Anes
Anes
Anes
HISTORY of ANESTHESIA
ANESTHESIA is one of
America’s greatest
contribution to the field of
Medicine and to mankind.
Try to imagine today's health care
without surgery.
Equally impossible.
Without anesthesia,
many of modern medicine's greatest benefits
simply would not exist
Pain, a Burden to be Borne
• 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.
HISTORY of ANESTHESIA
Most commonly used substances to kill pain:
• opium derived from the poppy flower,
Papaver somniferum.
• alcohol or wine,
• mandragora or mandrake from the plant
Atropa mandragora,
• belladonna from the deadly nightshade,
• marijuana or Cannabis indica.
• From: René Descartes.
From: René Descartes. L'homme de Rene Descartes.
Renatus Des Cartes de homine. Lvgdvni Paris:
Batavorvm: Charles Angot, 1664
Petrvm Leffen & Fransciscvm Moyardvm,
Rene Descartes was the one who first
1662
Described the pain pathway
HISTORY of ANESTHESIA
• PREOP EVALUATION
• INTRAOP MX
• POSTOP PREPARATIONS AND MX
Ultimate Goals of Preanesthetic
& Preoperative Assessment
5. Laryngospasm
Complications of General
Anesthesia
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) Larryngeal spasm & hiccups
b. Lower Airway Obstruction
1) Aspiration
2) bronchospasm
3. Cardiovascular Complications
a. Hypotension
b. Hypertension
c. Arrythmias
4. Occular 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. O2 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 à rapid elimination
and awakening. (ULTRA SHORT
DURATION of ACTION)
E. Sevoflurane
• Fluorinated isopropyl ether
• Reacts with CO2 absorbents to form a
special halokene (COMPOUND A) à
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 à 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% O2
INTRAVENOUS AGENTS
Drugs
1. Barbiturates
2. Non-Barbiturates
• Benzodiazepines • Analgesic- Hypnotic Combinations
Thiopental
• Ultra short acting barbiturates
• Blocks central brain core (RAS) à
unconsciousness
• rapid onset short duration of action
Indications
• Induction of anesthesia
• As a sole anesthetic agent
• Supplementation to other drugs
• Conjunction with regional anesthesia
• Treatment of Status Epilepticus
• Cerebral protection with raised ICP
Contraindications
• Severe shock or hypovolemia
• Status asthmaticus
• Porphyria
• Absence of IV access, or general
anesthetic equipment
Non-Barbiturates
1. Benzodiazepenes
• MOA: potentiation of neural inhibition
mediated by GABA-aminobutyric acid
• Pharmacologic effect
Ø Anxiolytic
Ø Sedative
Ø Hypnotic
Ø Muscle relaxant
Ø Amnesic (ANTEROGRADE AMNESIA)
Ø Anticonvulsant
Benzodiazepenes
a. Diazepam
• Insoluble in water
• Relieves muscle spasm and spasticity via central
effect
b. Lorazepam
• Insoluble in water
• 5 to 10 X potent as diazepam
• Used as premedication
• PROFOUND ANTEROGRADE ANESTHESIA
c. 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
1) Outpatient anesthesia
2) Minor procedures and regional anesthesia
3) Intensive care
Non-Barbiturates
3. 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 vomitting
Non-Barbiturates
4. 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
1. Opiods
• Classification
Ø AGONISTS
Ø AGONIST/ANTAGONIST
Ø ANTAGONIST
Morphine
– Central actions and side effects
• DEPRESSANT EFFECT à analgesia, sedation,
depresses respiration & cough reflex, decreases
GI motility
• EXCITATORY EFFECT à euphoria, miosis,
nausea & vomiting, bradycardia, release of ADH
