Principles of Anesthesia
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Learning Objectives
• Differentiate among local, Regional and general anesthesia.
• Mention the routes of administering local anesthesia.
• Identify two methods of administering general anesthesia.
• Manage the adverse effects of local anesthesia.
• Identify the stages of general anesthesia.
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Principles of anesthesia
Anesthesia Is the absence of sensation which may be produced
in Specific body area or systemically.
Anesthesiology –Branch of medicine concerned with the
administration of anesthetic agent to relieve pain and support
physiologic function during a surgical procedure.
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Principles of anesthesia…
Common terms in anaesthesia
Analgesia- lessening sensitivity to pain (Pain relief without loss
of feeling or movement)
Anastasia – loss of feeling or sensation of pain
Anaesthetic- drug that induce loss of sensitivity
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Common terms…
Anaesthetist- person who trained to administer anaesthesia
Anaesthesiologist- medical doctor who trained to administer
anaesthesia
Anoxia –absence of oxygen
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Common terms…
• Hypnosis - a state of altered consciousness
• Hypnotic – a drug that induces sleep
• Assisted respiration - the maintenance of adequate
alveolar ventilation by supplementing the patients
respiration by manual or mechanical means.
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Common terms…
• Apnea - cessation of breathing
• Induction - period from administration up to loss of
pain
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Principles of anesthesia
Types of anesthesia
• Local anesthesia
• Regional anesthesia
• General anesthesia
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A) Local anesthesia
• Used to numb a small site for minor procedures
• They act on afferent nerve fibers –more on nociceptors
• Prevents generation and conduction of action potential
• It acts on a single nerve, a group of nerves or on superficial nerve
endings and blocks the conduction of pain.
• During all types of local anesthesia, the patient remains conscious
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A) Local anesthesia
Examples of local anesthesia
Lidocaine –Has rapid induction, good
penetration
Bupivacaine –has slow onset, long medium
duration, tissue
penetration,
commonly used in long surgeries, has high cardio
toxicity.
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A) Local anesthesia
Advantages:
It needs minimal and simple equipment
Loss of consciousness doesn’t occur
It doesn’t need fasting/NPO
Surgeon can administer with out anesthesiologist
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A) Local anesthesia…
Contra indication to local anesthesia
Allergic sensitivity
Local infection
Septicemia
Hypertension
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A) Local anesthesia…
Local anesthesia can be given in different ways
Local infiltration
Nerve block
Topical
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1) Local infiltration
The agent is injected intracutaneously and subcutaneously
into tissues at and around the incisional site to block
peripheral sensory nerve stimuli at their origin.
The surgery should not be extensive
• It is used to suture superficial lacerations or for excision of
minor lesions
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Local infiltration…
Adrenaline is added to prolong anesthesia & minimize local
bleeding
Addition of Adrenaline (Epinephrine) to the anesthetic agent
causes vasoconstriction to slow circulatory uptake and
absorption, thus prolonging anesthesia
Use a calibrated syringe to avoid over dosage
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Local infiltration…
• The patient receiving Adrenaline should be well oxygenated
• Agents with Adrenaline are contraindicated for operative
procedures involving fingers and penis
• High levels of local anesthetic are toxic
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Local infiltration…
Administration of it takes place as part of the sterile
procedure - use sterile needle and syringe.
When highly vascularized areas are to be injected,
epinephrine is sometimes added to the anesthetic (to
minimize local bleeding, prolong the effect of the agent).
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Local infiltration…
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A) Local anesthesia…
2) Nerve block
• Anesthesia of a large single nerve or nerves
• Injection is done not necessarily at the immediate surgical site.
• The nerve supplying body part is anesthetized
• Commonly used in surgery that is performed on fingers and toes.
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2) Nerve block…
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A) Local anesthesia…
3) Topical
• Used to numb superficial nerve endings particularly those of
the mucous membranes
• The agent may be swabbed, sprayed or applied in drops as for
eye surgery
• Useful in preparing the patient for endoscopic procedures, such
as bronchoscopy and esophagoscopy.
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B) Regional Anesthesia
Is use of local anesthetics to block sensations of pain from large area of
the body like arm, leg or abdomen
It is Method of blocking of nerve impulses before they reach the central
nervous system in order to induce analgesia.
