General
anesthesia
General anesthesia
The goals of general anesthesia: - Mandatory: -amnesia/sedation/hypnosis -analgesia -maintenance of homeostasis - Optionally: -muscle relaxation
-surgical procedures requiring analgesia and muscle relaxation, that cannot be performed using regional anesthesia techniques: upper abdominal surgery, thoracic surgery, head and neck surgery, shoulder surgery etc. -surgical procedures that significally interfere with vital functions: neurosurgery, thoracic surgery, cardiac surgery, surgery of the aorta etc.
-volatile liquids
halothane, isoflurane, sevoflurane si desflurane
The advantage of entering and leaving the body by ventilation with minimal metabolization. They result in sedation, analgesia and light muscle relaxation.
MAC intubation ( MAC that facilitates the intubation in 50% of the patients); MAC bar (MAC that abolishes the hemodynamic response in 50% of the patients); MAC awake (MAC at which awakening occurs in 50% of the patients).
Class
Concentration Advantages/disadvantages Side effects in balanced anesthesia 40-66% Light analgesia Accumulation in airway spaces Bronchodilatation Slow dynamics Bronchodilatation Medium dynamics Bronchodilatation Fast dynamics Cardio-vascular stability Airway irritant Special vapporiser Risk of hypoxemia Euforia Cardiovascular depression Vasodilatation
Gaseous
Volatile
1,5-2%
Isoflurane
Volatile
1,5-2%
Sevoflurane
Volatile
2-3%
Compound A
Desflurane
Volatile
6-8%
Sympathetic stimulation
Intravenous
anesthetics:
metohexital thiopental, tiamital Imidazolic compounds etomidate Alkylphenols propofol Steroids eltanolone Long acting: Ketamine Benzodiazepines diazepam, midazolam
THIOPENTAL:
-very rapid induction; maximal effect in 40 s; -superficial anesthetic sleep; -NO an analgesic effect; -weak muscle relaxation. Administration: slow i.v. Side effects: risk of respiratory and circulatory depression
PROPOFOL -very liposoluble fatty acid; -hepatic metabolisation in great extent short effect;
Pharmacodynamic action: -pharmacologic effects similar with those of Thiopental; -less residual effects.
KETAMINE Pharmacodynamic action: Dissociative anesthetic: - dissociation from the environment - superficial sleep - strong analgesia Advantages:-No respiratory depressant effect; -hemodynamic stability by the release of catecholamines -bronchodilatatory effect
Hypnotic
Class
Side effects
Thiopental
Arterial hypotension, respiratory depression, tachycardia, decreases the cardiac output Arterial hypotension, respiratory depression, tachycardia Adrenal glad inhibition Interindividual response variability Respiratory depression
Propofol
Alkylphenol
1-2 mg/kg
5-10 min
Etomidat Diazepam
Midazolam
Benzodiazepines
0,2-0,3 mg/kg
5-15 min
Analgetics:
Opioids: -the class of analgesics with the broadest intraanesthetic utilisation; -profound dose-dependant analgesia; -in spite of their quasi-constant use during general anesthesia, the opioids are not anesthetics because the loss of consciousness is not a regular effect -they regularly result in respiratory dosedependent depression. Cardiovascular depression is a variable effect.
Opioids
Class
Side effects
Morphine
Agonist
Respiratory depression, sedation. hTA, bradycardia Sedation, nausea/vomiting, HTA, tachycardia Respiratory depression Respiratory depression Respiratory depression
Pethidine
1 mg/kg
20-30 min
20 min
Muscle relaxants:
-substances that act at the neuromuscular junction level and prevent the transmission of the physiologic stimulus for the muscular contraction; -NO action on the CNS, NO loss of consciousness, NO analgesia; -utilized for the facilitation of the airway instrumentation, of mechanical ventilation and of the surgical intervention; -results in alveolar hypoventilation or apnea by the action on the respiratory muscles; -minimal cardio-vascular effects.
Class
Single dose duration of action 10-15 min 30-40 min 20-30 min
D ND ND
Atracurium
ND
0,5 mg/kg
20 min
Cisatracurium
ND
0,2 mg/kg
20 min
Kidney failure
Mivacurium
ND
0,2 mg/kg
10-15 min
Rocuronium
ND
0,6-0,9 mg/kg
30-60 min
Anesthesia apparatus
Anesthesia Apparatus
Components:
-connection with the sources of medical fluids -flowmeters -vaporizers -anesthetic circuit -CO2 scavenger system -balloon ventilation system -overpressure valve -mechanical ventilation module -emergency oxygen delivery circuit
-ventilation parameters setting module; -ventilation parameters and inhalation anesthetics monitoring module; -alarm module; -vacuum system (sucction).
