LECTURER: KHALID ALJIDIAWI

GENERAL SURGERY 4TH STAGE

Anesthesia & Pain Control

I. Introduction and Historical
Anesthesia is a cornerstone of modern surgery that allows for the performance of
complex procedures without pain. Its evolution is marked by key historical milestones:

• 1844–1846: Early demonstrations by pioneers such as Horace Wells (using

nitrous oxide for dental extractions) and William Morton (using ether at
Massachusetts General Hospital) paved the way for modern techniques. These
early innovations showed that a patient could be rendered pain-free,
revolutionizing surgical care.
• Modern Practice: Today’s anesthesia incorporates various drugs and
techniques to ensure patient safety, comfort, and rapid recovery. A
collaborative approach between anesthesiologists and surgical teams is crucial
to optimize patient outcomes.

II. General Anesthesia: Fundamentals and

Components
General anesthesia is a medically induced, reversible state characterized by three
essential components:

1. Unconsciousness: The patient is unaware and does not experience pain during
the procedure.
2. Analgesia: Effective control of pain signals, ensuring that the patient does not
feel pain.
3. Muscle Relaxation: Reduction of muscle tone to facilitate surgical access and
prevent involuntary movements.

A. Induction of Anesthesia

Induction is the process of initiating general anesthesia. It is typically achieved through

intravenous (IV) medications. Here are some commonly used agents:

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 • Propofol:
o Usage: Most widely used due to its rapid onset and quick recovery
profile.
o Benefits: Smooth induction, antiemetic effects.
o Limitations: Can lead to hypotension in some patients.
• Thiopentone:
o Historical Use: Once the standard induction agent, now less common.
o Limitations: Longer recovery time and more side effects compared to
newer agents.
• Etomidate and Ketamine:
o Special Situations: Used when cardiovascular stability is a concern
(etomidate) or in shock (ketamine).
o Unique Features: Ketamine preserves airway reflexes but may cause
hallucinations.
• Inhalational Agents (e.g., Sevoflurane):
o Usage: Particularly useful for children, patients with needle phobia, or
when a difficult airway is anticipated.
o Benefits: Non-invasive, rapid induction.

Table 1. Comparison of Common Induction Agents

Agent Route Key Benefits Potential Limitations

Rapid onset; quick recovery; May cause hypotension;
Propofol IV
antiemetic injection discomfort
Familiarity from historical Longer recovery; increased
Thiopentone IV
use side effects
Minimal cardiovascular Risk of myoclonus; possible
Etomidate IV
effects adrenal suppression
Preserves airway reflexes; Can cause hallucinations;
Ketamine IV
beneficial in shock increases heart rate
Ideal for children; non- Higher cost; environmental
Sevoflurane Inhalational
invasive induction concerns

B. Total Intravenous Anesthesia (TIVA)

TIVA involves using IV agents exclusively for both induction and maintenance of
anesthesia. Advantages include:

• Stable Hemodynamics: Fewer fluctuations in blood pressure.

• Quick Recovery: Absence of residual inhalational agent effects.
• Environmental Benefits: No concerns about the environmental impact of
inhalational gases.

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III. Airway Management
During general anesthesia, the loss of muscle tone can lead to airway obstruction.
Proper airway management is therefore essential.

A. Devices for Maintaining the Airway

1. Laryngeal Mask Airway (LMA):

o Description: A soft mask with an inflatable cuff inserted into the
mouth, which creates a seal around the laryngeal inlet.
o Advantages: Less invasive and traumatic; simpler to insert; can be
easily used in emergency settings by non-anesthesiologists.
2. Endotracheal Tube (ETT):
o Description: A tube inserted into the trachea, often with an inflatable
cuff, ensuring a secure airway.
o Usage: Preferred for long surgeries and situations where controlled
ventilation is required.

Diagram 1. Airway Management Decision Flowchart

[Induction of General Anesthesia]

│
Loss of Protective Airway Reflexes
│
Airway Management Needed
│
┌────────────────┴─────────────────┐
│ │
[Laryngeal Mask Airway (LMA)] [Endotracheal Tube (ETT)]
│ │
Suitable for short Allows positive pressure
or emergency procedures ventilation and lung protection

B. Difficult Intubation and Complications

Difficult Intubation:

• Challenges: In some patients, anatomy or pathology makes intubation

challenging.
• Solution: Use of a fiberoptic bronchoscope allows for visualization of the
airway and guided tube placement under local or general anesthesia.

Table 2. Common Complications During Intubation

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 Complication Description
Failed Intubation Inability to insert the tube into the trachea
Accidental Bronchial Tube enters one bronchus instead of the trachea, causing
Intubation uneven ventilation
Injury to teeth, soft tissues (pharynx, larynx) during tube
Trauma
placement
Aspiration Inhalation of stomach contents into the lungs
Disconnection, blockage, or kinking of the endotracheal
Equipment Issues
tube
Scar formation leading to narrowing of the trachea over
Delayed Tracheal Stenosis
time

IV. Ventilation Strategies During Anesthesia

Mechanical ventilation is necessary when patients cannot breathe adequately on their
own during surgery. Two common modes include:

A. Volume-Controlled Ventilation (VCV)

• Mechanism: The ventilator delivers a fixed volume of air with each breath,
regardless of changes in airway pressure.
• Considerations:
o High airway resistance (as seen in obesity or lung disease) can lead to
excessive pressure, potentially causing barotrauma.
o Ideal in patients with stable lung mechanics.

