NOTES ON ANESTHESIA

COLLEGE OF SHYWANS - ht4D -SURGEONS

COLUMBIA UNIVERSITY, NEW YORK

 I n t h e absence of an adequate anestheeia textbook,

t h e following notes are offered as a supplement t o t h e r e f e r -

ences l i s t e d on t h e next page. The student who f l n d e that t h e

physiological mechanisms b r i e f l y referred t o i n t h i s o u t l i n e

a r e unfamlliar t o him w i l l do w e l l t o review them a t t h i s

time i n h i s textbooks, and l e c t u r e notes of previoua courees.

There a r e t h r e e people of great importance i n t h e

conduct of the anestheeia: t h e p a t i e n t , t h e a n e s t h e t i s t and

t h e surgeon, The statements which follow take f o r granted an

i d e a l s i t u a t i o n : an experienced surgeon who works quickly

and gently, and leaves the choice of t h e a n e s t h e t i c agent

and technic and the conduct of t h e anesthesia t o t h e ones-
t h e t i s t ; a wholly capable a n e s t h e t i s t who knows how t o choose

and use a l l t h e a n e s t h e t i c agents and technics well, and who

understands f u l l y t h e eurgeon's needs; and t h e most Important,

b u t a l s o the most v a r i a b l e individual, t h e p a t i e n t . He be-

comes l e e s unpredictable t h e more t h e surgeon and anesthetist

know about h i e disease and how it affects him as a whole, The

a n e s t h e t i s t cannot adequately evaluate h i s p a t i e n t unlees he

i s first a good physician w i t h a work- knowledge of physi-

ology,
 SUGGESTED READING

1. Guedel, A. E. "Fundamentale of In%alation Aneetheeia"

2. Goodman and G i b n . "Phsrmacological Baaie of Therapeutics"
F i r s t 100 pagee, Chaps. 9, 12 and Seotion V.

3, American Medical Aseociation. '%undamentala of Aneetheela" 2nd Ed.

4. Cuflen, S. C. "Anesthesia in General Practice"
5. Cowville, C. B. '?Jntoward Reactims to Ritrous Oxide Anesthesia"
Excellent for pathology of anoxia.

6. Brinker, c b K. "Puhonary Edema and Inflamtnation"

Good background for pulmomary compllcatione.

7. Miller, W. S. "The Lungt1

9. Adrfanf, John "Pharmacology of Anesthesia"

"Chemfatry of Aneetheaia"
"Technics and Procedure6 of Anesthesia"

10, "Anesthesiology, I' a monthly Journal

11. Gillespie, N. aEndotracheal Anesthesia" 2nd Ed.

12. Leigh, M.D. "Pediatric Anestheeia"

 RESPIRATION

It i s most important t h a t the a n e s t h e t i s t be thoroughly f a m i l i a r w i t h

t h e physiology of r e s p i r a t i o n since the lungs a r e t h e only s i t e a t which oxygen
may e n t e r the body, t h e chief s i t e of excretion of carbon dioxide, and t h e e i t e

of absorption and excretion of many of t h e anesthetic agents, The mechanics,

physical p r i n c i p l e s , and physiological c o n t r o l which cauae these gases and
vapors t o e n t e r and leave the lungs should therefore be well understood, i n
order t h a t t h e a n e a t h e t i s t may recognize the changes which take place when t h e

n o m 1 s t a t e passes t o t h e pathological, o r when consciousness is replaced by

progressively deepening anesthesia , Careful observation of a l l phaeee of r e s p i -

r a t i m t e l l e more about t h e depth of anesthesia than a l l t h e other eigne c m -

bined.

Control

The conscious c o n t r o l of r e s p i r a t i o n disappears e n t i r e l y w i t h the m-

s e t of t h e anesthetic s t a t e . Respiration becomes machinelikw, and v a r i a t i o n s in

it depend e n t i r e l y on the mechanical o r physiological changes produced by t h e

ane 8 t h e t ist o r 6 urge on.

The unconscious or automatic c o n t r o l i s c h i e f l y chemical i n nature. It

i8 t h e oonoentration cjf t h e H ions i n t h e respiratoaPy center whiob aff& aeomd

t e aeclond osntr31 of respimtdon. Beosuse of t h e great d i f f w i b i l i t y of earbon

dioxide through c e l l nembranes, it usually oauees these changes i n pH, b u t they

may be due t o l a c t i c a c i d , unoxidized f a t t y a c i d s , e t c . Hyperpnea f O l h J 8 an

increase i n a c i d i t y and diminished t i d a l volume follcwa a decrease i n a c i d i t y .

When t h e r e a p i r a t o r y c e n t e r i s abnormally depressed by druga (anesthetic agent,

morphine, b a r b i t u r a t e s , e t c . ) t h e site of automatic c o n t r o l i e probably s h i f t e d
t o t h e c a r o t i d bodies. A low oxygen tension i s now t h e r e s p i r a t o r y etimulant,
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not pH changes. Excess oxygen under these conditions w i l l cause a period of

apnea, until either t h e hypoxic stimulus recurs, or t h e C02 teneion rises above

t h e l e v e l of t h e r e s p i r a t o r y c e n t e r ' s threshold.
Reflex c o n t r o l is present t o a l e s s e r extent. Copmnon s i t e s of o r i g i n
€ o r t h e a f f e r e n t inpulses a r e t h e s k i n (pain, cold), t h e receptors of t h e vagus
i n tho r e s p i r a t o r y t r a c t , the peritoneum, r e c t a l sphincter, the c a r o t i d sinue,

a o r t i c arch, and c a r o t i d body. The a f f e r e n t impulae probably t r a v e l 6 up t h e

p e r i p h e r a l o r eamatic nerves t o the r e s p i r a t o r y center. The e f f e r e n t impulse may
t r a v e l down the vagus t o t h e larynx and bronobi t o cause lar,vngoepaem Or bron-
chospasm, or dawn the cord t o t h e c e r v i c a l region (phrenics) and thoracic re-
gions innervating t h e i n t e r c o s t a l musclee.

It ie an e r r o r t o presuppose a n o m a 1 r e e p i r a t o r y c e n t e r in t h e eurgl-
c a l p a t i e n t , Although sometimes stimulated (pain, f e v e r ) it i s m o r e often de-
pressed, and its threshold t o s t i m u l i r a i s e d because of drugs wed, or because
of abnormal metabolism a r i s i n g from t h e p a t i e n t ' s illness, In order of frequency,
the m o s t cannon r e s p i r a t o r y depreasants are the a n e s t h e t i c agent, t h e premedice-

t i o n drugs, oxygen l a c k and a marked C02 excees.

The production of oxygen lack, o r carbon dioxide r e t e n t i o n is ae In-
excusable as an overdose of premedication drugs o r anesthetic agents. A r e l a t i v e
oxygen lack (hypoxia) is frequently present w i t h c e r t a i n diseases such a8 hyper-

thyroidism, aevem anemia, pulmonary f i b r o a i e and poorly compeneated c i r c u l a t o r y

systems, b u t t h e oxygen l a c k should be t r e a t e d before operation is caneidered.

Anatmv

A knowledge of t h e a n a t m y of t h e r e e p i r a t o r y t r a c t i s Important e o

t h a t we may p r e d i c t and thereby prevent r e s p i r a t o r y obstruction, or looate it

p r m p t l y should it occur. Respiratory obstruction is t h e ccomnoneet aneethetio

complication. Frequent causes f o r obstruction and t h e i r treatment are

l i s t e d on t h e next page.
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Upper Re e@fratbry Tract Treatment

Tongue a g a i n s t pharyngeal w a l l i n C h a q i n g p o s i t i o n of head;

supine poeition a r t i f i c i a l airway

Large tone i l a , pharyngea 1 t m o r s ; Artif i o i a l airway beyond

pharyngeal edema point of obatruation

FluidrJ: mucus, blood, pue, vomitus Prophylaxis, premedication,

head down, s u c t i o n

Laryngospasm: d i r e c t i r r i t a t i o n aneethet- Slower induction, uae of non-

i a agent, n u c u ~ ,vanitus, pus i r r i t a t i n g agent f i r s t , pre-
medication, properly f i t t i n g
airway, g r a v i t y and s u c t i o n

Reflex laa!yngosp,sm Gentle suraery; adequately deep

anestheeia; avoidance of oxygen
lack and GO2 excess

Nasal obetruotion plus t i g h t l y closed Preoperative shrinkage n a e a l

mouth : adenoids, r h i n l t i e , muc oua membrane ; ora 1 8 irway
weeping early

Lawer Beapiratorz Tract

Fluids : mucue, v m i t u s , blood, pus Prophylaxis ; head down, s u c t i o n

Asthma; ref lex bronchospasm Proper s e l e c t i o n aneathetic agent;
helium
Subst e ma 1 thyroid, me d i a st I n a 1 Airway eetabliehed beyond
tumara canpressing trachea obatruction; helium