Before performing conduction block,full facilities for
resuscitation should be available
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B) Advantage of regional Anesthesia
Cheap
High Patient Satisfaction
Maintain Patent Airway
Decreased blood Loss
Selective Muscle Relaxation
Decreased Incidence of DVT & PE
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B) Dis adv. of regional Anesthesia
Hypotension
Risk of toxicity
Many patients prefer to be asleep
Skills are required
Patient Can talk
Patient Anxiety
Not Reliable for Surgery > 2 hours
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Regional Anesthesia…
1) Epidural
• The agent is Introduced into the epidural space of the spine
• The agent baths the nerve roots of the spinal cord and the area supplied by
these nerves is anesthetized
• The anesthetic is injected outside the spinal canal (no direct
contact
between spinal fluid and anesthetic).
• The patient should be closely because anesthetics affect
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watched C1N6 S,CVS,RS… Firaol R.(MSc)
Epidural ….
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2) Spinal anesthesia
• Anesthetic agent is injected into the subarachnoid space at the 4th
or
5th lumbar interspace.
• Anesthetic agent does come into contact with the spinal fluid
Used for surgery of the lower pelvis, such as cesarean section
or hernia repair; lower extremities.
• It has risk of infection in the spinal canal if the puncture
site27 is contaminated. Firaol R.(MSc)
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2)Spinal anesthesia…
Spinal absorption depends on :
Position during and immediately after injection
CSF pressure
Volume and dose
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2)Spinal anesthesia…
1. Common position for spinal anaesthesia
• Lateral position- the most common
• Prone position
• Sitting position
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Common Local and regional Anesthetic Agents
Anesthetic agent Uses Duration of Dosage
action
Bupivacaine hydrochloride Local Regional 2-3hr 400mg
block epidural
Procaine hydrochloride Infiltration ¼- ½ hr. 100mg or
Spinal nerves 14mg/kg)
Cocaine hydrochloride Topical ½ hr. 200mg(4mg/kg)
Lidocaine Topical ½- 2hr 200mg
hydrochloride(xylocaine) Infiltration, 500mg or
peripheral nerve, 7mg/kg
nerve block,
spinal, epidural
Tetra Caine hydrochloride Topical 2-4 hr 20mg
Spinal
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Adverse reactions to local anesthesia
Stimulation: patient may become very talkative or anxious, signs
of tachycardia, thready pulse, convulsion.
Depression: patient may appear sleepy and unresponsive,
bradycardia, hypotension.
Other signs: patient may develop cyanosis, sweating, feel cold,
restless (signs of shock),dizzness,headaches, blurred vision etc..
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Treatment of the Reaction
• Discontinue the anesthetic immediately
• Oxygen administration may be needed
• Cardiopulmonary resuscitation is initiated, if necessary.
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C) General Anesthesia
• Causes unconsciousness, provides analgesia and muscle relaxation
• A combination of different anesthetic agents is frequently
used to achieve the desired level of muscle relaxation and analgesia.
• Intravenous and inhaled gases may be used
• It is medically induced coma
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General Anesthesia…
There are four stages of general anesthesia.
• Induction
• Excitement
• Relaxation
• Danger
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1) Induction
• Is a period when the patient goes from consciousness
to
unconsciousness.
• Lasts until the patient is unconscious
• During this phase, the patient retains an exaggerated sense of hearing
so it is mandatory to remain as quiet as possible during induction.
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2) Excitement
• During this phase, the patient is delirious and sensitive to
external stimuli
• Involuntary muscle activity and struggle may be seen
• The critical phase for different adverse events
• Thrashing, vomiting, laryngospasms and dysrhythmias
• Patient is physiologically unstable
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3) Relaxation(surgical phase)
• In this stage there is gradual loss of muscle tone and reflex.
• This phase is the level at which surgery may be performed safely.
The patient is relaxed, unconscious of pain and is
physiologically stable
• Breathing is steady and automatic
• This phase ends at its deepest level with respiratory paralysis.
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4) Danger
This stage begins when the amount agent causes severe
of
that the patient is in
depression of the central nervous
system
immediate danger of cardiopulmonary arrest.
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Methods of Administering General Anesthesia
1) Inhalation
• In this case the anesthetic agent is administered by
anesthesia machine
• The most controllable method in the up take and
elimination of anesthetic agent
• Are mainly accomplished by pulmonary ventilation
• The blood and lungs functioning as the transporting system
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Inhalation…
The techniques of inhalation anesthetic used are:
A) Mask inhalation: in closed system of anesthetic machine. Excess
carbon dioxide is absorbed by soda lime.
