ANESTHESIA

Compiled By Touqeer

Postoperative Pain Management

Goals Of Pain Treatment

Improve quality of life for the patient. Reduce morbidity. Facilitate rapid recovery and return to full function Allow early discharge from hospital.

Categories Of Pain
Postoperative pain can be divided into acute pain & chronic pain Acute pain is experienced immediately after surgery (up to 7 days) Pain which lasts more than 3 months after the injury is considered to be chronic

Postoperative Pain Management

Non-opioid analgesics
Paracetamol , Dipyrone NSAIDs (including COX-2 inhibitors) Codeine Tramadol Morphine Pethidine Oxycodone

Weak opioids
Strong opioids

Adjuvant
Ketamine Gabapentine , Pregabalin Clonidine, Dexmedetomidine

ASA CLASSIFICATION OF PHYSICAL STATUS

1 =A normal healthy patient
2 =A patient with a mild systemic disease 3 = A patient with a severe systemic disease that limits activity, but is not incapacitating

4 =A patient with an incapacitating systemic disease that is a constant threat to life

5 =A moribund patient not expected to survive 24 hours with or without operation

Monitoring Patient Under Anesthesia

1. The anaesthetist must be present and care for the patient throughout the conduct of an anaesthetic. * 2. Monitoring devices must be attached before induction of anaesthesia and their use continued until the patient has recovered from the effects of anaesthesia. 3. The same standards of monitoring apply when the anaesthetist is responsible for a local /regional anaesthetic or sedative technique or an operative procedure. 4. A summary of information provided by monitoring devices should be recorded on the anaesthetic record. Electronic record keeping systems are now recommended. 5. The anaesthetist must ensure that all equipment has been checked before use. Alarm limits for all equipment must be set appropriately before use. Audible alarms must be enabled during anaesthesia. 6. These recommendations state the monitoring devices which are essential and those which must be immediately available during anaesthesia. If it is necessary to continue anaesthesia without a device categorised as essential, the anaesthetist must clearly note the reasons for this in the anaesthetic record.

Monitoring Patient Under Anesthesia

The following monitoring should beestablished during induction of anaesthesia. Pulse oximeter Blood pressure ECG Capnograph

Monitoring Patient Under Anesthesia

During general anaesthesia inspired oxygen concentration, peripheral oxygen saturation (pulse oximetry), expired carbon dioxide concentration (capnograph) and electrocardiogram (ECG) are monitored continuously. Blood pressure and vapour concentration should also be monitored. In a ventilated patient ventilatory parameters such as tidal volume, minute ventilation and airway pressures should be monitored. Core temperature, invasive blood pressure, central venous pressure, cardiac output, neuromuscular block, blood loss and urine out put monitoring is dictated by the nature of surgery and physical status of the patient.

Monitoring Patient Under Anesthesia

During local anaesthesia and sedation continuous ECG, pulse oximetry, non-invasive blood pressure and respiration should be monitored. In addition a verbal contact should be maintained throughout the procedure.

1. ECG 2. Pulse oximeter waveform 3. Capnograph waveform 4. Inspired/ expired gas and aneasthetic agent concentration

Types of Anesthesia
Types of anesthesia include local anesthesia, regional anesthesia, general anesthesia, and dissociative anesthesia. Local anesthesia inhibits sensory perception within a specific location on the body, such as a tooth or the urinary bladder. Regional anesthesia renders a larger area of the body insensate by blocking transmission of nerve impulses between a part of the body and the spinal cord.

Types of Nerve Blocks

Trigeminal nerve blocks (face) Ophthalmic nerve block (eyelids and scalp) Supraorbital nerve block (forehead) Maxillary nerve block (upper jaw) Sphenopalatine nerve block (nose and palate) Cervical epidural, thoracic epidural, and lumbar epidural block (neck and back) Cervical plexus block and cervical paravertebral block (shoulder and upper neck) Brachial plexus block, elbow block, and wrist block (shoulder/arm/hand, elbow, and wrist) Subarachnoid block and celiac plexus block (abdomen and pelvis)

Spinal anesthesia

Spinal anesthesia It is the injection of small amounts of local anaesthetics into the ( CSF ) at the level below ( L2 ) ,where the spinal cord ends , anesthesia of the lower body part below the umbilicus is achieved.
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Advantages of SPA
Cost: The costs associated with SPA are minimal Patient satisfaction: the majority of patients are very happy with this technique. Respiratory disease: SPA produces few adverse effects on the respiratory system as long as unduly high blocks are avoided. Patent airway: As control of the airway is not compromised, there is a reduced risk of airway obstruction or the aspiration of gastric contents. Diabetic patients: There is little risk of unrecognised hypoglycaemia in an awake patient.

