ANESTHESIOLOGY LECTURE NOTES

HISTORY OF ANESTHESIOLOGY
ANESTHESIA is one of Americas greatest
contribution to the field of Medicine and to
mankind
In the early days, most people expected to
experience pain in their lives
Pain was one of God's punishments for the
wicked and purifying trials for the good;
For the woman in labor, pain was the
spiritual experience that would transform
her into a self-sacrificing mother.
Before anesthesia, the best surgeons were
the fastest.
Four Herculean men would hold a patient on
a gurney and surgery would proceed. (PIGIL
ANESTHESIA)
Quick and simple procedures such as
amputations were the majority of surgeries
and most patients would just faint from the
unbearable pain.
Most commonly used substances to kill pain:
o Opium derived from the poppy flower,
Papaver somniferum
o Alcohol or wine
o Mandragora or mandrake from the
plant Atropa mandragora
o Belladonna from the deadly
nightshade
o Marijuana or Cannabis indica
Rene Descartes was the one who first
described the pain pathway
In the 1800s the enigma of pain, has yielded
slowly to determined investigators and
clinicians
1800 June 25: Humphry Davy completes the
introduction to his classic work, Researches,
Chemical and Philosophical; Chiefly
Concerning Nitrous Oxide, or
Dephlogisticated Nitrous Air, and its
Respiration.
o What eventually evolved into
anesthesia as we know it today was
ushered in with the chance
observation that the inhalation of
nitrous oxide ("laughing gas")
produced a state of intoxication
during which people became highly
amused and insensitive to pain.
Horace Wells (1815-1848), a New England
dentist, experimented with anesthetics in
the early 1840s. He attempted at a public
demonstration of nitrous oxide anesthesia
failed, humiliating him.
In 1846, Charles Thomas Jackson
(Massachusetts) suggested to Morton (his
student) that he use sulfuric ether
o Ether was used:
As a sedative in the treatment
of tuberculosis, asthma and
whooping cough, and as a
remedy for toothache
Its anesthetic potential had
never been exploited.
o In 1846, Morton made his famous
demonstration of surgical anesthesia
at the Massachusetts General
Hospital, using a hastily rigged
apparatus to deliver ether to the
patient.
On March 30, 1842, Crawford Long made
the first use of ether as a surgical
anesthetic when he removed a tumor from
the neck of patient James Venable.
In the subsequent bitter debate over who
"discovered" anesthesia, Charles Thomas
Jackson attempted to claim the
achievement for himself.
By 1873, however, Jackson had been
admitted to an insane asylum where he died
in 1880.
In late 1847 Simpson discovered the
anesthetic properties of chloroform
o In 1847 he began to administer ether
at St. George's Hospital in London
and published a book on ether
anesthesia.
o In 1853 and 1857 he administered
chloroform to Queen Victoria for the
births of Prince Leopold and Princess
Beatrice
Cocaine was first used to achieve topical
anesthesia in 1884.
Spinal and epidural anesthesia were
discovered soon after and a combination of
drugs was being used to allow optimal
conditions for physicians to perform
surgery.
By the 1880s anesthesia, with aseptic
technique, was standard practice in
American and European surgical theaters
While the surgeon's prestige and power
soared, the anesthetist was a mere
assistant--a nurse, intern or medical
student.

The development of the independent
medical specialty of anesthesiology would
not occur until the early 20th century
After World War II ended in 1945, major
developments in the field of anesthesiology
opened new avenues of medical and surgical
care that were previously unthinkable. Thus
began the modern era of anesthesia

ROLE OF AN ANESTHESIOLOGIST - constantly
changing and its unique role expanding to include
but not limit itself to :
1. Provision of insensibility to pain
2. Monitoring and restoration of homeostasis
3. Diagnosis & treatment of painful syndromes
4. Clinical Management of Cardiac and
Pulmonary Resuscitation
5. Evaluation of Respiratory function and
application of Respiratory Therapy

