ANAESTHESIA

ANAESTHESIOLOGY

It is that branch of medicine

which is concerned with the

administration of anaesthetics
& the management of the
patient under anaesthesia.

WHAT DOES ANAESTHESIA MEAN?

The word anaesthesia is derived from

the Greek: meaning insensible or without

feeling.
ANAESTHETIC
also known as anaesthesiologist.
He is a doctor or a person specially

trained in administering anaesthesia.

DEFINITION OF ANAESTHESIA
It is apharmacologicallyinduced and reversible

state ofamnesia,analgesia, loss of responsiveness,

loss ofskeletal musclereflexes, decreased
stress response, or all of these simultaneously.
These effects can be obtained from a single drug
which alone provides the correct combination of
effects, or occasionally a combination of drugs
(such ashypnotics,sedatives,paralyticsand
analgesics) to achieve very specific combinations of
results.
This allows patients to undergo surgery and other
procedures without the distress and pain they would
otherwise experience.

TOOLS OF ANAESTHESIA

1. Anaesthetic machine.
2. Monitoring system.

ANAESTHETIC MACHINE
1. Oxygen gas supply.
2. Nitrous oxide gas
3.
4.
5.
6.

supply.
Flow meter.
Vaporizer specific
for every agent.
Mechanical
ventilator.
Tubes for
connection.

MONITORING
1. Pulse, ECG.
2. Blood pressure.
3. Oxygen saturation.
4. End tidal CO2.
5. Temperature.
6. Urine output, CVP, EEG, bispectral

index, muscle tone, ECHO, drug

concentration.

TYPES OF ANAESTHESIA
LOCAL ANAESTHESIA inhibits

sensory perceptionwithin a specific

location on the body, such as a tooth or
the urinary bladder.
REGIONAL ANAESTHESIA renders a

larger area of the body insensate by

blocking transmission of nerve impulses
between a part of the body and the
spinal cord. Two frequently used types
of regional anaesthesia arespinal

GENERAL ANAESTHESIA refers to

inhibition of sensory, motor and sympathetic

nerve transmission at the level of the brain,
resulting inunconsciousnessand lack of
sensation.
DISSOCIATIVE ANAESTHESIA uses agents

that inhibit transmission of nerve impulses

between higher centers of the brain (such as
thecerebral cortex) and the lower centers,
such as those found within thelimbic system.

GENERAL ANAESTHESIA

 General anaesthetics are drugs that brings about a

reversible loss of all sensation and consciousness.

Cardinal signs of general anaesthesia:i.
ii.
iii.
iv.

Loss of all sensation.

Sleep and amnesia.
Immobility and muscle relaxation.
Abolition of reflexes.

CLASSIFICATION

1.INHALATIONA
L
Gas

Liquid

Nitrous oxde

Ether
Halothane
Isoflurane
Desflurane

2.

INTRAVENOUS

Inducing agents

Slower acting draugs

Thiopentone sodium

1. Benzodiazepines:
Diazepam , Lorazepam ,
Midazolam.

Methohexitone sod.

2. Dissociative
anaesthesia: Ketamine.

Propofol

3.

Opiod
Fentanyl.

analgesia:

Mechanism of action
Exert

their action by the activation of

inhibitory
CNS
receptors
and
their
inactivation of CNS excitatory receptors.

Ligated gated ion channels are the major

targets of anaesthetic action.

The

GABA receptor gated

channel is most important.

chloride

ion

Many inhalational anaesthetics, barbiturates,

BZDs and propofol potentiate the action of

inhibitory transmitter GABA to open chloride
ion channels

 Each one interacts with its own specific binding site

on the GABA receptor Cl-complex.

Action of glycine in the spinal cord & medulla is

augmented by barbiturates,
inhalational anaesthetics.

propofol

&

many

This action may block responsiveness to painful

stimuli resulting in immobility of the anaesthetic

state.
Fluorinated

anaesthetics & Barbiturates inhibit

neuronal cation channel gated by nicotinic
cholinergic receptor which may mediated analgesia
& amnesia.

