Anesthesia and pain

relief
 The use of a set of safety checklists in the operating theatre in the
form of the World Health Organisation’s Surgical Safety Checklist has
shown a reduction in incidence of perioperative untoward events.
The role of the modern anesthetist has evolved from just being
responsible for the patient in the operating suite into a ‘perioperative
physician’ who optimises the patient for surgery, assessing and
minimising risk, cares for them during the operation, and then manages
both pain and homeostasis in the postoperative period.
 Key features of commonly used intravenous
anesthetic agents.
Propofol (di-isopropyl phenol) Smooth induction, better hemodynamic
stability, blunting of autonomic reflexes and ability to use as a continuous
infusion
Thiopentone (barbiturate) Rapid induction, myocardial depression.
Reduced metabolic rate and lowering of intracranial pressure is useful in
neurosurgical patients but drop in blood pressure can give detrimental
effects
Etomidate (steroid derivative) Good hemodynamic stability, brief
duration of action, but concern over adrenocortical depression
Ketamine (phencyclidine derivative) Preservation of blood pressure and
respiratory reflexes together with excellent analgesia makes it an ideal
choice for field anesthesia. Emergence delirium is associated with
administration of ketamine
 GENERAL ANAESTHESIA
General anesthesia is
commonly described as the
triad of unconsciousness,
analgesia and muscle
relaxation.
 Induction of general anesthesia is
most frequently done by intravenous
agents. Propofol has replaced
thiopentone as the most widely used
induction agent and can be used for
maintenance of anesthesia. Other
infrequently used intravenous agents
include etomidate and ketamine.
Newer agents based on benzodiazepine
receptor agonists, etomidate
derivatives and fospropofol are still in
the experimental stage.
 Inhalational induction using agents such as non-pungent sevoflurane
is useful in children, needle-phobic adults and those in whom a difficult
airway is anticipated. These patients will have a higher risk of
developing airway obstruction
Rapid sequence induction (RSI) using a predetermined dose of
intravenous anesthetic agent together with rapidly acting muscle
relaxant is used in those with high risk of regurgitation in order to
secure the airway quickly. Commonly needed in emergency surgery it is
also a technique of choice in any non-emergency surgery in a patient
with delayed emptying of stomach.
 Total intravenous anesthesia (TIVA ) is becoming popular following
the introduction of propofol and the ultra-shortacting opioid
remifentanil. The lack of a cumulative effect, better hemodynamic
stability, excellent recovery profile and concerns over environmental
effects of inhalational agents have made TIVA an attractive choice. TIVA
is routinely used in neurosurgery, airway laser surgery, during
cardiopulmonary bypass and for day-case anesthesia
 Maintenance of anesthesia, on the other hand, can be done using
continuous infusion of intravenous agent (propofol) or inhaled vapour
such as isoflurane, sevoflurane or desflurane.
The use of nitrous oxide is declining despite its analgesic and weak
anesthetic properties due to concerns over postoperative nausea and
vomiting. It also increases the size of the air bubble causing adverse
effects, for example in eye, ear and abdominal surgery. Finally, it is
possibly mutagenic and is a powerful greenhouse gas.
 Management of airway during
anesthesia
Loss of muscle tone as a result of general anesthesia means that the
patient can no longer keep their airway open. Therefore, the patients need
their airway maintained for them. The use of muscle relaxants will mean
that they will also be unable to breathe for themselves and so will require
artificial ventilation. Head tilt, chin lift and jaw thrust manoeuvres, along
with adjuncts such as oropharyngeal airways, are used to facilitate bag-
mask ventilation while induction agents exert full effect. Laryngeal mask
airway or endotracheal tube are then inserted and the patient is allowed
to breathe spontaneously or is ventilated during the procedure.
The addition of a cuff to the endotracheal tube facilitates positive
pressure ventilation and protects the lungs from aspiration of regurgitated
gastric contents.
 Supraglottic airways
●● Laryngeal mask airway (LMA). Developed by Dr Archie Brain in the
UK, the original LMA is a first generation supraglottic airway. The mask
with an inflatable cuff is inserted via the mouth and produces a seal
around the glottic opening, providing a very reliable means of maintaining
the airway. Its placement is less irritating and less traumatic to a patient’s
airway than endotracheal intubation. The technique can be easily taught
to non-anesthetists and paramedics and can be used as an emergency
airway management tool. Several varieties of first generation LMAs are
available, including the classic LMA and the flexible LMA. Further
advancement has led to the development of second-generation
supraglottic devices such as the ProSeal LMA, the i-Gel and LMA Supreme
 Difficult intubation.
Endotracheal intubation is feasible in most patients, but in a certain
proportion of patients this may be difficult or impossible; if compounded
by inability to ventilate the patient by bag-mask, consequences can be
catastrophic hypoxia. One specialised method for intubation in difficult
situations is the use of the fibreoptic intubating bronchoscope facilitated
by topical local anesthetic in awake patients or using general anesthesia.
The anesthetist places the endotracheal tube in the trachea by threading
the tube over the bronchoscope, and so places the tube in the trachea
under direct bronchoscopic vision.
 Double lumen tubes and endobronchial tubes
are used in procedures such as thoracoscopic,
pulmonary and esophageal surgery to allow
collapse of one lung (while ventilating the other)
for ease of surgery. Their use is also essential to
isolate the healthy lung in pyopneumothorax
and in the case of a bronchopleural fistula.
Ventilating bronchoscopes and endobronchial
catheters can be used to maintain oxygenation
during laryngo-tracheal surgery or bronchoscopy
by using intermittent jets of oxygen.
Complications of intubation