During Surgery:
1. The Operating theater is still their
domain
2. Provide utmost stability of the different
vital organ systems during surgery by
vigilant monitoring and interventions if
necessary due onslaught of the stresses
of surgery per se.
3. Provide adequate analgesia during surgery
4. Provide adequate sedation with the
objective of negative recall or awareness
5. Deliver pain management and provide life
sustaining care for the pts during surgery
6. Treat acute and chronic pain via
multidisciplinary approach
7. Perioperative Physician
a. Evaluate and assess the patient
preoperatively and optimize these
findings to the benefit of the pts in
terms of risks.
b. Develop risk assessment in terms of
the evaluation, identification of the
details of the planned procedure and
incorporate local management related
to the anesthesia applied and the
means of keeping the patient at an
optimum level of stability.
8. Supervise post-operative care
9. Intensivists

Pain Management
NO PAIN : PATIENTS GAIN
Acute pain management- caused by trauma
or other acute illnesses but more so in
postoperative analgesia
Chronic pain- alleviates patients sufferings
due to nagging and debilitating pain utilizing
multi modal therapy approach
Participate in the multidisciplinary
management of cancer

Perioperative Physician
PREOP EVALUATION
INTRAOP MANAGEMENT
POSTOP PREPARATIONS AND
MANAGEMENT

Ultimate Goals of Pre-Anesthetic and Pre-operative
Assessment (Michael Roizen,ASA Refresher Course
2005)
Reduce the morbidity of surgery
Increase the quality but reduce the cost of
preoperative care
To return the patient to desirable
functioning as quickly as possible

Pre-Operative Evaluation, Preparation and Pre-
Medication
Consists of doing a good history of the
patient
Present & past history
Presence of coexisting diseases
General survey of the patient (anticipate
technical difficulties spinal deformity,
facial abnormalities & degree of hydration
Preoperative orders fasting prior to OR,
preoperative medications & IV fluid
maintenance ordered during the visit

ASA Physical Status
CLASS I no organic, physiologic,
biochemical or psychologic disturbance
Example: Hemorhoidectomy
CLASS II mild to moderate systemic
disturbance caused by the condition to be
treated or concomitant disease
Example: Px with DM or HPN
CLASS III severe systemic disturbance
that limits activity
Example: recent MI
CLASS IV severe systemic disturbance
that is life threatening
Example: Cardiac Insufficiency or
Advance Pulmonary disease
CLASS V Moribund subjected to surgery
in desperation

Cortical and
Psychic Centers
Basal Ganglia
and Cerebellum
Spinal Cord
Medullary
Centers

Importance of Pre-Medication
1. To alleviate apprehension and fear
2. To lower BMR
3. To diminish secretions
4. To decrease reflex excitability
5. To counteract undesirable effects of
anesthesia
6. To produce amnesia

Drugs Used for Pre-Medication - may consist of any
2 or 3 of the following drugs:
A. Tranquilizers Sedative
1. Barbiturates short acting
(phenobarbital)
2. Phenothiazines
3. Benzodiazepines
B. Opiates Analgesics
1. Meperidine
2. Nalbuphine
3. Butorphanol
4. Morphine SO
4

C. Belladona alkaloids Anticholinergic
1. AT SO
4

2. Scopolamine SO
4


Types of Anesthesia
General
Local

Anesthetic agents introduced either of the following
routes, producing a depression of the brain:
1. Oral
2. Rectal
3. Intramuscular
4. Intravenous
5. Inhalational
Mask inhalation
Nasal insufflation
Endotracheal intubation

General Anesthesia
Definition: reversible state of
unconsciousness produced by anesthetic
agents, with loss of the sensation of pain
over the whole body
MOA- results of reversible changes in
neurologic function caused by drugs that
inhibits synaptic transmission
In Inhalational Anesthesia (volatile
anesthetics) inhibition of synapses
in the NEURO-BASAL THALAMUS
In IV anesthesia drug receptor
interactions
Indications:
Infants and children
Adults who prefer GA
Extensive surgical procedures
Patients with mental disease
Long duration of surgery
Surgery for which LA is impractical
or unsatisfactory
Hx of toxic or allergic reactions to
LA drugs
Anticoagulant treatment

Order of Descending Depression


Components of General Anesthesia
1. Sensory Block loss of sensation
2. Motor Block loss of muscle tone
3. Reflex Block loss of reflexes
4. Mental Block loss of consciousness

Clinical Signs of General Anesthesia
a. Insufficient Depth breath holding,
delirium, involuntary movement, retching
and increase mucus secretion
b. Sufficient Depth stable Cardiovascular
response, adequate muscle relaxation,
amnesia and absence of troublesome
reflexes
c. Excessive Depth no response, nor ability
to resume normal ventilatory function at the
end of the operation with decrease blood
pressure and obtundation

