically stable and not likely to breakdown into poisonous
products. They can be distinguished from each other by their specific
properties; such as, potency, speed of onset, smell and partition
coefficient, as further highlighted here. 1,4,6,18,20
The potency of anesthetic gases is expressed as minimum alveolar

concentration (MAC) at 1 atmosphere (atm) required to keep 50% of
adults unmoving in response to a standard skin incision. MAC concept
is a useful concept introduced for the first time by Ted Eger, Giles
Merkel and collaborators in 1963. It helps comparing potencies of
different agents. Isoflurane has a MAC value of 1.2%; it means that at
equilibrium, with the concentration of 1.2% of isoflurane in the lungs,
50% of adults will not move in response to a skin incision.
Sevoflurane, on the other hand, is less potent with a MAC of 2% and
desflurane even less with a MAC of 6%. At equilibrium, it is considered
that the lung's concentration is equivalent to the concentration in the
blood stream, and this in turn is equivalent to the concentration in the
brain. Therefore, the measurement of the volatile agent in the expired
breath of the patient gives a close approximation to the brain
concentration of the anesthetic gas.
The MAC values are additive, so a patient with 0.5% MAC of isoflurane
and 0.5% MAC of sevoflurane is said to have a 1.0 MAC of anesthetic
in total. Since giving more than 1 MAC will result in less than 50% of
adults moving in response to a painful stimulus, it is understood that
MAC correlates with the depth of anesthesia. Interestingly, whereas
44
immobility is produced around 1.0 MAC, amnesia is produced at a
much smaller dose of typically 0.25% MAC, and unconsciousness at
0.5 MAC. This implies that a patient might move in response to the
surgical stimulus without being conscious or remembering it
afterwards.
Potency has also been shown to correlate with lipid solubility. This
property is known as Meyer-Overton correlation.
Speed of onset is inversely proportional to water solubility. Desflurane
is the least water-soluble of all agents and has the most rapid onset
and offset. It is followed by nitrous oxide, sevoflurane and isoflurane.
Pungency is not a desirable property for an anesthetic agent during

the induction of general anesthesia. In contrast to isoflurane and
desflurane, sevoflurane has a fruity smell, which makes it more
suitable for inhalational induction.
Partition coefficient is the concentration of an inhalation anesthetic in

blood or tissue is the product of its solubility and partial pressure. This
solubility is commonly expressed as blood-gas (alveolar) or tissue
blood partition coefficient. An agent with a blood:gas partition of 2 will
reach twice the concentration in the blood phase as in the gas phase
when the partial pressure is the same in both phases (at equilibrium).
Ether, a very soluble gas, has a very high blood-gas partition
coefficient equal to 12, while a relatively insoluble agent like nitrous
oxide has a coefficient less than 1. Because high solubility constantly
decreases the alveolar gas pressure, the lower the blood-gas partition
coefficient of anesthetic agent then the more rapid the induction with
that agent.
45
Influencing Factors
Blood-gas partition coefficients are affected by the concentration of

serum constituents such as albumin, globulin, triglycerides and
cholesterol. These molecules bind to anesthetics increasing their blood
solubility.20
Drug uptake from the lung and delivery to the tissues, particularly the
brain, is increased by a higher cardiac output although this does not
lead to faster induction since the alveolar concentration is lowered by
the high uptake. In contrast, a decreased cardiac output will be
accompanied with a slow uptake, higher alveolar pressure and thus
faster induction. A larger fat compartment in obese individuals leads to
a longer equilibration time after induction and a slower emergence due
the high absorption of anesthetic agents in the fat tissue and their slow
release. Infants and children have a faster rate of induction than
adults; this has been attributed to a larger ratio of alveolar ventilation
to functional residual capacity, a greater delivery to a richer healthier
vasculature, as well as to lower albumin and cholesterol levels.
Halogenated Anesthetics and Other Gases
Halogenated inhalational anesthetics are currently the most common

drugs used for the induction and maintenance of general anesthesia.
Halothane (Fluothane)
The first chlorofluorocarbon to be developed from chloroform in 1951

is halothane. It was once considered an ideal anesthetic agent in that
46
it was volatile and non-inflammable and had a high anesthetic potency
with a MAC of 0.75%.20,22,23
Pharmacologic Effects of Halothane
Respirations become rapid and shallow with a reduction in the minute

volume causing a reduction in the ventilatory responses to carbon
dioxide; fluothane produces bronchiolar dilation.
Arterial blood pressure is decreased in a dose-dependent manner;

there is an increase in cutaneous blood flow, and depression of
myocardial contractility. Halothane antagonizes the sympathetic
response to arterial hypotension and decreases cardiac sympathetic
activity, which results in a slow heart rate. Although uncommon,
arrhythmias have been associated with the use of halothane.
As anesthesia deepens, fast, slow voltage electroencephalogram waves

are replaced by slow, high voltage waves. At 1 MAC, the glomerular
filtration drops by 50%.
Halothane causes muscular relaxation by both central and peripheral

mechanisms, increases the sensitivity to neuromuscular blocking
agents, and like all inhalation compounds can trigger malignant
hyperthermia, a very severe complication. It can also depress liver
function and may lead to hepatic necrosis.
Excretion of Halothane
About 70% of Halothane is eliminated through the lungs in the first 24

hours after administration. The remaining is metabolized by the
47
cytochrome p-450 system in the endoplasmic reticulum of the
liver, which causes hepatic injury.22
Enflurane
Enflurane is a potent anesthetic obtained from the fluorination of

ether; it has a MAC of 1.68%. Enflurane causes mild stimulation of
salivation, produces tracheobronchial secretions and suppresses
laryngeal reflexes. All of these parameters need to be taken in account
during the ventilation of the patient. 20
Like halothane, enflurane produces a dose-dependent respiratory

depression and has similar effects on blood pressure and myocardium
as well as on the renal glomerular filtration. However, bradycardia and
cardiac output are not as much decreased as with halothane. Enflurane
also acts directly on the neuromuscular junction providing adequate
relaxation to the muscles, including uterine smooth muscle. On the
other side, enflurane increases intracranial pressure and produces an
electroencephalic pattern similar to seizure activity or frank seizures.
Therefore, it is contraindicated in epileptic patients. It is eliminated in
80% as expired gas; free fluoride is released and as little as 5% are
metabolized in the liver. Nevertheless, hepatic necrosis cases have also
been reported after repeated administration of enflurane.
Isoflurane
Isoflurane a methyl-ethyl diether-like desflurane, while sevoflurane is