● Failed intubation
● Accidental bronchial intubation
● Trauma to teeth, pharynx, larynx
● Aspiration of gastric contents during intubation
● Disconnection, blockage, kinking of tube
● Delayed tracheal stenosis
Ventilation during anesthesia
Mechanical ventilation is required when the patient’s spontaneous
ventilation is inadequate or when the patient is not breathing because
of the effects of the anesthetic, analgesic agents or muscle relaxants.
In volume control ventilation, a preset volume is delivered by the
machine irrespective of the airway pressure. The pressure generated
will be in part dependent on the resistance and compliance of the
airway.
 In laparoscopic surgery requiring
the Trendelenburg position (the
patient is positioned head down),
and in morbidly obese patients and
those with lung disease, this may
result in excessive pressures being
developed, which may lead to
barotrauma (pneumothorax).
 In pressure control mode, the ventilator generates flow until a preset
pressure is reached. The actual tidal volume delivered is variable and
depends on airway resistance, intra-abdominal pressure and the degree
of relaxation. end expiratory pressure (PEEP) is often applied to help
maintain functional residual capacity (FRC). This avoids lung collapse by
opening collapsed alveoli, and maintains a greater area of gas exchange
so reducing vascular shunting.
 Monitoring and care during
anesthesia
A minimum basic monitoring of cardiovascular parameters is required
during surgery. This includes:
●● Vascular:
●● electrocardiogram (ECG);
●● blood pressure;
●● Adequacy of ventilation:
●● inspired oxygen concentration;
●● oxygen saturation by pulse oximetry;
●● end tidal carbon dioxide concentration.
 LOCAL ANAESTHESIA