Maintenance of Airway in GA:
1. Chin lift or jaw thrust maneuver
2. Pharyngeal airway
3. Tracheal intubation


Advantages of Endotracheal Intubation
1. Airway patency is assured
2. Protection from aspiration
3. Gastric distention is prevented
Disadvantage: not being adept to the technique

Complications of General ET Anesthesia
1. Trauma during intubation
2. Endobronchial intubation
3. Esophageal intubation
4. Endotracheal tube obstruction
5. Laryngospasm

Complications of GA:
A. Intra-operative Complications
1. Respiratory Difficulties
hypoventilation due to respiratory
depression
2. Airway Obstruction
a. Upper Airway Obstruction
1) Falling back of the tongue
2) Foreign bodies above glottis
3) Endobronchial intubation
4) Laryngeal spasm & hiccups
b. Lower Airway Obstruction
1) Aspiration
2) bronchospasm
3. Cardiovascular Complications
a. Hypotension
b. Hypertension
c. Arrythmias
4. Ocular Complications
5. Malignant Hyperthermia
B. Post-operative Complications
1. Respiratory Complications
a. Atelectasis
b. Pneumothorax
2. Post Anesthesia Shivering

Prevention of Post-Operative Complications in GA:
1. Continuous monitoring post-op, BP, PR, RR,
T
2. Avoid excessive sedation
3. O
2
inhalation
4. Turn from side to side
5. Deep breathing
6. Steam inhalation to liquefy sputum
secretions

Inhalational Anesthetics
Anesthetic potency of volatile anesthetic is
measured by MAC (Minimum Alveolar
Concentration)
Value represents alveolar concentration of
an anesthetic (at one atmosphere) that
prevents movement in 50% of the subjects
response to pain

Commonly Used Inhalational Anesthetics
A. Halothane
Halogenated alkane
Sensitize the myocardium to the
action of Epinephrine
May cause cardiac dysrhytmias
Maybe toxic to the liver causing
necrosis HALOTHANE
HEPATITIS
B. Enflurane
Nonflammable fluorinated ethyl
methyl ether
Bio-transformation releases Fluoride
but not nephrotoxic levels
Increases ICP, increase risk of
seizure activity
May cause Tonic-CLonic Twitching of
the muscles of the face & limbs at
high concentrations
C. Isoflurane
Methyl ethyl ether isomer of
enflurane
Can cause coronary artery
vasodilatation which might lead to
CORONARY ARTERY STEAL
SYNDROME
D. Desflurane
Fluorinated methyl ethyl ether
Cannot be delivered by standard
vaporizers. Requires USE OF
ELECTRICALLY HEATED
VAPORIZERS
Low tissue solubility rapid
elimination and awakening. (ULTRA
SHORT DURATION of ACTION)
E. Sevoflurane
Fluorinated isopropyl ether
Reacts with CO
2
absorbents to form a
special halokene (COMPOUND A)
metabolized to nephrotoxins which
can lead to Kidney damage
Potential nephrotoxicity due to
organic fluoride avoided in pre-
existing Renal disease
F. Nitrous Oxide
Laughing gas
Only INORGANIC gas in clinical use
At room tempreture Gas BUT is
Liquid under pressure in the tank

Weak Anesthetic BUT Potent
Analgesic
Causes DIFFUSION HYPOXIA
SHOULD NOT be used in doses
higher than 70 % and combined with
30% O
2


Intravenous Agents
1. Barbiturates
2. Non-Barbiturates
Benzodiazepines
Ketamine
Propofol
Neuroleptanalgesia
Analgesic- Hypnotic Combinations
Balanced Anesthesia
Muscle relaxant
N
2
O

Barbiturates
- MOA: enhances and mimic action of GABA
by binding to the receptor
- Thiopental
o Ultra short acting barbiturates
o Blocks central brain core (RAS)
unconsciousness
o rapid onset short duration of action
- Indications:
o Induction of anesthesia
o As a sole anesthetic agent
o Supplementation to other drugs
o Conjunction with regional anesthesia
o Treatment of Status Epilepticus
o Cerebral protection with raised ICP
- Contraindications:
o Severe shock or hypovolemia
o Status asthmaticus
o Porphyria
o Absence of IV access, or general
anesthetic equipment

