Anesthesia

➢ From Greek anaisthesis means ”not sensation”

➢ Listed in Bailey´s English Dictionary 1721.
➢ When the effect of ether was discovered”anesthesia”
used as a name for the new phenomenon.
 Basic Principles of Anesthesia

➢ Anesthesia defined as the abolition of sensation

➢ Analgesia defined as the abolition of pain
➢ “Triad of General Anesthesia”
➢ need for unconsciousness
➢ need for analgesia
➢ need for muscle relaxation
 History of Anesthesia

➢ Ether synthesized in 1540 by Cordus

➢ Ether used as anesthetic in 1842 by Dr.
Crawford W. Long
➢ Ether publicized as anesthetic in 1846 by
Dr. William Morton
➢ Chloroform used as anesthetic in 1853 by
Dr. John Snow
 History of Anesthesia

➢ Endotracheal tube discovered in 1878

➢ Local anesthesia with cocaine in 1885
➢ Thiopental first used in 1934
➢ Curare first used in 1942 - opened the “Age
of Anesthesia”
 Anesthesia Overview
Modern surgery is possible because of the development of
safe and effective anesthesia. Without the ability to
eliminate pain, most surgical procedures could not be
performed.
Anesthesia is administered by an anesthesiologist, a doctor
who undergoes several years of specialized training after
the completion of medical school. Anesthesia is sometimes
administered by a certified registered nurse anesthetist
(CRNA). A CRNA is a registered nurse who has
undergone advanced training in anesthesia. Certified
registered nurse anesthetists are able to administer
anesthesia during a surgical procedure, but usually work
under the supervision of an anesthesiologist.
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.
What is the indication for the proposed surgery? It is elective
or an emergency?
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).
What are the inherent risk of this surgery?
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?
Has the patient had anesthesia before? Were there
Complication such as difficult airway management?
Does the patient have risk factor for difficult
airway management?
 Creating the Anesthesia Plan

After the preoperative evaluation, the anesthesia plan can

be completed. The plan should list drug choices and doses
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.
 Preparing the Operating Room

After determining the anesthesia plan, the

trainee must prepare the operating room .
 Anesthesia Providers
➢ Anesthesiologist ( a physician with 4 or more years
of speciality training in anesthesiology after medical
school)
➢ 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.
 Preoperative preparation patient
evaluation

➢ Anaesthesiologist:
➢ reviews the patient´s chart,
➢ evaluate the laboratory data and diagnostic studies such
as electrocardiogram and chest x-ray,
➢ verify the surgical procedure,
➢ examins the patient,
➢ discuss the options for anesthesia and the attendant risks
and
➢ ordered premedication if appropriate
 The physical status classification

➢ Developed by the American Society of Anesthesiologist (ASA) to

provide uniform guidelines for anesthesiologists.
➢ It is an evaluation of anesthetic morbidity and mortality related to the
extent of systemic diseases, physiological dysfunction, and anatomic
abnormalities.
➢ 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
➢ The type and duration of the surgical procedure
➢ The patients´s physiologic status and stability
➢ The presence and severity of coexisting disease
➢ The patient´s mental and psychologic status
➢ The postoperative recovery from various kinds of anesthesia
➢ Options for management of postoperative pain
➢ Any particular requiremets of the surgeon
➢ There is major and minor surgery but only major anesthesia
 Types of Anesthesia
There are three main types of
anesthesia: local, regional and general.
The type of anesthesia used for a surgical
procedure is determined by several factors:
➢ Type and length of the surgery
➢ Patient health
➢ Preference of the patient and physician
 Local Anesthesia

➢ Local anesthesia blocks the nerves in a small, specific area of the body. For
example, if a surgical procedure is performed on the right hand, a local
anesthetic is used to numb that hand without affecting any other part of the
body.
➢ This type of anesthesia is generally used for minor surgeries (e.g., breast
biopsies, vasectomies) and to stitch small wounds. It is usually administered
by injection, which can be painful. However, the discomfort only lasts for a
brief moment, and the anesthesia usually takes effect very quickly.
 Local Anesthesia

➢ Sometimes local anesthesia is applied topically, as a spray or a cream.