B) Endotracheal administration: inhaled in the trachea through nasal or oral
tube insertion
Intubation: insertion of tube directly in to the trachea
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Inhalation anesthetic agents
Nitrous oxide(N2O)
• Comfortable, induction and recovery, non toxic and non
rapid
• Few side effect except headache, Vertigo and drowsiness
irritating
• Excellent analgesia for minor operation
Disadvantage
• Poor relaxation, excitement, laryngospasm and hypoxia
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Inhalation anesthetic agents …
Cyclo propane
Very potent gas very seldom used, highly explosive
Advantage
Pleasant, rapid induction, moderate relaxation, support circulation
Disadvantage:
Flammable, explosive
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Inhalation anesthetic agents …
Halothane (fluothane)
Volatile liquids ,very widely used, Has a pleasant
odor
Advantages:
Non flammable, potent ,chemically stable, rapid induction
Non-irritating for respiratory tract, doesn’t stimulate
respiratory secretion
Useful for patients with bronchial asthma
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Inhalation anesthetic agents …
Disadvantage
• Potentially toxic to liver
• Respiratory, CVS depressant
• Hypotension, bradycardia,cardiac arrest
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2) Intravenous (IV) and intramuscular (IM) administrations
• Injections are also used in general anesthesia.
• Liquid agents may be administered directly into the blood stream.
• A continuous intravenous drip is maintained throughout surgery.
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Intravenous agents
Thiopental sodium (pentothel sodium)
• Short acting in small doses and used for induction
Advantage
• Pleasant rapid induction
• Non flammable and non irritating
• Nausea and vomiting are rare
Large dose causes rapid; prolonged and circulatory
respiratory depression Coughing, laryngospasm
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Intravenous agents
Ketamine hydrochloride
Can be administered IV or IM
Produces rapid induction (30 seconds IV and 2-4 minutes IM)
Advantage:
Used for short procedure-in children (age 2-10 yrs.) for plastic
and eye procedure
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Intravenous agents
Disadvantage:
Emergence reactions with psychologic manifestations in
recovery
periods like delirium ,hallucination , increase B/P
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Choice of Anesthesia
• Choice of anesthesia is made by anesthesiologist or surgeon
• Anesthetic drugs depress activities of all cells. So the primary
consideration with any anesthetics is that it should be associated with low
morbidity and mortality
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Choice of Anesthesia…
The one who select the anesthetic agent should include some or all of
the following:
• Provide maximum safety and comfort for the patient
• Provide optimum operating condition
• Have a low index of toxicity
• Provide potent, predictable analgesia extending to post
operative
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The factors to consider during anesthesia
Age of the patient
Physical and mental status of the patient
Presence of complicating systemic disease
Previous anesthesia experience
Position required for operation
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The factors to consider …
• Type and expected length procedure
• Local and systemic toxicity of the agent
• Expertise of the anesthesiologist
• Presence of infection at the site of operation
• Preference of the patient
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Pre-medication
It is the type of medication given to the client prior to operation in order
to alleviate anxiety.
It is usually given 45-60 minutes prior to induction.
Purposes of premedication
To alley pre-operative anxiety
T4o3 have dull awareness of the OR environment
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Pre-medication…
Purposes of premedication…
It decreases secretion in the respiratory tract
It counter act undesirable side effect of anesthesia
Prolong the effect of the anesthetic and increase a
respiratory depressant effect
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Pre-medication…
The 4 common classes of pre medications
are;
1) Barbiturates (Nembutal, Secobarbital)
Produces a hypnotic effect as sedatives
2) Opiates (Metapon, Demerol, Morphine)
Act as analgesia
Produces narcosis (unconsciousness)
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Pre-medication…
3) Belladonna Derivatives (Atropine, scopolamine)
Inhibit mucus secretion
4) Tranquilizers (valium, vistaril, chlorpromazine)
These relax and allay apprehension and allow for smooth induction.
Reduce anxiety, fear and tension
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Special considerations in pre-medication
• Hypnotics: is valuable as a premedicant - in children
• Heavy smokers, alcoholics hyper thyroid, toxic, emotional, high
fever
patients require more medication.
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The nurses role in anesthetized patient
• The patient position
• Patient’s ability todetoxify, anesthetic agents(liver function) and
tolerate stress
• Patient’s respiratory and circulatory care
• Team members must be constantly aware of potential trauma to
the patient
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Thank you!!
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