Advantages of SPA
Muscle relaxation: SPA provides excellent muscle relaxation for lower abdominal and lower limb surgery. Bleeding: Blood loss during operation is less than when the same operation is done under general anaesthesia. Splanchnic blood flow: Because of its effect on increasing blood flow to the gut, spinal anaesthesia reduces the incidence of anastomotic dehiscence. Visceral tone: The bowel is contracted by SPA and sphincters relaxed although peristalsis continues. Normal gut function rapidly returns following surgery. Coagulation: Post-operative deep vein thromboses and pulmonary emboli are less common following spinal anaesthesia.

Indications
Operations below the umbilicus : hernia repairs , gynaecological and urological operations Any operation on the perineum or genitalia All operations on the leg except for limb amputation which is possible but an unpleasant experience for an awake patient so here te patient is supplied with light general anesthetic.

Contra-indications
Patient refusal Uncooperative patients : like young children and psychiatric or mentally handicapped patients Clotting disorders : as bleeding from ruptured peridural vein is common , patients with low platlet count or those on anticoagulant drugs (heparin + warfarin ) are at high risk of hematoma formatiom Septicemia : leading to CSF infection and meningitis

Contra-indications
Hypovolemia : since SPA has marked hypotensive effect ,hypovolemic patients must be adequately rehydrated and resuscitated Anatomical deformities (relative contraindication) as it will probably only serve to make the dural puncture more difficult. Neurological disease. Any worsening of the disease postoperatively may be blamed erroneously on the spinal anaesthetic. Inadequate resuscitative drugs and equipment. No regional anaesthetic technique should be attempted if drugs and equipment for resuscitation are not immediately to hand.

Local anesthetics for SPA

Local anesthetic agents are either hyper,hypo- or isobaric.
Hyperbaric agents tend to spread below the level of injection and they are easier to predict thats why they are prefered over iso- and hypobaric agents.
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Local anesthetics for SPA

Bupivacaine ( Marcaine ) : 0.5% hyperbaric bupivacaine is the best

0.5% isobaric bupivacaine is also popular

Lasts longer than most spinal anesthetics from 2-3 hours
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Local anesthetics for SPA

Lidocaine ( Xylocaine ) : 5% hyperbaric lidocaine is the best lasting 45-90 mins. 2% lidocaine can be used but as a much shorter duration of action. 0.2 ml of adrenaline 1:1000 + lidocaine will prolong the duration of action Lidocaine from ( multi dose vials ) should not be used intrathecally as they contain potentially harmful preservatives.
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How to perform the spinal injection?

Clean the patients back with antiseptic. Locate a suitable interspinous space. Raise an intradermal wheal of LA agent at proposed puncture site.

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How to perform the spinal injection?

Insert the needle: the structures that will be passed skin , subcutaneous tissue, supraspinous ligament , interaspinous ligament , lagementum flavum , dura mater.

When CSF appears then slowly inject the local anesthetic.

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Complications of spinal Anaesthesia

Hypotension : due to vasodilatation and a functional decrease in the effective circulating volume. By giving fluids and oxygen mask. Raising the legs: simple and effective. increase the speed of IV infusion: until the blood pressure is restored. If the pulse low give atropine IV. Vasoconstrictor (ephedrine).
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Complications of spinal Anaesthesia

Headache : within 12-24 h and may last for 1 week. it is postural and it is often occipital associated with astiff neck , nausea, vomiting , Dizziness and photophobia. Ask to lying flat in bed and give simple analgesics.
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Complications of spinal Anaesthesia

Urinary retention : the sacral autonomic fibers are among the last to recover. Permanent neurological complications (rare): meningitis, arachnoiditis , peridura abscess Permanent paralysis: in elderly patient other cause: direct injury of the spinal cord .