Mechanics
Contraction of t h e diapbragm and e x t e r n a l i n t e r c o a t a l e producee t h e
negative pressure which pulla t h e lungs outwards, causing a n inrueh of air. Re-
l a x a t i o n of these muscles cause8 t h e reverse prooem, expiration. Only i n foroed
e x p i r a t i o n a r e t h e internal i n t e r c o e t a f s and the abdaminal musolee contracted.
Normally t h e r e is always a negative presaure in %he p l e u r a l apace, It can becane

more negative by i n e p i r i n g against a cloaed g l o t t i s , or by p r o d u c i q a rtaesive

a t e l e c t a a i s . It is more poaPtive with forced expiration against a aloeed glottic

(beginning of a cougfi) and w i t h pneumothorax. The intrapulmonary presaure, i n

t b e r e e t i n g phaee of r e s p i r a t i o n , i a the a a m aa atmoepheric pressure. Dieturbed

 4
i n t r a t h o r a c i c pressure r e l a t i o n s may embarrass t h e c i r c u l a t i b n ae w e l l as t h e
r e e p i r a t i o n by altering; t h e venoue return t o t h e h e a r t . Maintenance of t h e

proper pressure relatime depends a l s o on a n I n t a c t thoracic cage, with good

mobility a t the coetovertebral and sternoclavicular j o i n t s
Lung motion i a e s s e n t i a l l y passive. Active changes i n bronchial lumen

and length may contribute t o lung expaneion w i t h i n s p i r a t i o n and expiration is

aided by t h e e l a s t i c r e c o i l of t h e lung t i s a u e . The beat aerated portions a r e

t h e lower lobes and a n t e r i o r p a r t s of t h e upper lobes. With i n s p i r a t i o n t h e apex

and lung r o o t move downward, t h e lung baee downward and outward, the remainder

of t h e lung outward and slightly upward.

Nwneroue factors may i n t e r f e r e with the meohanice of r e a p i r a t i m ,

causing a decrease i n v i t a l capacity, and thereby producirq inadequate t r a n s p o r t
of a n e s t h e t i c gase8, oxyeen and carbon dioxide t o and from the blood atream.

Pathological:

Pulmonary.. ..Fibrosie of i n t e r s t i t i a l tissue

Chronic bronchitis; emphysema
Aathma
Tuberculosis
Pneumonia
Atelectasis
Pne m o t h orax
Rilpyema
Ple ura 1 a dhes ions

Skeletal. ...Oeteoarthritis of' spine

Previoue rib reeections
Kyph o m olios is
Muecular. ..Residual poliomyelitis
diaphragmatic p a r a l y s i s
i n t e r c o s t a l paralyais
paralyzed s p i n a l musclee with c h e s t deformity
Diapkragina t i c hernia

Mediastinal. .Tuxtors s u b s t e r n a l thyroid

Pericardia 1 e f f u s i o n
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Abdminal. .. .Distension of hollow viscera
Pregnancy
Ovarian cyst; f i b r o i d uterue
Ascites
Bepato-.and s p l e n m e g a l i e s

Produced d u r i n g operation:
Change i n position: head dawn, prone, l a t e r a l , Mdney b r i d g e
Open chest f o r t h o r a c i c surgery
Weight of a s s f a t a n t ' s arm on cheet
,
R m w a 1 of r i b a t h orac oplaety
Retractore on c o e t a l margin
Pad8 against diaphragm
Depreseion of muscular a c t i v i t y by aneathetic drugs
A t e Isc t a si8
IIIEPLRATORY OBSTRUCTION

CIRCULATION

CSroulation is as important a8 r e e p i r a t i o n i n t h e proper d i s t r i b u t i o n

of oxygen and t h e aneathetic agent t o t h e t i s a u e e , and i n t h e excretion of

carbon dioxide and t h e anesthetic sent. Circulatory signs a r e not e e p e c i a l l y

h e l p f u l i n determining t h e depth of anesthesia, but a r e of g r e a t aesistance In

dotemining the r e a c t i o n of t h e p a t i e n t t o the operative trauma and t h e anesthe-

e i a r Only w i t h a n accurate and frequent record of p u l s e r a t e by palpation, and
blood pressure by a u s c u l t a t i o n can a proper i n t e r p r e t a t i o n and prbgnoeie be made.

C ontsol

The c o n t r o l of t h e c i r c u l a t i o n i e l i k e r e s p i r a t i o n i n t h a t t h e stimu-
l u s i e chemical i n nature, b u t unlike r e s p i r a t i o n , i n t h a t t h e "paoemaker" i e in
a p e r i p h e r a l region r a t h e r t h a n i n t h e medulla. The eino-auricular node ie t h e
o r i g i n of tho h e a r t b e a t , and change8 in a c i d i t y of t h e t i s e u e s which make up
t h e S-A node influence the r h y t h m greatly. In t h e h e a r t , t h e important chemical

s t i m u l i a r e t h e inorganic ions, Ca, K and Na, not carbon dioxide. The condmting
t i e s u e of the h e a r t i a q u i t e d i f f e r e n t frcan t h e nervous tlssue carrying the
r e s p i r a t o r y impulees, b u t i n both system8 a c t i v i t y leads t o a r e f r a c t o r y period,
when f u r t h e r a c t i v a t i o n cannot take place.

S e v e r a l neurological connections e x i s t which contribute t o the c o n t r o l

of c i r c u l a t ion .
a. The right and l e f t vagus nerves supply t h e S-A and A-V mdee respec-
t i v e l y . Their normal a c t i o n is one which keeps t h e h e a r t i n check. S t i m u l a t i o n
of t h e vagus produces a marked a f m i n g i n r a t e , w i t h o r without a h e a r t block.
b. Tbe a c c e l e r a t o r nerves, belonging t o the sympathetic nervous Bystam,

supply the h e a r t much more diffusely. Their c e l l bodies a r e located i n t h e tho,

r a o i c cord, frum T1 t o TG and t h e i r first synapee occurs i n any of the c e r v i c a l

and upper f i v e thoracic sympathetic ganglia. The postganglionic f i b e r s may t r a v e l

i n the cardiac plexus, or a c t u a l l y j o i n t h e vagus nerve trunk. The aympathetics

and vagus tenti t o balance one another normally, b u t stimulation of one eystem

depresses t h e a c t i v i t y of t h e other, and blocking of one system produces an exag-

g e r a t i o n of t h e s i @ of a c t i v i t y of t h e other.

C. Both t h e diviaions of t h e autonmic nervous system supply t h e peri-

.
pheral a r t e r i o l e s Vasmonstriction occure w i t h eympathetic stimulation; vaaodi-

l a t i o n occurs loae f o r c e f u l l y but is probably mediated by t h e parasympathetic

system. Exceptions t o t h i a g e m r a l r u l e a r e t h e coronary and c e r e b r a l vessels,

which d i l a t e with aympathetic stimulation. C a p i l l a r i e s apparently possess con-

t r i c t i l i t y Q u i t e independent of t h e s t a t e of t h e a r t e r i o l e s , ar neurological
connectione
Afferent connections of t h e nervous aystem w i t h t h e c i r c u l a t i o n e x i s t
i n many places * The morst important f olfm :
8. Carotid sinus : Receptors two preeent i n tbe walls of the c a r o t i d ainue,

a t t h e b i f u r c a t i o n of t h e ccgnmon c a r o t i d i n t o i t s e x t e r n a l and internal bramhes,

The a f f e r e n t impulaea pas8 along t h e c a r o t i d 8inue nerve, a branch of t h e glaeeo-

pharyneeal nerve, and branchee of t h e vague and c e r v i c a l sympathetlce. Reflexee

 7
f r m t h i s region normally keep t h e blood pressure a t a constant level. Pressure

changes inside o r outside t h e sinus w a l l a r e t h e chief stimulating factors.

Overstimulation r e s u l t s i n hypotension and bradycardia .
3. Aortic arch: the a f f e r e n t path is up the vagus nerve t o the medulla.
I t s reactions a r e similar t o the c a r o t i d sinus reflexes.
All these impulses a r e c o l l e c t e d by t h e vasomotor c e n t e r i n the me-
d u l l a , which synchronizes t h e c i r c u l a t o r y reaction. Changes i n r e s p i r a t i o n fre-

quently occur a t the same time because of the cloae r e l a t i o n of t h e r e s p i r a t o r y

and vasomotor centers.

