BASIC TYPE OF ANAESTHESIA

Muhammad Syamil – 1129200919453

Nurul Farhanim - 1129200919568
Sri Amelia Natasha - 1129200919455
Tuan Nur Syahirah Amani – 1129200919460
M. Khaled Hamwi - 1129200919502

Supervised by: Dr. Rozila Aziz

Muscle Relaxant
Muscle
Relaxant
 Depolarizing Agent:
Suxamethonium (Succinylcholine/Scoline)
Spontaneous breathing without muscle relaxant

• Induction with sedation drug (Propofol) and analgesic (Fentanyl) only.

• Indications:
Laparoscopic surgeries
Regional anesthesia
Short simple surgeries

• Using LMA

In certain surgeries, especially those that don’t require deep levels of anesthesia, anesthesiologists
may use techniques that allow patients to maintain spontaneous breathing. This involves
administering lighter doses of anesthetic drugs, providing a balance that keeps the patient
comfortable and pain-free while allowing them to breathe on their own.
• Intubation and mechanical ventilation cause a redistribution of ventilation, compared with
spontaneous breathing (SB) in the awake state in supine position, positive-pressure ventilation
(PPV) increases the aereation in the ventral parts of the lung, whereas the dorsal parts contain
less air. General anesthesia with a laryngeal mask airway (LMA) allows safe and sufficient patient
ventilation with both SB and PPV, and SB during general anesthesia could prevent the
redistribution of ventilation.
• Pressure support ventilation (PSV) was originally invented as a weaning tool for intensive care
patients. Contrary to pressure-controlled ventilation (PCV), which replaces the patient’s own
breathing efforts, PSV supports the patient’s breathing; when the patient inhales, the ventilator
exerts a positive pressure to facilitate the patient’s inspiration. Since SB remains intact during PSV,
PSV will cause less redistribution of ventilation than PCV.
Spontaneous breathing during GA

Spontaneous Breathing during General Anesthesia

Positive-pressure ventilation causes a ventral

redistribution of ventilation. Spontaneous
breathing during general anesthesia with a laryngeal
mask airway (LMA) could prevent this
redistribution of ventilation.
Monitored
Purposes
Anesthesia Care • Safe sedation
(MAC)  wide spectrum of knowledge on sedatives and
analgesics available and degree of sedation is
individualized according to the medical condition
• A planned procedure of the
during which the • Comfort
patient undergoes
local anesthesia  administration of the proper dosage of anxiolytics
together with as a premedication can provide patient amnesia
sedation, and and comfort without compromising
analgesia is provided cardiovascular function
by an • Pain Control
anesthesiologist
 Adequate control of pain with analgesia during
and after the procedure
• Satisfaction
 4. Effective communication between
Preoperative Evaluation patients and the anesthesia care team is
vital for monitoring sedation levels,
providing verbal assurance, and
1. Preoperative evaluation same as general enhancing patient cooperation.
or regional anesthesia, requiring a 5. MAC may be chosen for patients with
comprehensive patient assessment. cardiovascular or respiratory instability,
2. Patient cooperation is important, but limitations arise with persistent
readiness for the procedure is determined cough or movement during microscopic
by assessing their ability to respond to procedures.
orders.
6. Preoperative evaluation focuses on
3. While general anesthesia may be an determining whether patients
alternative if patients cannot cooperate can cooperate without movement during
during MAC, there are no specific exclusion the procedure, emphasizing
criteria, making MAC suitable for the the importance of patient readiness for
elderly or high-risk individuals. MAC.
Preoperative Evaluation
1. Should be effective, applicable, noninvasive,
and economical
2. Patient oxygenation, ventilation, circulation,
and temperature must be monitored
continuously
3. Prevention of respiratory depression through
continuous respiratory monitoring is
essential during the infusion of
sedatives and analgesics
4. observe clinical signs continuously through
detection of arterial pulses and observation
of chest movement and the surgical field.
Monitoring the 1. The Observer Assessment of
Alertness/Sedation scale
3-4 (moderate level of
sedation-analgesia)​
Level of (OAA/S scale) 1-2 (unconsciousness)​
Consciousness • Measure the level of
consciousness in patients
>3 (required MAC)
sedated with midazolam
2.The Ramsay
Sedation Scale
(RSS)
• evaluate the level of
consciousness during
titration of sedative
medications in the
intensive care unit
3. Bispectral Index • Real time and continuous monitoring of
(BIS) the sedative level
• EEG variations, which correspond to
different levels of sedation
• Sedatives and analgesics specifically
change the frequency and amplitude of
EEG waves
• A decrease in the BIS was associated
with the incidence of amnesia during the
operation
Iowa Satisfaction with • Measuring patient satisfaction
Anesthesia during anesthetic experiences