 On the other hand N2O , Ketamine dont affect GABA

, glycine gated Chloride channels.Rather they

selectively inibit the excitatory NMDA type of
glutamate receptor.
This receptor gates mainly Calcium ion selective

cation channels in the neurons & their inhibitor

appears to be the primary mechanism of
anaesthetic action of ketamine as well nitrous oxide.
Volatile

receptor.

anaesthetics have little action on this

GENERAL ANAESTHETIC TECHNIQUES

1. INHALATION
2. INJECTION (Intravenous or

Intramuscular)

Inhalation
Substances are either volatile liquids or gases , & are

usually delivered using an:1.

Anaesthesia machine.
An anaesthesia machine allows composing a mixture
of oxygen,anaesthetics & ambient air,delivering it to
the patient & machine parameters.

2.

Anaesthetic chamber induction:-Uses sturdy, seen

through containers.
Cautions-Small patients only difficult to monitor
patient risk of vomiting/regurgitation hyperthermia
waste gas contamination of room & exposure of
personnel.

3.

Laryngeal mask airway.

4.

Tracheal tube connected to some type of

anaesthetic vaporiser & an anaesthetic delivery
system.

5.

Mask induction suited for critical patients.

Caution: Prevention anaesthetic gas pollution of room use tightfitting mask risk of stressing patient use pre-anaesthetic sedation
may be dangerous with animals with poor respiratory function.

6.

Gases or vapors which produce general anaesthesia by inhalation

are stored in gas cylinders & administered using flowmeters.

 Liquid anaesthetics are vaporised in machine & are

quite hydrophobic.
Ideal volatile anaesthetic agent offers: smooth & reliable induction.
maintainance of general anaesthesia with minimal

effects on other organ systems.

odourless or pleasant to inhale.
safe for all ages.
rapid in onset & offset.
cheap to manufacture & easy to transport.
store with long shelf life.

INJECTION
Injectable anaesthetics are used for the induction &

maintainance of a state of unconsciousness.

Anaesthetics prefer to use intravenous injections , as

they are faster , less painful & more reliable than

intramuscular or subcutaneous injections.
Standard dose is calculated , drawn into syringe

injected as needed directly into vein.

Techniques of Mandibular Anesthesia

Mandibular Anesthesia
Lower success rate than Maxillary anesthesia
- approx. 80-85 %
Related to bone density
Less access to nerve trunks

Mandibular Nerve Blocks

Inferior alveolar
Mental - Incisive
Buccal
Lingual
Gow-Gates
Akinosi

Mandibular Anesthesia
Most commonly performed technique
Has highest failure rate (15-20%)
Success depends on depositing solution
within 1 mm of nerve trunk

Inferior Alveolar Nerve Block

Not a complete mandibular nerve block.
Requires supplemental buccal nerve block
May require infiltration of incisors or mesial
root of first molar

Inferior Alveolar Nerve Block

Nerves anesthetized
Inferior Alveolar
Mental
Incisive
Lingual

Inferior Alveolar Nerve Block

Areas Anesthetized
Mandibular teeth to midline
Body of mandible, inferior ramus
Buccal mucosa anterior to mental foramen
Anterior 2/3 tongue & floor of mouth
Lingual soft tissue and periosteum

Inferior Alveolar Nerve Block

Indications
Multiple mandibular teeth
Buccal anterior soft tissue
Lingual anesthesia

Inferior Alveolar Nerve Block

Contraindications
Infection/inflammation at injection site
Patients at risk for self injury (eg. children)

Inferior Alveolar Nerve Block

10%-15% positive aspiration

Inferior Alveolar Nerve Block

Alternatives
Mental nerve block
Incisive nerve block
Anterior infiltration

Inferior Alveolar Nerve Block

Alternatives (cont.)
Periodontal ligament injection (PDL)
Gow-Gates
Akinosi
Intraseptal

Inferior Alveolar Nerve Block

Technique
Apply topical
Area of insertion:
medial ramus, mid-coronoid notch,
level with occlusal plane (1 cm above),
3/4 posterior from coronoid notch to
pterygomandibular raphe
advance to bone (20-25 mm)