Sh oc :1

T h i s is the c m o n e s t c i r c u l a t o r y accident. The word is poorly chosen,

for many connotations have been ascribed t o it. What i s meant i s a discrepancy
between t h e q i r c u l a t i n g blood volume and t h e c a p i l l a r y bed. The sequence of
events i n increasing shock l a :

1. P r e c i p i t a t i n g trauma : severe burn, hemorrhage, prolonged s u r g i c a l

trauma, deep anesthesia
2. Capillary d i l a t a t i a n and a r t e r i o l a r c o n s t r i c t i o n : trapping of much
blood i n c a p i l l a r y bed making it unavailable for general c i r c u l a t i o n

3. Constriction 01 spleen t o supply zilore blood

4. Increased h e a r t r a t e , t o deliver diminished volme b e t t e r

5- Diminighed venous r e t u r n
5. Increased r e a p i r a t i o n s (hypoxic etimulua t o c a r o t i d body) t o supply
more oxygen t o overworking h e a r t , u n t i l center damaged by hypoxia

7. Lose of proteins through c a p i l l a r y w a l l t o tissues

8. Viscosity of blood g r e a t e r - lcore d i f f i c u l t f o r h e a r t aa a pump

9- Further c a p i l l a r y damage from prolonged hypoxia IVm i r r e v e r s i b l e

10 . F a i l u r e of myocardiura because of poor oxygenation

It is obvious t h a t treatment of ahock must be prompt and r a t i o n a l . It

is directed tawards:
 8
1. Supplying ample oxygen

2. Restoring blood volume

3. Restoring plaspls proteins

4. Restoring RBC, i f blood has been l o s t
The a n e s t h e t i s t ' 8 inmediate r e e p o n s i b i l l t y is t o i n s t i t u t e mans of providing
t h e p a t l e n t ' s t i s s u e s , ehpecially t h e oerebral t i s s u e s , w i t h ample oxygen# and
t o maintain optimal oxygenation w h i l e f l u i d s , blood and blood substitutm~are
obtained and administered by &hers. If help is not available t h e a n e s t h e t i e t
should f i r s t set up a ~ o u r o eof excess axygen and an i n f a l l i b l e alrway, befme

embarking on What may be a d i f f i c u l t and time-oonsuming venipundum in a pa-

t i e n t with peripheral vascrmcrtor collapse.

There is no r a t i o n a l e i n giving cardiao rstimulants. Adrenalin, A n a -

l e p t i c s (coramine, metrazol, e t c .) and carbon dioxide stimulate h e a r t muscle
ONLY i f it is w e l l oxygenated.

Ane a the t i c Ihp l i c a t iom

1. Evaluation of t h e r i s k of a cardiac p a t i e n t is merely the evaluation

of h i s compensation and reeerve. Any s u r g i c a l operation o r aneetheaia impoms a

s t r a i n on h i s c i r c u l a t o r y system, and a c a r e f u l h i s t o r y of h i s tolerance of
other kinds o f s t r a i n w i l l give b e t t e r clues a s t o t h e length and e e v e r i t y of
t h e s u r g i c a l procedure he car, t o l e r a t e , than phyeioal examination of h i s h e a r t

and p e r i p h e r a l vessels . Determining the presence or absence of murmur^, abnormal

rhythms, or vascular thickening cannot alone lead t o an accurate prognosis 4s t o

functional e f f i c i e n c y and a d a p t a b i l i t y of the c i r c u l a t o r y system.

2. A l l anesthetic agente depress h e a r t muscle directly, mklng it a l e s s

e f f e c t i v e pump. The deeper the anesthesia, the worse i s the depression, Chloro-

form and e t h y l chloride are the moet sevwe depreseants,

3. Ether anesthesia, c a r r i e d no deeper than second plane, is probably tbe

 9
s a f e s t f o r a cardiec p a t i e n t . Because of i t s i r r i t a t i n g e f f e c t on the reepira-
t m y system, i n s p i r a t i o n is stimulated which causes a b e t t e r venous r e t u r n t o
the h e a r t . Within c e r t a i n limits, t h i s meam an improved c i r c u l a t i o n .
11. Oxygen lack is the worst depreseant f o r h e a r t nuscle e s p e c i a l l y i f it
i s already danaged. (Myocarditis, rheumatic fever.) Ample oxygen MIET be sup-
p l i e d t o cardiac p a t i e n t s .

3. The conduction system I n %he heart i s often affected by the agent.

Cyc lopropane frequently produces i r r e g u l a r i t i e s i n rhythm wh fch are not perma-

nent. A l l druge, even procaine and t h e b a r b i t u r a t e s , cause EXZ: changes.

5. The vasomotor center i s depressed e s p e c i a l l y by the non-volatile drug8 :
short-acting b a r b i t u r a t e s a v e r t i n . Deep anesthesia w i t h the i n h a l a t i o n agents
€11130cauees a m r k e d depremion, s o t h a t compensation for impending shock, by
vasoconatriction, is completely lost.

Tbe anest21etist always attempta t o keep t h e blood preeawe and pule6

a t t h e i r normal leve18, i n s p i t e of t h e surgery. Following are some of the CQDS

mon reasons for changes i n them.

Increased Puleo Bate Rise i n Blond Pressure

Oxygen want, e a r l y Poeition of p a t i e n t

Carbon dioxide excess head dmn
Eemorrhage l i t h o t coly
Ligh’t anestheeia Oxygen want, e a r l ?
Ether Carbon dioxide exce8e
Exceeeive sweating Manipulatian of t o x i c thgroid
W r e a s e d adrena l i n output Analeptics
Fluids given t o o f a e t Fluids
AnaLept ice
Large doees atropine or scopolamine

Decreased Pulse Rate F a l l ia Blood Pressure

Eigb epinaf anestheeia P o s i t i o n of p a t i e n t

Neasynephrine a i t t ing
Sudden, eevere anoxia change during anesthesia
Carotid sinus reflex prolonged Trendelenbur6
Celiac plexus ref lex Ckygen want, l a t e
Chloroform, e t h y l chloride Marked carbon dioxide excess
cyclopropane Deep anesthesia
 10

Decreased Pulse Rate F a l l i n Blood Pressure

Heart block High s p i n a l aneethesia

Vomiting Avertin, i.v. b a r b i t u r a t e
Drainage of cerebrospinal f l u i d vomit in$
Procaine r e a c t i o n Carotid sinus, c e l i a c plexus
Prolonged operative trauma
Sympathectcrmy f o r hypertension
Hemorrhage
. Accidents1 i.v. procaine
' Sudden release of increased
abdominal pressure : pregnancy,
ascites, cysts
Decreased Pulse Pressure
Carotid sinus r e f lex
Celiac plexus or other t r a c t i o n reflexes
S h i f t of mediastinum: thoracic surgery
H i g h s p i n a l anesthesia
I n t r a c r a n i a l pre Gswe change8
f n t r a c r a n i a l manipulation

CENTRAL IvERvuus S
Ym

A r e v e r s i b l e and oontroUahle depression of t h e nervous system i s t h e

aim of' any anssthesla. It would be desirable t o limit the a c t i o n of the drugs t o
the nervous system alone, b u t by most technics t h i s i s impossible, since the
drugs are c a r r i e d by t h e blood stream. Only by regional blocks ( s p i n a l , psrw

blocks, l o c a l i n f i l t r a t i o n ) a r e p a r t s of the nekrvous system anesthetized d i -

rectly.
The i n h a l a t i o n agents cause an ascending p a r a l y s i s of the s p i n a l cord.

This means t h a t t h e i n t e r c o s t a l muscles, supplied b y the thoracic c o r d a r e para-

kyzed before the diaphragm, w i t h its c e r v i c a l innervation. During deepening

anesthesia, the lower, t h e n t h e upper i n t e r o o s t a l s and f i n a l l y the diaphragm

lose t h e i r a c t i v i t y and tone, an8 during recovery f r m deep anesthesia, them
musclea recover i n t h e reverse order. Otservatian of the comparative a c t i v i t y of
these t w o groups of muscles gives UB one of our most important r e s p i r a t o r y

signs .
 11

Concomitant w i t h the ascending cord paralysis, deprespJim of the b r a i n

progresses from i t e most specialized t o i t s l e a s t specialized centers. The cere-

brum i s depressed f i r s t , w i t h e a r l y loss i n j u d p e n t and reason, followed by

loss of memory and consciousness. Of the s p e c i a l senee6, hearing remains i n t a c t

the longest, and recovers first. The cerebellum t h e n shares i n the depression as
evidenced by the ataxia of second stage. ObJective signs of f u r t h e r depression

a r e not obvious, b u t progress dawn through the thalamus, midbrain and medulla.
sgvere lnaduUary depression indicatea an approaching i r r e v e r s i b i l i t y of the an.
esthesia.

'RlemOSt s e r i o u s depressant for the nervous s y s t m i s oxygen lack. In

normal persons, it is a matter only Qf minutes (cerebrum, 8 min.; medulla, 30

min.) before permanent destruction t a k e s place. In a person who is already i n a

chronic hypoxic s t a t e (cardiac, pulmonary pathology, anemia, prolonged p a r t i a l

obstruction of airway) t h i s time i n t e r v a l is reduced t o seconds. After a mvere

hypoxic episode, permanent sequellae, such a s personality change#, v i s u a l dis-

turbances, and changes in muscle tonus, sensation and c o n t r o l of f i n e movements

may occur. Cerebral hypoxia i n t h e newborn i s known t o be r e l a t e d t o c e r t a i n

types of mental deficiency and s p a s t i c s t a t e s appearing during the c h i l d ' s de-

velopment. An eplsode of hypoxia severe enough t o be inccaapatible w i t h recovery
f a c h a r a c t e r i s t i c a l l y follcwed by f a i l u r e t o regain consciousness, r e s t l e s s n e s s ,
convulsians, hyperthermia, c m and death. Since no treatment can change t h i s

p i c t n r e once it develops, prevention of oxygen want i s t h e only mema of control-

l i n g t h i a problem.