Local anesthetic drugs may be used to

provide anesthesia and analgesia as a
sole agent or as adjuncts to general
anesthesia. Available techniques include
topical anesthesia, local infiltration,
regional nerve blocks and central
neuroaxial blocks (spinal and epidural
anesthesia).
 Local anesthesia techniques can lead to complications that may be
local, such as infection or hematoma, or systemic due to overdose or
accidental intravascular injection. The systemic effects of local
anesthetic agents are dose dependent and manifest as cardiovascular
(cardiac arrhythmia, cardiac arrest) or neurological (depressed
consciousness, convulsions). Prilocaine overdose causes
methaemoglobinaemia while bupivacaine overdose causes treatment-
resistant ventricular arrhythmia and cardiac arrest.
 The addition of adrenaline to local anesthetic solutions hastens
onset, prolongs duration of action and permits a higher upper dose
limit. The use of adrenaline is contraindicated in patients with
cardiovascular disease, those taking tricyclic and monoamine oxidase
inhibitors and in end-arterial locations.
Appropriately skilled personnel, resuscitation equipment and oxygen
should always be available with local anesthetic use because of the
potential risks of life-threatening complications.
Regional anesthesia
Regional anesthesia involves central neuroaxial or peripheral nerve
or plexus blocks. It has a clear advantage where general anesthesia
carries a higher risk of morbidity and mortality, such as in patients with
debilitating respiratory and cardiovascular disease and obstetric cases.
It also provides excellent pain relief in the postoperative period,
reducing the need for analgesics such as opioids.
 Localising nerves using anatomical landmarks and eliciting
paresthesia alone carries a high risk of nerve damage, intravascular
injection and has lower success rate. The use of nerve stimulators to
localise nerves improves success rate and reduces risks. Ultrasound-
guided regional anesthesia allows the visualisation of nerves and the
spread of local anesthetics, enabling the use of a smaller dose of local
anesthetic agents, with improved success rates and safety.
 Nerve blocks
Interscalene block for shoulder
surgery produces excellent
postoperative analgesia.
Complications include phrenic nerve
block, Horner’s syndrome, as well as
accidental intravascular and spinal
injection.
Axillary brachial plexus block can be
used as the sole anesthetic technique
for upper limb surgery.
Femoral and sciatic nerve blocks
are often used for anesthesia and
analgesia for lower limb surgery.
 TRANSVERSUS ABDOMINIS
PLANE BLOCK
Transversus abdominis plane block
(TAP) is growing rapidly in popularity.
The technique has been shown to
provide effective analgesia after a
wide range of abdominal surgery. The
T6–L1 segmental nerves enter the
triangle of Petit just medial to the
anterior axillary line. Injection of
local anesthetic into the fascial plane
between the internal oblique and
transversus abdominis muscles
allows a block of all these nerves,
and excellent anesthesia of the
anterior abdominal wall
 INTRAVENOUS REGIONAL ANAESTHESIA
(BIER’S BLOCK)
Bier’s block produces excellent anesthesia for short surgery, particularly for the
upper limb (e.g. carpal tunnel release). Exsanguination using an Esmarch
bandage, inflation of proximal cuff of the double tourniquet is followed by
intravenous injection of prilocaine into the vein on the back of the hand that is
being operated on. After 5–10 minutes the distal cuff of the tourniquet is inflated
and then the proximal one deflated. Even if surgery is finished, the tourniquet
should be left inflated until the local anesthetic has bound to tissues (20
minutes), so that release of local anesthetic into the systemic circulation does not
occur.
Spinal anesthesia

Spinal anesthesia alone, and in

combination with general anesthesia
or sedation is used extensively for
lower limb, obstetric and pelvic
surgery. Injection of a ‘single shot’
local anesthetic agent intrathecally
produces intense and rapid block for
surgery. Addition of opioids provides
prolonged postoperative analgesia
but carries the risk of late respiratory
depression.
 Autonomic sympathetic
blockade produces hypotension,
particularly if the level of block is
above T10. Caution is needed in
patients with hypovolemia and
cardiovascular disease.
The incidence of dural puncture
headache can be minimized by
limiting the number of punctures
and use of fine bore pencil tip
needles designed to split rather
than cut the dura.
 Epidural anesthesia
Epidural anesthesia is slower in
onset than spinal, but has the
advantage of prolonged analgesia
by multiple dosing or continuous
infusion through a catheter placed
in the epidural space. Being slower
in onset, the resulting hypotension
from sympathetic blockade can be
better controlled and can reduce
blood loss.
 Continuous infusion (with a patient-controlled bolus) of weak local
anesthetic combined with opioids (such as fentanyl) is routinely used
for postoperative analgesia. Placement of an epidural catheter in the
high thoracic region provides excellent analgesia for a wide variety of
upper abdominal and thoracic surgical operations, enabling early
mobilisation and reducing respiratory complications.
Epidural anesthesia is technically more difficult than spinal
anesthesia, with a higher failure rate and carries the risk of nerve
damage, spinal injuries, accidental spinal injection of large volume of
local anesthetics and risk of infection and epidural hematoma.
Chronic pain management
In surgical practice, the patient with chronic pain may present for
treatment of the cause (e.g. pancreatitis, malignancy), or concomitant
benign pathology. Acute pain after surgery may progress to chronic
pain and is believed to be due to inadequate treatment of acute pain
itself.
Chronic pain may be of several types:
Nociceptive pain;
Neuropathic pain;
Nociceptive pain
may result from musculoskeletal disorders or cancer activating
cutaneous nociceptors (pain receptors). Prolonged ischemic or
inflammatory processes result in sensitisation of peripheral nociceptors
and altered activity in the central nervous system, leading to
exaggerated responses in the dorsal horn of the spinal cord. The
widened area of hyperalgesia and increased sensitivity (allodynia) has
been attributed to the increased transmission in the central nervous
system.

