ANAESTHESIA

PREOPERATIVE ASSESSMENT

History

• 1. Chronic cough, smoking, alcohol, drug intake, drug allergy.

• 2. Any previous diseases like hypertension, diabetes mellitus, epilepsy,
bronchial asthma, tuberculosis, hepatitis, cardiac diseases.
• 3. Drug therapy: Steroids, antihypertensives, sedatives, anti biotics,
antiepileptics.
Examination

• General: Posture, teeth, mouth opening, dilated veins, neck

movements, tremor, airway. Anaemia, oedema, jaundice, cyanosis.
• Respiratory system: To look for asthma, tuberculosis, emphysema,
COPD.
• Airway: Mouth opening, Mallampati scoring, thyromental distance,
temporomandibular joint assessment.
• Thyromental distance: It is the distance between mentum and thyroid
cartilage, measured externally. If it is more than 6.5 cm (i.e. more than
4 fingers breadth) intubation is easier, if it is less than 6.5 cm
intubation is difficult.
• Cardiovascular system: Hypertension, ischaemic heart disease,
arrhythmias, cardiac failure, valvular diseases.
• Spine: Curvature, intervertebral space, skin over the area for any
infection.
• Other systems: Abdomen, skeletal system.
 Preoperative Investigations

• Haematocrit,
• blood sugar,
• blood urea,
• serum creatinine,
• electrolytes,
• chest-X ray,
• ECG,
• blood grouping,
• blood-gas analysis,
• cardiac assessment.
Preoperative Treatment

• Control of respiratory and cardiac diseases.

• Improvement of Hb% status, if anaemia is present.
• Preoperative antibiotics are given.
• Blood should be kept ready for major cases.
• Starvation for 4 hours for liquids and six hours for solids.
• Bladder and bowel should be emptied to prevent soiling on the
operation table.
• Urinary catheter may be passed and enema may be given.
• Dentures, contact lenses, jewellery must be removed.
• Surgical area should be cleaned and properly prepared.
GENERAL ANAESTHESIA

• It means abolition of all sensations, i.e. touch, pain, posture and

temperature with a state of reversible loss of consciousness.

• It has got three components:

• (1) Analgesia.
• (2) Hypnosis.
• (3) Muscle relaxation.
ANAESTHETIC AGENTS

Volatile anaesthetics:

• They vaporise in room air.

• Agents used are: Ether, trichloroethylene, halothane, enflurane,
isoflurane, sevoflurane.
• Ether which is irritant, unpleasant, flammable, is commonly used agent in
developing countries.
• Enflurane and isoflurane are non-inflammable, non explosive, non-irritant and
stable.
• Here anaesthesia is rapid with faster recovery.
Gaseous anaesthetics:

• Nitrous oxide: It is non-inflammable, non-irritant, good analgesic but

weak anaesthetic agent.
• It is given along with 30-50% oxygen for balanced anaesthesia (blue
coloured cylinder in India).
• Cyclopropane is highly flammable.
Intravenous anaesthetics:

• Thiopentone:
• It is ultrashort acting barbiturate which causes hypnosis during induction of
anaesthesia.
• It does not have analgesic effect.
• It causes hypotension, respiratory depression, laryngeal and bronchospasm.
• Recovery is rapid.
• It can cause anaphylaxis.
• Ketamine:
• It is a good analgesic.
• It causes dissociative anaesthesia.
• It can lead to hypertension, apnoea, laryngospasm.
• It does not require intubation for small procedures.
• Propofol:
• It is widely used induction agent which has got predictable onset and
recovery.
• It has got least side effects on CVS and respiratory system.
• It is also used for total IV anaesthesia.
OXYGEN

• Oxygen is given through Boyles apparatus (33.3%).

• Oxygen in high concentration is respiratory depressant and also affects
eyes.
• Oxygen is available in black and white coloured cylinder.
MUSCLE RELAXANTS
Depolarising Muscle Relaxants

• They act at the level of acetylcholine receptors which widens the

refractory period after depolarisation causing paralysis.
• It is short acting muscle relaxant.
• Suxamethonium chloride (scoline):
• It lasts for 2-4 minutes.
• It causes muscle twitching—fasciculations—paralysis.
• It is metabolised by plasma pseudocholinesterase.
• Atypical or deficiency of this enzyme prolongs the action of the scoline.
 Non-Depolarising Muscle Relaxants

• They block the channels of entry of acetylcholine.