• Increases smooth muscle tone
• HISTAMINE RELEASE à 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
2. Muscle Relaxants – Neuromuscular
blockers
• Types of Neuromuscular Blockers (NMB)
a. Depolarizer
b. Non-depolarizer
a. Depolarizers
MOA: prolongs depolarization/ mimic Ach action
reduces sensitivity of the post-junctional
membrane to Ach
SUCCINYLCHOLINE
– Depolarization of the membrane w/c persists
until the drug diffuses away
– Manifest 1st 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
b. Non-Depolarizers
MOA: acts by competitive inhibition
• Reversed by Anticholinesterases (prostigmine,
neostigmine)
• Do not cause muscular contractions
(fasciculations)
Types of non-depolarizers
a) Long acting (45 mins)
Pancuronium – eliminated via kidney
b) Intermediate acting (20-30 mins)
1) Atracurium – eliminated vai HOFFMAN elimination
pathway
2) Vecuronium – eliminated thru the biliary
3) 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
PHYSIOLOGY OF NERVE
CONDUCTION
• Nerve Stimulation
– Gates open
– Na+ rushing in
– Shifting of polarity
– Depolarization
Classification of
Regional Anesthesia
(according to SITE of application)
§ Peripheral vein of
upper / lower extremity
§ Desanguinated
extremity
§ Esmarch elastic
bandage
§ 2 tourniquets (BP cuffs)
§ bandage removed
§ LA injected over 2-3
minutes
§ Proximal tourniquet
deflated
§ Slow release of
tourniquet after at least
15-20 minutes
B. 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
Peripheral Nerve Blocks
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
Peripheral Nerve Blocks
3. CERVICAL PLEXUS BLOCK
• Indication:
operations of upper extremity
Axillary approach
Peripheral Nerve Blocks
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
INTERCOSTAL NERVE BLOCK
INTERCOSTAL NERVE BLOCK
INTERCOSTAL NERVE BLOCK
Peripheral Nerve Blocks
6. WRIST BLOCK
• Ulnar nerve
• Median
• Radial
• Indications:
– surgery or analgesia
distal to
metacarpophalangeal
joints
– suture of lacerations
– paronychia, abcess
Peripheral Nerve Blocks
7. DIGITAL NERVE BLOCK
• Digital branches of
ulnar, median, radial
• Indications:
– minor procedure in
fingers
• Reminder:
– avoid using large volume
of LA
– do not add
vasoconstrictors
Peripheral Nerve Blocks
8. ANKLE BLOCK
• Indications
– Surgery of foot and toes in frail patients
who cannot tolerate hemodynamic effects
of GA or neuraxial block
Peripheral Nerve Blocks
8. ANKLE BLOCK
• Precaution
– Avoid epinephrine to
reduce risk of
ischemia
• Complication
– Intravascular
injection
Peripheral Nerve Blocks
9. PUDENDAL
NERVE BLOCK
• Indications
– perineal surgery
o hemorrhoids
o lacerations
– obstetric vaginal delivery
• Complications
– puncture of fetal head
– inadvertent IV infection
Peripheral Nerve Blocks
10. DORSAL PENILE BLOCK
• Indications
– Penile surgery
– Post-op pain relief
Peripheral Nerve Blocks
10. DORSAL PENILE BLOCK
• Precautions
– Avoid big volume of solution
– Avoid epinephrine or any vasoconstrictor
• Complication
– Artery spasm – ischemic injury to penis
Central Blocks
A. SPINAL ANESTHESIA
Sub Arachnoid Block, Intrathecal Block
• Relative
– Hemorrhage
– Back problem due to muscle strain, arthritis
– Extremely tense / psychotics
– Children
– Respiratory disease
Drugs Used
• Tetracaine
• Lidocaine
• Bupivacaine
A. Position
– Lateral decubitus – knees flexed to chest
hin put down on chest (nose-to-knee)
– Sitting – when lateral approach is difficult (e.g.
