General & Local Anesthestics

Historical Perspective
Anesthesia dates back to the mid-1800s. Before the discovery of
anesthesia over a century ago, few surgeries could be performed
In 1842, Dr. Crawford Long of Georgia used ether to perform the first
painless surgery. Dr. Horace Wells demonstrated painless dentistry
under nitrous oxide in 1844. In 1846, Dr. William Morton astonished
doctors at Massachusetts General Hospital when he achieved
anesthesia with ether.

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Overview
Anesthetics
drugs that reduce or eliminate pain by depressing nerve function in the
(CNS) and/or the peripheral nervous system (PNS).
state of reduced neurologic function is: ANESTHESIA
General or local anesthesia
General anesthesia
complete loss of consciousness, loss of body reflexes, elimination of pain
and other sensations throughout the entire body, and skeletal and smooth
muscle paralysis, including paralysis of respiratory muscles
Local anesthesia
does not involve paralysis of respiratory function but does involve
elimination of pain sensation in the tissues innervated by
anesthetized nerves
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General Anesthetics

Drugs that induce general

anesthesia
Most commonly used to
induce anesthesia during
surgical procedure
Parenteral anesthetics:
Route: intravenously
Uses: induction and/or
maintenance of general
anesthesia, induction of
amnesia, and as adjuncts to
inhalation-type anesthetics 4
Anesthesia

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Adjunct Anesthetics
Helper drugs when their use complements the use of any other
drug(s).
Used simultaneously w/general anesthetics for anesthesia initiation
(induction), sedation, reduction of anxiety, and amnesia
Include:
neuromuscular blocking drugs (NMBDs)
sedative-hypnotics or anxiolytics [propofol-Diprivan]
benzodiazepines (e.g., diazepam [Valium], midazolam [Versed]),
barbiturates (e.g., thiopental, methohexital)
opioid analgesics (e.g., morphine, fentanyl)
anticholinergics (e.g., atropine)
antiemetics (e.g., ondansetron (Zofran)

BALANCED ANESTHESIA 6
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INHALATIONAL GENERAL ANESTHETICS

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Indications
Produce unconsciousness as well as relaxation of
skeletal and visceral smooth muscles for surgical
procedures
Electroconvulsive therapy [ECT] for severe
depression in patients w/psychosocial/mental health
problems

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Adverse Effects of Anesthesia by System

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Malignant Hyperthermia
Potentially fatal, genetically linked adverse metabolic
reaction to general anesthesia.
Classically associated w/use of volatile inhalational
anesthetics & the depolarizing NMBD succinylcholine
Signs include
rapid rise in body temperature, tachycardia,
tachypnea, and muscular rigidity
Rx:
cardiorespiratory supportive care
direct-acting skeletal muscle relaxant: dantrolene
[Dantrium]
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Interactions
Antihypertensives and beta blockers: additive effects when
combined with general anesthetics
(i.e., increased hypotensive effects from
antihypertensives, and increased myocardial depression
with beta blockers)

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Isoflurane [Florane] & Sevoflurane (Ultane)
Isoflurane [Florane
fluorinated ether that is a chemical isomer of the older fluorinated
ether enflurane.
more rapid onset of action,
causes less cardiovascular depression, and has little or no
associated toxicity
Sevoflurane (Ultane)
Pharmacokinetics: rapid onset and rapid elimination
useful in outpatient surgery settings.
Nonirritating to the airway, which greatly facilitates induction of an
unconscious state, especially in pediatric patients.

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Ketamine Hydrochloride [Ketamine HCL]

Dissociative anesthestic Schedule III non-opioid

Route: Parenteral
Uses: general & moderate sedation
Common used in ED setting for setting bones
For conscious sedation: SQ, IM, Epidural, PO, Intranasal, rectal,
transdermal and topically
Highly lipid soluble-penetrates BBB-rapid onset of action
AE: disturbing psychomimetic effects-HALLUCINOGENIC
Interactions: NMBD [prolonged paralysis] and halothane Reduced CO &
BP]
Street names: Cat tranquilizer, Cat valium, Jet, Jet K, Kit kat, Purple,
Special K, Special La Coke, Super acid, Super K, Vitamin K
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Nitrous Oxide [N2O]

Laughing gas sweet air

used primarily for dental procedures or as a
supplement to other, more potent anesthetics.