a methyl-isopropyl ether; all of these gases derive from the
fluorination of ether. Isoflurane is actually an isomer of enflurane. It
also produces respiratory depression and a fall in arterial blood
pressure, with the advantage of being a better myorelaxant than
halothane and enflurane. Moreover, unlike enflurane, isoflurane does
48
not cause seizures; and, unlike halothane, isoflurane does not induce
arrhythmias. For these reasons, isoflurane is the anesthetic of choice
among the halogenated volatiles compounds.20
Adverse Effects of Halogenated Anesthetics
About 25% of halothane is metabolized by oxidative phosphorylation

via hepatic cytochrome P450 systems. The major metabolite is
trifluoroacetic acid (TFA), which is protein-bound and this TFA–protein
complex (neoantigens) has been shown to induce a T-cell-mediated
immune response resulting in hepatitis ranging from mild to fulminant
hepatic necrosis, and possibly death. According to the National
Halothane Study, the risk of fatal hepatic necrosis is one in 10,000
anesthetic procedures.
Current volatile gases such as enflurane, isoflurane and desflurane are

also metabolized in the liver through the metabolic pathway involving
cytochrome P-450 2E1 (CYP2E1) which produces trifluoroacetylated
components; however, in comparison with halothane, only 2–5% of
isoflurane, sevoflurane, and desflurane are metabolized; the remaining
is excreted unchanged in exhaled air.20
The severity of hepatotoxicity of these compounds is associated with

the degree by which they undergo hepatic metabolism by cytochrome
P-450.20,22 Enflurane, isoflurane, desflurane, and sevoflurane have
different molecular structures to that of halothane and they seem to
be associated with less hepatotoxicity; however, rare cases of acute
liver injury have also been reported with all of these agents. The
pattern of liver injury described with enflurane, isoflurane and
desflurane has common features with that of halothane, and evidence
49
of autoimmune response to trifluoroacetylated liver proteins has been
reported.20,22
Unlike other halogenated anesthetics, sevoflurane is not metabolized

to hepatotoxic trifluoroacetylated proteins; nevertheless, very few
reports have described liver injury after sevoflurane exposure.
Consequently, a history of anesthesia-induced hepatitis is a
contraindication to halothane or other halogenated anesthetics re
exposure. The susceptibility to malignant hyperthermia is another
contraindication.4,18
Nitrous Oxide
Nitrous oxide (N2O) is an inorganic inert, odorless, gas which can be

compressed into a liquid. Although, chemically different (with respect
to their properties) from halogenated gases mentioned above, it has
similar behavior. The MAC of nitrous oxide is 105.2%, which means
that it needs hyperbaric conditions to reach a level of I MAC. For
maintaining anesthesia a concentration of 75%-80% is required.
Although nitrous Oxide is a powerful analgesic that is well tolerated
and has rapid onset of action and recovery, it is a weak anesthetic.
Therefore, to achieve a more complete anesthesia, the use of nitrous
oxide needs to be supplemented by a narcotic agent as well as a
neuromuscular blocking agent. More often, nitrous oxide is used in
combination with other potent anesthetic agents, and because of that
it is probably the most widely used general anesthetic agent. 1,6,19
An inhalation of 50:50 mixture of nitrous oxide with oxygen known as

“gas and air” is offered sometimes to women in labor because it is
effective enough to relieve pain without causing general anesthesia.
50
Moreover, at 50% concentration, its effects on breathing are minimal.
N2O is excreted primarily through the lungs as expired air. 1,6
Adverse Effects and Contraindications of N2O
Because of its high partial pressure in blood and its low blood:gas
partition coefficient, N2O diffuses into air–containing cavities and thus
expands the volume of gas in air pockets. This effect can result in
bowel distension, rupture of a pulmonary cyst, rupture of the tympanic
membrane in the middle ear, and pneumocephalus. In the blood it can
enlarge the volume of air embolus. Therefore, the use of N2O is
contraindicated in bowel obstruction, air embolism and chronic
obstructive pulmonary disease. It can lead to diffusion hypoxia at the
end of anesthesia if a patient starts breathing room air all of a sudden.
An outward movement of N2O causes hypoxia from the tissues to the

blood and then to the alveoli where it decreases alveolar tension and,
by the same token, lowers arterial oxygen levels. To circumvent this
drawback, one has to administer 100% oxygen for a short period of
time at the end of the N2O anesthesia. N2O is also associated with a
higher incidence of postoperative nausea and vomiting and should be
avoided whenever possible in patients with a positive history of
PONV.6,23
Xenon
Xenon (Xe) is odorless and nonirritant to the airway, which favors a

smooth induction; and with a MAC of 71% it is considered as potent
enough to be given alone with oxygen. Its blood:gas partition
coefficient is 0.12, which means that it provides a rapid onset and
51
recovery from anesthesia. It is a more potent intraoperative analgesic
than sevoflurane.1,20
Xenon produces depression of postsynaptic excitatory transmission via

NMDA receptor block. It has minimal cardiovascular side effects, even
in cases of severely limited myocardial reserve. Although a mild
respiratory depressant, xenon decreases respiratory rate and increases
tidal volume, in contrast to volatile agents. Experimental models
suggest that it has a significant neuroprotective action, but this benefit
seems to be offset by an increase in cerebral blood flow, which elevates
intracranial pressure.
Xenon causes an increase in pulmonary resistance due to its high

relative density. Because of this, it should be used with caution in
patients with severe chronic obstructive pulmonary disease and
premature infants. It is not metabolized in the liver or kidneys, has no
negative environmental effect and it does not trigger malignant
hyperpyrexia. Despite all these advantages its use is still very marginal
due to higher cost of production and its rapid diffusion through ordinary
anesthetic hoses thus requiring specialized equipment. 1,20
Oxygen
Oxygen (O2) is produced by distillation of liquid atmospheric air. At

ordinary temperatures, oxygen cannot be liquefied so it is stored as
compressed gas in cylinders. Medical air is atmospheric air filtered to
remove particles (such as pollen, oil droplets), and dehydrated to
remove moisture then compressed into cylinders. In addition to being
used throughout anesthesia procedure, compressed medical air may
be used in the operating room to power surgical tools. In anesthesia
52
oxygen is used in combination with air or nitrous oxide but rarely alone
as it can be harmful to the lungs if the administration is prolonged. 1,19
Delivery Methods of Inhalation Anesthesia
The three most common methods used to control the airway during
general anesthesia are: the mask (facemask), the laryngeal mask
airway and the endotracheal tube.1,19
Mask Ventilation
Mask ventilation is performed with proper airway maintenance

