ANESTHESIA

HISTORY OF ANAESTHESIA

Anaesthetics were administered from the early 1840s, but the impact
on general medical practice began after William Morton publically
administered ether to Gilbert Abbott on 16 October 1846 at
Massachusetts General Hospital, Boston.

On 19 December 1846, Francis Boott, an American botanist who had

heard the news from Boston, watched dental surgeon James Robinson
administer the first ether anaesthetic in England. Two days later,
Robert Liston operated on Frederick Churchill at University College
Hospital and a medical student, William Squire administered the
anaesthetic.

Before anaesthesia, surgery was a terrifying last resort, a final attempt

to save life. Few operations were possible and surgeons were judged
by their speed. Some doctors had tried using alcohol, morphine and
other sedatives to dull the pain of surgery but most patients were held
or strapped down, some luckily fainted from the agony. Many died.
Anaesthesia allowed surgeons to take more time, be more accurate
and undertake more complex procedures.

Professor James
Young Simpson (by
kind permission of
the Royal College of
Physicians of
Edinburgh )

Other agents soon followed. In November 1847, James Simpson,

Professor of Obstetrics in Edinburgh, introduced chloroform. It was
more potent but could have severe side effects such as sudden death
and late onset severe liver damage. It became popular because it
worked well and was easier to use than ether.

Local anaesthesia was introduced after Carl Koller performed the first
operation using cocaine at the suggestion of Sigmund Freud in 1884.

Which in turn led to the introduction of infiltration anaesthesia, nerve

blocks, spinal and epidural anaesthesia, then at the turn of the century
came control of the airway using tubes placed in the trachea to help
breathing.

By the 1920's intravenous induction agents were introduced which

enabled patients to fall asleep quickly and pleasantly. Muscle
relaxants were introduced in the 1940s.

Today, anaesthetists are highly

trained and skilled physicians who
provide a wide range of patient care.
They often run High Dependency and
Intensive Care Units. They are
involved in obstetric analgesia and
anaesthesia, emergency medicine in A & E departments, resuscitation,
major accident care, pain management and patient transfers between
hospitals.

Anaesthesia is now very safe, with mortality of less than 1 in 250,000

directly related to anaesthesia. Nevertheless with today's
sophisticated monitoring systems and a greater understanding of
bodily functions, the anaesthetic profession will continue to strive for
improvement over the next 150 years.

ANESTHESIA

 Total or partial loss of sensation to touch or pain, caused by

nerve injury or disease, or induced intentionally, especially by
the administration of anesthetic drugs, to provide medical
treatment.
 It is a pharmacologically induced and reversible state
of amnesia, analgesia, loss of responsiveness, loss of skeletal
muscle reflexes or decreased stress response, or all
simultaneously. This allows patients to undergo surgery and
other procedures without the distress and pain they would
otherwise experience. An alternative definition is a "reversible
lack of awareness," including a total lack of awareness (e.g. a
general anesthetic) or a lack of awareness of a part of the body
such as a spinal anesthetic.
Definition of Terms

Local anesthesia- is any technique to render part of the body

insensitive to pain without affecting consciousness

Regional anesthesia- is anaesthesia affecting only a large part of the

body, such as a limb.
General anesthesia- is a state of unconsciousness and loss of
protective reflexes resulting from the administration of one or more
general anaesthetic agents.
Preoperative care- Care given before surgery when physical and
psychological preparations are made for the operation, according to
the individual needs of the patients.
Intraoperative care- Care provided to a patient during surgery that
is ancillary to the surgery.
Postoperative care- Postoperative care is the management of a
patient after surgery. This includes care given during the immediate
postoperative period, both in the operating room and the post-
anesthesia care unit (PACU), as well as during the days following the
surgery.
Pre-operative medications
Peak effect is desired at the time of induction. Pre-medication is
usually given at least 45 minutes before induction, some drugs
requires 60-90 minutes to reach peak effect.

Purpose
 To allay fear and anxiety
 To produce amnesia
 To decrease secretions in the respiratory tract
 To reduce reflex irritability
 To contract some undesirable side effect to the anesthesia
 To raise the pain threshold
 To lower the body metabolism so that less anesthesia will be
used

Drugs used – may be given orally or IM

I. Sedatives and tranquillizers
Produce a calm and hypothetic state. Reduces the effect of
anxiety; amnesia helps to provide comfort.
A. Benzodiazepines – produce excellent amnesia and
mild sedation sufficient to reduce anxiety and fear. They
cause an inhibitory effect on interneuronal transmission
to sites in the CNS associated with anxiety and fear.
 Diazepam (VALIUM) - given orally for pre-
medication.
  The pharmacological action of diazepam
enhances the effect of the neurotransmitter
GABA by binding to the benzodiazepine site on
the GABAA receptor leading to central nervous
system depression
 to reduce tension and anxiety, and in some
surgical procedures to induce amnesia
 Lorazepam (ATIVAN) - given orally or IM; has
good antiemetic action & acts more quickly than
diazepam
 Lorazepam is used for the short-term treatment of
anxiety, insomnia, acute seizures including status
epilepticus and sedation of hospitalized patients,
as well as sedation of aggressive patients.
Anesthesiology
The branch of medicine specializing in the use of drugs or other agents
that causes insensibility to pain. Anesthesiology may also be defined
as continuity of patient care involving preoperative evaluation,
intraoperative and postoperative care and the management of systems
and personnel that support these activities. The subspecialties within
anesthesiology include cardiothoracic anesthesiology, critical care,
neuroanesthesia, obstetrical anesthesiology, pain management,
pediatric anesthesiology, and ambulatory anesthesia.