Cocaine is used medically as a sprayed anesthetic to numb the inside of the
nose and throat. For the removal of a growth on the surface of the skin, an
anesthetic cream can be applied to numb the area.
➢ In minimally invasive procedures that can be completed in a few minutes, an
injection of local anesthesia is all that is used. More involved operations
require sedation with the anesthesia to make the patient more comfortable and
the injection more tolerable. Sedatives relax the patient and induce
drowsiness, but they do not put patients into a deep sleep. They are usually
administered by injection or through an intravenous (IV), but can be given
orally or by rectal suppository, particularly in children.
 Regional Anesthesia
➢ Regional anesthesia numbs a large area, or region, of the body and is
used for more extensive and invasive surgery. Regional anesthesia is
often used for procedures involving the lower part of the body, such as
caesarian sections, prostate surgery, and operations on the legs. For
example, if regional anesthesia is used for prostate surgery, the patient
is numb from his navel to his toes. Some patients feel pressure or
tugging during surgery performed under regional anesthesia.
➢ The most common types of regional anesthesia are spinals and
epidurals. Spinal anesthesia is injected into the spinal fluid with a
special needle that penetrates the spinal column through the back.
There may be some discomfort involved with the injection, but it
passes as the anesthetic takes effect.
➢ Epidural anesthesia is injected into an area outside the spinal column
called the epidural space. Sometimes a small tube or catheter is
inserted into the epidural space, which allows the anesthesiologist to
administer more medication as needed. Epidurals are often used when
long-term pain relief is needed, such as during childbirth.
➢ Sedatives are commonly used with regional anesthesia and are
generally administered intravenously.
 General Anesthesia
➢ General anesthesia renders the patient
completely unconscious and with no
memory of the surgical procedure upon
awakening. Because it carries a higher risk
for complications than other types of
anesthesia, general anesthesia is used
primarily for procedures that cannot be
done utilizing other methods and for
patients who prefer to be asleep during
surgery.
➢ General anesthesia is given intravenously
or inhaled through a breathing mask, and
sometimes both methods are used. Sedation
may also be given before the patient is
taken into the operating room.
 General Anesthesia
➢ Once the anesthesia has taken effect, patients need
assistance breathing. Several devices are used. One is
a piece of curved, hollow plastic called an oral airway.
Another is a mask that fits over the nose and mouth.
The most sophisticated device, a long plastic tube
called an endotracheal tube, is placed in the patient's
mouth (less frequently the nose) and is gently
extended into the trachea, or windpipe. The trachea
connects the mouth with the lungs. The endotracheal
tube is used when the surgery is lengthy or involved,
and the patient receives a large amount of anesthesia.
The endotracheal tube is one of the safest and most
reliable means of assuring adequate breathing with
general anesthesia.
➢ Patients are closely monitored by the anesthesiologist
throughout the surgery. Heart rate, blood pressure, and
blood oxygen levels are continuously recorded. The
amount of anesthesia received is carefully controlled
and adjusted for the duration of the procedure.
➢ When the operation is complete, the anesthesiologist
reverses the anesthesia to allow the patient to wake
up.
Important complications of general
anaesthesia
➢ The practice of anaesthesia is fundamental to the practice of
medicine. However, anaesthesia is not without its problems. It
is difficult to determine exactly the incidence of deaths
directly attributable to general anaesthetics, as the cause of
death is often multifactorial and study methodology varies
making comparisons difficult. Estimates of the number of
deaths where general anaesthesia was the direct cause have
been quoted in the range from 1:10,000 operations to 1:1700
(study in 1982 by the Association of Anaesthetists of Great
Britain and Ireland). Nonetheless, in 1987 a confidential
enquiry into perioperative deaths revealed that very few
deaths were actually as a direct result of general anaesthesia -
incidence of 1 in 185,086 (first Confidential Enquiry into
Perioperative Deaths (CEPOD)).
Important complications of general
anaesthesia

