Anesthesia

Dr Abdollahi
Anesthesia
From Greek anaisthesis means not sensation
Listed in Baileys English Dictionary 1721.
When the effect of ether was discoveredanesthesia
used as a name for the new phenomenon.
Basic Principles of Anesthesia
Anesthesia defined as the abolition of sensation
Analgesia defined as the abolition of pain
Triad of General Anesthesia
need for unconsciousness
need for analgesia
need for muscle relaxation
History of Anesthesia
History of Anesthesia
Ether synthesized in 1540 by Cordus
Ether used as anesthetic in 1842 by Dr.
Crawford W. Long
Ether publicized as anesthetic in 1846 by
Dr. William Morton
Chloroform used as anesthetic in 1853 by
Dr. John Snow
History of Anesthesia
Endotracheal tube discovered in 1878
Local anesthesia with cocaine in 1885
Thiopental first used in 1934
Curare first used in 1942 - opened the Age
of Anesthesia
Anesthesiologists care for the surgical patient in the
preoperative, intraoperative, and postoperative
period . Important patient care decisions reflect the
preoperative evaluation, creating the anesthesia
plan, preparing the operating room, and managing
the intraoperative anesthetic.
Preoperative Evaluation

The goals of preoperative evaluation include assessing the
risk of coexisting diseases, modifying risks, addressing
patients' concerns, and discussing options for anesthesia
care.
What is the indication for the proposed surgery? It is elective
or an emergency?
The indication for surgery may have particular anesthetic
implications. For example, a patient requiring esophageal
fundoplication will likely have severe gastroesophageal
reflux disease, which may require modification of the
anesthesia plan (e.g., preoperative non particulate antacid,
intraoperative rapid sequence induction of anesthesia).
What are the inherent risk of this surgery?
Surgical procedures have different inherent risks.
For example, a patient undergoing coronary artery
bypass graft has a significant risk of problems
such as death, stroke, or myocardial infarction.
A patient undergoing cataract extraction has a low
risk of major organ damage.
Does the patient have coexisting medical problems?
Does the surgery or anesthesia care plan need to
be modified because of them?
Has the patient had anesthesia before? Were there
Complication such as difficult airway management?
Does the patient have risk factor for difficult
airway management?
Creating the Anesthesia Plan

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

After determining the anesthesia plan, the
trainee must prepare the operating room .
Anesthesia Providers
Anesthesiologist ( aphysician with 4 or more yearsof
speciality training in anesthesiology after medical
school)
Certified registered nurse anesthetist (CRNA),
working under the direction and supervision of an
anesthesiologist or a physician
CRNA must have 2 years of training in anesthesia
Patient Safety
Patient risk and safety are concerns during surgery and
anesthesia .
Data from a number of studies of death caused by
anesthesia indicate a death rate ranging from 1 per 20,000-
35,000.
A fourfoulded decline over the last 30 years even though
surgical procedures are undertaken on increasingly sicker
and much higher risk patients than in the past.
Awareness of potential problems and constant vigilance (the
process of paying close and continuous attention) are crucial
to good patient care.
Preoperative preparation patient
evaluation
Anaesthesiologist:
reviews the patients chart,
evaluate the laboratory data and diagnostic studies such
as electrocardiogram and chest x-ray,
verify the surgical procedure,
examins the patient,
discuss the options for anesthesia and the attendant risks
and
ordered premedication if appropriate

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


Choice of anesthesia
The patients understanding and wishes regarding the type of
anesthesia that could be used
The type and duration of the surgical procedure
The patientss physiologic status and stability
The presence and severity of coexisting disease
The patients mental and psychologic status
The postoperative recovery from various kinds of anesthesia
Options for management of postoperative pain
Any particular requiremets of the surgeon
There is major and minor surgery but only major anesthesia
Types of anesthesia care
General Anesthesia
Reversible, unconscious state is characterised
by amnesia (sleep, hypnosis or basal narcosis),
analgesia (freedom from pain) depression of
reflexes, muscle relaxation
Put to sleep
Types of anesthesia care
Regional Anesthesia
A local anethetic is injected to block or ansthetize a
nerve or nerve fibers
Implies a major nerve block administered by an
anesthesiologist (such as spinal, epidural, caudal, or
major peripheral block)
Types of anesthesia care
monitered anesthesia care
Infiltration of the surgical site with a local
anesthesia is performed by the surgeon
The anasthesiologist may supplement the local
anesthesia with intravenous drugs that provide
systemic analgesia and sedation and depress
the response of the patients autonomic nervous
system
Types of anesthesia care
local anesthesia
Employed for minor procedures in which the
surgical site is infiltrated with a local anesthetic such
as lidocaine or bupivacaine
A perioperative nurse usually monitors the patients
vital signs
May inject intravenous sedatives or analgesic drugs
Premedication

Purpose: to sedate the patient and reduce anxiety
Classified as sedatives and hypnotics, tranquilizers, analgesic or narcotics and
anticholinergics
Antiacid or an H2receptor-blockingdrug such as cimitidine (tagamet) or ranitidine
(Zantac) to decrease gastric acid production and make the gastric contents less acidic
If aspiration occur this premedication decreases the resultant pulmonary damage
Given 60-90 minutes before surgery, or may be given i.v. After the pat. arrives in
the surgical suite
NPO for a minimum of 6 hours before elective surgery
Not given to elderly people or ambulatory patients because residual effects of the
drugs are present long after the pat. have been discharged and gone home
Perioperative monitoring
Undergeneral anesthesia: monitoring
Inspired oxygen analyzer(FiO2) which calibrated to room air and
100% oxygen on a daily basis
Low pressure disconnect alarm, which senses pressure in the
expiratory limb of the patient circuit
Inspiratory pressure
Respirometer (these four devices are an integral part of most modern
anesthesia machine
ECG
BP-automated unit
Heart rate
Precordial or esophagel stethoscope
Temp