Scale(ISAS)
Systemic Sedatives and Analgesics
Continuous infusion Complications
• velocity of the drug infusion can be determined • Airway obstruction
according to the patient’s level of consciousness and
clinical signs • Hypoxia
Target controlled infusion (TCI) • Cardiovascular collapse
• calculates the infusion velocity to obtain and maintain
specific plasma level or effect site concentration
targets, based on the patient’s pharmacokinetic
parameters
Patient controlled sedation (PCS)
• allows patients to administer intravenous drugs and
achieve a specific level of consciousness
• bolus injection and a lock out time
 Midazolam (most common)
Sedatives
• Typically co-injected with propofol
• used for amnesia and anxiety relief
• maximal CNS effects within 2–3 min
• level of sedation can be monitored
through patient communication and Propofol
hemodynamic variables • Faster cognitive function recovery
• Using PCS, the infusion rate of • Lower postoperative dizziness,
sedatives can be individualized amnesia, postoperative nausea and vomiting (PONV)
according to the patient’s needs.
• Do not have an analgesic effect, other opioid
• Ideal characteristics analgesics are often required
 rapid onset and recovery Dexmedetomidine and clonidine
 easy titration
• α2 agonists which results in a sedative-analgesic effect
 minimal respiratory and without respiratory depression
cardiovascular depression
• Dexmedetomidine is 8 times more selective for the α2
receptor than clonidine which relieves patient anxiety
• Analgesic properties and reduces opioid requirements
• leads to hypotension and bradycardia
• Onset and offset is slower than midazolam considering
delayed recovery
Analgesics Ketamine
• Does not cause clinically significant
• relieve the discomfort and pain
respiratory depression or PONV
Fentanyl (most common)
• Low dose ketamine-propofol has been
• onset of 3–5 min and duration of used for plastic surgery
45–60 min
• Ketamine-dexmedetomidine
Alfentanil combination is known to be effective in
• injected intermittently sedation and analgesia for pediatric
patients during MRI
Remifentanil
• ultra-short-acting opioid with a rapid Ketorolac (NSAIDS)
onset time (1 min) and • cause less adverse effects than opiods
short duration of action (3–10 min) such as pruritus and PONV
• ideal opioid for continuous • used as an adjunct analgesic during
infusion, and for managing pain local anesthesia or propofol infusion
related to surgical stimulation
•
Procedures Performed Under MAC
• Eye surgery • Pain procedures
• Otolaryngologic surgery • Gastroendoscopic procedure
• Inguinal herniorrhaphy • Flexible bronchoscopy
• Cardiovascular procedures • Neurosurgery
Regional Anaesthesia (Central)
TUAN NUR SYAHIRAH AMANI (1129200919460)

Regional anaesthesia is anaesthesia affecting

only a specific area of the body when the
patient is conscious; for example: foot, arm,
lower extremities, insensate to stimulus of
surgery / other instrument.
 • In practise, an epidural is

Epidural Anaesthesia sited adjacent to the nerve

root that supply the surgical
site;
o Lumbar region: pelvic &
• Deposition of a local lower limb surgery
anaesthetic drug into the o Thoracic region:
potential space outside the
dura. abdominal surgery
• This space extends from the • To aid identification of the
craniocervical junction if
epidural space, a technique
C1 to the sacrococcygeal
membrane. termed ‘loss of resistance’ is
used

A. 18 G Tuohy needle
B. 19 G catheter
C. Luer-lock connector for the
catheter
D. 10 mL low resistance syringe.
Extent of anaesthesia is determined
by: Indication
• spinal level of insertion of the • Hip & knee surgery
epidural: for a given volume, • Lower extremity vascular
spread is greater in thoracic surgery
region than in the lumbar • Lower extremity amputation
region. • Obstetrical- Labor & C/S
• Volume of local anaesthesia • Thoracic surgery– Post-op pain
injected control
• Gravity: tip the patients head • Thoracic trauma
down encourages spread • Abdominal surgery- Post-op
cranially. • Control
Spinal Anaesthesia
• Injection of a local anaesthetic drug directly into
cerebrospinal fluid (CSF) within the subarachnoid
space through the skin and interspinous ligament.
• The spinal needle can be inserted below the second
lumbar and above the first sacral vertebra; the upper
limits is determined by the termination of the spinal
cord and the lower limit because the sacral vertebrae
are fused and access becomes virtually imposable.