Inferior Alveolar Nerve Block

Target Area
Inferior alveolar nerve, near mandibular
foramen
Landmarks
Coronoid notch
Pterygomandibular raphe
Occlusal plane of mandibular posteriors

Inferior Alveolar Nerve Block

Precautions
Do not inject if bone not contacted
Avoid forceful bone contact

Inferior Alveolar Nerve Block

Failure of Anesthesia
Injection too low
Injection too anterior
Accessory innervation
-Mylohyoid nerve
-contralateral Incisive nerve innervation

Inferior Alveolar Nerve Block

Complications
Hematoma
Trismus
Facial paralysis

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Faisal A. Quereshy, MD, DDS, FACS

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Long Buccal Nerve Block

Anterior branch of Mandibular nerve (V3)
Provides buccal soft tissue anesthesia
adjacent to mandibular molars
Not required for most restorative procedures

Buccal Nerve Block

Indications
Anesthesia required - mucoperiosteum
buccal to mandibular molars
Contraindications
Infection/inflammation at injection site

Buccal Nerve Block

Advantages
Technically easy
High success rate
Disadvantages
Discomfort

Buccal Nerve Block

Alternatives
Buccal infiltration
Gow-Gates
PDL
Intraseptal

Buccal Nerve Block

Technique
Apply topical
Insertion distil and buccal to last molar
Target - Long Buccal nerve as it passes
anterior border of ramus
Insert approx. 2 mm, aspirate
Inject 0.3 ml of solution, slowly
- 25-27 gauge needle
Area of insertion:
- Mucosa adjacent to most distal

Buccal Nerve Block

Landmarks
Mandibular molars
Mucobuccal fold

Buccal Nerve Block

Complications
Hematoma (unusual)
Positive aspiration
0.7 %

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Mental Nerve Block

Terminal branch of IAN as it exits mental
foramen
Provides sensory innervation to buccal soft
tissue anterior to mental foramen, lip and
chin

Mental Nerve Block

Indication
Need for anesthesia in innervated area
Contraindication
Infection/inflammation at injection site

Mental Nerve Block

Advantages
Easy, high success rate
Usually atraumatic
Disadvantage
Hematoma

Mental Nerve Block

Alternatives
Local infiltration
PDL
Intraseptal
Inferior alveolar nerve block
Gow Gates

Mental Nerve Block

Complications
Few
Hematoma
Positive aspiration
5.7 %

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Faisal A. Quereshy, MD, DDS, FACS

March 5, 2007

Incisive Nerve Block

Terminal branch of IAN
Originates in mental foramen and proceeds
anteriorly
Good for bilateral anterior anesthesia

Not effective for anterior lingual anesthesia

Incisive Nerve Block

Nerves anesthetized
Incisive
Mental

Incisive Nerve Block

Areas Anesthetized
Mandibular labial mucous membranes
Lower lip / skin of chin
Incisor, cuspid and bicuspid teeth

Incisive Nerve Block

Indication
Anesthesia of pulp or tissue required
anterior to mental foramen
Contraindication
Infection/inflammation at injection site

Incisive Nerve Block

Advantages
High success rate
Pulpal anesthesia w/o lingual anesthesia
Disadvantages
Lack of lingual or midline anesthesia

Incisive Nerve Block

Complications
Hematoma
Positive aspiration
5.7 %

LOCAL
ANAESTHESIA

Local anaesthesia is defined as a loss of

sensation in a circumscribed area of the body

caused by a depression of excitation in nerve
ending or inhibition of the conduction process
in the peripheral nerves
It does not cause loss of consciousness.

CLASSIFICATION

MECHANISM OF ACTION
The local anaesthetics block nerve conduction by

decreasing the entry of Na+ ions during upstroke

of action potential. As the concentration of LA is
increased, the rate of rise of action potential and
maximum depolarization decreases causing
slowing of conduction. Finally, local depolarization
fails to reach the threshold potential and
conduction block ensues.

