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Dr.

Roshana Mallawaarachchi

01/06/2010

Anesthesia is defined as the abolition of sensation.

Analgesia is defined as the abolition of pain.

First public demonstration of ETHER anaesthesia was given in 1846 for the removal of a vascular tumour.
Later in 1846, an American dentist administered ETHER during a dental extraction.

Contemporary re-enactment of Morton's October 16, 1846, ether operation

1. Regional (Local) Anaesthesia


2. General Anaesthesia

What are the methods? 1. Local infiltration 2. Nerve Block 3. Topical 4. Intravenous Blocks 5. Spinal Anaesthesia 6. Epidural anaesthesia

ESTERS Procaine Benzocaine Cocaine Tetracaine

AMIDES Lidocaine Prilocaine Ropivacaine Bupivacaine

1. Unconsciousness
2. Analgesia

3. Muscle relaxation

A variety of drugs are given to the Patient that have above effects.

1. Reduces intraoperative patient awareness and recall. 2. Allows proper muscle relaxation for prolonged periods of 3. 4. 5. 6. 7.

time. Facilitates complete control of the airway, breathing, and circulation. Can be used in cases of sensitivity to local anesthetic agent. Can be administered without moving the patient from the supine position. Can be adapted easily to procedures of unpredictable duration or extent Can be administered rapidly and is reversible

1. Requires increased complexity of care and associated


2. 3. 4. 5.

costs. Requires some degree of preoperative patient preparation. Can induce physiologic fluctuations that require active intervention. Less serious complications. Eg: nausea or vomiting, sore throat, headache and shivering. Associated with malignant hyperthermia, a rare, some (but not all) general anesthetic agents results in acute and potentially lethal temperature rise, hypercarbia, metabolic acidosis, and hyperkalemia.

Management of the airway & maintenance of anaesthesia

Aneasthesia machine

General Anaesthesia usually involves the administration of 3 different drugs: 1. Premedication 2. Induction of anaesthesia 3. Maintenance of anaesthesia

Clinical assessment of the patient:


History/Examination/Investigation

Pre operative optimization:


Correction of anaemia , Hypovolaemia & Dehydration Control of medical disease

Premedication

2 main aims: 1. Prevention of the parasympathomimetic effects of anaesthesia. Eg: Bradycardia/bronchial secretion 2. Reduction of anxiety and pain

Anxiolytics: Relief from anxiety

Eg: Benzodiazepines (Diazepam/Lorazepam/Midazolam) Analgesics: When there is existing pain or as a supplement to an anaesthetic agent. Eg: Paracetamol, NSAIDs, Opiates Parasympathetic blockers: (Anti Muscaranic) To reduce bronchial and salivary secretions Eg: Atropine / Hyoscine / Glycopyrronium

Acid aspiration prophylaxis

Eg: Cimetidine/Ranitidine
Antibiotic Prophylaxis

Eg: Invasive dental procedures


Antithrombotic Prophylaxis Eg: Subcutaneous Heparin injection

1. Intravenous anesthetics Eg: Thiopentone / Propofol / Ketamine 2. Inhalational anesthetics Eg: Halothane / Isoflurane / Desflurane / Sevoflurane / Nitrous Oxide

1. Intravenous anesthetics are still the most common method. Eg: Thiopentone / Propofol / Ketamine
May be used either to induce or maintenance of anaesthesia. Anaesthetic effect once it reaches the central nervous system (One arm brain circulation time)

Advantages: IV anesthesia include rapid and smooth induction of anesthesia. Less equipment requirement (syringes, needles, Cannula) Easy administration of drugs.

Gauge
14G 16G 17G 18G 20G 22G 24G

Color Code
Orange Grey White Green Pink Blue Yellow

Disadvantages: Difficult retrieval of drug once administered. Less control of depth and duration of anesthesia. Lack of ventilatory support. Poor tolerability.

high therapeutic index no toxic metabolites potent, so small volume is required for anesthetic

induction/maintenance long shelf life and resistance to microbial contamination compatible with other drugs quick and smooth induction and recovery reversible with specific antagonist non-allergenic no cardiopulmonary depression independent of liver and kidneys for metabolism and excretion no effect on cerebral blood flow no endocrinologic effect no pain on injection inexpensive

The most widely used barbiturate.


Causes unconsciousness within 3045 second persists

for about 4-7 mins. It has no analgesic properties. Strongly Alkaline; causes severe necrosis in accidental extra-vascular administration. Inject through catheters to avoid this. Thiopental is not used to maintain anesthesia in surgical procedures. Because it displays zero-order elimination kinetics.