maneuvers during induction of general anesthesia. The mask has an
airtight seal around the mouth and nose allowing the patient to breathe
the anesthetic gas mixture efficiently. Ideal mask position is obtained
by lifting the patient's chin upward positioning the head in the so-called
“sniffing” position and bringing the mandible forward to move the
tongue from the oropharynx.
Mask ventilation can be challenging in neck and head surgeries,

including ophthalmic procedures, as the anesthesiologist and the
surgeon share a focus on the airway. Mask ventilation is frequently
employed in short procedures, when the anesthetist has access to the
patient's airway or when tracheal intubation is difficult or impossible.
Some studies report an incidence of impossible mask ventilation
ranging between 1.4 to 5 percent.
Sleep disordered-breathing (SDB) in particular has been identified as a

non-negligible risk factor for difficult mask ventilation, given the fact
that the prevalence of SDB is as high as 69% of the general surgical
population. Reports show that patients with SDB who undergo general
53
anesthesia have pharyngeal airways that are narrower and more
collapsible when compared to non-SDB patients.25,26 Mask ventilation
has changed little in contrast to significant improvement of tracheal
intubation techniques and devices in the past decade.
Laryngeal Mask Airway
The laryngeal mask airway (LMA) is made of soft rubber and is inserted
via the mouth into the back of the throat resting just above the vocal
cords. Its distal extremity is connected to the anesthesia machine
breathing circuit. Because the laryngeal mask does not penetrate into
the trachea, it is less irritating to the vocal cords and the throat than
the endotracheal tube. However, the LMA tube does not protect against
aspiration pneumonia and ventilation cannot be controlled as reliably as
it can be done with the endotracheal tube.
Endotracheal Tube
Intubation with endotracheal tube

was a major progress in the field of
anesthesia as it has allowed for
controlled mechanical ventilation and
more invasive surgeries. Typically,
the endotracheal tube is placed in the
patient after the induction phase of
anesthesia and will be removed
before awakening. The process by
which the endotracheal tube is
inserted in the trachea is called
intubation. Optimal intubating
54
conditions are achieved when the tragus of the ear is aligned with the
sternum allowing a direct visualization of the vocal cords while
performing direct laryngoscopy.
The endotracheal tube is made of soft plastic, and is inserted through

the mouth or the nose and guided with a laryngoscope through the
vocal cords into the trachea. The distal end coming out of the mouth is
connected to the anesthesia breathing circuit. A balloon (low pressure
cuff) on the outer portion of the endotracheal tube is positioned inside
the trachea and inflated to produce an airtight seal between the tube
and the trachea in order to prevent any gastric fluid or secretions from
entering the lungs. The incidence of aspiration pneumonia has been
considerably reduced by the use of cuffed endotracheal tubes. In
preparation for the intubation, the anesthetist's preoperative evaluation
of the patient should be focused on airway conditions, including mouth
opening, dentition, receding jaw, and limitations in neck anatomy and
range of motion.
Difficult laryngoscopy/intubation has been reported to occur in 5.8% of

general anesthesia;26 various scoring systems based on orofacial
measurements have been used to predict difficulties during intubation.
The most widely known is the Mallampati score, which identify patients
in whom the pharynx is not well visualized through the open mouth. It
may be obtained on a seated patient with the mouth open and the
tongue protruding without phonating. If a predisposing factor has been
detected during this assessment, a more appropriate strategy for
intubation should therefore be planned.
Intravenous Induction Agents

55
As opposed to anesthesia, analgesia is the relief of pain without loss of
consciousness. This section covers combination anesthesia and pain
medications used during the anesthesia induction phase. 1,6,19-21,27-29
Morphine is the most abundant analgesic opiate found in opium; it is

extracted from the poppy seed and is a potent pain reliever. Opioid on
the other side is a term used in reference to both naturally occurring
opiates and synthetic drugs having similar actions. Opioid substances
impair pain sensation through opiate receptors of several types that
have been identified in the central nervous system. These receptors
are found in:
• The limbic system, including the hypothalamus

• The medial and lateral thalamus and the area postrema, site of
the trigger zone for nausea and vomiting (emesis)
• The nucleus of the solitary tract, location of the cough center •
The spinal cord
Neuroleptanesthesia
A combination of a neuroleptic (also called antipsychotic or major

tranquilizer) with a powerful narcotic is used to provide
neuroleptanalgesia; and, the addition of nitrous oxide and oxygen to
the combination of neuroleptic/narcotic agents produces
neuroleptanesthesia.
The most frequently used agents to achieve neuroleptanalgesia are

droperidol, a butyrophenone derivative, and fentanyl, an opioid with a
short duration of action. However, both of them exert a marked
respiratory depressant effect, which outlasts the analgesic effect and
56
they both induce hypotension. Fentanyl should be administered slowly
over 5 to 10 minutes and adequate ventilation and oxygenation are
required. After neuroleptanalgesia, nitrous oxide administration starts.
This latter method is useful in obstetrics and in minor procedures such
as diagnostic explorations if the patient is cooperative. The most
common adverse effects after neuroleptanesthesia are confusion and
mental depression.
Dissociative Anesthesia
Dissociative anesthesia is a state similar to neuroleptanalgesia in

which patients feel totally dissociated from their surroundings.
Ketamine is the only drug used at the present time to produce this
state. Ketamine was introduced as a derivative of the hallucinogenic
drug phencyclidine in 1965. It is a very atypical induction agent as it
does not suppress consciousness as most general anesthetics do, but
disrupts it. With ketamine the patient has a rather normal muscular
tone, the eyes may remain open, and by observing the
electroencephalogram tracings it may wrongly be concluded that the
patient is awake.
Ketamine produces profound analgesia and amnesia. Unlike other

agents, skeletal muscle tone, heart rate, arterial blood pressure and
cerebrospinal fluid pressure can be increased by ketamine. Moreover,
ketamine does not affect the laryngeal reflexes and maintains a normal
respiratory cycle with a strong bronchodilator effect. To counteract
ketamine's known excessive salivation effect, which poses a potential
risk of aspiration in the deeply sedated patient, atropine is added in the
premedication to reduce mucous and salivary secretions.
57
Several routes including oral, rectal and intramuscular can be used to
administer Ketamine. Its duration of action is between 10 to 20
minutes; therefore, it is commonly used in children and adults for
short diagnostic procedures. Because of its hallucinogen effect,
recovery from ketamine anesthesia is accompanied by emergence
delirium and agitation. Ketamine is contraindicated in patients with
psychiatric disorders, with a cerebrovascular disease, intracranial
hypertension, arterial hypertension and glaucoma.
Barbiturates
Thiopental:
Thiopental is a short acting barbiturate, brought into practice for the