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Epidural Anesthesia
Local anaesthetic solutions are deposited in the peridural space between the dura mater and the periosteum lining the vertebral canal. The peridural space contains adipose tissue, lymphatics and blood vessels. The injected local anaesthetic solution produces analgesia by blocking conduction at the intradural spinal nerve roots.
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Epidural Anesthesia

Epidural Anesthesia
Technique: Loss of resistance technique to identify the epidural space. 0.5% Bupivacaine (mainly) or lidocaine (2.0%) is usually used to produce epidural anaesthesia.
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Epidural Anesthesia
Indication and Contraindication: the same of spinal anaesthesia. Additional indication is the post operative Paine management using the epidural catheter technique. Complications: the same of spinal anaesthesia, except the post dural puncture headache.
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Differences between Spinal and Epidural Anesthesia

Spinal anaesthesia Extradural Anaesthesia
Level: below L1/L2, where the spinal cord Level: at any level of the vertebral column. ends Injection: subarachnoid space i.e punture of the dura mater Injection: epidural space (between Ligamentum flavum and dura mater) i.e without punture of the dura mater Identification of the subarachnoid space: When CSF appears Identification of the Peridural space: Using the Loss of Resistance technique.

Dosis: 2.5- 3.5 ml bupivacaine 0.5% heavy Doses: 15- 20 ml bupivacaine 0.5% Onset of action: rapid (2-5 min) Density of block: more dense Hypotension: rapid Headache: is a probably complication Onset of action: slow (15-20 min) Density of block: less dense Hypotension: slow Headache: is not a probable.
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REGIONAL ANESTHESIA

Regional anesthesia - Definition

Rendering a specific area of the body, e.g. foot, arm, lower extremities, insensate to stimulus of surgery or other instrumentation

Regional anesthesia - Uses

Provide anesthesia for a surgical procedure Provide analgesia post-operatively or during labor and delivery Diagnosis or therapy for patients with chronic pain syndromes

Regional anesthesia - types

Topical Local/Field Intravenous block (Bier block) Peripheral (named) nerve, e.g. radial n. Plexus - brachial, lumbar Central neuraxial - epidural, spinal

 Pain - 25% of patients still experience pain despite spinal anaesthesia Post-dural headache from 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 preoperatively Anaphylaxis Urinary retention Spinal cord infarction

Complications of Regional Anaesthesia

Topical Anesthesia

Topical Anesthesia
A topical anesthetic is a local anesthetic that is used to numb the surface of a body part. They can be used to numb any area of theskin as well as the front of the eyeball, the inside of the nose, ear or throat, the anus and the genital area. Topical anesthetics are available in creams, ointments, aerosols, sprays, lotions, and jellies. Examples include benzocaine, butamben, dibucaine, lido caine,oxybuprocaine, pramoxine, proparacaine, proxymetacaine, and tetracaine (also named amethocaine)

Topical Anesthesia
Topical anesthetics are used to relieve pain and itching caused by conditions such as sunburn or other minor burns, insect bites or stings, poison ivy, poison oak, poison sumac, and minor cuts and scratches.[2] Topical anesthetics are used in ophthalmology and optometry to numb the surface of the eye (the outermost layers of the cornea andconjunctiva)

Topical Anesthesia
Lidocaine Dibucaine Tetracaine Benzocaine EMLA

Complications of GA
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

 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

Complications of GA

General Anesthesia

Sleep induction Loss of pain responses Amnesia Skeletal muscle relaxation Loss of reflexes

General Anesthesia
Stages of Anesthesia
Stage I

Analgesia

Stage II

Disinhibition
Surgical anesthesia

Stage III

Stage IV

Medullary depression

Inhalation Anesthetics
Ether (diethyl ether) Nitrous Oxide Halothane (Fluothane) Enflurane (Ethrane) Isoflurane (Forane)

Intravenous anesthetics
Ketamine Etomidate Propofol Thiopental

Local Anesthetics - Definition

A substance which reversibly inhibits nerve conduction when applied directly to tissues at non-toxic concentrations

Local anesthetics
Esters Cocaine Chloroprocaine Procaine Tetracaine Amides Bupivacaine Lidocaine Ropivacaine Etidocaine Mepivacaine

Types of Local Anesthesia

Topical anesthesia (surface) Infiltration Plexus block Epidural (extradural) block Spinal anesthesia (subarachnoid block)

Local anesthetics
Techniques of administration
Topical: benzocaine, lidocaine, tetracaine Infiltration: lidocaine, procaine, bupivacaine Nerve block: lidocaine, mepivacaine Spinal:
bupivacaine, tetracaine bupivacaine

Epidural:

Caudal: lidocaine, bupivacaine

Local anesthetics
1.Vasoconstrictors ,Epinephrine is added to local anesthetics in extremely dilute concentrations 2.Epinephrine will prolong duration of action of all local anesthetics 3.Vasoconstrictors should not be used in Fingers,Toes, Nose, Ear lobes & Penis

Complications of Local Anaesthesia

Pain Bleeding and haematoma formation Nerve injury due to direct injury Infection Ischaemic necrosis

Local/Field Anesthesia
Application of local subcutaneously to anesthetize distal nerve endings Uses:
Suturing, minor superficial surgery, line placement, more extensive surgery with sedation

Advantages:
minimal equipment, technically easy, rapid onset

Disadvantages:
potential for toxicity if large field

IV Block - Bier block

Injection of local anesthetic intravenously for anesthesia of an extremity Uses
any surgical procedure on an extremity Advantages: technically simple, minimal equipment, rapid onset

Disadvantages:
duration limited by tolerance of tourniquet pain, toxicity

Peripheral nerve block

Injecting local anesthetic near the course of a named nerve Uses:
Surgical procedures in the distribution of the blocked nerve

Advantages:
relatively small dose of local anesthetic to cover large area; rapid onset

Disadvantages:
technical complexity, neuropathy

Plexus Blockade
Injection of local anesthetic adjacent to a plexus, e.g cervical, brachial or lumbar plexus Uses :
surgical anesthesia or post-operative analgesia in the distribution of the plexus

Advantages:
large area of anesthesia with relatively large dose of agent

Disadvantages:
technically complex, potential for toxicity and neuropathy.

Central neuraxial blockade - Spinal

Injection of local anesthetic into CSF Uses:
profound anesthesia of lower abdomen and extremities

Advantages:
technically easy (LP technique), high success rate, rapid onset

Disadvantages:
high spinal, hypotension due to sympathetic block, post dural puncture headache.

Central Neuraxial Blockade - epidural

Injection of local anesthetic in to the epidural space at any level of the spinal column Uses: Anesthesia/analgesia of the thorax, abdomen, lower extremities Advantages:
Controlled onset of blockade, long duration when catheter is placed, post-operative analgesia.

Disadvantages:
Technically complex, toxicity, spinal headache

Preoperative Fasting
The standard order of NPO past midnight for preoperative patients is based on the theory of reduction of volume and acidity of the stomach contents during surgery. Recently, guidelines have recommended a shift to allow a period of restricted fluid intake up to a few hours before surgery The ASA recommends that adults stop intake of solids for at least 6 hours and clear fluids for 2 hours. When the literature was recently reviewed by the Cochrane group, they found 22 trials in healthy adults that provided 38 controlled comparisons.

Current guidelines for fasting time :

For healthy adult with no risk of aspiration ( e.g. gastrointestinal obstruction, gastroesophageal reflux, DM due to gastroparesis, abdominal distention as in obesity-ascites- pregnancy, trauma, and drugs that cause delayed emptying time ). The following is recommended : 1- For solids 8 hours. 2- For soft diet 6 hours. 3- For fluids that are not clear 4 hours. 4- For clear fluids 2 hours.

Routine Pre-operative Anesthetic Evaluation

I- History:1- Current problem 2- Other known problems 3- Medication history 4- Previous anesthetics ; surgery & obstetric deliveries. 5- Family history. 6 Last oral intake.

Review of organ systems: General ( including activity level ). Respiratory. Cardiovascular. Renal. GIT. Hematological. Neurological. Psychiatric. Endocrinal

II- Physical Examination

Vital signs. Airway. Heart. Lungs. Extremities. Neurological Examination.

III- Laboratory Evaluation

Hematocrite or Hemoglobin concentration :All menstruating women. All patients over 60 years. All patients who are likely to experience significant blood loss & may require transfusion. Serum glucose & Creatinine. ECG & Chest X-ray.

IV- ASA Classification

Class
1

Definition
A normal healthy patient.

2
3 4

A patient with mild systemic disease & no functional limitation. Moderate to severe systemic disease that result in some functional limitation. severe systemic disease that is a constant threat to life and functionally incapacitating.

IV- ASA Classification

Class Definition
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( continued )

A patient who is not expected to survive 24 hours with or without surgery.

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E

A brain-dead patient whose organs are being harvested.

If the procedure is an emergency, the physical status is followed by E.