• They are long acting relaxants.
• 1. Tubocurarine
• 2. Gallamine
• 3. Pancuronium bromide
• 4. Vecuronium bromide
• 5. Rocuronium
• 6. Atracurium
REVERSAL AGENTS
• They are anticholinesterase drugs which increase the acetyl choline
and thus act as antagonising agents for non-depolarising muscle
relaxants.
• They cause brady cardia.
• Neostigmine is used commonly along with atropine .
INSTRUMENTS IN ANAESTHESIA
 Boyle’s apparatus:

• It consists of:
• a. Cylinders for N2O and O2.
• b. Pressure gauge—to know the
amount of gas remaining.
• c. Pressure regulator—to regulate the
pressure of gas used.
• d. Rotameter—to know the flow of gas.
• e. Vaporiser
Endotracheal tube:

• These are tubes inserted into the

trachea and is used to conduct gases
and vapours to and from the lungs.
Depending on the diameter, it is
available in various sizes.
• It has a cuff at one end which, when
inflated stabilises the tube in position
and also prevents regurgitation.
• Non-cuffed tubes are also available.
• The other end near the mouth is
connected to the breathing circuit through
which anaesthetic gases are delivered.
• The tube is inserted using a direct
laryngoscope.
• The proper placement in the airway is
confirmed by auscultating for the breath
sounds over the chest when the gases are
delivered.
Magill’s forceps.
Mouth gag.
Magill’s forceps.
Laryngoscope.
Connectors.
 Laryngeal mask airway (LMA):

• Laryngeal mask consists of a wide bore

tube whose proximal end connects to
breathing circuit and distal end is attached
to an elliptical cuff which can be inflated.
• It is made up of silicone rubber.
• The deflated cuff is lubricated and inserted
into the hypopharynx, so that once inflated,
the cuff forms a low pressure seal around
the entrance into the larynx.
Premedication

• It is given one hour before surgery:

• For sedation and relief of anxiety.
• Pethidine 50 mg/ morphine 10 mg/diazepam 10 mg, midazolam 1-2.5
mg.
• To suppress vagal activity-Atropine 0.6 mg IM.
• To reduce vomiting-Promethazine (phenargan) 12.5 mg.
Induction:

• Patient is preoxygenated with 100% oxygen for 3 minutes then induced

with IV thiopentone, given 4-5 mg/kg.
• Patient loses consciousness.
• Induction is maintained by 67% nitrous oxide and 33% oxygen.
• Scoline is given IV to relax muscles so as to facilitate endotracheal
intubation.
• Once intubated, ventilation can be either controlled using muscle
relaxants or spontaneous using a volatile anaesthetic agent.
• Reversal is done using neostigmine and atropine or glycol-pyrrolate.
COMPLICATIONS OF GENERAL ANAESTHESIA
• Intra-arterial injection of the drug.
• Myocardial depression and cardiac arrest.
• Hypertension.
• Laryngeal and bronchial spasm.
• Cardiac arrhythmias.
• Respiratory failure.
• ARDS.
Mendelson’s syndrome:

• It is due to regurgitation of the acid from the stomach causing

aspiration of acid leading into bronchospasm, pulmonary oedema and
circulatory failure.
• This is treated with oxygen, suction, hydrocortisone, aminophylline,
antibiotics,
• Ryle’s tube aspiration and ventilator support.
• Hypoxia.
• Pneumothorax.
• Anaphylaxis.
• Hypothermia.
 Malignant hyperthermia:

• It is an inherited myopathic disorder occurs under anaesthesia due to drugs like halo
thane, scoline.
• There is marked increase in metabolic rate, with rise of temperature.
• There is high levels of CPK enzyme.
MONITORING THE POSTOPERATIVE PATIENT
• Pulse, temperature, BP chart.
• Breathing type.
• Level of consciousness.
• Urine output.
• Oxygen saturation and heart rate using pulse oximeter.
• Checking and encouraging limb movements.
• Skin colour, tongue colour for adequacy of oxygenation.
• Tongue for hydration.
• Cardiac monitor.
• Blood gas analysis in case of patient on ventilator.
• Serum electrolytes assessment.
REGIONAL ANAESTHESIA
• Carl Koller, an ophthalmologist introduced cocaine as local anaesthetic in ophthalmic
practice.
• Mode of action: It causes temporary conduction block of the nerve, thus preventing
the propagation of nerve impulse.
• Advantages of local anaesthetic agent:
 Technically simpler.
 General anaesthesia is avoided.
 Consciousness is retained.
 Patient can have food earlier after surgery.
• Drugs used:
• Cocaine, procaine, cinchocaine—amino esters.
• Lignocaine, prilocaine, bupivacaine, ropivacaine—amino amides
 NERVE BLOCK