AUTONOMIC NERVOUS SYSTEM

The autoncanic mrvoua system i s one of tbe most cmpUcated and one of
t h e most fascinating ooncepts i n physiology. For a c l e a r presentation of the
problem, e s p e c i a l l y of t h a t p a r t r e l a t i n g to chemical mediatian of t h e nerve im-

pulse, Chapter 19 i n Goodman and G i h n , i s recammended.

None of t h e anesthetic drugs f i t s e n t i r e l y i n t o an adrenergic 0.1-

cholinergic c l a s s i f i c a t i o n b u t t h e common agents can be divided roughly a s fol-

Adrenergic stimulation: e t h e r , chlorof o m , oxygen lack, C02 excess

Cholinergic stimulation: cyclopropane, b a r b i t u r a t e s , morphine

Spinal or nerve blocks paralyze t h e sympathetic f i b e r s t o t h e p a r t
anesthetized
Atropine and scopolamine depress cholinergic a c t i v i t y
Although a p a t i e n t may be anesthetized t o various stages of depression,
s t i m u l i a r e not prevented f r m reaching the nervous system and produciw re-

sponses. Most of these . r e f l e x e s a r e r e s p i r a t o r y and c i r c u l a t m y i n nature and

a r e mediated by. the a u t o n m i c nervous system. Correctly speaking, t h i s i s solely

an e f f e c t o r system, b u t many a f f e r e n t f i b e r s run i n autonomic nerve trunks

(splanchnic, vagus).. The c e l l bodies f o r these f i b e r s a r e i n the d o r s a l r o o t

ganglia, or the vagus nucleus.

Origin of a f f e r e n t impulses :

Traction on upper abdominal viscera, mesentery, cecum, pelvic organs,

perinem
Manipulation of r e c u r r e n t and superior laryngeal nerves, phrenio nerves,
vagi
-
P e r i o s t e a l s t h u l a t i o n e s p e c i a l l y r i b periosteum
Lung hilum s t i n u l a t i o n
Stimulation of c e l i a c plexus: manipulation of conanon duct, pads, r e t r a c t o r s ,
elevated kidney r e s t
S t i m u l a t i o n of c a r o t i d sinus: neck infections, head dawn position, re-
t r a c t o r i n thyroid surgery, neck dissections, a n e s t h e t i e t 's f i n g e r
pressure, extreme l a t e r a l f l e x i o n OT neck
D i l a t a t i o n of rectum, vagina, cervix
Overdistention of lungs
I r r i t a t i o n of n a s a l o r t r a c h e a l mucous membranes
Marked apprehension preoperatively; marked excitement stage
The e f f e r e n t e f f e c t s may b e :
Respiratory: hryngospam, or adduction of vocal cords apnea, YMTegular
r e s p i r et ion, b ypo ypqea , b r mch ospa 8m
Circulatory: change i n pulse r a t e , arrhythmia, hypotension, diminution i n
pulse pressure, hypertensian
Increase i n puscle tanus, agnvulsions

Treatment is mainly prophylactic

1. Deep anesthesia before t r a c t i o n i a exerted
2. 3roduction of a8 l i t t l e trauma a s poesible, and i f necessary gently
and steady, not sudden t r a c t i o n
3 , Adequate premedication t o c o n t r o l psychic s t a t e and t o diminish irri-
t a b i l i t y of the nervous system (morphine)
4, Endotracheal airway f o r upper abdcaninal and neck surgery
5 , Blocking of area of reflex a c t i v i t y w i t h procaine
A n e r ref lex has occurred, treatment may be :
1. Stopping trauma or t r a c t i o n when POSSible : reexerting t r a c t i o n slowly
and s t e a d i l y
2. Blocking the reeion w i t h procaine l o c a l l y
3 . Changiw l e v e l of anesthesia, giving adequate oxygen, and removing
excess C02
4. Supplementing l i g h t anesthesia w i t h a d d i t i o n a l doses of morphine (with
mopolamine o r atropine) f o r general r e f l e x depreseion
5. me of some drug t o cban&e the balance i n the autonomic system: atro-
pine ephedrine, physostigmine, ergotamine : a l l have been succeesful
in @ m e cases

PHEMEDICATION

Premedication is a s important i n anesthesia a s the choice of' agent or

technic. The reasons f o r using premedication a r e several:

1. Psychic depression of p a t i e n t : Abolition of undue alertness and anxiety

reduces t h e incidence of excitement during induction, and increases the eaee

w i t h which subsequent anesthesias may be given t o t h e same person. A atoMoy In-

duction usually leads t o hyperactive r e f lexes and increased secretions, come-

quently t o a stormier uaintenance and recovery.

2. To lower p a t i e n t '8 ref-lex i r r i t a b i l i t y , which p a r a l l e l s h i s metabolic

r a t e . Less anesthetic agent i n a c t u a l amount i s needed t o produoe and maintain

s u r g i c a l anesthesia i f t h e s t a r t i n g paint of t h e anesthesia i s a t a r e l a t i v e l y
l o w metabolic plane, Excretion of the agent and recovery f r m anesthesia is
 14
consequently more p r m p t If ref lex i r r i t a b i l i t y is depressed by premedication,

t h e r e i s less likelihood of such c m p l i c a t i o n s as v m i t i n g during inductian,

breath holding and coughing w i t h i m i t a t i n g agents, and r e f l e x L a r p g o s p a s m .

3. To prevent excessive s e o r e t i m e in t h e r e s p i r a t o r y t r a c t . The develop-

ment and r e t e n t i o n of excessive s e c r e t i o n s during anesthesia increases t h e ever-

t h e stimulation of s e c r e t i o n s by e t h e r t h a t t h e t e r n itether pneumonia" was

coined. T h i s misnamer is camonly applied t o what s t a r t s a8 a n atelectasils and

l a t e r develops i n t o pnewaonia .
4. To prevent t h e convulsant a c t i o n of drug6 used f o r l o c a l , block o r

s p i n a l anestheaia. Acarding t o experimental evidence t h e b a r b i t u r a t e s a r e t h e

most e f f e c t i v e

5. To coynteract autonomic nervous system e f f e c t s of c e r t a i n anesthetic

agents; i .e., intravenous b a r b i t u r a t e s and cyclopropane are apparently cholin-
ergic drugs and are b e s t preceded by scopolamine or atropine.
k P E S OF DRUGS USED:

B a r b i t u r a t e s are b e s t for psychfc depression, and f o r counteracting

t h e convulsant e f f e c t s of t h e regional drugs. They a r e not s a t i s f a c t o r y for

lowering reflex i r r i t a b i l i t y . Alone, they cause increased secretions.

Morphine is the best drug for genere1 lletabolio depreaeion and

dim;irutirn of reflex lrritabillty, Dsrmerol is almost a8 s a t i s f a a t m y and h a

the addea advantage of produalng brcmchobilatien, leas reeplratary center

b a p c s s i o n and lees nausea an8 v d t i n g t& comparable riosea qf mrgkir-e,
Atropine and sccrgolamine ere both good drugs f o r preventing eecmtians,

counteracting t h e r e s p i r a t m y depression and t h e tendency t o vamit a f t e r mor-

phine, and preventing excessive parasympathetic a c t i v i t y . The only important d i f -

ference between the two drugs i s t h e i r opposite e f f e c t on the c e r e b r a l centera:

atropine i e a t i k u l a t i n g , causing increased a l e r t n e s s , w h i l e scopolamine is a

mild depressant causing drowsiness, and suinetimes amnesia .

Avertin i s a premedicatim and not a n anesthetic drug. It i s desirable
from the p a t i e n t ' s point of view because of the ease w i t h which it produces un-

consciousness, but is undesirable because of t h e length of time p r o t e c t i v e

(cou&) reflexera a r e depressed. Used, however, only t o produce amnesia, most or'

the ObJections t o t h e drug are outweighed.

Intravenous b a r b i t u r a t e s a l s o produce p r m p t and easy lOS8 of con-

sciousness but i n moderate doses a r e preferable t o averbin since they a r e meta-
bolized s o quickly t h a t laryngeal and cough reflexes r e t u r n rapidly.

The dose of these d r u g s depends upon c e r t a i n f a c t o r s i n t h e p a t i e n t ' s

pathology and physiolog;!.