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Propofol [Diprivian]

Route: parenteral
Uses: general anesthetic {induction and
maintenance of general anesthesia] & sedation
for mechanical ventilation in intensive care unit
(ICU) settings.
Lower doses: sedative-hypnotic for moderate
sedation.
Lipid-based emulsion, and prolonged use, or if given
in conjunction with total parenteral nutrition, requires
serum lipids to be monitored.
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Dexmedetomidine [Precedex]
Alpha-2 adrenergic receptor agonist
Produces dose-dependent sedation, decreased
anxiety and analgesia w/out respiratory
depression
Uses: procedural sedation & for surgeries [short
duration]
Short-half life
Used in ICU setting: mechanically vented pts
[sedative purposes]
AE: hypotension, bradycardia, transient HTN,
nausea
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Drugs for Conscious Sedation
Does not cause complete loss of consciousness and
does not normally cause respiratory arrest
Common agents: Propofol, Versed, combo of
Versed w/MSO4 or fentanyl
HCP must have ACLS; no other duties than to
monitor the patient w/ability to intubate
Route: Parenteral
Oral route of drug administration is commonly used
in pediatric patients
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Local Anesthetics Caine Family
Action:
reduce pain sensations at the level of peripheral nerves,
although this can involve intraspinal anesthesia.
AKA regional anesthetics because they render a specific
portion of the body insensitive to pain.
They work by interfering with nerve transmission in specific
areas of the body, blocking nerve conduction only in the
area in which they are applied without causing loss of
consciousness
Route: parenteral (injectable) or topical anesthetics.

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Types
Spinal or intraspinal anesthesia:
Anesthetic drugs are injected into the
area near the spinal cord within the
vertebral column.
Intrathecal anesthesia involves
injection of anesthetic into the
subarachnoid space.
Epidural anesthesia involves injection
of anesthetic via a small catheter into
the epidural space without puncturing
the dura.
commonly used to reduce maternal
discomfort during labor and delivery and to 22
Types of Local Anesthesia
Local anesthesia of specific peripheral nerves is accomplished by
nerve block anesthesia or infiltration anesthesia.
Infiltration: Small amounts of anesthetic solution are injected into the
tissue that surrounds the operative site. This approach to anesthesia
is commonly used for such procedures as wound suturing and dental
surgery.
Nerve block: Anesthetic solution is injected at the site where a nerve
innervates a specific area such as a tissue
Topical anesthesia: The anesthetic drug is applied directly onto the
surface of the skin, eye, or any mucous membrane to relieve pain or
prevent it from being sensed. It is commonly used for diagnostic eye
examinations and skin suturing. i.e. Lidocaine

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Action of Local
Nerve conduction is blocked only in the area in which the anesthetic is
applied, and there is no loss of consciousness.
Local anesthetics also produce sympathetic blockade; that is, they
block the action of the two neurotransmitters of the sympathetic
nervous system: norepinephrine and epinephrine.
The cardiac effects include a decrease in stroke volume, cardiac
output, and peripheral resistance.
The respiratory effects include reduced respiratory function and
altered breathing patterns, but complete paralysis of respiratory
function is unlikely.

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Indications
Local anesthetics are used for surgical, dental, or diagnostic
procedures, as well as for the treatment of various types of chronic
pain.
Spinal anesthesia is used to control pain during surgical procedures
and childbirth. i.e. epidural
Nerve block anesthesia is used for surgical, dental, and diagnostic
procedures and for the therapeutic management of chronic pain.
Infiltration anesthesia is used for relatively minor surgical and dental
procedures.