TECHNIQUES
SURFACE ANAESTHESIA

SURFACE ANAESTHESIA
It is produced by topical application of surface
anaesthetics to mucous membranes and abraded
skin. Only the superficial layer is anaesthetized.
Onset and duration depends on site, drug, its
concentration and form.
It is used extensively in the eye, throat, urethra
and anal canal. Topical LA is occasionally applie
din mouth for stomatitis, ulcers.

INFILTRATION ANAESTHESIA
Dilute solution of LA is infiltrated under the skin in
area of operation- blocks sensory nerve endings.
Onset of action is almost immediate.
It is used for minor operations, eg. Incisions,
excisions, some dental procedures etc when area
to be anaesthesized is relatively small.
Relatively large amount of LA is required but motor
function is not affected.

CONDUCTION ANAESTHESIA
This includes:
1.FIELD BLOCK: Produced by injecting the LA
subcutaneously in a manner that all nerves coming
to a particular field are blocked.
It is done for dental procedures, appendicectomy,
operations on legs and forearms etc.

2.NERVE BLOCK:
It is produced by injection of the LA around the
appropriate nerve trunks or plexuses. The
muscles supplied by injected nerve are
paralysed.
In dentistry 2 important nerve blocks are there
Maxillary nerve block
Mandibular nerve block

MAXILLARY
NERVE BLOCK

MAXILLARY NERVE BLOCK

It includes:
A. posterior superior alveolar

block
B. middle superior alveolar block
C. anterior superior alveolar
block
D. greater palatine block
E. infraorbital block
F. nasopalatine block

 pulpal anesthesia: through anesthesia of each nerves

dental branches as they extend into the pulp tissue (via the
apical foramen)

periodontal: through the interdental and interradicular

branches

palatal: soft and hard tissues of the palatal periodontium

(e.g. gingiva, periodontal ligaments, alveolar bone)

PSA block: recommended for maxillary molar teeth and

associated buccal tissues in ONE quadrant

MSA block: recommended for maxillary premolars and

associated buccal tissues

ASA block: recommended for maxillary canine and the

incisors in ONE quadrant

greater palatine block: recommended for palatal tissues

distal to the maxillary canine in ONE quadrant

POSTERIOR SUPERIOR ALVEOLAR

BLOCK
target: PSA nerve
as it enters the maxillar
through the PSA foramen on
the maxillas infratemporal
service
into the tissues of the
mucobuccal fold at the apex
of the 2nd maxillary molar
mandible is extended
toward the side of the
injection, pull the tissues at
the injection site until taut
needle is inserted distal and
medial to the tooth and
maxilla
depth varies from 10 to 16
mm depending on age of
patient
no overt symptoms (e.g. no lip
or tongue involvement)

MIDDLE SUPERIOR ALVEOLAR

BLOCK
limited clinical usefulness
can be used to extend the infraorbital block

distal to the maxillary canine

can be indicated for work on maxillary premolars and mesiobuccal root of 1st molar
if the MSA is absent area is innervated by
the ASA
blocks the pulp tissue of the 1 st and 2nd
maxillary premolars and possibly the 1 st molar
+ associated buccal tissues and alveolar bone
useful for periodontal work in this area
to block the palatine tissues in this area may
require a greater palatine block

target area: MSA nerve at the apex of the

maxillary 2nd premolar mandible extended

towards injection site
stretch the upper lip to tighten the

injection site
needle is inserted into the
mucobuccal fold
tip is located well above the apex of
the 2nd premolar
harmless tingling or numbness of the upper lip
overinsertion is rare

ANTERIOR SUPERIOR ALVEOLAR

BLOCK
can be considered a local infiltration
used in conjunction with an MSA block
the ASA nerve can cross the midline of the

maxilla onto the opposite side!

used in procedures involving the maxillary
canines and incisors and their associated
facial tissues
pulpal and facial tissues involved

restorative and periodontal work

blocks the pulp tissue + the gingiva,

periodontal ligaments and alveolar bone in

that area

target: ASA nerve at the apex of the maxillary

canine
at the mucobuccal fold at the apex of the
maxillary canine
harmless tingling or numbness of the upper lip
overinsertion is rare