Non-Barbiturates
1. Benzodiazepenes
MOA: potentiation of neural
inhibition mediated by GABA-
aminobutyric acid
Pharmacologic effect
Anxiolytic
Sedative
Hypnotic
Muscle relaxant
Amnesic (ANTEROGRADE
AMNESIA)
Anticonvulsant
Diazepam
Insoluble in water
Relieves muscle spasm and
spasticity via central effect
Lorazepam
Insoluble in water
5 to 10 X potent as diazepam
Used as premedication
PROFOUND ANTEROGRADE
ANESTHESIA
Midazolam
Same as diazepam
Water soluble & has an imidazole
ring
Anterograde amnesia is shorter
than Lorazepam
Short elimination half life (t1/2):
2hrs
Useful drug for sedation in
outpatient anesthesia, minor
procedures and regional
anesthesia, intensive care
2. Propofol
Rapid loss of consciousness with rapid
recovery
Bolus dose of 2mg/kg is ~4-5 minutes
Minimal accumulation due to rapid
metabolism
Advantages:
Rapid clearance and few residual
effects on awakening
Decrease ICP, reduced IOP, arterial
BP
Effective in treating nausea and
vomiting
3. Neuroleptanalgesia
Combination of a potent analgesic and
a neuroleptic tranquilizer (fentanyl +
droperidol = Innovar)
Produces state of mental detachment
and indifference to pain
MOA: competitive antagonism at
Dopaminergic receptors
DROPERIDOL
FENTANYL
Neuroleptanesthesia - addition of
nitrous oxide, oxygen and muscle
relaxants

IV Drugs used as Adjuncts to Anesthesia
Opiods
1. Classification
AGONISTS
AGONIST/ANTAGONIST

ANTAGONIST

Morphine
Central actions and side effects
DEPRESSANT EFFECT analgesia,
sedation, depresses respiration &
cough reflex, decreases GI motility
EXCITATORY EFFECT euphoria,
miosis, nausea & vomiting,
bradycardia, release of ADH
Increases smooth muscle tone
HISTAMINE RELEASE
broncospasm, erythema

Meperidine
Actions similar to morphine
Shorter duration of respiratory depression
Not as marked euphoria
More pronounced nausea & vomiting
Mild quinidine like effect
Less histamine release
Less or no GIT actions

Naloxone (Pure opioid Antagonist)
Competitive antagonists at the opioid
receptor sites

Muscle Relaxants Neuromuscular blockers
Types of Neuromuscular Blockers (NMB)
Depolarizer - prolongs depolarization/
mimic Ach action reduces sensitivity
of the post-junctional membrane to
Ach
Non-depolarizer - acts by competitive
inhibition; reversed by
Anticholinesterases (prostigmine,
neostigmine); do not cause muscular
contractions (fasciculations)

SUCCINYLCHOLINE
Depolarization of the membrane w/c
persists until the drug diffuses away
Manifest 1
st
muscle twitching and
fasciculation
ONLY DEPOLARIZING AGENT IN
CLINICAL USE
Elimination: enzymatic destruction by
PSEUDOCHOLINESTERASE
Onset of action: 30 secs Duration: 5 mins
Recovery within 5 to 10 mins
Types of non-depolarizers
a) Long acting (45 mins)
Pancuronium eliminated via kidney
b) Intermediate acting (20-30 mins)
Atracurium eliminated vai
HOFFMAN elimination pathway
Vecuronium eliminated thru the
biliary
Rocuronium eliminated thru the
kidney
c) Short Acting (15- 20 minutes)
Mivacurium eliminated by
pseudocholinesterases

Clinical Uses:
Facilitate tracheal intubation
Provide skeletal muscle relaxation during
surgery (adjunct to GA)
Used in intensive care units

Regional Anesthesia

Physiology of Nerve Conduction
Nerve Fiber impulse transmitting unit
Membrane
90% of lipids
10% protein
Channels guarded by gates
K+ pass freely in and out
Na+ barred outside
Negative resting potential -70 to -90 mV
Nerve Stimulation
Gates open
Na
+
rushing in
Shifting of polarity
Depolarization