B. Pressure-Controlled Ventilation (PCV)

• Mechanism: The ventilator limits the airway pressure, delivering air until a
preset pressure is reached. The volume delivered may vary based on lung
compliance.
• Advantages:
o Reduces the risk of high-pressure-induced lung injury.
o Particularly useful in patients with variable lung conditions.

Table 3. Comparison: Volume vs. Pressure-Controlled Ventilation

Volume-Controlled
Aspect Pressure-Controlled Ventilation
Ventilation
Control Variable Tidal Volume Airway Pressure

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 Volume-Controlled
Aspect Pressure-Controlled Ventilation
Ventilation
Tidal Volume Fixed regardless of airway Variable; depends on lung compliance
Delivery pressure and resistance
High pressures may lead to Unpredictable volume in case of
Risk
barotrauma severe resistance
Patients with stable lung Situations where protecting the lungs
Clinical Use
conditions is critical

Note: The use of Positive End-Expiratory Pressure (PEEP) in both modes helps
maintain alveolar openness, ensuring efficient gas exchange and reducing the risk of
alveolar collapse.

V. Intraoperative Monitoring and Patient Care

During anesthesia, continuous monitoring is vital to ensure the patient’s safety. The
following parameters are routinely monitored:

A. Cardiovascular Monitoring

• Electrocardiogram (ECG): Monitors heart rhythm and detects arrhythmias.

• Blood Pressure: Regular measurements ensure hemodynamic stability.

B. Respiratory Monitoring

• Pulse Oximetry: Measures oxygen saturation to ensure adequate oxygenation.

• Capnography: Monitors end-tidal CO₂ levels, providing information on
ventilation status.
• Inspired Oxygen Concentration: Ensures the correct mixture of gases is being
delivered.

C. Additional Monitoring

• Temperature: Body temperature is closely monitored during lengthy

procedures.
• Ventilation Parameters: Tidal volume and airway pressures are observed to
adjust ventilatory support.
• Anesthetic Delivery: Monitors ensure that the correct concentration of
anesthetic agents is maintained.

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 • Urine Output & Central Venous Pressure (CVP): Used in major surgeries to
monitor fluid balance and circulatory status.

VI. Pain Management: Concepts and Techniques

Effective pain control is essential, not only during surgery but also in the management
of chronic conditions. It involves the assessment, treatment, and ongoing evaluation of
pain.

A. Types of Pain

1. Nociceptive Pain:
o Definition: Pain arising from tissue injury or inflammation.
o Examples: Musculoskeletal injuries, surgical incisions, cancer-related
pain.
o Treatment: Typically managed with NSAIDs, paracetamol, and, when
necessary, opioids.
2. Neuropathic Pain:
o Definition: Pain caused by nerve injury or dysfunction.
o Characteristics: Often described as burning, shooting, or stabbing,
sometimes accompanied by numbness.
o Treatment: Often less responsive to opioids; managed with tricyclic
antidepressants and anticonvulsants (e.g., gabapentin, pregabalin).
3. Psychogenic Pain:
o Definition: Pain that is influenced by psychological factors such as
depression or anxiety.
o Management: A combination of pharmacotherapy (antidepressants)
and psychotherapy is usually effective.

Table 4. Overview of Pain Types and Management

Pain Type Characteristics Typical Treatment Options

Localized, often sharp pain;
NSAIDs, paracetamol, mild to
Nociceptive results from tissue damage or
strong opioids
inflammation
Tricyclic antidepressants,
Burning, shooting pain; may
Neuropathic anticonvulsants (gabapentin,
include numbness
pregabalin)
Associated with mood disorders;
Psychogenic may not have a clear physical Antidepressants, psychotherapy
cause

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B. Pain Control in Malignant Disease

Cancer-related pain can be particularly challenging due to its severity and complexity.
The World Health Organization (WHO) recommends a stepwise approach known as
the "pain ladder" to tailor treatment to the patient’s pain intensity.

Diagram 2. WHO Pain Ladder

[Step 1]
Non-opioid analgesics (Aspirin, Paracetamol, NSAIDs)
│
[Step 2]
Weak opioids (Codeine, Tramadol)
│
[Step 3]
Strong opioids (Morphine, Oxycodone)

• Step 1: Start with simple analgesics; if pain is mild to moderate, these may
suffice.
• Step 2: If pain persists or increases in severity, introduce weak opioids.
• Step 3: For severe pain, strong opioids are used to provide adequate relief.
Note: This ladder helps clinicians adjust medications gradually, balancing pain
control with the risk of side effects.

C. Multimodal Pain Management

Often, combining different types of medications (a multimodal approach) can lead to

better pain control while reducing the side effects associated with high doses of a single
agent. Techniques such as local anesthetic injections, nerve blocks, and non-
pharmacological methods (e.g., acupuncture, transcutaneous electrical nerve
stimulation) are also valuable components of a comprehensive pain management plan.

VII. Summary and Key Takeaways

• Anesthesia Evolution: The development of anesthesia has allowed surgery to
become safer and less painful, with a strong history of innovation leading to
current practices.
• General Anesthesia Components: Unconsciousness, analgesia, and muscle
relaxation are essential, with various drugs available for induction and
maintenance.
• Airway Management: Critical for patient safety, using devices like the LMA
and ETT, with protocols for difficult intubation.

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• Ventilation Strategies: Choosing between volume-controlled and pressure-
controlled modes depends on patient lung mechanics and surgical factors.
• Monitoring: Continuous intraoperative monitoring of cardiovascular,
respiratory, and other parameters is vital to respond promptly to any changes.
• Pain Management: Effective pain control involves understanding the type of
pain, using a stepwise approach for malignant pain, and considering multimodal
strategies.