INFRAORBITAL NERVE
BLOCK
anesthetizes both the MSA and ASA
used for anesthesia of the maxillary

premolars, canine and incisors

indicated when more than one premolar or
anterior teeth
pulpal tissues for restorative work
facial tissues for periodontal work
also numbs the gingiva, periodontal ligaments
and alveolar bone in that area
the maxillary central incisor may also be
innervated by the nasopalatine nerve
branches

target: union of the ASA and MSA with the IO

nerve after the IO enters the IO foramen

also anesthesizes the lower eyelid, side of
nose and upper lip
IO foramen is gently palpated along the IO
rim
move slightly down about 10mm until you
feel the depression of the IO foramen locate
the tissues at the mucobuccal fold at the
apex of the 1st premolar
place one finger at the IO foramen and the
other on the injection site figure 9-17
locate the IO foramen, retract the upper lip
and pull the tissues taut
the needle is inserted parallel to the long
axis of the tooth to avoid hitting the bone
harmless tingling or numbness of the upper
lip, side of nose and eyelid

GREATER PALATINE BLOCK

used in restorative procedures that involve

more than two maxillary posterior teeth or

palatal tissues distal to the canine
also used in periodontal work since it blocks
the associated lingual tissues
anesthetizes the posterior portion of the hard
palate from the 1st premolar to the molars
and medially to the palate midline
does NOT provide pulpal anesthesia may
also need to use ASA, PSA, MSA or IO blocks
may also need to be combined with
nasopalatine block

 target: GP nerve as it
enters the GP foramen
located at the junction of
the maxillary alveolar
process and the hard palate
at the maxillary 2nd or 3rd
molar
palpate the GP foramen
midway between the
median palatine raphe and
lingual gingival margin of
the molar tooth
can reduce discomfort by
applying pressure to the
site before and during the
injection
-produces a dull ache to
block
pain impulses
-also slow deposition of
anaesthesia will also

NASOPALATINE BLOCK
useful for anesthesia of the bilateral

portion of the hard palate

from the mesial of the right maxillary 1st

premolar to the mesial of the left 1st premolar

for palatal soft tissue anesthesia

periodontal treatment
required for two or more anterior

maxillary teeth
for restorative procedures or extraction
of the anterior maxillary teeth may
need an ASA or MSA block also
blocks both right and left nerves

target: both right and left nerves as they

enter the incisive foramen from the

mucosa of the anterior hard palate
posterior to the incisive papilla

injection site is lateral to the incisive

papilla
head turned to the left or right
inserted at a 45 degree angle about 6-10
mm gently contact the maxillary bone
and withdraw about 1mm before
administering
can reduce discomfort by applying
pressure to the site before and during the
injection

produces a dull ache to block pain impulses

also slow deposition of anesthesia will also help

can anaesthetize the labial tissues

between the central incisors prior to

SPINAL
ANESTHESIA

Anatomy.

Skin
Subcutaneous fats
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Epidural space
Dura
Subarachnoid space

The spinal cord usually ends at the level of

L1in adults and L3 in children.
Dural puncture above these levels is asso with
a slight risk of damaging the spinal cord
and is best avoided.
An important landmark to remember is that a
line joining the top of the iliac crests is at
L4 to L4/5

Mechanism of action
Local anaesthetic solution injected into the subarachnoid

space blocks conduction of impulses along all nerves with

which it comes in contact, although some nerves are more
easily blocked than others. There are three classes of nerve:
motor, sensory and autonomic. Stimulation of the motor
nerves causes muscles to contract and when they are blocked,
muscle paralysis results. Sensory nerves transmit sensations
such as touch and pain to the spinal cord and from there to
the brain, whilst autonomic nerves control the calibre of
blood vessels, heart rate, gut contraction.

Indications
Spinal anaesthesia is best reserved for
operations below the umbilicus e.g. hernia
repairs, gynaecological and urological
operations and any operation on the perineum
or genitalia.