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


Perioperative monitoring
For special conditions other monitors as
transesophageal echocardiography
Electroencephalogram
Cereral or neurological may be used
Inhalational Anesthetic Agents
Inhalational anesthesia refers to the delivery
of gases or vapors from the respiratory
system to produce anesthesia
Pharmacokinetics--uptake, distribution, and
elimination from the body
Pharmacodyamics-- MAC value
Regional Anesthesia
Defined as a reversible loss of sensation in
a specific area of the body
Spinal anesthesia
Epidural anesthesia
IV Regional Blocks
Peripheral Nerve Blocks
Spinal Anesthesia
A local anesthetic agent (lidocaine,
tetracaine or bupivacaine) is injected into
the subarachnoid space
Spinal anesthesia is also known as a
subarachnoid block

Blocks sensory and motor nerves,
producing loss of sensation and temporary
paralysis
Possible Complications of Spinal
Anesthesia
Hypotension

Post-dural puncture headache (Spinal headache) caused by
leakage of spinal fluid through the puncture hole in the dura-
can be treated by blood patch

High Spinal- can cause temporary paralysis of respiratory
muscles. Patient will need ventilator support until block wears
off

Epidural Anesthesia
Local anesthetic agent is injected through
an intervertebral space into the epidural
space.

May be administered as a one-time dose, or
as a continuous epidural, with a catheter
inserted into the epidural space to
administer anesthetic drug
Dr. Aidah Abu Elsoud Alkaissi
Division of Intensive Care and
Anaesthesiology University of
Linkping Sweden
Complications of Epidural
Anesthesia
Hypotension
Inadvertent dural puncture
Inadvertent injection of anesthetic into the
subarachnoid space


IV Regional Blocks
Also known as a Bier Block
Used on surgery of the upper extremities
Patient must have an IV inserted in the
operative extremity
IV Regional Block
After a pneumatic tourniquet is applied to
extremity, Lidocaine is injected through the
IV.

Anesthesia lasts until the tourniquet is
deflated at the end of the case.

IV Regional Blocks
IMPORTANT- to prevent an overdose of
lidocaine it is important not to deflate the
tourniquet quickly at the end of the
procedure.

Peripheral Nerve Blocks
Injection of local anesthetic around a
peripheral nerve

Can be used for anesthesia during surgery
or for post-op pain relief

Examples: ankle block for foot surgery,
supraclavicular block for post-op pain
control after shoulder surgery
Monitored Anesthesia Care (MAC)
Generally used for short, minor procedures
done under local anesthesia
Anesthesia provider monitors the patient and
may provide supplemental IV sedation if
indicated
Conscious Sedation
Used for short, minor procedures

Used in the OR and outlying areas
(ER, GI Lab, etc)

Patient is monitored by a nurse and receives
sedation sufficient to cause a depressed level of
consciousness, but not enough to interfere with
patients ability to maintain their airway
Inhalation Anesthetics
Nitrous Oxide- can cause expansion of
other gases- use of N
2
0 contraindicated in
patients who have had medical gas instilled
in their eye(s) during retinal detachment
repair surgery
Inhalation Anesthetics
Cause cerebrovascular dilation and increased
cerebral blood flow

Cause systemic vasodilation and decreased blood
pressure

Post-op N&V

All inhalation anesthetics, except N
2
0, can trigger
malignant hyperthermia in susceptible patients


Intravenous
Induction/Maintenance Agents
Propofol (Diprivan)- pain/burning on injection,
can cause bizarre dreams

Pentothal (Sodium Thiopental)- can cause
laryngospasm

General Anesthesia
During induction the room should be as quiet as
possible

The circulator should be available to assist
anesthesia provider during induction & emergence

Never move/reposition an intubated patient
without coordinating the move with anesthesia
first
General Anesthesia
Laryngospasm may happen in a patient having a
procedure with general anesthesia

When laryngospasm occurs, it is usually during
intubation or emergency

Assist anesthesia provider as needed- call for
anesthesia back-up if necessary
Difficult Airway Cart
Anesthesia maintains a Difficult Airway
Cart containing equipment & supplies for
difficult intubations

This cart is stored in one of the anesthesia
supply rooms

Page anesthesia tech if the cart is needed for
your room

Cricoid Pressure or Sellick Maneuver
Used for patients at risk for aspiration
during induction, due to a full stomach or
other factors such as a history of reflux

Pressure on the cricoid cartilage compresses
the esophagus against the cervical vertebrae
and prevents reflux
Sellick Maneuver
Cricoid pressure is maintained, as directed by
anesthesia provider, until the ETT cuff is inflated:
Regional Anesthesia
Circulator may need to assist anesthesia
provider with positioning for spinal or
epidural anesthesia.

Patient usually is positioned laterally for
placement of regional anesthesia, but may
be positioned sitting upright.
The Awake Patient
Patients undergoing surgery with regional
or local anesthesia, even if sedated, may be
aware of conversation and activity in room

Post sign on door to OR, Patient is Awake
so that staff entering room will be aware
that patient is conscious
When Patient is Awake
Limit any discussion of patients medical
condition and prognosis

Avoid discussion of other patients & limit
unnecessary conversation-- a sedated
patient can easily misinterpret conversation
they overhear