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Adverse Effects
One notable complication of spinal anesthesia is spinal headache
self-limiting and is treated with bed rest and conventional analgesic
medications.
Oral or intravenous forms of the CNS stimulant caffeine are also
sometimes used.
Severe cases of spinal headache may be treated by the anesthetist by
injection of a small volume (roughly 15 mL) of venous sample of the
patient's own blood into the patient's epidural space. i.e. blood
patching
skin rash, urticaria, and edema to anaphylactic shock. Such allergic
reactions are generally limited to a particular chemical class of
anesthetics called the ester type

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Ester Type Local Anesthetics- end in Caine
Ester Type
benzocaine
chloroprocaine
cocaine
procaine
proparacaine
propoxycaine
tetracaine

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Toxicity and Management of OD
vasoconstrictor such as Epinephrine [Adrenalin] is often
coadministered with the local anesthetic to maintain
localized drug activity (e.g., lidocaine/epinephrine or
bupivacaine/epinephrine)

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Lidocaine [Xylocaine]
Belongs to the amide class of local anesthetics
One of the most commonly used local anesthetics.
It is available in several strengths, both alone and in different
concentrations with epinephrine, and is used for both infiltration and
nerve block anesthesia.
With Epinephrine-minimize bleeding in surgical area
Lidocaine is also available in topical forms, including the unique
product EMLA [great for use with Peds population]
This is a cream mixture of lidocaine and prilocaine that is applied to skin to
ease the pain of needle punctures (e.g., starting an intravenous line).
There is also a transdermal lidocaine patch for relief of postherpetic
neuralgia).
Parenteral lidocaine is also used to treat certain cardiac dysrhythmias.
Lidocaine is a pregnancy category B drug. 29
Neuromuscular Blocking Drugs
Neuromuscular blocking drugs (NMBDs) prevent nerve transmission in
skeletal and smooth muscles, leading to paralysis.
They are often used as adjuncts with general anesthetics for surgical
procedures.
Neuromuscular blocking drugs also paralyze the skeletal muscles
required for breathing: the intercostal muscles and the diaphragm.
The patient is rendered unable to breathe on his or her own, and
mechanical ventilation is required to prevent brain damage or death by
suffocation.
Phases of muscle paralysis:
1. Muscle weakness, 2. Paralysis of small rapidly moving muscles (fingers,
eye), 3. Paralysis of muscles of the limbs, neck, and trunk,
4. Paralysis of intercostals and diaphragm muscles
NMBD Group Types
NMBDs are classified into two groups based on mechanism of action:
depolarizing and nondepolarizing.
Depolarizing NMBDs work similarly to the neurotransmitter
acetylcholine (ACh). They bind in place of ACh to cholinergic receptors
at the motor endplates of muscle nerves or neuromuscular junctions.
Thus they are competitive agonists.
i.e. d-tubocurarine and succinylcholine
Nondepolarizing NMBDs also bind to ACh receptors at the
neuromuscular junction, but instead of mimicking ACh, they block its
actions [Ach]. Therefore, these drugs are competitive antagonists of
Ach
I.E. Vecuronium and pancuronium

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Agents- end in ronium or rarine or curium
Short-Acting Drug-
succinylcholine (Anectine]-Depolarizing
mivacurium (Mivacron)
Intermediate-Acting Drugs
atracurium (Tracrium)
rocuronium (Zemuron)
vecuronium (Norcuron)-Nondepolarizing

Long-Acting Drugs
doxacurium (Nuromax)
pancuronium (Pavulon)-Nondepolarizing
tubocurarine (dTC)