The following conditions a r e c ~ l l l l l o nones demanding t h a n average

doses of depressant d r u g s :

Fever Hyperactive personality

Pa i n Muscular c o n s t i t u t i o n
Ma rke d appm h e n s ion Chronic alcoholism
Hyperthyroidism Pregnancy
Neurosis Adolescence
Manic type of psychosis. Determination t o r e s i s t sleep

-
The following demand less than average doses:

Anemia Ne ph r it is
Hemorrhage S e n i l i t y , infancy
Shock Previ o u ~depressant drug
Hypothyroidism Jaundice
Chronic illness Mental deficiency
Weight l o s s Sc h iz oph re nia
Acute alcoholism Senile psychosis
Cardiac diaease Phlegmatic personality
Obesity Addison's disease

The route of administration of these drugs depends on t h e time a v a i l -

a b l e before s t a r t of anesthesia, since it i s desirable t h a t t h e peak of a c t i o n

of the p r ~ ~ d i c abet ireached
~ or j u s t paswd a t t h e tima anesthesia is begun,
When the medication is given h ~ o d ~ ~ i c a 90
l l mZnu%es
y is necessary far t h e de-
velopment of ~x~~ e f f e c t , when i n t r ~ u s ~ u ~ r 45-60
l y , minutes, w h i l e only 10
t o 15 ~ n u t e sa r e needed for the peak of a c t i o n after intravenous p r e ~ d i ~ a t i ~ .
The last is, therefore, t h e only e f f i c a c i o u s route when t h e tlme between

s c ~ e d u an
l ~ operation
~ and the start; of a ~ s t h e s iis~ short. The mal and

r e c t a l r o u t e s a r e both ~ d e ~ n d a because
~ l e of t h e maw variabla f a c t o r s i n ab-
s o r p t i on.

The f o l l w i n g ~ e ~ ~ a la r~e ts i~ e~ ~s t far

e d ~ d i c a before
t ~ ~ various

. Nitrous oxide needs heavy premedication. Nitrous oxide is nat; a patent

agent, therefore t h e metabolfc r a t e and r e f l e x i r r i t a b i l f t y mu& be brought t o
t It
Lbasaf conditions" by appropriate doses of morphine o r by a b a s a l aneElfrhetiGff
(Avertin) i n order t o produce s u r g i c a l anesthesia without s a c r i f i c i n g adequate
oxygenation, Reduction of reflex i r r i t a b i l i t y and metabalio r a t e not on& Bsmn
the amount of n i t r o u s oxide necemary, b u t also tend t o reduce the oxygen re-
quirements of the t i s s u e s .

Cyclopropane i s potent and r a p i d i n e f f e c t , therefore need not be g m -

ceded by the d e ~ r e s ~ a ntype
t of ~ ~ ~ i c a t biu~t because
n , it is cholinergic a t r a .

pine OT aoopolamine should be administered t o counteract t h i s effect,

Ether, because of' 5ts slaw onset and unpleasant i m i t a t i n g qualltfels

should be preceded by moderate doses of t h e d ~ p ~ drugs
~ s and
a ~sufficierrt

atropine or ~ c o ~ t o i n~h i b~i t excess

~ e secretions.

XmaL, ~ ~ i n or
a 1regiona3. technics a m b e s t preceded by B short a c t i n g
b a r b i t u r a t e , and 8 mall dose of morphine, b u t i n b i b i t i o n of s a c r e t i a s is not
necessary unless t h e use of ~ u ~ p l a e~ s ~t h e~s i ~a(ether,
a ~ c ~ l o p r ~ a n ei.v4
,

a ~anticipated,
b a r ~ ~ t ~ is e s ~ ~ o p o ~ i inB efrequently used before local,

blaok o r s p i n a l anesthesia, b u t it is used for its counteracting of r e s p i r a t o r y

depression and nausea from morphine, and f o r i t s production of amnesia, r a t h e r
than f o r its e f f e c t on secretions.

Intravenous barbituratee, l i k e cyclopropane a r e cholinergic, and are

frequently accompanied by increased secretione. Atropine o r scopolamine should

therefore be given before t h e i r use. Small doses of morphine t o reduce pain per-
ception a r e helpful s i n c e reeponses t o pain s t i m u l i a r e abolzshed only with r e -

l a t i v e l y deep barbiturate anesthesia, Oral premedication w i t h ems11 amounts of

other b a r b i t u r a t e e i s not contraindicated, but is ueually unnecessary and beat

omit ted.

Avertin is e s e e n t i a l l y a depreeeant premedication, and eo should be

preceded by minimal doees of morphine ( f o r r e f l e x depression) but t h e neceeattry

amount of atropine or ecopolamhe should not be reduced.

Suggested dosea i n healthy a d u l t s a r e

Magendie 0.3 C.C. (morphine .009 gm} + Scopolamine 0,0004 gm.

Demerol 0.075 gm + Scopolamine 0.0004 gm.

General p r i n c l p l e e of medication:
1. A combination of two depressant drugs, i.e., nembutal and morphine is
more depressant than e i t h e r one alone. Correct t h i s by decreasing t h e dose of

each.

-
2. Because t h e cambination of b a r b i t u r a t e , morphine and a general anesthe-

t i c so often produces marked r e s p i r a t o r y depreesion, it is b e t t e r t o give the

b a r b i t u r a t e t h e n i g h t before operation, uslng; a medium or long a c t i n g one so

that its a c t i o n w i l l be present but waning on t h e morning of operation. For

case8 scheduled l a t e i n t h e morning a short-acting b a r b i t u r a t e (nembutal,

seconal) given "on awakening" w i l l a l l a y anxiety, yet be past it8 peak of a c t i o n

when the pre-operative morphine l e given,

3. Beware of using depressant drugs i n p a t i e n t s w i t h preexisting

 18
r e s p i r a t o r y d i f f i c u l t y . Such p a t i e n t ' 6 r e s p i r a t o r y exchange may be j u s t adequate
t o keep them oxygenated without such drugs, b u t even s l i g h t r e s p i r a t o r y depres-

s i o n caused by t h e drugs nay lead t o mvere hypoxia. Patient8 with severe hemor-
rhage, anemia, asthma , cardiac decmpensation, substernal thyroids, marked e-
phosis, and marked abdominal d i s t e n t i o n , are i n t h i s group, a s well a s those
w i t h pulmonary disease

4. Every t i m e a depressant drug is used, t h e cough reflex i s diminished.

me dosage of o p i a t e s necessary t a control cough is m a t e r i a l l y smaller t h a n t h a t

neceasary t o r e l i e v e pain, An a c t i v e cough r e f l e x is t h e b e s t prophylaxis

against r e s p i r a t o r y complications. THINK TWICE before ordering depressant drugs.

INHALATION AGENTS

There are a t l e a s t t e n anesthetic gases and vapors. A omparison of im-

portant p r o p e r t i e s of the s i x most common i s tabulated on page 19.

The a n e s t h e t i c gases obey a l l the well-established physical gas l a w s ,

b u t the one of p a r t i c u l a r importance t o t h e physiology of aneatheeia i s t h a t t h e

d i r e c t i o n of d i f f u s i o n of a gas 18 from a region of high tension ( p a r t i a l pres-

sure) t o regions of lower tensions. This i s t h e machanim by which gases pass

from t h e a l v e o l i t o t h e blood stream and thence t o t h e t i s s u e s when they a r e ad-

ministered, and pass i n t i e reverse d i r e c t i o n t o be excreted when administration

I s stopped,

An important difference between the v o l e t i l e agents and t h e nun-vola-

t i l e one8 is t h a t they a r e not changed i n t h e body, and a r e q u a n t i t a t i v e l y ex-.

a r e t e d by t h e lungs. A negligfble amount d i f f u s e s through t h e sMn and i n t o the
sweat, urine, and other s e c r e t i o n s , but the l i v e r and kidneys a r e spared t h e $
metabolic work of i n a c t i v a t i n g the d r u g s . The significance of t h i s mode of exom-

tion :E t h a t should overdose occur, t h e d r u g can be removed from t h e body by

 SCME PROPERTIES OF CCNMON INEALATION ANESTVE!l?IC AGElpflS
CHLOROI CYCLO- N-rrROUS
NAME ETHER FORM VINE!I'HENE PROPANE E'J3YIZI'?E OXIDE

~.
.

STABa
m FAIR FAIR POOR GOOD GOOD GOOD

4.1 2.42 1.45 *97 1.52

FIRE 80 EXPLOSZON ++* 0 ++++ ++++ ++++ 0

HAZAiW

PCVEIICY WITHUJT
OfiGEll WANT

$ IN INSPIfiED A I R 4.C$
(2nd plane)

MPLDITY OF INDtfc-
-
T I O N CONTROL & 4- ++ ++ U++ ++++ ++++
IIECOVERY

MA
RGm OF S
AW Depends on a b i l i t y 05 a n e s t b e t i s t

IKR. SECRETIOHS ++++ +++ ++++ +' + 0

ADVERSE METAB.%tC
CHANGES +++ +U+ +++ ++ + 0

CAUSE OF liESP. CARDIAC RESP ma.