Intraanesthesic monitoring
Standard II:
-oxygenation: inspiratory oxygen concentration (FiO2), pulsoxymetry (SpO2); -ventilation: clinical evaluation, auscultation, capnography; -circulation: electrocardioscopy (continuous), noninvasive arterial blood pressure and pulse measurement; -body temperature.
Monitoring Respiratory Airway pressure, tidal volume, minute ventilation, respiratory rate, O2/CO2 inspiratory concentration, concentration of volatile anesthetic agent, pulsoxymetry Non-invasive arterial pressure, multiple leads ECG, computerized analysis of ST segment, central venous pressure, pulmonary artery pressure (systolic, medium, diastolic, wedge) cardiac output, extra-vascular pulmonary water, peripheral vascular resistance, ScvO2, SvO2. BIS (bispectral index) Peripheral nerve stimulator Diuresis
Cardiovascular
Hypnosis Muscle relaxation Renal Temperature Acid - base equilibrium Electrolytes Haematological analysis, coagulation studies Oxygen transportation Metabolic
Central, peripheral
Blood gas analysis Na, K, Cl, Ca Platelets, aPTT, INR
Preanesthetic visit
Preanesthetic exam:
-psychological preparation of the patient; -clinical and laboratory evaluation of the patient; -asignement to an anesthetic risk group (ASA scale) -choosing the anesthetic technique and obtaining informed consent; -set up of an anesthetic plan.
Risk I Risk II Risk III Risk IV Risk V Risk VI E Patient without systemic diseases Patient with systemic diseases without functional limitation Patient with systemic diseases with functional limitation Patient with uncompensated systemic disease Dying patient Brain dead patient, organ donor Emergency procedure
the
Optimizing the patient status: -the correction of dysfunctions and diseases in the preoperative period. Premedication : -reduced anxiety and reduced need for intraoperative anesthetics; -decreasing certain risks (parasympathetic reflexes, the risk of aspiration); -the facilitation of postoperative analgesia.
Induction phase: -the period of transition from the state of conscious to the state of general anesthesia; -CNS depression, ventilatory, cardiovascular depression, muscle relaxation; -securing the airway. Maintenace phase: -providing the adequate depth of anesthesia by administering anesthetics, analgesics and muscle relaxant agents. Emergency phase: -the interruption of the administration of all volatile or intravenous anesthetic agents; -the antagonisation of the muscle relaxant drug.
anesthesia; Intravenous anesthesia; Volatile anesthesia; Combined techniques of general and regional anesthesia: -general anesthesia + epidural anesthesia.
General anesthesia complications Respiratory Cardio-vascular CNS Digestive Renal Metabolice Hidro-electrolitics Acid-base Coagulation Allergical Cutaneous Hypoxemia, hypercapnia laryngeal spasm, bronchospasm, aspiration, ARDS, atelectasis High/low blood pressure, tachy/bradycardia, myocardial ischemia, arrhythmia , hypovolemia, low cardiac output Convulsions, shivers, post anoxic encephalopathy, paresis by compression or elongation of peripheral nerves Vomiting or regurgitation, hiccup Oligo/anuria, urinary retention, pre - renal failure Hyper/hypoglycemia, malignant hyperthermia Extracellular space expansion (interstitial oedema), hypo/hyperkalemia, hypocalcemia Hypercloremic metabolic acidosis, lactacidemic Thrombocytopenia, dilutional coagulopathy, deep venous thrombosis Cutaneous eruptions, Quincke oedema, bronchospasm, anaphylactic shock Decubitus injury, accidental burns
Regional anesthesia
Regional anesthesia
Indications: -the area can be anesthetised using regional blocks; -the surgical procedure does not affect the vital functions; -patient's informed consent; Contraindications: -patient's refusal; -active coagulation disorders or anticoagulant treatment; -infections or haematoma at injection site; -neurological deficit and lack of cooperation.
Local anesthetics
Amides Lidocain Mepivacain Bupivacain Prilocain Etidocain Ropivacain Esters Procain Tetracain Benzocain
Clinical use of local anesthetics Central regional anesthesia/analgesia Regional intravenous anesthesia Peripheral nerve block or plexus Infiltration anesthesia Local anesthesia Blocking of thehemodynamic response during tracheal intubation in regional anesthesia we frequently use the combination between a local anesthetic and adrenaline, an opioid or clonidine, increasing the duration and quality of the block
oxygenation,
circulation,
blood
Spinal
Epidural anesthesia
Caudal anesthesia
Local anesthesia
contact topical - skin, mucous membrane application tissue infiltration