first time in 1934. Although it provides a rapid and stable induction of
general anesthesia, it is cleared very slowly from the body. So it is not
suitable for maintenance of anesthesia and an alternative volatile
agent must be used for that matter. It also causes a dose-dependent
depression of heart rate and blood pressure.
Etomidate:
Etomidate, which has been introduced in 1973, is an ultra-short acting

hypnotic, which can induce amnesia within 5 to 15 seconds after a
single bolus dose and unlike thiopental, has virtually no cardiovascular
effects. However, it has other drawbacks such as pain on injection,
myoclonic movements at induction, and post-operative nausea and
vomiting especially in combination with opioid use. Its use as a
sedative in the intensive care unit has also been reported to be
associated with suppression of synthesis of endogenous steroids by
58
adrenal glands. Therefore, etomidate should not be used in the
maintenance of anesthesia.
Propofol
Propofol was introduced in 1985; it is a short-acting intravenous

anesthetic that can induce unconsciousness within 1 minute, but it has
a short-lived effect of 3-5 minutes due to its rapid redistribution. These
properties make propofol suitable for induction and maintenance of
general anesthesia. Moreover, it produces a rapid clear-headed
recovery, which is useful in ambulatory surgery.
Pre-anesthetic Medications
A well-thought and planned premedication not only will foster an

uncomplicated anesthesia and post-operative course by reducing the
anxiety of the patient, and by improving the rapidity and the
smoothness of induction, but it will also compensate for the side
effects of the anesthetics including salivation, bradycardia, and post
operative nausea and vomiting. Pre-anesthetic medications include
sedatives, opioids, tranquillizers and anticholinergic agents.
Sedatives or barbiturates, such as secobarbital and pentobarbital are

the most commonly used sedatives as they produce less nausea and
vomiting than opioids. Opioids such as fentanyl and morphine are
given to patients in combination with nitrous oxide and thiopental.
They can also be administered with a barbiturate for regional
anesthesia.
Phenothiazine derivatives like promethazine are often administered

with opioids due to their potentiation effects on analgesia without
increasing the side effects. Tranquilizers are useful as preoperative
59
sedation, and they help to prevent central nervous system stimulation
caused by the local anesthetics and provide amnesia. Anticholinergic
agents such as atropine and scopolamine are commonly used to
reduce salivation.
Muscle Relaxants/Neuromuscular Blockers
They are valuable adjuncts to general anesthesia and should be

administered only to anesthetized patients. They should not be used to
stop patient's movement because they have no analgesic or amnestic
effect.
Neuromuscular blockers act at the neuromuscular junction via their
effects on acetylcholine, which is the major neurotransmitter at the
motor endplate. There are two levels of action; the post junctional
effects such as those produced by depolarizing neuromuscular blockers
like succinylcholine (which consist in a prolonged depolarization by
desensitization of acetycholine receptors), inactivation of voltage gated
sodium channels at the neuromuscular junction, and increases in
potassium permeability of the cell membrane, resulting in a failure of
action potential generation and muscular block. As for the prejunctional
effects, they are produced by nondepolarizing neuromuscular blockers,
which affect the receptors on motor nerve endings involved in the
modulation of acetycholine release and preventing it from being made
available.
The main advantages of neuromuscular blocking agents are

improvement of face mask ventilation and facilitation of tracheal
intubation. They also provide surgical relaxation. The required
intensity of neuromuscular blockade that is desired depends on the
type of surgical procedure. There are, however, important safety
60
issues with their use due to their cardiovascular and respiratory side
effects.
Succinylcholine, a rapid onset, short-acting depolarizing muscle

relaxant has been traditionally used when rapid tracheal intubation is
needed in emergency or during an elective surgery. It can provide
muscle relaxation in 60 to 90 seconds and its effect lasts only 6 to 10
minutes. However, it has numerous side effects, which include severe
effects such as cardiac arrest, severe arrhythmias, prolonged
respiratory depression, and malignant hyperthermia. Further, it is
contraindicated in patients with known hyperkalemia, major crush
injuries, and muscular dystrophy. Succinylcholine has also been
associated with increase in intracranial and intraocular pressures.
Intermediate-acting neuromuscular blockers include steroid-based
compounds, pancuronium, vecuronium, atracurium and cisatracurium;
however, none is as rapid as succinylcholine. Rocuronium, which is
also a steroid based non-depolarizing muscle relaxant, has been
proposed as a replacement for succinylcholine. However, due to its
longer duration of action (37 to 72 minutes), rocuronium has to be
used with caution in patients with myasthenia gravis, hepatic disease,
neuromuscular disease, severe cachexia and carcinomatosis. Allergy is
the only contraindication to the use of rocuronium.
Except for the relatively new drugs atracurium and cisatracurium, the
kidney generally excretes muscle relaxants that are metabolized in the
plasma (Hofmann elimination), and thus can be used in case of renal
or hepatic impairment.
Reversal of Neuromuscular Blockade

61
The neuromuscular blockade induced at the beginning of the general
anesthesia needs to be reversed at the end of surgery with the use of
anticholinesterases drugs which act primarily by inhibiting
acetylcholine esterase, thus prolonging the existence of acetylcholine
at the motor endplate. Neostigmine, a commonly used reversal agent,
is administered at 60-80 µg/kg and usually combined with atropine to
antagonize the muscarinic side effects of neostigmine.
Sugammadex (modified gamma-cyclodextrin) is a selective relaxant

binding agent which complexes with steroid-based neuromuscular
blocking agents, helping in rapid removal from plasma and excretion
through the kidney. The recommended dose for sugammadex is
between 2-16 mg/kg of body weight.
To avoid relying only on neuromuscular blocking agents, it is important

to keep in mind that there are other alternatives that will provide
adequate relaxation in the operating room. These options are the
adjustment of the depth of anesthesia, regional anesthesia, and proper
positioning of the patient on the operating table. The anesthetist has a
choice to make depending on the estimated time remaining before the
end of the surgery, the anesthetic technique and the type of surgery.
Intravenous Administration of Fluids
Anesthetists commonly administer intravenous fluids for a wide variety