Anesthesiologist
Anesthesiologist is a physician (or, less often, a dentist) who is
specialized in the practice of anesthesiology while an anesthetist is a
nurse or technician trained to administer anesthetics.
Level of Anesthesia according to type of surgery
1. Minimal or Light sedation (ANXIOLSIS)
- A mild sedative, such as diazepam, used for relief of anxiety.
Called also antianxiety agent and minor tranquilizer.
- Drug induce state during which patients respond normally to
verbal command, cognitive function and coordination may be
impaired but ventilation and cardio vascular functions are
unaffected.
2. Moderate sedation/Analgesic (CONSCIOUS SEDATION)
- Drug introduce depression of consciousness during which
patient can respond purposely to verbal commands, either
alone or accompanied by light tactile stimulation.
- A drug or medicine given to reduce pain without resulting in
loss of consciousness. Analgesics are sometimes referred to
as painkiller medications. There are many different types of
analgesic medications available in both prescription and over-
the-counter preparation
3. Deep Sedation (ANALGESIA)
- Drug induce depression of consciousness during which
patient can respond purposefully after a painful stimulation.
- Sedation is the act of calming by administration of a
sedative. A sedative is a medication that commonly induces
the nervous system to calm.
4. Full anesthesia - drug induced loss of consciousness during
which patient cannot be roused, even by painful stimulation.
Types of Anesthesia
☺ General Anesthesia
-is the induction of a state of unconsciousness with the absence
of pain sensation over the entire body, through the administration of
anesthetic drugs. It is used during certain medical and surgical
procedures.
- Central nervous system depressant used to loss pain
sensation and consciousness.
- Pain is controlled by general insensitivity
- When administering general anesthetics several drugs are
combined to achieve.

Purpose

 pain relief (analgesia)

 blocking memory of the procedure (amnesia)
 producing unconsciousness
 inhibiting normal body reflexes to make surgery safe and easier
to perform
 relaxing the muscles of the body

a. Analgesia - The inability to feel pain while still conscious. From

the Greek an-, without + algesis, sense of pain.
b. Unconsciousness - Lacking awareness and the capacity for
sensory perception; not conscious.
c. Amnesia - Partial or total loss of memory, usually resulting from
shock, psychological disturbance, brain injury, or illness.
d. Interference with undesirable reflexes
 e. Muscle relaxation - A contractile organ consisting of a special
bundle of muscle tissue, which moves a particular bone, part, or
substance of the body

Three methods of administration

a. Inhalation - The act of taking in breath. Inhalation results from

the negative pressure in the lungs caused by contraction of the
diaphragm, which causes it to move downwards and to expand
the chest cavity
b. IV injection
c. IM – not used occasionally in pediatrics because retention &
absorption in the colon in unpredictable.

Induction of General Anesthesia

a. Pre-oxygenation - Administration of pure oxygen prior to

induction of general anesthesia in order to eliminate nitrogen
from the lungs and body tissues.
b. Loss of consciousness - A partial or complete loss of
consciousness with interruption of awareness of oneself and ones
surroundings.
c. Intubation - passage of a tube into a body aperture, specifically
the insertion of a breathing tube through the mouth or nose into
the trachea to ensure a patent airway for the delivery of
anesthetic gases and oxygen or both

Depth of General Anesthesia

Peak
Normal
------------------------------------------

Stage1 (Induction or Analgesic Stage)

 Starts from induction of anesthesia up to the loss of

consciousness
 Characterized by loss of pain sensation and the patient is
still conscious and able to communicate
 Patients reaction are drowsiness, dizziness and amnesia
 Nursing actions: Close OR doors; keep room quite. Stand
by to assist, initiate cricoids pressure (Sellick’s maneuver)
if requested

Stage II (EXCITEMENT STAGE)

 Starts from loss of consciousness up to relaxation or light

hypnosis
 Period of excitement and often patient has combative behavior
with many signs os symptomatic stimulation and low probability
of recall
 Patient’s reaction. May be excited with irregular breathing and
movement of extremities, patients is susceptible to external
stimuli such as noise and touch.
 Physiological effects. Pupils – contracted. Respiration and pulse-
irregular and fast, BP- elevated.
  Nursing Actions: Restrain patients, patient’s side; quietly but
ready to assist.