Psychogenic pain is associated with depressive illness; chronic pain and

the illness may exacerbate each other.
Neuropathic (or neurogenic)
pain
is dysfunction in peripheral or central nerves (excluding the
‘physiological’ pain due to noxious stimulation of the nerve terminals).
It is classically of a ‘burning’, ‘shooting’ or ‘stabbing’ type and may be
associated with allodynia, numbness and diminished thermal sensation.
It is poorly responsive to opioids. Examples include trigeminal
neuralgia, postherpetic and diabetic neuropathy. Monoaminergic,
tricyclic inhibitors and anticonvulsant drugs are the mainstay of
treatment.
Chronic pain control in benign disease

Surgical patients may present with chronic persistent pain (more

than 3 months’ duration) from a variety of disorders including
postoperative neuropathic pain, chronic inflammatory disease,
recurrent infection, degenerative bone or joint disease, nerve injury
and sympathetic dystrophy. This may result from persistent excitation
of the nociceptive pathways causing spontaneous firing of pain signals
at N-methyl-Daspartate receptors in the ascending pathways. This pain
does not respond to opiates or neuroablative surgery and would merit
neuropathic pain management.
 Amputation of limbs may result in
phantom limb pain; the likelihood is
increased if the limb was painful
before surgery. Continuous regional
local anesthetic blockade (epidural
or brachial plexus) established
before operation and continued
postoperatively for a few days, is
believed to effectively reduce the
risk of phantom limb pain.
Local anesthetic and steroid injections can be effective around an
inflamed nerve and they reduce the cycle of constant pain transmission
with consequent muscle spasm. Transforaminal selective root blocks in
the epidural space are used for the pain of nerve root irritation
associated with or without minor disc prolapse, followed by active
physiotherapy and rehabilitation to promote mobility.
Nerve stimulation procedures such as acupuncture and transcutaneous
nerve stimulation, increase the endorphin production in the central
nervous system. Nerve decompression craniotomy rather than
percutaneous coagulation of the ganglion is now performed for
trigeminal neuralgia. Spinal cord stimulation by dorsal column
stimulation is now a recognised and effective management of
intractable neuropathic pain. This involves placement of electrodes in
the posterior epidural space to allow dorsal column stimulation through
an implantable pulse generator inserted in the body.
 Drugs in chronic non-malignant
pain
Paracetamol and the non-steroidal anti-inflammatory drugs (NSAIDs)
are the mainstay of musculoskeletal pain treatment. The tricyclic
antidepressant drugs and anticonvulsant agents are often useful for the
pain of nerve injury, although side effects can prove troublesome and
reduce compliance. Both pregabalin and gabapentin reduce spontaneous
neuronal activity by their action on the alpha-2-delta subunit of calcium
channels, and are now used for managing neuropathic chronic pain. In
more severe and debilitating non-malignant chronic pain, opioid
analgesic drugs are used in slow release oral preparations of morphine
and oxycodone, and transcutaneous patches delivering fentanyl and
buprenorphine.
Treatment of pain dependent on
sympathetic nervous system
activity
Even minor trauma and surgery, (often of a limb) can provoke chronic
burning pain, allodynia, trophic changes and Resultant disuse due to
excessive sympathetic adrenergic activity inducing vasconstriction and
abnormal nociceptive transmission.
Management includes antineuropathic pain medications (pregabalin,
gabapentin, amitriptyline) as part of multimodal analgesia with a
multidisciplinary pain management approach including considerable input of
psychological, targeted physiotherapy and counselling. Interventional
treatment may include local anesthetic injection of stellate ganglion for
upper limb symptoms. Percutaneous chemical lumbar sympathectomy with
local anesthetic is used for relief of rest pain in advanced ischemic disease of
the legs.
 Pain control in malignant
disease
Pain is a common symptom associated with cancer, more so during the
advanced stages. In intractable pain, the underlying principle of
treatment is to encourage independence of the patient and an active life
in spite of the symptom. The World Health Organisation’s booklet
advises use of a ‘pain stepladder’:
●● First step. Simple analgesics: aspirin, paracetamol, non-steroidal
anti-inflammatory agents, tricyclic drugs or anticonvulsant drugs.
●● Second step. Intermediate strength opioids: codeine, Tramadol or
dextropropoxyphene.
●● Third step. Strong opioids: morphine
 Infusion of subcutaneous, intravenous,
intrathecal or epidural opiate drugs
The infusion of opiate is necessary if a patient is unable to take oral
drugs. Subcutaneous infusion of diamorphine is simple and effective to
administer. Epidural infusions of diamorphine with an external pump can
be used on mobile patients. Intrathecal infusions with pumps
programmed by external computers are used; however, there is a
possibility of developing infection with catastrophic effects. Intravenous
narcotic agents may be reserved for acute crises, such as pathological
fractures.