obese patients)
B. Puncture Sites
– Interspaces between L2-L3, L3-:4, L4-L5
– Line joining highest points of iliac crests
crosses either body of L4 or interspace
between L4-L5
Structures Traversed By Spinal Needle
a. Skin
b. Subcutaneous Tissue
c. Supraspinous ligament
d. Interspinuous ligament
e. ligamentum flavum
f. Dura
PHYSIOLOGIC EFFECTS (Immediate
Complications)
A. Cardiovascular
Sympathectomy ⇒ vasodilation ⇒ ⇓ BP, ⇓ CR
B. Respiratory
Difficulty of breathing
Apnea (high level)
C. Gastrointestinal
Nausea / vomiting in 20%
DELAYED COMPLICATIONS
– Headache – leak of CSF
– Backache
– Urinary retention
– Hemiplegia – hematoma
Levels of Spinal Anesthesia –
Dermatomes Involved
• Loss of resistance
– Plunger of syringe pushed without resistance
once epidural needle is in
• Hanging Drop
– Drop of saline at hub of epidural needle is
sucked in once it enters space
Indications
• All operations below diaphragm
• May be used in
– Poor risk patients
– Cardiac diseases
– Pulmonary diseases
– Metabolic disturbances
– When GA is contraindicated
– When spinal anesthesia is contraindicated
– Painful conditions including post-op pain relief
Contraindications – similar to spinal
• Severe hemorrhage
• Coagulation defects
• Previous laminectomy
• Uncooperative / apprehensive
• Local inflammation at site
• Patient refusal
Advantages
• Well-defined area of anesthesia
• Longer duration
• More severe disturbances of spinal anesthesia
minimized
• GI complaints minimized
• Catheterization minimized
• Less respiratory effects
Disadvantages
• Technically more difficult
• Muscle relaxation not complete
• Large volume necessary
• Danger of dural puncture
• Incomplete / patchy block
Physiologic Effects
• Similar to those observed in spinal anesthesia
• Slower onset
• Less intensity of motor and sensory block
Physiologic Effects
• Similar to lumbar epidural
• Related to level achieved – volume of
drug
Complications
• Accidental Dural puncture
• General systemic reactions
• Infection at site of injection
Disadvantages
• Difficult to obtain high level
• Needs big amount – systemic reactions
possible
• Infection possible
• 5-10% failure – anatomic anomalies or
incorrect method
ANESTHETIC AGENTS
&
LOCAL TOXICITY
• No loss of consciousness
Clinical Usefulness
Depends on:
• Inherent Anesthetic potency
• Rate of onset
• Duration of effect
4. Additives
5. Mixture of LA
1. Dosage
• Primary qualities of regional anesthesia
(onset, duration, depth) are related to the
mass of the drug à volume x concentration
2. Site on Injection
• Due to the particular anatomy of the area of
the injection, variation in the rate of
absorption & amount of drug used
• In Spinal anesthesia, lack of nerve sheath
around spinal cord are responsible for the
rapid onset
3. Additives
a. CO2
b. NaHCO3 – increase pH near pKA more ionized à
faster entry faster onset
c. KCl
d. Dextran
2. AMINO-AMIDES
• Amide linkages
Local Anesthetics Classification
1) Amides CH3
O CH2 CH3
NH C CH2 N
CH2 CH3
CH3
Lidocaine, Bupivacaine,
Ropivacaine, Levobupivacaine
2) Esters CH3
O CH3
CH2
C C CH2 CH2 N
CH2 CH3
CH3
Procaine, Chloroprocaine,
Cocaine, Tetracaine
Mechanism of Action
prevent transmission
of nerve impulses
a. Low anesthetic potency & short duration of
action à procaine & chloroprocaine
Ø Dizziness
Ø disorientation
Ø drowsiness
Objective CNS Signs
(at low dose)
Ø shivering
Ø Muscular twitching
• Rate of Injection
+ +
RACEMIC MIXTURES N N
equal amounts of C4H9 C4H9
enantiomers in a
chiral compound R (+) enantiomer
S (-) enantiomer
LEVOBUPIVACAINE DEXTROBUPIVACAINE
Clinical Relevance of Stereoisomers
• Tissue Redistribution
• Metabolism
• Excretion
Factors Affecting Absorption
• Site of injection – more blood supply >
absorption
• Dosage