Stage III (SURGICAL ANESTHERSIA OF RELAXATION)

 Starts from surgical anesthesia stage of relaxation up to the loss

of reflexes and depression of vital functions.
 Involves relaxation of skeletal muscles return respirations &
progressive loss of eye reflexes and pupil dilation.
 Patient’s reaction. Regular or steady and slow respiration and
pulse, contracted pupils, reflexes disappear, muscles relax,
auditory sensation lost, BP is normal.
 Nursing action: Position patients and prep skin only when
anesthesiologist indicates the stage is reached under control.

Stage IV (MEDULLARY PARALYSIS)

 Starts when the vital functions are too depressed up to

respiratory failure and possible cardiac arrest
 Characterized by very deep CNS depression with loss of
respiratory and vasomotor center stimuli in which death occurs.
 Patient’s reaction: not breathing, little or no pulse or heartbeat
 Nursing action: prepare for cardiopulmonary resuscitation
 Induction- stage 1 to 3
 Maintenance- stage 3 to completion of surgery
 Recovery- period from discontinuation of anesthetic until the
patient has regained consciousness movement and ability to
communicate

 Most commonly used general anesthetic agents

 I. Inhalation agents

 Techniques

1. Mask inhalation- The invention describes an inhalation or

breathing mask for therapeutic nebulizers in which around a
connecting socket 4 for the therapeutic nebuliser is arranged
an exhalation valve consisting of exhalation openings and a
flexible valve element
2. Laryngeal mask- A laryngeal mask of the type used to
facilitate lung ventilation and the insertion of endo-tracheal
tubes or related medical instruments through a patient's
laryngeal opening as used during general anesthesia, intensive
care, or critical patient care.
3. Endotracheal- An endotracheal tube has a proximal end and
a distal end and includes a tracheal portion having an opening
at the proximal end and a bronchial portion attached at an
angle to the tracheal portion.
4. Insufflation- An insufflation system that includes a first tube
that inserts into a patient's airway for providing a primary flow
of breathing gas to such a patient.
5. Open drop-A volatile liquid anesthetic is dropped into a
permeable face mask. Vapor which is formed in contact with
the air is inhaled.

Drugs

Anesthetic Gases

Local Anesthetic Drugs

 A. Amino Amides –metabolized more slowly in the liver and serum
levels of these drugs can increase and lead to toxicity.

1.Bupivacaine (Marcaine,Sensorcaine)- related chemically

and pharmacologically to the aminoacyl local anesthetics. It is a
homologue of mepivacaine and is chemically related to lidocaine.
All three of these anesthetics contain an amide linkage between
the aromatic nucleus and the amino, or piperidine group. They
differ in this respect from the procaine-type local anesthetics,
which have an ester linkage.

2.Dibucaine (Nupercainal)- belongs to a group of medicines

known as topical local anesthetics. It deadens the nerve endings
in the skin. This medicine does not cause unconsciousness as
general anesthetics do when used for surgery.

3.Etidocaine (Duranest HCl)- a local anesthetic of the amide

type used for percutaneous infiltration anesthesia, peripheral
nerve block, and caudal and epidural block.

4.Levobupivacaine (Chirocaine)- It is used for local and

regional anesthesia, for pain management, and for continuous epidural
analgesia.

5.Lidocaine (Xylocaine)- an anesthetic with sedative,

analgesic, and cardiac depressant properties, applied topically in the
form of the base or hydrochloride salt as a local anesthetic; also used
in the latter form as a cardiac antiarrhythmic and to produce
infiltration anesthesia and various nerve blocks.

6.Mepivacaine (Carbocaine)- a lidocaine analogue used in the

form of the hydrochloride salt as a local anesthetic.
 7.Prilocaine (Cilanest)- A local anesthetic used in its
hydrochloride form for nerve blocks and in combination with lidocaine
for topical use.

8.Ropivacaine (Naropin)- It is used to produce peripheral

nerve block, caudal anesthesia, central neural block, and vaginal block.

B. Amino esters-broken down immediately in the plasma by

pseudocholinesterase enzyme (plasma esterase)

1.Benzocaine (Lanacane)- The white, odorless, tasteless crystalline

ester of para-aminobenzoate, used as a local anesthetic.

2.Cocaine- is a whitish crystalline powder that produces feelings of

euphoria when ingested.

3.Chloroprocaine (Nesacaine)- a local anesthetic with a chemical

structure similar to that of procaine.Safest local anesthetic.

4.Procaine (Novocain)- A white crystalline powder used in its

hydrochloride form as a local anesthetic,similar to cocaine but less
toxic.

5.Tetracaine (Pontocaine)- a member of the procaine series of

compounds. It is a local and spinal anesthetic used in the form of the
hydrochloride salt. Can be administered by local injection but is also
useful by topical application to conjunctiva, mucosae and skin.