DEATH DEPrnSS. mPmss, rnPRESs* DEPrnSS.
AFlJOX;LA ANOXIA ANOXIA ANOXIA ANOXIA ANOXIA

W a x e prepdkations administered Intravenously can be used t o produce

r e l a x a t i o n of s t r i a t e d muscle and i s e s p e c i a l l y indicated with t h e lese potent

a n e s t h e t i c agents. Some r e s p i r a t o r y depression always accompanies its use and

some method of a s s i s t e d v e n t i l a t i o n should always be a t hand t o assure proper

exchange of eases.
 20
a r t i f i c i a l r e s p i r a t i o n provided t h a t t h e c i r c u l a t i o n h a s not e n t i r e l y ceased t o
c a r r y the drug from t h e t i s s u e s t o t h e lungs. There i s more s a f e t y i n using a
drug which can be removed i n the same way it i s administered, t h a n i n using a
d r u g which must be metabolized by t h e p a t i e n t before l i & t e n i a g of the anesthe-

s i a can DCCLW.

Many t h e o r i e s (see Goodman and Gilman, p. 3 2 ) have been advanced t o

explain t h e phenmenon of narcosis, b u t few a r e equally applicable t o a l l types

of anesthetic drws. It is most likely t h a t t h e ultimate mechanism of t h e pro-

duction of narcosis i s a n interference w i t h t h e oxidative enzyme systems of
nervous t i s s u e . The oil-water s o l u b i l i t y r a t i o of t h e a n e s t h e t i c drug, it8 ad-
sorptive p r o p e r t i e s , o r its a l t e r a t i o n of surfaoe tension may be of importance
only i n intermediate stepe leading t o t h e a f t e r a t i o n of t i s s u e oxidation. This
assumption explains why s e v e r a l of t h e t h e o r i e s may have coneiderable corrobora-

t i v e evidence without being s u f f i c i e n t l x applicable t o a l l drugs t o permit t h e i r

acceptance. It is f a r from established a t t h e p m s e n t time t h a t enzyme d i s t u r b -

ances a r e t h e explanation of r e v e r s i b l e cell depression (narcosie), b u t a s h i f t

i n t h e r e l a t i v e importance of d i f f e r e n t enzyme systems is a tempting way of ex-
p l a i n i n g haw nerve cell a c t i v i t y (energy production) can be i x h i b i t e d by anes-
t h e t i c d r u g s without causing death of t h e c e l l .

IMlALATION TECHNICS

I n h a l a t i o n methods a s previously mentioned are t h e on$y ones i n which

t h e a n e s t h e t i c drug can be removed frm t h e p a t i e n t a t w i l l , and thereby a r e t h e
-
s a f e s t of a l l methods. They also allow t h e most accurate individualization of

dosage

The follawing f a c t o r s d i r e c t l y influence i n h a l a t i o n anesthesia:


Change i n the inspired atmosphere
Minute volume exchange
Available alveolar surface
Pat lent 's r e s p i r a t m y tract
21
Efficiency of the c i m u l a t i o n
Blood supply t o various t i s s u e s
Amount of adipose t i s s u e i n body
Composition of the blood

There a r e t h r e e fundamental types of inhalation technics, w i t h n m r -

ous variation; open drop, carbon dioxide absorption, and i n s u f f l a t i o n technics.
The open drop method i s characterized by the use of a w i r e mask

covered t h i n l y w i t h layers of gauze, on which the l i q u i d anesthetic agent is

dropped and allowed t o vaporize. The vapor being heavier than a i r , ooncentratea

under and close t o the mask, and i s inhaled b y the p a t i e n t , Exhalation through
t h e mask increases the r a t e of vaporization of the liquid.
The carbon dioxide absorption system involves t h e u s 0 of a machine
w i t h yokes for attaching tanks of cmpressed gasee, valves t o adjust the r a t e

a t which the gases escape from the tanks, a f h m e t e r t o indicate the flaw of

gas, a rubber bag t o a c t 88 a r e s e r v o i r f o r the gas mixture, and a c a n i s t e r of

absorbing m a t e r i a l (sodalime, baralyme) t o absorb t h e carbon dioxide made by the

patient .
Ineufflation m t h o d s are characterized by blowing an anesthetic mix-

t u r e i n t o t h e p a t i e n t ' s r e s p i r a t o r y t r a c t (naso-pharynx, mouth or t r a c h e a ) i n

s u f f i c i e n t concentrations t o maintain s u r g i c a l anesthesia, a f t e r it h a s been

induced by one of the above methods. The anesthetic mixture may be oainposed of
gases delivemd frcan high presaure tanks a t a mure r a p i d r a t e of flow than used

w i t h the closed system, and nay be used a s vehicle8 t o c a r r y t h e vapor of a l i q -

u i d drug from a r e s e r v o i r t o t h e m t i e n t . (Exanplea: Insufflation of n i t r o u s

oxide and oxygen, & h e r vapor earried by a atream of oxygen.) Cmpmsaed a i r

piped t o t h e operatine; room from a c e n t r a l source, o r delivered by a motor-

driven pump o r f o o t b e l l m e , may be used instead of oxygen a s the vehicle for

the vapor of v o l a t i l e agents.

All t b r e e systems can be considered a6 extensions of the respiratory

 22

system of t h e p a t i e n t . The gases under the mask, i n the breathing bag, o r i n the
i n s u f f l a t i o n stream come i n t o equilibrium w i t h t h e a l v e o l a r gas concentrations

a f t e r a s h o r t time. From t h i s point, equilibrium i s reached w i t h the blood

stream, and finally w i t h t h e t i s s u e s .

There a r e advantages and disadvantage of each method:

Open drop
PRO
- -
C ON

1. SSmple, portable 1. No c o n t r o l of r e s p i r a t i o n
2. Inexpensive equipment 2. Poor set-up f o r r e s u s c i t a t i o n
3 . Minimal rebreathing C02 3. Very wasteful, anes. agent
4. Minimal reaistance t o 4. Loss of h e a t , and water vapor
breathing 5. I r r i t a t i n g , cold vapor
6. Always lower oxygen than a i r
7. F i r e hazard
E;. Skin burns, l i q u i d e t h e r
,Absorption
1. Good c o n t r o l r e s p i r a t i o n 1. I n i t i a l expense h i @
2. Re susc I t a t i on easy 2. Less portable; tanks o f gases
3. Economical, anes. agent 3. Can g e t out of order
4, Heat, water vapor preserved 4. Increased temperature inspired
5. Oxygen e a s i l y added, carbon a ir
dioxide removed 5. S l i g h t r e s i s t a n c e t o breathing
5. Explosion hazard
Insufflation
1. Technically easy, head and 1,2,3,4,5, and 7 same a8 open
neck surgery drap metbad
2. Lowest rebreathing C% 1 and 3 mnte a s a b 8 ~ r p t i O n
3 . Easy route t o add 02 Re l a t ive ly purtab le when foat
bellows type used
C i f f i c u l t t o maintain deep
a m st h e a i a
To each ayetern, a n endotracheal airway, introduced througb t h e nose or

mouth, may be added. I t s advantages and disadvantages a r e l i s t e d below:

PRO
I_ -
C ON

1. Free airway, cc~nmons i t e s of 1. Moderate obstruction t o respf-

ob struot i on under c o n t r ol r a t i o n if tube t o o low o r
(tongue , larynx 1 narrow
2. Dead apace diminished -
quieter 2. Possible trauma t o larynx and
r e s p i r a t i o n , lower C02 pharynx by inexperienced
3. Prevention of m a t e r i a l from ane s t h e t ist
entering trachea ( t u b e w i t h 3. Possible i n j u r y t o epithelium
cuff o r packing) of trachea o r larm by
4. Pathway for auction established pressure of tube or cuff
5. Control. of pressure i n chest 4. Anesthesia m u s t be kept deep
5. Ideal aet-up f o r r e s u s c i t a - enou& t o abolish cough
tion ref lex
 Indications for endotracheal airwag

1. Operations i n a r e a s of high r e f l e x i r r i t a b i l i t y : upper abdomen

2. Operatiom on p a t i e n t s with high r e f l e x i r r i t a b i l i t y : a l c o h o l i c s
3. Head and neck surgery: a n e s t h e t i s t out of surgeon's way, b u t goad con-
t r o l of airway
4. Poor r i s k p a t i e n t s : if r e s u s c i t a t i o n may be necessary; eapecially
neurological p a t i e n t s
5. Thoracic surgery: c o n t r o l of pressure r e l a t i o n s i n chest; suction of
s e c r e t i o n s f r m trachea and branchi
5. I n s u f f l a t i o n technics, delivery of agent more e f f i c i e n t and e f f e c t i v e
7. Long operations i n unphysiological positions: Ex. : s p i n a l fusion, i n
prone positJon. Respirations o f t e n aided by a n e s t h e t i s t
8. P a t i e n t s i n whom an adequate airway cnanot be e s t a b l i & e d and main-
t a i n e d by simpler means: receding jaw, s h o r t neck, i n t r a c t a b l e
laryngospasm
9. In war s q e r y when one a n e s t h e t i s t must manage s e v e r a l g e n e r a l anes-
t h e s i a s a t once

OmEER TECHNICS
Rectal, Intravenous, Regional Blocks

I n these technics, d ~ u g scan be administered w i t h comparative ease,

b u t cannot be recovered a t w i l l . The p a t i e n t destroys and excretes t h e metabo-

l i z e d drug a t varying and w o n t r o l l a b l e r a t e s of speed.