reasons.4,18, Bleeding is the most obvious one. Patients may also be
dehydrated preoperatively due to the disease, particularly a bowel
disease, or fasting. In such cases the anesthetist must estimate the
patient's fluid status and correct it if necessary, using urine output if
the patient is catheterized, central venous pressure and blood tests.
62
Five categories of intravenous fluids need to be mentioned: 1) 5%
Dextrose in water (D5W) is useful because this solution has the same
concentration of the blood plasma. When D5W is administered the
cells rapidly absorb dextrose, which leaves only water in the
circulation. This is therefore an effective way to deliver water to the
body as pure water is harmful causing the cells to rupture. 2) 0.9%
normal saline solution (sodium chloride) is commonly used during
surgery for immediate venous/arterial access for intravenous
medication. 3) Compound sodium lactate (Hartmann solution) is
another salty solution that contains sodium, potassium, calcium
chloride and lactate in levels similar to those of human blood. When a
patient loses blood the most important measure is to maintain the
circulating volume. If blood is not immediately available, salt
containing solutions are used. However, in this scenario each volume
of blood lost needs to be replaced by twice or three times the volume
of salty solutions due to the fact that they leak out to the tissues over
time. 4) Solutions, known as colloids, containing large molecules like
certain proteins (gelatin) or carbohydrates (dextran) are retained
much longer in the bloodstream and can fulfill the purpose.
Unfortunately, they can be responsible for severe allergic reactions
and also interfere with blood coagulation. 5) Blood products include
red cells fraction, platelets, coagulation factors, and they are replaced
according to the need of the patient.
General Anesthesia Procedure
Before proceeding it is important for the anesthetist to verify that all

the necessary equipment and material needed are available and ready
63
for use. The mnemonic DAMMIS is a reminder of what should be
checked: Drugs, Airway equipment, Machine, Monitors, IV,
Suction
The stages of general anesthesia include:4,18,29
• Stage I:
Stage of induction or analgesia
• Stage II:
Stage of excitement or delirium (dilated reactive pupil due to the
preponderance of the sympathetic system)
• Stage III:
Stage of surgical anesthesia (normal pupil); it is divided into
four planes (Guedel's classification). Stage III is the state into
which the patient should be maintained for general anesthesia.
• Stage VI:
Stage of medullary paralysis (dilated non-reactive pupil)
General anesthesia has three phases, which are important to consider:

these are the induction, maintenance and recovery phase.
Induction
Induction is the period between the administration of inductions

agents and loss of consciousness where the patient status evolves
from analgesia without amnesia to analgesia with amnesia. It is
considered as the most dangerous time since the medications can
result in hemodynamic instability, apnea and loss of airway tone.
Coughing, breath-holding and laryngospam may occur at this phase.
64
Overdose or an inadequate choice of medication for induction is one of
the most common causes of death during general anesthesia. A review
of anesthesia-related cardiac arrest based on a database of 217,365
procedures showed that 64% of anesthesia-attributable cardiac arrest
were caused by airway complications that occurred during induction,
emergence or in the postoperative period, with a 29% rate of
mortality. On the other hand, anesthesia-contributory cardiac arrest
occurred during all phases of anesthesia and led to a 70% mortality
rate.
As seen previously, induction can be performed using either

intravenous route, or via inhalation of an anesthetic gas. The latter
method is used especially in the pediatric population before the
anesthetist can have access to an intravenous route. Intravenous
induction involves also the administration of an analgesic (fentanyl) in
anticipation of the pain the patient may feel during endotracheal
intubation and which may raise the blood pressure and the heart rate.
Since the next step will be to secure the airway, muscle relaxants will
be added to facilitate endotracheal intubation if needed, and thus
mechanical ventilation. However, if during the patient's preoperative
assessment, the anesthetist has identified predictors of difficult airway
access, then intubation of the patient should be performed before
induction using an advanced tool like a fiberoptic bronchoscope.
After induction, eyelids should be taped gently in a closed position to

avoid corneal exposure or accidental erosion and to prevent nerve
injuries, the patient should be positioned with the arms at less than 90
degrees in relation to the body, padding of the regions in contact with
hard surfaces and a neutral neck position are recommended.
65
In general, intubation is indicated in an emergent case with a potential
for airway contamination including full stomach, altered state of
consciousness, and polytrauma. In elective surgery, the indication may
be, among other reasons, gastroesophageal reflux, pharyngeal
bleeding, surgical need of deep muscle relaxation with long-acting
muscle relaxants (abdominal or thoracic surgery), and predictable
difficulty to use mask ventilation (ie., due to facial anomaly, orofacial
surgery, or surgery requiring a lateral or prone positioning of the
patient).
The induction phase is characterized by an intense and frequent
monitoring of the patient's parameters. In addition to clinical
observation of the patient, a routine practice is to measure blood
pressure every minute along with a continuous electrocardiogram,
pulse, temperature, oxygen saturation, and end-tidal carbon monoxide
concentrations.
Rapid Sequence Induction
A specific type of induction called rapid sequence induction (RSI),

consists of rapid sequential intravenous administration of an induction
anesthetic, a sedative and a muscle relaxant with or without a
narcotic; this is followed by endotracheal intubation within one minute
of injection of the muscle relaxant (usually succinylcholine due to its
fast onset and duration). RSI is indicated in emergency situations
where the patient is unstable or considered to be at high risk for
aspiration or in elective surgery and if there is increased intracranial
pressure.
Maintenance of Anesthesia
66
Maintenance of anesthesia is the continuation of general anesthesia
with the use of intravenous or inhalational agents, independently from
the mode of induction. Most frequently, the patient will be kept
anesthetized with the administration of inhalational agents via the
breathing system of the anesthesia machine. The patient may be
breathing spontaneously the oxygen/anesthetic mixture, or artificially
under pressure by a ventilator, particularly if the surgery required the
use of deep muscular blocking agents which indiscriminately impede
the function of respiratory muscles.4,18
The maintenance phase is usually the most stable part of the

anesthesia process. Nevertheless, the anesthetist should still keep the
same level of vigilance and ensure a regular monitoring of the patient.
The measurement of the blood pressure, respiratory rate, heart rate,
oxygen saturation, temperature, oxygen administration and gases,
end-tidal carbon dioxide, will be recorded. Depending on the type of
surgery and/or preexisting medical conditions of the patient, additional
parameters such as central venous pressure, urinary output will have
to be included.
It is also critical for the anesthetist to stay updated about the progress
of the surgical procedure, as clear communication with the surgical
team supports planning of the next phases of anesthesia. As the
surgical procedure progresses, adjustments in anesthetic doses might
be needed to maintain the required level of anesthesia, while keeping
the patient safe with the minimum amount of medications. The depth
of anesthesia can be estimated via the electroencephalographic (EEG)
recording on the monitor screen, as well as by the bispectral index
monitoring, if available. However, experienced anesthetists should be
67
able to recognize inadequate anesthesia when the patient moves or
coughs.
If the patient has been administered myorelaxants, the anesthetist