Older patients and those with systemic

disease such as chronic respiratory disease,
hepatic, renal and endocrine disorders such
as diabetes.
It is suitable for managing patients with trauma
In obstetrics, it is ideal for manual removal of
a retained placenta (again, provided there is
no hypovolaemia).

Advantages
1.Cost
2.Patient satisfaction
3.Respiratory disease
4.Diabetic patients
5.Muscle relaxation
6.Blood loss during operation is less

Contra-indications to Spinal Anaesthesia:Absolute:

1.Inadequate drugs and equipment
2.Coagulopathy or other bleeding disorders
3.Severe hypovolaemia(Shock)
4.Patient refusal
5.Increased Intracranial Pressure
6.Severe aortic stenosis
7.Severe Mitral stenosis

Local Anaesthetics for Spinal Anaesthesia:Local anaesthetic agents are either heavier
(hyperbaric), lighter (hypobaric), or have the
same specific gravity (isobaric) as the CSF.
Hyperbaric solutions tend to spread below the
level of the injection, while isobaric solutions
are not influenced in this way. It is easier to
predict the spread of spinal anaesthesia when
using a hyperbaric agent. Isobaric preparations
may be made hyperbaric by the addition of
dextrose.

Bupivacaine (Marcaine):- 0.5% hyperbaric

(heavy) bupivacaine is the best agent to use if
it is available. 0.5% plain bupivacaine is
also popular. Bupivacaine lasts longer than
most other spinal anaesthetics: usually 2-3
hours.
Lignocaine (Lidocaine/Xylocaine):- Best
results are obtained with 5% hyperbaric
(heavy) lignocaine which lasts 45-90 minutes.

Cinchocaine (Nupercaine, Dibucaine,

Percaine, Sovcaine):- 0.5% hyperbaric
(heavy) solution is similar to bupivacaine.
Amethocaine (Tetracaine, Pantocaine,
Pontocaine, Decicain, Butethanol, Anethaine,
Dikain):- A 1% solution can be prepared with
dextrose, saline or water for injection.
Mepivacaine (Scandicaine, Carbocaine,
Meaverin) :- 4% hyperbaric (heavy)
solution is similar to lignocaine.

Pre-loading :All patients having spinal anaesthesia must have a

large intravenous cannula inserted and be given
intravenous fluids immediately before the spinal.
The volume of fluid given will vary with the age of the
patient and the extent of the proposed block. A
young, fit man having a hernia repair may only need
500 mls. Older patients are not able to compensate
as efficiently as the young for spinal-induced
vasodilation and hypotension and may need 1000mls
for a similar procedure. If a high block is planned,
at least a 1000mls should be given to all patients.

The fluid should preferably be normal saline or ringer

lactate.
5% dextrose is readily metabolised and so is not
effective in maintaining the blood pressure.

Position:1.Lateral ( Lt lateral )
2.Sitting

Males tend to have wider shoulders than hips and so

are in a slight "head up" position when lying on their
sides, whilst for females with their wider hips, the
opposite is true.

LEFT LATERAL POSITION

SITTING POSITION

The sitting position is preferable in the obese

whereas the lateral is better for uncooperative or
sedated patients.

Complication
1.Immediate complication
- Hypotension and Cardiac arrest.
- Total spinal block leading to respiratory arrest.
- Urinary retention.
- Epidural hematoma, Bleeding.
2.Late complication
- Post dural puncture headache (PDPH)
- Backache
- Bacterial meningitis

Treatment of spinal headache:

1.Remain lying flat in bed as this relieves the
pain.
2.They should be encouraged to drink freely or,
if necessary, be given intravenous fluids to
maintain adequate hydration.
3.Simple analgesics such as paracetamol,
aspirin or codeine may be helpful.

Caffeine containing drinks such as tea, coffee

or Coca-Cola are often helpful.
Prolonged or severe headache may be
treated with epidural blood patch performed
by aseptically injecting 15-20ml of the
patient's own blood into the epidural space.
This then clots and seals the hole and
prevents further leakage of CSF.
It used to be thought that bedrest for 24 hours
following a spinal anaesthetic would help
reduce the incidence of headache.

THANK YOU