Needle
• 24-29 G needle
• Pencil point / tapered point
• Wide bore ‘introducer’ needle is inserted to aid
passage of the needle.
Factor influencing the spread:
• Specific gravity (baricity) of the
anaesthetic solution relative to CSF.
• Positioning of the patient either Indication
during or after the injection. • Lower abdominal surgery
• Sitting position • Inguinal surgery
• Supine position —> extend to • Urogenital surgery
thoracic nerves around T5-6, • Rectal surgery
• Increasing the dose (volume and / or • Lower extremity surgery
concentration) of local anaesthetic • Lumbar spinal surgery
drug. • Obstetrical- C/section
• The higher the placement of the
spinal anaesthetic in the lumbar
region, the higher the level of the
block obtained
Contraindication to epidural and spinal
anaesthesia
• Hypovolaemia: as a result of either blood loss or • Raised intracranial pressure: a risk of precipitating
dehydration. Such patients are likely to experience coning.
severe falls in cardiac output as any compensatory • Known allergy to amide local anaesthetic drugs.
vasoconstriction is lost. • A patient who is totally uncooperative.
• A low, fixed cardiac output: as seen with severe • Concurrent disease of the central nervous
aortic or mitral stenosis. The reduced venous return system(CNS): some would caution against the use of
further reduces cardiac output, jeopardizing these techniques for fear of being blamed for any
perfusion of vital organs. subsequent deterioration.
• Local skin sepsis: risk of introducing infection. • Previous spinal surgery or abnormal spinal
• Coagulopathy: as a result of either a bleeding anatomy: although not an absolute contraindication,
dathesis (for example, haemophilia) or therapeutic epidural or spinal anaesthesia may be technically
anticoagulation. This risks causing an epidural difficult.
haematoma. There may also be a very small risk in
patients taking aspirin and associated drugs that
reduce platelet activity. Where heparins are used
perioperatively to reduce the risk of deep venous
thrombosis, these may be started after the insertion
of the epidural or spinal.
Regional
anesthesia
Peripheral : Upper
limb block & lower
limb block

Presented by:
M. Khaled Hamwi
1129200919502
There are multiple locations for each block depends on the area needed.
• Upper extremity blocks (interscalene, suprascapular, infraclavicular, axillary,
intercostobrachial, wrist, and digital nerve blocks.)
• Lower extremity blocks (lumbar plexus (psoas compartment), femoral nerve
block, fascia iliaca, obturator nerve, popliteal, saphenous, ankle, and digital
nerve block.)
Upper limb block: Brachial plexus block
Lower limb block:
Lumbosacral
plexus block
• In the technique, known as a nerve block, local anesthetics are applied to a targeted set of
nerves to block sensation and movement. Patients feel no pain or discomfort in the
targeted area, and they may choose to remain fully conscious or to receive mild
sedatives to lessen anxiety and feel more comfortable.
• For peripheral nerve blocks, the local anesthetic agent is injected near the nerve and
diffuses along with the nerve's mantle layer to the core. Anesthesia is achieved slowly after
infiltration in a proximal to distal direction on the nerve distribution to the injection point.
• Ultrasound guidance and nerve stimulator techniques are typically used to locate the
anatomic structures and define the placement of the needle or catheter.
 Electrical nerve stimulations
Low-intensity (up to 5 mA) ,
short-duration (0.05-1 ms)
electrical stimulus (at 1-2 Hz
repetition rate) to obtain a
defined response (muscle twitch
or sensation) to locate a
peripheral nerve or nerve plexus
with an (insulated) needle.

The goal is to inject a certain

amount of local anesthetic in
close proximity to the nerve.
• Advantages: Disadvantages:
• Can be performed in all age, • Difficult in obese
• Avoid multiple drug Administration • Need expertise
• Early recovery • Nerve injury
• Excellent analgesia • Local anesthetic toxicity
• No GA complications
Indications: Contraindications:
• Surgical procedure involving the area. • Uncooperative patient,
• Fracture reduction • High bleeding tendency
• Postoperative pain relief (anticoagulant, hemophilia),
• Chronic pain management. • Infection
• Complex Regional Pain Syndrome • Peripheral neuropathy.
Complications
1. Nerve Injury: Needle insertion or local anesthetic toxicity can lead to temporary or permanent sensory
or motor nerve damage.
2. Infection: Although rare, infection at the injection site is a potential complication, necessitating strict
aseptic technique.
3. Bleeding or Hematoma: Hematoma formation at the injection site may occur, causing nerve
compression and potential compromise of blood flow.
4. Vascular Puncture: Accidental blood vessel puncture during needle insertion can result in hematoma
or systemic toxicity from local anesthetic.
5. Local Anesthetic Systemic Toxicity (LAST): Rare but serious, systemic absorption of local anesthetic
may lead to seizures, cardiovascular collapse, or respiratory arrest.
6. Allergic Reactions: Although uncommon, allergic reactions to local anesthetics or injectate
components are possible.
7. Neurological Symptoms: Transient post-block neurological symptoms, like tingling or weakness, may
occur but are usually temporary.
8. Pneumothorax (for Brachial Plexus Blocks): In brachial plexus blocks, accidental pleural puncture and
pneumothorax formation are rare but serious complications.
References:
• Folino TB, Mahboobi SK. Regional Anesthetic Blocks. Nih.gov. Published January 29, 2023.
• Regional Anesthesia for Orthopedic Surgery | Nerve Blocks. Hospital for Special Surgery.
Published 2023. ‌
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