should be alerted by an onset of hypertension, tachycardia, sweating
and capillary dilation and determine whether adjustment of the level of
anesthesia depth is required. Conversely, a decreased heart rate and
hypotension may mean excessive depth and must be corrected
immediately to prevent severe complications.
It is worth mentioning that the drugs administered during the induction

phase may still continue their effects during the maintenance phase.
Similarly, effects of the drugs used during the induction and
maintenance phase may still be exerting their effect during the
recovery phase. This should be taken into account to estimate the
doses for maintenance and to evaluate possible adverse effects due to
drug interactions.
Recovery from Anesthesia
Recovery from anesthesia, also called the emergence phase, is

planned in collaboration with the surgeon as the surgery is drawing to
a close. Again, vigilance and close monitoring by the anesthetist of all
the parameters are of paramount importance during this critical
phase, which is marked by exacerbated autonomic responses and
instability.4,19,30-33
First, the anesthetic gas administration level is lowered or even

interrupted. Assisted ventilation is stopped and the patient is restored
to breathing independently and progressively emerging to
68
consciousness. In a second step, if muscular blocking agents were part
of the anesthesia regimen their action is reversed. Traditionally,
anticholinesterases drugs (neostigmine) have been used to reverse this
action. However, their efficacy has not been consistent in resolving
deep levels of neuromuscular block. A more selective agent
sugammadex is now available. Concurrently, the regression of muscle
paralysis should be monitored and its reversal objectively assessed.
Clinical evaluation of the muscle blockade relies on the return of

muscle strength (head lift, jaw clench and grip strength) or respiratory
parameters (vital capacity and tidal volume). However, clinical signs
are not considered sensitive enough to serve as criteria upon which the
anesthetist should base his/her decision to extubate the patient.
Therefore, the prevalent opinion within the medical community is more
in favor of using a peripheral nerve stimulator to evaluate the
blockade. Most commonly, the anesthetist will observe the contraction
of the adductor pollicis muscle elicited by the stimulation of the ulnar
nerve either at the wrist or at the elbow. If patient positioning limits
access to the arms to stimulate the ulnar nerve, then the peroneal
nerve or the facial nerve may be used for monitoring.
Objective evaluation of the depth of neuromuscular blockade is

important for the determination of the appropriate dose of
sugammadex to be administered, as well as the timing of tracheal
extubation to ensure no residual weakness is present at the end of the
anesthetic procedure.
Postperative residual neuromuscular block has been associated with

impaired pharyngeal function, increased aspiration risk, upper airway
69
weakness and partial upper airway obstruction. It can considerably
jeopardize the recovery of the patient as it has been shown to lead to
postoperative pulmonary complications in 28% of the cases and even
to tracheal reintubation. Therefore, regardless of the clinical
experience of the anesthetist, objective assessment of neuromuscular
function has become mandatory.
Once the patient has regained his/her airway reflexes, the anesthetist
will proceed with extubation and observe/monitor the patient until
complete stabilization and communication by the patient is made. If
the procedure was performed in an ambulatory setting, under no
circumstances should the patient be allowed to leave the health facility
unaccompanied or drive on the same day of having a surgical
procedure.
Total Intravenous Anesthesia
Total intravenous anesthesia (TIVA) is defined as a procedure that

achieves general anesthesia without inhaled hypnotics. This method
has several advantages. It is generally quicker and easier to perform
in a patient who does not need to be intubated.1,4,18
Main Indications of TIVA
• Risk of malignant hyperthermia

• Long QT syndrome
• History of severe postoperative nausea and vomiting •
Tubeless Eye nose and throat, and thoracic surgery •
Patients with difficult intubation/extubation
• Neurosurgery patients
70
• Neuromuscular disorders/myasthenia gravis
• Ambulatory exploration or surgery
Criteria for Pharmacologic Agents and System Requirements for TIVA
Drugs with fast onset and offset times are preferred because they
balance hypnosis and analgesia with rapid recovery. For example, the
co-administration of propofol and remifentanyl are synergistic and
considered a good drug combination. The use of target-controlled
infusions is key for the maintenance of adequate concentrations both
in the brain and the plasma, and the best way to achieve this level is
with pharmacokinetic infusion pump systems.1 Target controlled
infusion systems have the following components: 1) a user interface,
2) a microprocessor with pharmacokinetic software, 3) an infusion
pump which delivers up to 1200 ml/hr, and 4) a visual and audible
alarm system.
Preparing And Planning For Anesthesia
When the need for and type of anesthesia is being considered, the
patient interview with the anesthetist is a very important step. This is
particularly true in elective surgery. It will bring to light the patient's
temperament, mental status, level of cooperation, personal habits,
history of addictions (with their potential to interact with the anesthesia
drugs), and allergic antecedents. The patient's family history is also very
important; for example, family history may include malignant
hyperthermia in a parent or sibling, which is crucial to help guide the
patient make an informed decision about the choice of anesthesia and
agents that should be avoided.18,23,25,53,58,59,60-63
71
A pertinent assessment related to pathological conditions in the
patient's personal history with potential to lead to difficult airway
management during anesthesia gives certain cues as to what would be
required for airway management. For example, a positive history for
gastroesophageal reflux disease, dysphagia, and gastrointestinal
disorder may represent an increased risk of regurgitation and
pulmonary aspiration and will indicate a need for tracheal intubation.
The awareness about pre-existing diseases such as diabetes,

hypertension, coronary insufficiency, and hepatic or kidney
impairments, will help determine necessary preoperative investigations,
monitoring parameters, and the choice of premedication, adjuvant and
anesthetic drugs. Furthermore, it will increase awareness of known
potential intraoperative and postoperative complications.
Past History and Prior Anesthesia
Routinely asking about prior anesthetic experiences should be an

integral part of proper preparation for anesthesia. While doing so,
patients in need of psychological help can be detected, and those at risk
for adverse effects from anesthesia, such as post-op nausea and
vomiting (PONV), allergies, or susceptibility to malignant hyperthermia
can be identified.
A prior experience of inadvertent intraoperative awareness (the

unexpected and explicit recall by patients of events that occurred during
anesthesia) should be carefully researched as this has been recognized
as a strong predictor of another similar event. The issue of inadvertent
awareness is not only relevant to the patient's safety but also to the
standards for monitoring, as well as research in the field of neural
72
correlates of consciousness. The approximate incidence of awareness in
the general population is estimated to be 1-2 per 1000, while patients
with a history of intraoperative awareness with recall have an incidence
of 1 in 50.
The hypothesis of a genetic contribution is controversial. Since there is