➢ Figures of anaesthetic-related morbidity are more

difficult to determine. Estimates suggest that up to 2% of
intensive care unit admissions at any one time are related
to anaesthetic problems. Although general anaesthesia is
not without risk, it should be remembered that it allows
necessary procedures to be performed in a humane way -
without which the patient might otherwise die. Along
these lines, if a patient is high-risk for a general
anaesthetic (eg, pre-existing comorbidities) then they
should still be referred for surgery like any other patient.
The decision to operate and which form of anaesthesia to
use should then be decisions made by the surgeon and
anaesthetist.
 Important complications of general
anaesthesia
➢ Pain.
➢ Nausea and vomiting - up to 30% of patients.
➢ Damage to teeth - 1 in 4,500 cases.
➢ Sore throat and laryngeal damage.
➢ Anaphylaxis to anaesthetic agents - figures such as 0.2% have
been quoted.
➢ Cardiovascular collapse.
➢ Respiratory depression.
➢ Aspiration pneumonitis - up to 4.5% frequency has been
reported; higher in children.
➢ Hypothermia.
➢ Hypoxic brain damage.
 Important complications of general
anaesthesia
➢ Nerve injury - 0.4% in general anaesthesia and 0.1% in
regional anaesthesia.
➢ Awareness during anaesthesia - up to 0.2% of patients; higher
in obstetrics and cardiac patients.
➢ Embolism - air, thrombus, venous or arterial.
➢ Backache.
➢ Headache.
➢ Idiosyncratic reactions related to specific agents - eg,
malignant hyperpyrexia with suxamethonium,
succinylcholine-related apnoea.
➢ Iatrogenic - eg, pneumothorax related to central line insertion.
➢ Death.
Some specific complications of general anaesthesia

Anaphylaxis
➢ Anaphylaxis can occur to any anaesthetic
agent and in all types of anaesthesia.. The
severity of the reaction may vary but
features may include rash, urticaria,
bronchospasm, hypotension, angio-oedema,
and vomiting. It needs to be carefully
looked for in the pre-operative assessment
and previous general anaesthetic charts may
help.
➢ Patients who are suspected of an allergic
reaction should be referred for further
investigation to try to determine the exact
cause. If necessary, this may involve
provocation testing or skin prick testing and
patients should be referred to local
immunologists. Anaphylaxis needs to be
promptly recognised and managed and
patients should be advised to wear a
medical emergency identification bracelet
or similar once they recover.
 Some specific complications of general anaesthesia

Aspiration pneumonitis
A reduced level of consciousness can lead to an
unprotected airway. If the patient vomits they can
aspirate the vomitus contents into their lungs. This
can set up lung inflammation with infection. The
risk of aspiration pneumonitis and aspiration
pneumonia is reduced by fasting for several hours
prior to the procedure and cricoid cartilage pressure
during induction of anaesthesia. However, the
evidence for the use of cricoid pressure is not clearly
documented and further investigation is required.
Other methods of reducing aspiration pneumonitis associated with anaesthesia
are the use of metoclopramide to enhance gastric emptying
and ranitidine or proton pump inhibitors to increase the pH of gastric
contents. The evidence for the benefit of these methods appears promising.

Aspiration pneumonitis may also occur in spinal anaesthesia if the level of spinal
block is too high, leading to paralysis or impairment of the vocal cords and
respiratory impairment.
 Some specific complications of
general anaesthesia
Peripheral nerve damage
➢ This can occur with all the types of anaesthesia and results from
nerve compression. The most common cause is exaggerated
positioning for prolonged periods of time. Both the anaesthetist
and the surgeons should be aware of this potential complication
and patients should be moved on a regular basis if possible. The
severity varies and recovery may be prolonged. The most
common nerves affected are the ulnar nerve and the common
peroneal nerve. More rarely, the brachial plexus may be
affected.
➢ Injury to nerves can be avoided by prevention of extreme
postures for lengthy periods during surgery. If nerve damage
occurs then patients should be followed up and further
investigations such as electromyography may be required.
 Some specific complications of general anaesthesia

Damage to teeth
➢ It is now common practice to check the teeth in
the anaesthetist's pre-operative assessment.
Damage to teeth is actually the most common
cause of claims made against anaesthetists. The
tooth most commonly affected is the upper left
incisor.