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Indications
main therapeutic use of NMBDs is for maintaining skeletal muscle
paralysis to facilitate controlled ventilation during surgical procedures.
Shorter-acting NMBDs are often used to facilitate intubation with an
endotracheal tube.
This is commonly done for a variety of diagnostic procedures such as
laryngoscopy, bronchoscopy, and esophagoscopy.
When used for this purpose, NMBDs are frequently combined with
anxiolytics, analgesics, and anesthetics.
Additional nonsurgical applications include reduction of laryngeal or
general muscle spasms, reduction of spasticity from tetanus and
neurologic diseases such as multiple sclerosis, and prevention of bone
fractures during electroconvulsive therapy
also used for the diagnosis of myasthenia gravis, a disease
characterized by chronic muscular weakness.
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Adverse Effects
muscle paralysis induced by depolarizing NMBDs (e.g.,
succinylcholine) is sometimes preceded by muscle spasms, which
may damage muscles.
muscle fasciculations and are most pronounced in the muscle
groups of the hands, feet, and face.
Injury to muscle cells-postoperative muscle pain and release
potassium into the circulation-hyperkalemia[ self-limiting and
reversible]
NMBDs are sometimes administered with succinylcholine to minimize
these muscle fasciculations.
In spite of these disadvantages, succinylcholine is still popular due to
its rapid onset of action, its depth of neuromuscular blockade, and its
short duration of action. For these reasons, it is often preferred to
nondepolarizing NMBDs for rapid-sequence induction of anesthesia
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(e.g., for emergency intubation).
Interactions
Many drugs interact with NMBDs, which may lead to either synergistic
or opposing effects.
Aminoglycoside antibiotics, when given with an NMBD, can have
additive effects.
The tetracycline antibiotics can also produce neuromuscular blockade,
possibly by chelation of calcium

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Toxicity & OD Management
The primary concern when NMBDs are overdosed is prolonged
paralysis requiring prolonged mechanical ventilation
Collapseardiovascular
Anticholinesterase drugs such as neostigmine, pyridostigmine, and
edrophonium are antidotes and are used to reverse muscle paralysis.
Dysmetabolic syndrome known as malignant hyperthermia can also
occur with NMBDs, especially succinylcholine.

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Succinylcholine-Depolarizing Agent
Succinylcholine-currently available drug in the depolarizing subclass of
NMBDs
quick onset of action, succinylcholine is most commonly used to
facilitate endotracheal intubation
contraindicated in patients with personal or familial history of
malignant hyperthermia, skeletal muscle myopathies, and known
hypersensitivity to the drug.
Route: injectable form.

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Pancuronium (Pavulon]-Nondepolarzing

Nondepolarizing NMBDs are commonly used to facilitate endotracheal

intubation, reduce muscle contraction, and facilitate a variety of
diagnostic procedures. They are often combined with anxiolytics or
anesthetics. They may also be used to induce respiratory arrest in
patients on mechanical ventilation.
long-acting nondepolarizing NMBD.
It is used as an adjunct to general anesthesia to facilitate endotracheal
intubation and to provide skeletal muscle relaxation during surgery or
mechanical ventilation.
It is most commonly employed for long surgical procedures that
require prolonged muscle paralysis.
Route: Injectible

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Vercuronium [Norcuron]
intermediate-acting nondepolarizing NMBD.
Uses: adjunct to general anesthesia to facilitate tracheal intubation
and to provide skeletal muscle relaxation during surgery or mechanical
ventilation,
one of the most commonly used NMBDs.
Long-term use in the ICU setting has resulted in prolonged paralysis
and subsequent difficulty weaning from mechanical ventilation