Presented as powder and dissolved in water to required concentration.

Metabolism:
Initially distributed highly vascular tissues of the brain and other organs.

Subsequently diffuses into fatty tissues.


This process terminate the pharmacological effect.

It is slowly but entirely metabolized in the Liver.

Dosage:
Adults and Children 3-5mg/kg given slowly over 10-15 seconds.

Over dosage:
Respiratory depression - Assisted ventilation with oxygen may required. Hypotension progressing to circulatory collapse Head of the table must immediately be tilted down.

Contraindications:
Should not be used if there is doubt that a clear airway can be maintained. If allergy to barbiturates. If severe cardiovascular disease or hypotension.

Precausions:
Administered under supervision of an experienced anaesthetist.

Equipment for resuscitation should be available.


Patient should lie supine because even a small dose can cause hypotension.

Adverse Effects: Hypotension, Apnea, Airway obstruction (Due to cardiovascular and respiratory depression) Arrythmias Cough, Sneezing Hypersensitivity reactions

Drug Interations: Antihypertensives / Diuretics may augment the hypotensive effect.

Ketamine is used very rarely now. It has good analgesic properties. Anaesthesia persist for upto 15 mins.

Advantages:
Does not induce Hypotension Pharyngeal and Laryngeal reflexes are slightly impaired. (So airway may be less at risk) Rarely induces bronchospasms.

Disadvantages:
Does not produce muscle relaxation. It tends to raise Heart rate and intracranial and intraocular pressure. High incidence of Hallucinations. These can be reduced by diazepam or midazolam.

Indications:
Pediatric anesthesia Asthmatics or patients with chronic obstructive

airway disease. In emergency medicine in entrapped patients suffering severe trauma. Emergency surgery in field conditions in war zones. Painful procedures Dressing of burns, Minor orthopaedic procedures, Dental procedures

Dosage:
Induction 1-2 mg/kg (IV) 6-8mg/kg (IM) Maintenance Serial doses of 50% of IV dose or 25% of IM dose As an analgesic 0.5mg/kg IM or IV

Contraindications:
Moderate to severe Hypertension Congestive cardiac failure History of Cerebrovascular accident Acute and Chronic Alcohol intoxication Intracerebral mass or Haemorrhage Eye injury Psychiatric Disorders

Pregnancy

Associated with quick induction (30s) and

rapid recovery (4 min) Used both for induction and Maintenance. Sometimes pain on intravenous injection, which can be reduced by IV lidocaine.

Inhalational anesthetics are useful in young children or needle phobic adults. This may also used in patients at risk of Pulmonary aspiration. Halothane Isoflurane Desflurane Sevoflurane Nitrous oxide

It is a potent agent. Induction is smooth and pleasant. Produces moderate muscle relaxation. Vapour is non irritant.

Advantages:
Anaesthesia can be produced by 2-5min. Does not augment salivary or bronchial secretions.

Recovery is rapid and nausea and vomiting is low.

Disadvantages: (Adverse Effects)


Severe Hepatotoxity (1:50,000)
Respiratory depression results in raised in CO2 and

cause arrhythmias. Cardio depression causes Bradycardia

Contraindications:
History of unexplained Jaundice. Family history of malignant hyperthermia.

Precautions:
At least 3 months should be allowed to elapse between each re-exposure. (Minimize liver damage)

Isoflurane Similar in action to halothane. But less cardio depressant and unlikely to cause hepatotoxity
Desflurane Similar to isoflurane but is less potent Sevoflurane More potent than desflurane and recovery are rapid.

This is not potent enough to use for induction. So it is used for maintenance of anaesthesia.

For anaesthesia: a mixture with 70% gas and 30% oxygen

For analgesia: A mixture of NO and oxygen containing 50% of each. Self administration in labour (Entonox)

Adverse Effects: Nausea and Vomiting Repeated exposure can cause bone marrow depression.
Storage: NO is supplied under pressure in cylinders.

General anaesthesia is a procedure which is never without risk (including the risk of death). As a result, the General Dental Council in the UK recommends that "the decision to refer a patient for treatment under general anaesthesia should not be taken lightly.

It's not recommended for routine dental work like

fillings. Laboratory tests, chest x-rays and ECG are often required before having GA, because of the greater risks involved. Very advanced training and an anesthesia team are required, and special equipment and facilities are needed. GA does nothing to reduce dental anxiety. It's expensive.