Anesthesia

General Anesthesia Components :

Analgesia

Consciousness control (hypnosis, induced)

Muscle relaxation Stability of the autonomic nervous system

Complications of Acute Pain

Pulmonary respiratory muscle spasm immobility suppression of cough abdominal distension from decreased GI motility atelectasis from impaired ventilation mucus plugging from suppression of clearing mechanisms - V/Q mismatching and hypoxemia - Pulmonary infections

Complications of Acute Pain

Hematologic
-

increase thrombus formation by increasing blood viscosity increasing activity of clotting factors increasing platelet aggregation

Complications of Acute Pain

Cardiovascular Acute rise in HR, BP, Cardiac Output = increased cardiac work and oxygen consumption. This could be disastrous for patients with ischemic heart diseases and may lead to myocardial infarction and /or CHF

Complications of Acute Pain

Gastrointestinal
Ileus Nausea Vomiting Decreased bowel motility

Urinary - hypomotility of the urethra and bladder - difficulty with urination

Complications of Acute Pain

Neuroendocrine

and Metabolic

- increased sympathetic tone & hypothalamic stimulation - increased catecholamine and catabolic hormone secretion - increased metabolism and O2 consumption

Complications of Acute Pain

Psychological

fear anxiety depression frustration

ANESTHESIA - Partial or complete loss of sensation with or with out loss of consciousness as result of disease, injury, or administration of an anesthetic agent, usually by injection or inhalation.

Anesthesia
The main goal is control of the vital functions of the human body in the framework of the surgery in order to protect the patient from the operative stress

HISTORY OF ANESTHESIA PRIMITIVE TECHNIQUES

Cerebral concussion achieved by placing a wooden bowl over the head of the patient, and striking this until the patient became unconscious

Club

Strangulation Practiced in Italy as late as the seventeenth century Alcohol Popular in the eighteenth and nineteenth centuries. Mesmerism In 1779 Friedrich A. Mesmer of Vienna demonstrated a

capacity to bring certain subjects under hypnotic influence. surgical procedure under mesmerism was performed by J. a French surgeon in 1829. Mesmerism failed because than ether. First Cloquet, it was less efficient

Plants

Opium, Mandragora (Romans)

HISTORY OF ANESTHESIA INHALATION AGENTS Modern Agents Nitrous Oxide

1799 Davy 1824 Hickman 1844 Wells

Ether
1842 Long 1847 Snow

Halothane 1956 Modern Agents Enflurane 1972 Halothane 1956 Isoflurane 1981 Enflurane 1972 Sevoflurane and Desflurane Isoflurane 1981 Sevoflurane and Desflurane

Components of Anesthesia (detailed)

1st Line: Measures designed to diminish body reaction to surgical trauma

Systemic Analgesia Local Anesthesia Control of consciousness Control of Neuro-vegetative Response (Atar-algesia & Neurolept-analgesia) - Muscle Relaxation - Artificial/Deliberate Hypotencion

- Artificial/Controlled Hypothermia

2nd Line : Measures to control vital functions of the body (respiration, circulation, metabolism)

Anesthesia Management
I. Evaluation of the Patient and Preoprative Preparation
- Preoperative Assessment - Preoperative Medication

II. Equipment Preparation III. Patient Positioning IV. Immediate Preinduction Period and Induction V. Anesthesia Course and Monitoring VI. Ending Anesthesia and Weaning the Patient

Preoperative Assessment
I. Anesthetic Management Plan
a. Previous anesthetic experience (malignant hypepyrexia and adverse r.) b. Allergies (analgesics, antibiotics, radiographic dyes, latex) c. Review patients medical status (extent of the disease) d. Medications (can adversely interact with anesthetics) e. Fasting (to prevent aspiration pneumonitis) f. Physical Examination g. Laboratory tests (hemoglobin and ECG) h. The surgical procedure (choosing anesthesia and monitoring techniques) I. The anesthesia management plan

Preoperative Assessment
II. Risk and Anesthesia ASA Classification of Physical Status
ASA Category Description

I. II. III. IV. V.

Healthy patient Mild systemic disease no functional limitation Severe s. disease definite functional limitation Severe s. disease that is a constant threat to life Monitored patient not expected to survive 24 hours with or without an operation Emergency procedure

Preoperative Medication

Goals for Preoperative Medication

Anxiety relief Sedation Amnesia Analgesia Drying of airway secretions Prevention of autonomic nervous system responses Reduction of gastric fluid volume and increased pH Antiemetic effects Reduction of anesthetic requirements Facilitate induction of anesthesia Prophylaxis against allergic reactions

Anesthesia Equipment

Anesthesia Equipment

Immediate Preinduction Period and Induction Airway Management

Airway Management

Airway Management

Airway Management

Anesthesia Course and Monitoring

Inhalation Anesthesia
Blood/Gas

Partitition Coefficient & MAC

2.4 1.9 1.4 0.47 0.42 0.75% 1.7 % 1.2 % 105% 1.0 %

Halothane Enflurane Isoflurane

Nitrous

Oxide Desflurane

Intravenous Anesthetic Agents

A. Non-Narcotic Anesthetics
Barbiturates

(Thiopental, Thiamylal, Methoxexital) Benzodiazepines (Diazepam, Midazolam) Ketamine Propofol

B. Narcotic Analgetics (Morphine, Fentanil,

Alfentanil, Remifentanil, Meperidine)

Muscle Relaxants
Factors that influence use of muscle relaxants as part of general anesthesia
Surgical Procedure - anatomic location - patient positioning Anesthetic technique - inhalation v/s injection - airway management (mask vs endotracheal) - ventilation management (spontaneous vs controlled) Patient factors - body habitus (lean vs obese) - ASA status - Age

Muscle Relaxants Classification

Depolarizing
Succinylcholine (5-10 min)

Nondepolarizing

Long acting (60 90 min)

d- Tubocurarine Metocurine Pancuronium Doxacurium

Intermediate acting (20 - 30 min)

Atracurium Vecuronium

Short acting (10 20 min)

Mivacurium

Anesthesia Monitoring Requirements & Standards

I. Routine Monitoring
Presence of an Anesthetist Heart Rate (q 5 min) Blood Pressure (non-invasive vs invasive) ECG (continuous) Ventilation (observing the r. bag; auscultation; ET CO2) Disconnect Monitors (pressure alarms) Oxygen analyzer (inspired oxygen concentration) Pulse Oximeter Temperature Diuresis

II. Advanced Hemodynamic Monitoring (CVP, PCWP, CO, etc)

Local / Regional Anesthesia

A. Peripheral Nerve Blockade B. Spinal and Epidural

Spinal and Epidural Anesthesia Spinal Cord Anatomy

Spinal and Epidural Anesthesia Patient positioning

Spinal and Epidural Anesthesia Patient positioning

Epidural Anesthesia Lumbar and Thoracic Techniques