Embolism
➢ Embolism is rare during an anaesthetic but is
potentially fatal. Air embolism occurs more
commonly during neurosurgical procedures or
pelvic operations. Prophylaxis of
thromboembolism is common and begins pre-
operatively with thromboembolic deterrents
(TEDS) and low molecular weight heparin
(LMWH).
 Important complications of
regional anaesthesia
Central regional anaesthesia was first used at the end of the 18th
century. It provided a method of blocking afferent and efferent
nerves by injecting anaesthetic agents in either the epidural space
around the spinal cord (epidural anaesthesia) or directly in the
cerebrospinal fluid surrounding the spinal cord (ie in the
subarachnoid space called spinal anaesthesia). All nerves are
blocked including motor nerves, sensory nerves and nerves of the
autonomic system. Epidural anaesthesia takes slightly longer than
spinal anaesthesia to take effect and provides predominantly
analgesic properties. With both, the need for muscle paralysis and
ventilation is not usually required but there is a risk that a high
block will impair respiration, meaning that ventilation will be
necessary. Results from a review of 114 studies and a Cochrane
systematic review have shown that regional anaesthesia is
associated with reduced mortality and reduction in serious
complications in comparison with general anaesthesia.
 Important complications of
regional anaesthesia
➢ Pain - 25% of patients still experience pain despite spinal anaesthesia.
➢ Post-dural headache from cerebrospinal fluid (CSF) leak.
➢ Hypotension and bradycardia through blockade of the sympathetic nervous system.
➢ Limb damage from sensory and motor block.
➢ Epidural or intrathecal bleed.
➢ Respiratory failure if block is 'too high'.
➢ Direct nerve damage.
➢ Hypothermia.
➢ Damage to the spinal cord - may be transient or permanent.
➢ Spinal infection.
➢ Aseptic meningitis.
➢ Haematoma of the spinal cord - enhanced by use of LMWH pre-operatively.
➢ Anaphylaxis.
➢ Urinary retention.
➢ Spinal cord infarction.
➢ Anaesthetic intoxication.
 Some specific complications of regional
anaesthesia
Post-dural puncture headache
➢ Post-dural puncture headache is very common after spinal anaesthesia and especially in
young adults and obstetrics. The headache results from CSF leak from the puncture site. It
is enhanced by use of larger-gauge needles and reduced by pencil-tipped needles.
Presenting symptoms may include headache, photophobia, vomiting and dizziness.
➢ Post-dural puncture headache is usually treated with analgesia, bed rest and adequate
hydration. The evidence does not suggest that bed rest prevents or changes the outcome.
Occasionally epidural blood patch is used where 15 ml of the patient's blood are injected at
the site of the meningeal tear. Caffeine is also used and acts as a stimulant of the CNS and
has shown benefit. Other medications with benefit include gabapentin, theophylline and
hydrocortisone. Subcutaneous sumatriptan, adrenocorticotrophic hormone (ACTH) and
epidural saline have not shown consistent benefits.
Total spinal block
➢ Total spinal block can occur with the injection of large amounts of anaesthetic agents into
the spinal cord. It is detected by a high sensory level and rapid muscle paralysis. The block
moves up the spinal cord so that respiratory embarrassment may occur, as can
unconsciousness. In these situations the patient needs prompt assessment and may need to
be intubated and ventilated until the spinal block wears off.
 Some specific complications of regional
anaesthesia
Hypotension
➢ Up to half of patients receiving spinal anaesthesia will develop transient
hypotension as sympathetic nerves are blocked. This usually responds to prompt
fluid replacement, usually starting with crystalloids followed by colloids.
Occasionally hypotension can be severe and may require vasopressors along with
fluids.
➢ Care must be taken in patients with a cardiac history, as they may develop
myocardial ischaemia with minor drops in blood pressure. It is suggested that heart
rate variability prior to spinal anaesthesia represents autonomic dysfunction and
may help determine patients who are more likely to develop hypotension.
➢ Cases of bradycardia with asystole leading to cardiac arrest have also occurred and
it appears the underlying aetiology is complicated and not just related to autonomic
dysfunction.
Neurological deficits
➢ Cauda equina syndrome may occur and can be transient or permanent. This is a
common reason for patients to refuse spinal anaesthesia. There may also be
traumatic injury to the spinal cord.[
➢ Adhesive arachnoiditis is a longer-term sequela of spinal anaesthesia, occurring
weeks and even months later. It is characterised by proliferation of the meninges and
vasoconstriction of spinal cord blood vessels. This results in gradual sensory and
motor deficits from ischaemia and infarction of the spinal cord.
 Important complications of
local anaesthesia
➢ Pain.
➢ Bleeding and haematoma formation.
➢ Nerve injury due to direct injury.
➢ Infection.
➢ Ischaemic necrosis.
➢ All forms of anaesthetics are invasive to a patient and therefore
consent should be obtained as for other procedures. Ideally
patients should be given a leaflet regarding anaesthesia and then
counselled regarding the intended benefits and the risks of
anaesthesia. In a general practice setting it will be the
responsibility of the clinician who administers the local
anaesthesia to ensure good, non-coercive consent is obtained.
A coma is a prolonged state of unconsciousness.
During a coma, a person is unresponsive to his or her
environment. The person is alive and looks like he or
she is sleeping. However, unlike in a deep sleep, the
person cannot be awakened by any stimulation,
including pain.