• Block of inferior dental nerve and lingual nerves in the region of the mental
foramen for extraction of teeth.
• Finger block of digital nerves.
• Here plain xylocaine is used (without adrenaline).
• Intercostal block.
• Ankle block.
• Median and ulnar nerve block.
• Brachial plexus block (Winnie’s block).
• It can be given through: Interscalene, Axillary, Supraclavicular approaches.
• Supraclavicular approach is commonly used.
• 1 cm above the mid-point of the clavicle, needle is passed downwards,
backwards and medially towards first rib.
• Once needle hits the first rib, 15-20 ml of 1.5% xylocaine is injected (with
walking or stepping over the first rib).
• Complications are pneumothorax and injury to the great vessels.
• Other blocks: Cervical plexus block. Sciatic nerve block. Femoral
nerve block
SPINAL ANAESTHESIA
• It is the injection of local anaesthetic into the subarachnoid space
causing loss of sympathetic tone, sensation and motor function.
• The sympathetic block is 3 segments higher than sensory block, motor
block is 3 segments lower than sensory block.
• Position: Lateral decubitus position with
head, hips and knees being fully flexed
so as to open the inter-laminar spaces.

• Highest point of iliac crest corresponds

to 4th lumbar vertebra.

• Drugs used: Lignocaine 5% ,

Bupivacaine 0.5%
• Technique:
• 24-26 gauge needle with stillette is used.
• Needle is passed through the interspinous
space and ligamentum flavum to reach
the subarachnoid space to get clear fluid
(0.5 ml/ sec).
• Needle is rotated 360 degrees and drug is
injected slowly.
• Patient is repositioned to supine.
• Drug takes 15 minutes to act.
Types Advantages
DISADVANTAGES AND COMPLICATIONS
• CSF leak and aseptic inflammation of meninges causing headache.
• Meningism.
• Infection.
• Paraplegia- It is very rare.
• Occasionally it can become total spinal which requires intubation and
ventilator support.
SADDLE BLOCK
• It is used for surgeries in perineal and anorectal region.
• It is spinal anaesthesia using xylocaine or bupivacaine given in sitting
position.
EPIDURAL ANAESTHESIA
• It is a potential space between dura anteriorly and ligamentum flavum
posteriorly which has got negative pressure inside.
• It extends from foramen magnum to sacral hiatus.
• Touhy needle is used for epidural anaesthesia.
• Once the needle is in the space there will be sudden indrawing of air or
saline drop.
• An epidural catheter is placed in
the space and fixed.
• 2% xylocaine with adrenaline or
0.5% bupivacaine is injected into
the space to achieve
anaesthesia up to the desired
level.
Advantages

• It can be used for continuous

repeated prolonged anaesthesia.
• It can be used for postoperative
analgesia.
• It can be kept for several days
CAUDAL ANAESTHESIA
• Caudal space is the sacral component of epidural space and access is
through the sacral hiatus.
Indications
 Haemorrhoidal surgery
 Circumcision
 Small procedures in the perineum like cystoscopy
• It is given in lateral position.

• Needle is inserted through the

sacral hiatus to enter the caudal
epidural space.

• Drug is then injected into the

space.
Complications
 Trauma to anal canal
 Intravascular injection
 Failure of caudal block
• INFILTRATION BLOCK • FIELD BLOCK
• Direct injection of local • It is achieved by blocking the
anaesthetic under the skin for entire field of excision where
small procedures. lesion is located.
• TOPICAL ANAESTHESIA
• It is used for minor surgeries of eye, laryngoscopy, bronchoscopy,
cystoscopy, gastroscopy.

• It is available as instillation, spray, viscous, ointment, gel, EMLA

(Eutectic mixture of local anaesthetic).