-
PRO C ON
c _

Reotal route
Slmple, portable Unpre d i c tab le ab sorpt i on
Painless Variation i n r e c t a l preparation
No fire hazard Sph inc t e r r e l a x a t i on
(except e t h e r ) Needs cooperative p a t i e n t
Rectal patholaigy
Long recovery period, requiring
constant nursing care

Intravenous
' Simpl.5, portable Narrow margin of s a f e t y
Minimal p a i n Overdose of drug easy
No f i r e hazard No c o n t r o l of r e s p i r a t i o n'

Quick induction Only l i g h t anesthesia obtainable

Quick recovery May need h e l p t o keep free airway
Inte'rmittent dosage (two people d e s i r a b l e )
q u i t e accurate
Good supplement
for b l o c k s
 24
Nerve B l o c k s
Excellent re laxation Special knowledge and training
No f i r e hazard Limited duration of' block
Portable Need cooperation (children
Minima 1metabolic d i ff i ou l t )
disturbance because POsSible damage t o nerve
of limited area
of anesthesia

Avertin overdose results i n marked c i r o u l a t o r y and r e s p i r a t o r y depres-

s i o n (more of depth t h a n r a t e ) . Treat w i t h pressor drugs (ephedrine, neosyne-
phrine) and oxygen.
Pentothal overdose results i n apnea w i t h variable degrees of c i r c u l a -

t o r y depression. Treat w i t h a r t i f i c i a l r e s p i r a t i o n w i t h oxygen. Analeptic drugs

(coramine, benzedrine, metrazol, picrotoxin) a r e advisable only when overdose is
known t o be large since smaller doses of pentothal my be metabolized quickly
and the p a t i e n t then may have an overdose of t h e analeptic.
Procaine "reaction" f r m overdose or intravenous i n j e c t i o n results i n
one of two syndromes:

1. Marked blood pressure drop, bradycardia, p a l l o r , nausea and vcnniting.

Treat w i t h pressor drugs (ephsdrine, neosynephrine ) and oxygen.

2. Increased C .N.S. s t i m u l a t i o n : apprehension, r e e t l e ~ ~ ~ n econvuleions

ss,
afid hypoventilation from spasm of r e s p i r a t o r y muscles. Treat with intravenous
b a r b i t u r a t e and oxygen ( a r t i f i c i a l r e s p i r a t i o n if necessary) . Prevent by proper
premedication.

PRO
cc -
CON

Simple technic, portable Numerous uncontrollable f a c t o r s

Non -explosive Drug cannot be recovered
Excellent re l a x a t ion C i r c ula t o r y depre asion f req uent
Minima 1me t a b o l i o changes Pos8ible nerve r o o t damage
Late recovery of a c t i v e i n t e r c o s t a l e
Shwk more eevere a f t e r hemorrhage
 25

LI

8
d

0
8
x

h
x
d
d

9m
 26

Factors concerned i n t h e DURATION and HE^^ of s p i n a l anesthesia

Controllable Urn ontrollab le

Space of i n j e c t i o n Diffusion
Speed of i n j e c t i o n C i r c u l a t i o n cf s p i n a l f l u i d
Volume of s o l u t i o n used Movemnt of f l u i d by r e s p i r a t i o n s
Dosage of drug and pulsations
Specific g r a v i t y 601. Length of spine
P o s i t ion of p a t i e n t Previous pathology or a n m a l i e s
Choice of drug Movement of p a t i e n t
Change CSF pressure by s t r a i n i n g
Breaking needles during
a dmini s t r at i on
DRUGS used:
Procaine..
Monocaine ..........short acting, b u t least toxic
.isomer of procaine
Metycaine..
Pontocaine.
Nupercaine
.......longer
I'
a c t i n g t h a n procaine
.long a c t i n g , 1OX more toxic than procaine
I' , 20x
11
II 11

Glucose or alcohol may bo added t o t b e ffrst f o u r d r u g s t o make t h e

s o l u t i o n hyper- o r hypobaric. Nupercaine i s s l i g h t l y hyperbaric i n t h e 1:200

solution, and may have glucose added; it i s hypobaric i n t h e 1:1500 solution.
Continuous or i n t e r m i t t e n t method of administration allows for much
more accurate dosage, and es8ures adequate anesthesia u n t i l end of operation.

Severe r e s p i r a t o r y depression frmn t o o high a l e v e l oan be avoided e n t i r e l y .

Circulatory depression, hawever, h a s not been avoided by t h e continuous method.

some of the Taotors i n t h e production of c i r c u l a t o r y depreseion by

s p i n a l anesthesia during surgery, are listwa below:

1. Relaxation of s k e l e t a l muscles, followed by poorer venous return.

2. Vasodilatation of blood v o s s e l s i n t h e anesthetized r e g i m e .
3. Stagnation o f blood i n tAe peripfieral vaecolar bed.
4. D b i n i s h e d thoracic excursion f r m p a r t l y paralyzed i n t e r c o s t a l
muscles c a u e i w dieturbance of preseure r e l a t i o n s and poor venoue
return t o h e a r t .
5. Eypaxia of myocardium.
6. ?Toxic'' e f f e c t of a n e s t h e t i c drug i t s e l f .
7. Accentuated vagotonic response t o t r a c t i o n , due t o autonomic imbalance
r e s u l t i n g f r m anesthetized splanchnic nerves.
a. Poor adjustment t o change i n position.
9. Poor canpensation t o changes i n blood volume (hemorrhage).
10 . Decreased adrenalin output. (Adrenals functionally denervated.)
 Treatment is b e s t prophylactic, by use of a vasopressor drug, which

may act a t one of t h r e e sites, t h e vaaanotor o a n t s r , t h e h e a r t muscle, or on t h e

blood veesels peripherally. The b e s t vasopressor drug i s ephedrine, because of
i t s sustained action, and minimal toxic e f f e c t s . Other drugs i n use f o r t h i s
purpose a r e neospephrine, benzedrine, cobefrin and paredrine .
After the drop i n pressure h a s occurred, treatment should be directed

toward providing ample oxygenation for the b r a i n and h e a r t muscle.

1. Head down p o s i t i o n ( i f hyperbaric drug h a s not been added t o subarach-
noid space recently)
2, Oxygen, bg i n s u f f l a t i o n or c l o s e d i n h a l a t i o n system
3. Restoration of normal v e n t i l a t i o n by manual methods
4. Additional doses of pressor drug
5. Fluid therapy: blood, plasma or s a l i p e , a s indicated

Retchin6 is a c m o n and troublesome complication of s p i n a l anesthesia.

It may be caused b y :

1. Intraabdcaninal t r a c t i o n
2. Hypoxia due t o :
.
a . Marked blood preasure fall
b Respiratory p a r a l y s i s
c. Overdose premedication
3. Reaction t o premedication (morphine)
4. Psychic
a. Inadvertent seeing of blood on drapes
b. Odor of "prep" e t h e r -
odor of cautery
C . Anxiety
5. Reaction t o s p i n a l d r u g (only w i t h very laree doses)

Treatment of retching .under s p i n a l anesthesia depends on t h e cauee.

For 1: E x e r t t r a c t i o n as slowly and gently a s p o s 6 i b b . Depress reflex
i r r i t a b i l i t y with morphine or l i g h t general aneethesia.
For 2: Sapply oxygen: a r t i f i c i a l r e s p i r a t i o n w i t h mask and bag if t i d a l
volume i s t o o small or p a r a l y s i s c m p l e t e .

For 3 : Scopolamine or atropine may help. (1part:25 p a r t s morphine) add

t r e a t a s f o r $+.

For 4: Any treatment t h a t d i s t r a c t s p a t i e n t w i l l help: deep breathing,

ice water c m p r e s s t o forebead, aromatic a p i r i t a of ammonia,
etc

For 5 : A s f o r procaine overdose.