established evidence that incidence of awareness without recall is higher
than with recall, it is safe to assume that this risk is somewhat
underestimated. Intraoperative awareness with recall can lead to post
traumatic stress disorder (PTSD). The distress experienced by the aware
patient is particularly more intense when neuromuscular agents have
been administered.
Current Medications
A history of medication should be obtained and documented in all

patients, during the process of evaluation of general anesthesia.
Especially, in the geriatric population which consumes more systemic
medications than any other group.
Generally, administration of most drugs, with some exceptions, should

be continued up to the morning of surgery. The dosage of
antihypertensive drugs and insulin will have to be adjusted, while oral
hypoglycemic drugs should be discontinued. Diuretics, including
angiotensin converting enzyme (ACE) inhibitors, should be discontinued
the day before surgery due to their effects on water and electrolyte
balance; ACE inhibitors, which are routinely used in hypertensive
patients contribute to hemodynamic instability by interfering with the
renin-angiotensin-aldosterone system, a key player in the blood
73
pressure regulation. The group of monoamine oxidase inhibitors should
be interrupted 2 to 3 weeks before surgical procedure due to the risks of
interaction with anesthesia drugs. Oral contraceptives should be
discontinued at least 6 weeks before elective surgery because of the risk
of venous thrombosis.
The use of medications that potentiate bleeding needs to be carefully

evaluated taking in account the risk benefit ratio and the recommended
time frame for a discontinuation will be based on drug clearance and
half-life properties. Aspirin should be discontinued 7-10 days before
surgery and oral anticoagulants must be stopped 4-5 days prior to
surgery. The American Society of Anesthesiologists also recommends
discontinuing herbal supplements at least 2 weeks before surgery.
Allergies
The clinical spectrum of allergic manifestations ranges from mild

reactions such as skin rash to the most severe forms with difficulty
breathing and anaphylaxis. As a first approach, preanesthetic interview
with the patient may reveal a history of allergic reaction to known
products or drugs including foods, latex, disinfectants, antibiotics and
local anesthetics. This information will be recorded in the medical file
and used to exclude exposure to the sensitizing agent, and select an
appropriate alternative.
Asthma and Chronic Rhinitis
These two pathological conditions with underlying allergic mechanisms

are the most common chronic airway diseases and as such, merit a
74
close evaluation when planning anesthesia in patients with these
conditions.
Two types of asthma can be distinguished. The allergic and the

nonallergic types, and although they may overlap, the allergic type is
the most frequent in children and adults. The development of asthma is
thought to be due to both genetics and environmental factors such as
tobacco smoke, air pollutants, and exposure to allergens, which may
trigger its onset.
Allergic rhinitis is characterized by symptoms such as sneezing, nasal

blockage and itching of the nose, which can be intermittent or
permanent. More than 80% of asthmatic patients have rhinitis, and
10% to 40% of rhinitis patients have asthma. Because of this
association, patients with severe or uncontrolled rhinitis should be
evaluated for asthma before anesthesia.
Another meaningful association is sleep-disordered breathing which has

been found to be more prevalent in asthmatic individuals than in the
normal population.
Preoperative assessment and physical examination in asthmatic

patients should focus on preoperative pulmonary risk assessment. The
anesthetist should ask about exercise tolerance and clearly document
any drug sensitivities, especially aspirin given the high prevalence of
aspirin-induced asthma. The presence of decreased breath sounds,
sibilants, rhonchi, and prolonged expiratory phase, a recent
exacerbation with wheezing, cough, and dyspnea increases the risk of
75
perioperative pulmonary complications, in addition to an increased risk
of bronchospasm induced by tracheal intubation.
If the physical examination reveals the presence of an active

bronchospasm, elective surgery should be postponed until the patient
becomes free of wheezing, cough and dyspnea. Furthermore,
asthmatics who are smokers are strongly advised to abstain from
smoking at least 2 months before surgery.
Preparatory Phase
The key parameters in the prevention of perioperative bronchospasm in

asthmatic patients are the control of airway inflammation and reduction
of the associated symptoms. Spirometry evaluation of the lung function
is useful. The drugs used to control asthma should be continued
perioperatively.
General Anesthesia and Associated Drugs
Drugs associated with histamine release (morphine, atracurium) should

be avoided and intubation should be performed under adequate
analgesia (fentanyl). Short-acting anesthetic agents include propofol,
and ketamine, which is a bronchodilator. Extubation will be carried out
in a sitting position and breathing oxygen.
Intraoperative bronchospasm has been reported to occur in asthmatic

patients. Based on published literature, bronchospasm induced by
irritation of the airway, occurred more frequently in patients who had
predisposing factors such as asthma, heavy smoking or bronchitis,
76
during induction and maintenance phase of anesthesia. Other studies
showed that an allergic mechanism was present in a significant number
of the cases experiencing bronchospasm during induction.
The treatment of bronchospasm aims at relieving as quickly as possible

the airway obstruction to reestablish normal oxygenation. For this
purpose, oxygen concentration should be increased to 100% and
manual bag ventilation started to assess the pulmonary compliance.
The concentration of the volatile anesthetic (sevoflurane or isoflurane,
but not desflurane, which is an irritant) will be increased. Propofol or
ketamine will be added to rule out an inadequate depth of anesthesia
as a cause for the bronchospasm.
Quick acting beta 2-selective adrenergic agonists should be

administered with a nebulizer or a metered-dose inhaler to relieve the
bronchoconstriction. As an example, 8-10 puffs of salbutamol whose
onset of action is 5 minutes with a peak at 60 minutes and duration of
action extending to 4-6 hours, will be repeated at 15 to 30 min
intervals. Finally, steroids will be administered intravenously to speed
up the resolution of the airway inflammation.
Regional anesthesia is best suited for peripheral surgery in poorly

controlled asthmatic patients. In these cases, spinal technique is
considered safe.
Summary
There has been rapid growth and development of varied clinical roles
within anesthesia and surgical health teams to deliver inpatient and
outpatient treatment with the goal to improve available, cost-effective
77
patient care. Nurse anesthetists have a vital role in the management
of the perioperative patient as well as in the provision of clinical
support services outside the operating suite. As experienced
anesthesia clinicians, nurse anesthetists are able to assist in the
education and training of new nursing and medical staff in the
provision of varied anesthesia procedures, including pre- and post
anesthesia care.
Nurse anesthetists specifically have a vital role in the care of surgical

