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Anesthesia
When the effect of ether was discovered”anesthesia” used as a name for the new phenomenon.
History of Anesthesia
History of Anesthesia
History of Anesthesia
Anesthesiologists care for the surgical patient in the preoperative, intraoperative, and postoperative
period . Important patient care decisions reflect the preoperative evaluation, creating the anesthesia
plan, preparing the operating room, and managing the intraoperative anesthetic.
Preoperative Evaluation
The goals of preoperative evaluation include assessing the risk of coexisting diseases, modifying risks,
addressing patients' concerns, and discussing options for anesthesia care.
The indication for surgery may have particular anesthetic implications. For example, a patient requiring
esophageal fundoplication will likely have severe gastroesophageal reflux disease, which may require
modification of the anesthesia plan (e.g., preoperative non particulate antacid, intraoperative rapid
sequence induction of anesthesia).
Surgical procedures have different inherent risks. For example, a patient undergoing coronary artery
bypass graft has a significant risk of problems such as death, stroke, or myocardial infarction.
A patient undergoing cataract extraction has a low risk of major organ damage.
Does the patient have coexisting medical problems? Does the surgery or anesthesia care plan need to be
modified because of them?
Complication such as difficult airway management? Does the patient have risk factor for difficult airway
management?
in detail, as well as anticipated problems .Many variations on a given plan may be acceptable, but the
trainee and the supervising anesthesiologist should agree in advance on the details.
After determining the anesthesia plan, the trainee must prepare the operating room .
Anesthesia Providers
Certified registered nurse anesthetist (CRNA), working under the direction and supervision of an
anesthesiologist or a physician
CRNA must have 2 years of training in anesthesia
Patient Safety
Patient risk and safety are concerns during surgery and anesthesia .
Data from a number of studies of death caused by anesthesia indicate a death rate ranging from
1 per 20,000-35,000.
A fourfoulded decline over the last 30 years even though surgical procedures are undertaken on
increasingly sicker and much higher risk patients than in the past.
Awareness of potential problems and constant vigilance (the process of paying close and
continuous attention) are crucial to good patient care.
Anaesthesiologist:
evaluate the laboratory data and diagnostic studies such as electrocardiogram and chest
x-ray,
discuss the options for anesthesia and the attendant risks and
Developed by the American Society of Anesthesiologist (ASA) to provide uniform guidelines for
anesthesiologists.
Intraoperative difficulties occur more frequently with patients who have a poor physical status
classification.
Choice of anesthesia
The patient´s understanding and wishes regarding the type of anesthesia that could be used
Put to sleep
Infiltration of the surgical site with a local anesthesia is performed by the surgeon
The anasthesiologist may supplement the local anesthesia with intravenous drugs that provide
systemic analgesia and sedation and depress the response of the patient´s autonomic nervous
system
Employed for minor procedures in which the surgical site is infiltrated with a local anesthetic
such as lidocaine or bupivacaine
Given 60-90 minutes before surgery, or may be given i.v. After the pat. arrives in the surgical
suite
Not given to elderly people or ambulatory patients because residual effects of the drugs are
present long after the pat. have been discharged and gone home
Perioperative monitoring
Inspired oxygen analyzer(FiO2) which calibrated to room air and 100% oxygen on a daily basis
Low pressure disconnect alarm, which senses pressure in the expiratory limb of the patient
circuit
Inspiratory pressure
Respirometer (these four devices are an integral part of most modern anesthesia machine
ECG
BP-automated unit
Heart rate
Temp
Perioperative monitoring
Pulse oximeters
For selected patint with a potential risk of venous air embolism a doppler probe may placed
over the right atrium
Pulmonary artery catheter and continous mixed venous oxygen saturation measured
Perioperative monitoring
Electroencephalogram
Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to
produce anesthesia
Regional Anesthesia
Spinal anesthesia
Epidural anesthesia
IV Regional Blocks
Spinal Anesthesia
Hypotension
Post-dural puncture headache (“Spinal headache”) caused by leakage of spinal fluid through the
puncture hole in the dura-can be treated by blood patch
“High Spinal”- can cause temporary paralysis of respiratory muscles. Patient will need ventilator
support until block wears off
Epidural Anesthesia
Local anesthetic agent is injected through an intervertebral space into the epidural space.
Hypotension
IV Regional Blocks
IV Regional Block
After a pneumatic tourniquet is applied to extremity, Lidocaine is injected through the IV.
Anesthesia lasts until the tourniquet is deflated at the end of the case.
IV Regional Blocks
Can be used for anesthesia during surgery or for post-op pain relief
Examples: ankle block for foot surgery, supraclavicular block for post-op pain control after
shoulder surgery
Can be used for anesthesia during surgery or for post-op pain relief
Examples: ankle block for foot surgery, supraclavicular block for post-op pain control after
shoulder surgery
Generally used for short, minor procedures done under local anesthesia
Anesthesia provider monitors the patient and may provide supplemental IV sedation if indicated
Conscious Sedation
Patient is monitored by a nurse and receives sedation sufficient to cause a depressed level of
consciousness, but not enough to interfere with patient’s ability to maintain their airway
Inhalation Anesthetics
Nitrous Oxide- can cause expansion of other gases- use of N 20 contraindicated in patients who
have had medical gas instilled in their eye(s) during retinal detachment repair surgery
Inhalation Anesthetics
Post-op N&V
All inhalation anesthetics, except N20, can trigger malignant hyperthermia in susceptible patients
General Anesthesia
The circulator should be available to assist anesthesia provider during induction & emergence
Never move/reposition an intubated patient without coordinating the move with anesthesia
first
General Anesthesia
Anesthesia maintains a “Difficult Airway Cart” containing equipment & supplies for difficult
intubations
Used for patients at risk for aspiration during induction, due to a full stomach or other factors
such as a history of reflux
Pressure on the cricoid cartilage compresses the esophagus against the cervical vertebrae and
prevents reflux
Sellick Maneuver
Cricoid pressure is maintained, as directed by anesthesia provider, until the ETT cuff is inflated:
Regional Anesthesia
Circulator may need to assist anesthesia provider with positioning for spinal or epidural
anesthesia.
Patient usually is positioned laterally for placement of regional anesthesia, but may be
positioned sitting upright.
Patients undergoing surgery with regional or local anesthesia, even if sedated, may be aware of
conversation and activity in room
Post sign on door to OR, “Patient is Awake” so that staff entering room will be aware that
patient is conscious
Avoid discussion of other patients & limit unnecessary conversation-- a sedated patient can
easily misinterpret conversation they overhear