Classification of Regional Anesthesia
According to Site of Application:
1. TOPICAL skin or mucous membrane
Spray refrigeration (e.g. boils /
abcess)
Ointment insect bites
Instillation urethral meatus
Contact cotton pledgets in nasal
mucosa
2. INFILTRATION incision site / tissue to
be cut (e.g. sebaceous cyst)
3. FIELD BLOCK around tissue to be cut
(e.g. breast mass)
4. Intravenous Regional (Bier Block)
Peripheral vein of upper / lower
extremity
I.V. catheter inserted
Desanguinated extremity
Esmarch elastic bandage
2 tourniquets (BP cuffs)
bandage removed

LA injected over 2-3 minutes
Distal tourniquet inflated after 20-30
minutes
Proximal tourniquet deflated
Slow release of tourniquet after at
least 15-20 minutes
Use: short surgical procedure
< 45 minutes in upper / lower extremity
5. Conduction Block
Along nerve or course of nerves
1. Peripheral Nerve Blocks
2. Central Blocks

Peripheral Nerve Blocks
1. RETROBULBAR NERVE BLOCK
(ciliary ganglion)
Indications
Cataract surgery
Corneal transplant
Enucleation
Complications
Retrobulbar hemorrhage
Globe perforation
Contraindications
Bleeding disorders
Extreme myopia
Open-eye injury
2. GASSERIAN GANGLION BLOCK
Branches of trigeminal nerve
(ophthalmic, maxillary, mandibular)
Indications
Trigeminal neuralgia
Cancer pain in face
Operations in face teeth,
gum, mandible, etc.
Technique: LA injected into
respective foramen of nerve
branches
3. CERVICAL PLEXUS BLOCK
Anterior rami of C1-C4 spinal nerve
roots
Sensory supply to jaw, a neck,
occiput, chest-shoulders, clavicle,
upper border of scapula
Indications
Operations in the neck
Cervical lymph node biopsy
Carotid endarterectomy
Thyroid operations
4. BRACHIAL PLEXUS BLOCK
Anterior rami of C4-T2 spinal nerve
roots
Entire motor supply of upper
extremity
Almost entire sensory supply except
over shoulder and medial arm
Major Peripheral Branches
Axillary N shoulder
abduction
Musculocutaneous elbow
flexion
Radial elbow, wrist, and
finger extensions
Median wrist and finger
flexion
Ulnar wrist and finger
flexion
Indication: operations of upper
extremity
Approaches to Brachial Plexus Block
Interscalene approach
Supraclavicular
Axillary
5. INTERCOSTAL NERVE BLOCK
Anterior rami of 1st eleven spinal
nerves
At inferior surface of ribs
Indications
Post-op analgesia of thoracic
and upper abdomen surgeries
Relief of pain from rib
fractures, herpes zoster,
pleurisy, CA
Complications: pneumothorax
6. WRIST BLOCK
Ulnar nerve
Median
Radial
Indications:
Surgery or analgesia distal to
metacarpophalangeal joints
Suture of lacerations
Paronychia, abscess
7. DIGITAL NERVE BLOCK
Digital branches of ulnar, median,
radial
Indications:
Minor procedure in fingers
Reminder:
Avoid using large volume of
LA
Dont add vasoconstrictors
8. ANKLE BLOCK
Blocks five nerves supplying foot
Deep peroneal
Superficial peroneal
Saphenous
Posterior tibial

Sural
Indications
Surgery of foot and toes in
frail patients who cannot
tolerate hemodynamic
effects of GA or neuraxial
block
Precaution
Avoid epinephrine to reduce
risk of ischemia
Complication - intravascular injection
9. PUDENDAL NERVE BLOCK
Sacral plexus (S2 S3 S4)
Indications
Perineal surgery
Hemorrhoids
Lacerations
Obstetric vaginal delivery
Complications
Puncture of fetal head
Inadvertent IV infection
10. DORSAL PENILE BLOCK
Base of penis at symphysis pubis
Blocks dorsal nerve
Fan-shaped injection at the base
blocks dorsal and ventral branches
Indications
Penile surgery
Post-op pain relief
Precautions
Avoid big volume of solution
Avoid epinephrine or any
vasoconstrictor
Complication
Artery spasm ischemic injury to
penis

Central Nerve Blocks