pasien. This article provided an overview of local, regional and
general anesthesia, as well as the nurse's responsibilities in the
management of the patient while under anesthesia. Itu
responsibilities of the anesthetist to deliver pre- and post-operative
care relating to the administration of anesthesia were discussed. Ini
includes knowledge of the side effects and contraindications of the
different anesthesia techniques, as well as an understanding of the
three phases of anesthesia: induction, maintenance and recovery.
Anesthesia care teams work in collaboration with all members of the

surgical team, as well as in other health settings to provide a plan of
care tailored to each individual patient. This plan may include
intravenous sedation, pain control, or varied types of anesthesia
during emergency, surgical or other procedures, such as palliative
types, which nurse anesthetists might be called upon to manage and
to responsibly work in concert with their health teams in the delivery
of safe and appropriate anesthesia care for patients.
78
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requirement.
1. _____________ is used to anesthetize an area of the body.
Sebuah. Local anesthesia

b. General anesthesia
c. Sedation
d. Regional anesthesia
2. True or False: The term “asleep” is used when anesthesia

clinicians speak of a patient who is anesthetized because
general anesthesia is similar to sleep in physiological terms.
Sebuah. True
b. False
3. The triad model of anesthesia means that _______________

needed to produce all three of the intended effects of
anesthesia: narcosis, analgesia, and muscle relaxation.
Sebuah. sedation is
b. an anesthesia care team is
c. multiple agents are
d. only one agent is
4. Which of the following is characteristic of electrical brain

activity in an anesthetized subject but not an individual who
is sleeping?
Sebuah. Rapid eye movement (REM) sleep

b. Non-REM sleep
c. Burst suppression
79
d. Aniso-electric periods
5. Pain signals turn into perceived pain at the moment the

sensory pain signals arrive at the
a. thalamus.
b. the cortex.
c. nociceptors.
d. peripheral nerves to the spinal cord.
6. Peripheral nerve signals that head towards the central

nervous system (CNS) are known as
a. efferent signals.
b. descending signals.
c. isoelectric signals.
d. afferent signals.
7. True or False: General anesthesia require the use of

analgesics to produce unconsciousness.
Sebuah. True
b. False
8. _____________ in the central nervous system produce

muscle movement.
Sebuah. Efferent signals

b. The dorsal columns
c. Afferent signals
d. Nociceptors
9. An individual nerve transmits its signal along the axons by a

self-propagating electrical charge called
a. propagation.
b. an action potential.
c. infusion.
d. a resting potential.
80

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DASAR ANESTESIA:

Jassin M. Jouria adalah seorang dokter medis,

Pertumbuhan pesat perawat anestesi dalam bidang bedah dan

Kegiatan ini telah direncanakan dan dilaksanakan sesuai dengan

Penunjukan Kredit Pendidikan Berkelanjutan

Kegiatan pendidikan ini diberikan selama 4,5 jam. Perawat hanya

Pernyataan Kebutuhan Pembelajaran

Perawat anestesi perlu mengetahui peran dan tanggung jawab mereka

Memberikan pembelajaran lanjutan bagi dokter yang tertarik pada

Praktik Tingkat Lanjut Perawat Terdaftar dan Perawat Terdaftar

Penulis Kursus & Tim Perencanaan Pengungkapan Konflik

Kepentingan Jassin M. Jouria, MD, William S. Cook, PhD , Douglas

Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC - semua tidak

Pengakuan Dukungan Komersial

Tidak ada dukungan komersial untuk kursus ini.

Kesempatan untuk menyelesaikan penilaian diri atas

Sebuah. Anestesi lokal

2. Benar atau Salah: Istilah "tertidur" digunakan ketika dokter

3. Model triad anestesi berarti bahwa _______________

Sebuah. obat penenang adalah

4. Manakah dari berikut ini yang merupakan karakteristik

Sebuah. Rapid eye movement (REM) tidur

5. Sinyal nyeri berubah menjadi nyeri yang dirasakan

Tim perawatan anestesi bekerja sama dengan semua anggota tim

Gambaran Umum Anestesi Dan Konsep Umum

Karena perkembangan mutakhir alat bedah dan eksplorasi dalam

Anestesi melibatkan pengobatan yang diberikan untuk menghilangkan

Ada tiga jenis anestesi yang perlu dipertimbangkan: 1) anestesi lokal

Sedasi adalah bidang keterampilan penting lainnya dari staf medis

Ada beberapa tingkatan sedasi. Dosis yang ringan memungkinkan

Anestesi Umum dan Model Triad

Meskipun istilah tertidur digunakan ketika dokter anestesi berbicara

Pada tahun 1926, John Lundy memperkenalkan istilah "anestesi

Pemahaman mengapa anestesi tidak sama dengan tidur dapat dicapai

Aktivitas listrik yang intens terjadi selama siklus tidur, terutama

Analgesia Selama Anestesi

Tujuan dari analgesia adalah untuk menghilangkan sensasi nyeri

Kondisi optimal untuk anestesi umum memerlukan kombinasi

Relaksasi Otot Relaksasi

Sistem saraf diatur secara hierarkis. Otak dan sumsum tulang

Sinyal naik hampir semuanya bersifat sensorik, yang meliputi nyeri,

Sel saraf atau neuron terdiri dari

Saraf individu mentransmisikan sinyalnya di sepanjang akson dengan

Beberapa zat yang ditemukan di alam diketahui mengganggu

Turunannya Kokain adalah alkaloid yang ditemukan di daun tanaman

Pada tahun 1904 di Institut Pasteur, Ernest Fourneau berhasil

Amilokain dan prokain memiliki hubungan ester, yang dapat dipecah

Karena agen anestesi lokal bekerja dengan memblokir konduksi saraf

Tetracaine kira-kira 10 kali lebih kuat dan lebih beracun daripada

Lidocaine juga dikenal dengan nama xylocaine cepat diserap, memiliki

Bupivacaine digunakan terutama untuk anestesi regional dalam

Ropivacaine hampir identik dengan bupivacaine dalam hal onset,

Efek Merugikan Anestesi Lokal

Efek merugikan sistemik dari anestesi lokal diakibatkan oleh masuknya

Anestesi Lokal: Topikal dan Subkutan

Berbeda dengan kulit, selaput lendir menyerap anestesi topikal dengan

Anestesi Regional Anestesi

regional diperoleh dengan cara memblokir saraf, sehingga kulit,

Keuntungan Anestesi Regional

Selain mengontrol nyeri, anestesi regional memiliki sejumlah

Teknik Umum Teknik

anestesi regional melibatkan memasukkan jarum cukup dekat ke saraf