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Assessment
First, for any form of anesthesia and during any of the phases of
anesthesia, the major parameters to assess are airway, breathing, and
circulation (ABCs). General anesthesia: pay attention of age
Include in your assessment questions regarding allergies and use of
prescription as well as over-the-counter drugs, herbals, supplements,
and social and/or illegal drugs.
Another important area to assess is the patient's use of alcohol and
nicotine. Excessive use of alcohol may alter the patient's response to
general anesthesia, especially if there is liver impairment
Perform a respiratory assessment (e.g., respiratory rate, rhythm, and
depth; breath sounds; oxygen saturation level), especially history of
smoking or is currently a smoker. The patient's history of smoking is
important because nicotine has a paralyzing effect on the cilia within
the respiratory tract 40
Assessment
electrocardiogram, chest radiograph, and tests of renal function (e.g.,
BUN level, creatinine level, urinalysis with specific gravity) and hepatic
function (e.g., total protein and albumin levels; bilirubin level; ALP,
AST, and ALT levels).
Additional laboratory tests may include Hgb, Hct, WBC with
differential, and tests that indicate clotting abilities, such as PT-INR,
aPTT, and platelet count.
assess serum electrolytes, specifically potassium, sodium, chloride,
phosphorus, magnesium, and calcium, because abnormalities may
lead to further complications from the anesthesia.
assess the results of a pregnancy test in females of childbearing age,
if ordered, because of the possibility of teratogenic effects (adverse
effects on the fetus) related to the anesthetic drug.
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Assessment
Neurologic assessment includes a thorough survey of the patient's
mental status.
assess for in patients receiving general anesthesia is that of malignant
hyperthermia.
Signs and symptoms of malignant hyperthermia include a rapid rise in body
temperature, tachycardia, tachypnea, muscle rigidity, cyanosis, irregular
heartbeat, mottling of the skin, diaphoresis (profuse sweating), and an
unstable blood pressure, If there is no documented problem with general
anesthesia or if the patient is undergoing general anesthesia for the first time,
perform an astute and careful examination of all medical and medication hx

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 Neuromuscular blocking drugs (NMBDs), perform a complete head-to-
toe assessment with a thorough medical and medication history.
Which specific drug is being used and whether it is depolarizing or
nondepolarizing will guide your assessment, because of the action of
NMBDs on the patient's neuromuscular.
Complete a thorough respiratory assessment in patients receiving
NMBDs because of the effect of these drugs on the respiratory
system. In particular, these drugs have a paralyzing effect on the
muscles used for breathing

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Assessment
Use of spinal anesthesia requires thorough assessment with an
emphasis on the ABCs, respiratory function, and vital signs,
specifically blood pressure.
Baseline respirations with attention to rate, rhythm, depth, and breath
sounds are important to note, as are oxygen saturation levels obtained
via pulse oximetry.
Because of possible problems with vasodilatation from the spinal
anesthetic, document baseline blood pressure levels and pulse rate.
Record history of previous reactions to this form of anesthesia,
allergies, and a listing of all medications, and report any abnormal
reactions to the anesthesiologist and surgeon.
Neurologic assessment with notation of sensory and motor intactness
in the lower extremities, as well as documentation of any
abnormalities, is important. 44
Assessment
The use of epidural anesthesia requires special attention to overall
hemostasis through monitoring of vital signs and oxygen saturation
levels.
Assess baseline sensory and motor function in the extremities, and
document an intact neurologic system
Spinal headaches may occur with either spinal anesthesia or epidural

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Assessment
Local-topical anesthetics, such as lidocaine, used for either infiltration
or nerve block anesthesia may be administered with or without a
vasoconstrictor (e.g., epinephrine).
The vasoconstrictors are used to help confine the local anesthetic to
the injected area, prevent systemic absorption of the anesthetic, and
reduce bleeding.
In summary, it is important with any type of anesthesia to assess the
patient's level of homeostasis prior to actual administration of the drug.
This assessment may include taking vital signs as well as checking
the ABCs. Other parameters of interest may be oxygen saturation
levels measured by pulse oximetry, cardiovascular and respiratory
function, and neurologic function

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Nsg Dx
Impaired gas exchange related to the general anesthetic's CNS
depressant effect with altered respiratory rate and effort (decreased
rate, decreased depth)-Priority
Decreased cardiac output related to the systemic effects of anesthesia
Acute pain related to the adverse effect of spinal headache from
epidural anesthesia
Deficient knowledge related to lack of information about anesthesia
Risk for injury related to the impact of any form of anesthesia on the
CNS (e.g., CNS depression and decreased sensorium)
 Review implementation, Patient teaching, key points & brief
look at spinal headaches

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