 28
POSTOPERATIVE PULMONARY COMPLICATIONS

Pulmonary complications folluwing anesthesia and surgeryf o m t h e most

frequent and most s e r i o u s type of morbidity and mortality, Many f a c t o r s c m t r i b -

ute t o t h e i r incidence, b u t most revolve around t h e i n e f f e c t u a l removal of 88-

c r e t i o n s from t h e tracheobronchial t r e e . Under normal conditions, s e c r e t i o n s are

constantly produced i n t h i s t r a c t , a r e i n p a r t dried by the a i r c u r r e n t s , and i n
p a r t removed by the a c t i o n of t h e c i l i a t e d epithelium, a s w e l l as by t h e peri-

s t a l t i c a c t i o n of the bronchial musculature. Both these a c t i o n s a r e i n h i b i t e d by

anesthetic agents, and by therapeutic doees of morphine. The defense of the pa-
tient against accumulated s e c r e t i o n s i s further weakened by t h e presence of a n
ineffective cou&. The f o l l m i n g circumstances contribute t o i t s ineffectiveness.
1. I n a b i l i t y t o i n s p i r e deeply
S p l i n t i n g of abdominal musoles i n h l b i t i n g motion of diaphragm
Pam.1ysi.s or p a r e s i s of i n t e r o o s t a l s following spinal anesthesia
Fluid or a i r below diaphragm, o r i n chest
T i g h t binders
Prone, or l a t e r a l p o s i t i o n
IFhrenicect q r
Bronch ospaLm
2. Inadequate cough r e f l e x
Too much postoperative medication (morphine)
Irresponsive c e n t r a l nervous system
Weak, exhausted p a t i e n t , s e n i l i t y
3. I n a b i l i t y t o t i g h t e n abdominal lnuscles
Post- s p i n a l p a r e s i s
Ventral herniae, d i a s t a s i s f
Avitaminosis
4. I n a b i l i t y t o produce p o s i t i v e pressure i n chest
Eefect i n chest w a l l (thoracuplasty)
Open g l o t t i s (endotracheal tube) ; t r a c h e o t m y
The p t i e n t ; most l i k e l y t o develop postoperative pulmonary c m p l i c a -

tims a r e those w i t h :
1. Previous h i s t o r y of pulmonar=. camplication, e s p e c i a l l y postoperative
pne monia
2. Chronic r e s p i r a t o r y i n f e c t i o n , w i t h sputum: chronic b r o n c h i t i s and
3
4,
. emph yseme
Upper abdominal operations
Neurological operations
5. Long period of irmnob$lity i n imnediate postoperative period: p l a s t e r
m a t , or poor nursing car0
 6. Alcabolic h i s t o r y
7. Operations of over three hours' duration
8. Presence of shock dur3.ng operation o r i n postoperative period
The two types of pathology which dovelop are:
1. A t e l e c t a s i s : patchy or confined t o one lobe, or one lung. The o r i g i n
of t h e a t e l e c t a s i s i s most frequently obstruction by mucous plugs lodged i n t h e
major b r o n c h i , o r i n smaller d i v i s i o n s of the bronchi. The obstruction m y a b 0

be caused by reflex bronchospaam. The gases i n the lung d i s t a l t o t h e obstruc-

t i o n are absorbed i n t o t h e blood stream, %he a l v e o l i becme a i r l e s s , and t h e

s o l i d area of lung t h u s produced i s a perfect f i e l d for the development of in,
f e c t i o n s , or
2. Bronchopneumonia: the causative organisms of t h i s complication may be
thoae present i n t h e lower t r a c t before operation, or ones a s p i r a t e d during an-
esthesia. Aapiratian of vcanitus almost as6ures development of pnemonia, not so

much because of t h e b a c t e r i a present i n t h i s instance, but because t h e chemical

i r r i t a t i o n fram t h e hydrochloric a c i d predisposes t o infection.
Prophylactic treatment before operation c o n s i s t s of

1. Preventing s e c r e t i o n s by use of belladonna group.

2. Minimal use of belladonna group i f s e c r e t i o n s already present.
3. P o s t u r a l drainage t o remove sputum; occasionally bronchoecopy.
4.
5.
/
3.
Afternoon operations f a r thoracic surgery.

Good o r e 1 hygiene,
.
Choice of n o n - i r r i t a t i n g anesthotfc agent

7. Ernpty stomach before operation.

Prophylactic treatment a t end of operation c o n s i s t s of

1. ?rei%2nce of cough reflex before p a t i e n t k3aVeS operating row-.

2. Removal of s e c r e t i o n s by a s p i r a t i o n , and stimulation of cough reflex.
3. M h b w 1 postoperative medication f o r pain r e l i e f .
4.

5-
.
Byperventilation, by voluntary deep breathing, or b y c a r b m dioxide
i n h a l a t i o n s ( ~ O O $a i r ) if patient uncooperative
Frequent change i n positiolr.
6. Head dwn p o s i t i o n until p a t i e n t conscious.
7. ~ t e r c o a t a l .block i n upper abdcminal cases.
8. Use of non-diffusible gas a t end of anesthesia ( a i r or helium).
 Treatment if a t e l e c t a s i s oocurs:
1. Change i n position, w i t h affected lung uppermost.
2. Hyperventilation i n s e v e r a l positions.
3. Assistance w i t h e x p i r a t i o n by judioious pounding on chest.
4.
5.
6.
Bronchoscopy, i f above a r e inadequate
Pen; cil l i n therapy
.
Aspiration of trachea w i t h c a t h e t e r , and 8 t U u l a t i o n of cough r e f l e x .
.

The incidence of explosions w i t h ethylene, cyclopropane and ether i s

r o u @ l y between l:lOO,OOO and 1:500,000 cases. S t a t i s t i c a l l y t h i s i s one of
the most unimportant anesthesia c m p l i c a t i o n s , b u t it should be zero.
The cantroversy between s a f e t y of a c m p l e t e l y grounded operating
room VB. room completely i s o l a t e d fram ground s t i l l continues. Other questions
under investigation involve the use of conductive rubber, the use of inert
gases w i t h explosive gases t o make them non-explosive, and t h e t r u e nature of
s t a t i o e l e c t r i c i t y . A i r conditioning, by r a i s i n g the humidity i n the operating

room, permits p a r t i e l d i s t r i b u t i o n of s t a t i o cbargea s o t h a t sparks a r e less

a p t t o pas8 between p o i n t s of d i f f e r e n t p o t e n t i a l s . If the atmosphere h a s been
mebed f r e e of C02 by the a i r conditioning, however, even very humid a i r w i l l

not prevent sparks .

All t h e i n h a l a t i o n agents except n i t r o u s oxide and chloroform are
exploaive i n the ranges i n which we use them. A few common sense p r i n c i p l e s ap-
ply t o t h e i r w e :
1. If’ the use of e l e c t r i c a l equipment i s imperative f a r t h e surgery,
ohoose a non-explosive agent : n i t r o u s oxide, w i t h ample premedication; in$ra-
venous b a r b i t u r a t e , spinal, nerve block or l o c a l i n f i l t r a t i o n , or coanbinations

of‘ these technics.

2. If explosive agents a r e being used, avoid using e l e c t r i c a l equipment;

i.e ., carbolic knife for severing appendix instead of cautery.

 31
3. The danger zone w i t h these d r u g s , , i s a t ana near t h e face mask. It i s
t h e m i x t u r e leaking a t t h e face mask which i s hazardous, not blood or tissues

c o n t a l n i a t h e agent. If e l e c t r i c a l equipment must be used a t a distance frcnn

t h e face’, p a r t l a 1 protection may be afforded by h e p i n g f i t of t h e mask a s

t i g h t a s possible, or enclosing t h e area i n a wet towel.

4. It i s believed widely t h a t dapger is minimized if t h e p a t i e n t , machine

and a h e s t h e t i s t a r e kept a t t h e same e l e c t r i c a l p o t e n t i a l by using an inter-

coupler between these three - T h i s p r o t e a t s only against s t a t i c e l e c t r i c i t y , and

i s e n t i r e l y useless for sparks from a cautery, coagulating machine, o r X-ray

apparatus, and similar e l e c t r i c a l equipment.

5. Members of t h e operating rom s t a f f , v i s i t o r s and bystanders should

avoid brushing past t h e anesthesia machine o r bumping it w i t h metal obJects,

such a s s p o t l i g h t s , and portable t a b l e s .
5. Elncwn sources of s t a t i c s l e c t r i c i t y , such a s wool blankets and wool,
@ i l k o r rayon outer garments should be prohibited frm t h e operating roan.

RESUSCITATION

A €ew general p r l n c i p l e s apply t o any type of Pesusoltation done f o r

any H a s o n by any of a number of techpics.

I, There m u s t be a FIE3 A W 4 Y . A r t i f i c i a l r e s p i r a t i o n i s f u t i l e unless

t h e airway is patent.

Explore mouth w i t h finger, remove f o r e i g n bodies.

Remove f l u i d s by gravity: head dawn position.

Elevate chin, t u r n I n l a t e r a l or prone p o s i t i m t o keep tongue f r m
obstructing airway.
Introduce pharyngeal o r endotracheal airway i f available .
Po tracheotomy, ifabove not a v a i h b b .
 32
2. The p a t i e n t m u s t be ventilated. There i s no way t o s t o r e oxygen. It

m u s t be supplied bmedfately. Prone prensure method, o r mouth t o mouth respira-

t i o n a r e always available,
3. The p a t i e n t is i n shock. Warmth and head dawn position should be sup-
plied.
4. S t i m u l a t i n g drugs a r e of NO USE unless t h e p a t i e n t i s w e l l oxygenated.