Professional Documents
Culture Documents
Anesthesia NOTES PDF
Anesthesia NOTES PDF
Anesthesia NOTES PDF
Newer Drugs: Phase I- onset of automatic respiration and ends in cessation of eyeball
Fluorinated volatile anesthetic movement
1. halothane Phase II- cessation of eyeball movement to commencement of intercostals
2. enflurane- theoretical risk of seizure, not used in epileptic Px paralysis
3. isoflurane Phase III- commencement of intercostal paralysis to complete intercostal
4. sevoflurane paralysis
5. desflurane Phase IV- complete intercostal paralysis to diaphragmatic paralysis
*3,4,5-> commonly used today: 3,4,5- substituted halogenated ether
*Halothane- substituted halogenated alkane STAGE IV:
- breathing and circulation stops
Drugs difficult to use or administer due to: - cardiac arrest and death
1. narrow margin of safety of inhalational anesthetic - stage of overdosage
2. variability among patients- severe side effects because of variations of pts
- therefore must be used in titration; requires continuous monitoring *stages of anesthesia is best appreciated using ether
*most useful signs:
To produce its pharmacologic effects: eyelash reflex
drug administration at an adequate dose eyeball movement
sufficient potency dilation of pupils
deliver to active site of action changes in respiration - Most sensitive indicator of depth of
site of action: Brain anesthesia!
site of entry: lung
*Brief Procedures- start incision at stage III, phase I
STAGES OF ANESTHESIA: *long procedures (explore lap)- start at stage III, phase II; px may react to
- introduced by Arthur Guedel insertion of ETA
*surgeons should not start operation unless okayed by anesthesiologist
STAGE I:
- begins in induction and ends in loss of consciousness 3 GENERAL ANESTHESIA PHASES
- use eyelid reflex I. Induction
- eyelid reflex is lost - induce patient to sleep; critical period since anything can happen to
- analgesia and amnesia patient
- take vital signs as often as possible even at 3-5 mins
- occurs when anesthetizing partial pressure has been achieved by the brain anesthetizing partial pressure must be given in high
brain in high concentration concentration
- unique in a way since respiratory tract used as entry
- immediately during induction, give 3% to achieve anesthetizing partial 3. Alveolar Ventilation
pressure - faster ventilation, the more rapid is the uptake
III. Emergence/ Recovery Phase Barometric pressure- decrease with higher altitude
- lowers concentration of anesthetic so that partial pressure in the brain also - Higher conc. is needed in inc. altitude vs. in lower altitude because
lowers vagometric pressure is lower therefore decrease in pressure
Presenting symptoms of local anesthetic overdose during GA: If early symptoms cannot be recognized pt. goes to excitatory stage/phase
1. cardiac dysrhythmia -restlessness/ agitation
2. circulatory collapse -nervousness
- Paranoia
* Lidocaine in low conc. can provide treatment of arrhythmia
From CNS excitation CNS depression
* Bupivacaine cardiotoxic among the LA because it bounds stronger to NA Slurring of speech
channels and is compounded in pregnancy by hypoxemia & respiratory acidosis Drowsiness
- associated with pronounced depolarization changes Unconsciousness
-binding to cardiac Na channel at 1 degree of CHON binding, resuscitation more
prolonged & difficult to reverse Muscle twitching heralds onset of tonic clonic seizure convulsion continue
respiratory arrest
Excitatory reaction due to selective blockade of inhibitory pathways if LA is given - aggravated by:
esp. local infiltration, best precautionary measure is to give pt. benzodiazepine- hypovolemia
threshold of induced seizure individuals above 40 y.o.
block higher than T4 or T5
Management: - management:
1. oxygenate pt. patent airway maintained a. load patient with crystalloids or colloids before procedure
2. give anticonvulsant 250 mL to 1000 mL
If convulsion last > 15 min hypoxia 10-20 mL/kg BW
*Diazepam- onset of effect is delayed instead give thiopental (barbiturate) has b. after spinal anesthesia:
rapid of effect; if still ineffective may use m. relaxants such as succinylcholine give fluids: fast drip 50 cc
(muscle relaxant of choice) which has a rapid onset of effect if no increase in BP: sympathomimetic drugs or vasopressor drugs
epinephrine for profound hypotension
Pt. with ICP
- give lidocaine 1.5mg/kg to attenuate ICP sympathetic stimulation (pt. not *sensory level 2 dermatomes above block
yet adequately anesthetized) * motor level 2 dermatomes below block
* LP above L3 or L4 produces increased level of sympathetic block
Cocaine- stimulate CNS, causes sense of euphoria * Baseline systolic pressure <120/80 mm Hg also increases level of
- restlessness, emesis, tremors, convulsions & respiratory failure during cocaine sympathetic block
toxicity 2. Bradycardia
- occurs secondary to unopposed vagal tone from the high sympathetic
Systemic Toxicity of Local Anesthetics block
Precaution: - cardiac accelerator fibers at level of T1-T4
1. When you give LA, be ready with E drugs - management: anti-cholinergics (atropine sulphate)
Epinephrine for hypotension, if HR cannot be 3. Increased sensitivity to sedatives
Atropine- for bradycardia - due to the loss of peripheral input to reticular activating system
2. Pt. must be monitored constantly for s/symptoms of toxicity, injection may be 4. Nausea and vomiting
stopped, must be given early recognition and prompt treatment - secondary to hypotension
3. large doses of LA best administered in divided doses w/ frequent aspiration - decreased cerebral blood flow to vomiting center
- dose of any drug mistakenly given/ N may be limited 5. Post-dural puncture headache
4. Add epinephrine solution slows uptake of drugs & provide sensitive marker for - delayed complication
side effects like tachycardia - results from a leak in the dura mater losing CSF
5. Benzodiazepines may serve as anticonvulsant - post-spinal headachce
- dose required may be observed by CNS toxicity - not produced by epidural anesthesia
- severe headache at occipital area
SPINAL, EPIDURAL AND CAUDAL ANESTHESIA - change of position, upright position
- major conduction blockade anesthesia - use the smallest spinal needle possible
- position of needle upon insertion: bevel should face upwards
Complications: - management:
1. Hypotension a. analgesics
- immediate effect of spinal anesthesia b. hydration
- loss of sympathetic mediated peripheral resistance or venous c. abdominal binder to increase ICP
capacitance vessels d. supine position for at least 6 hours
- vasodilation -> pooling of blood -> decreased IV return -> decreased e. epidural patch autologous blood, 20 mL
cardiac output -> decreased BP
6. Total spinal 1. infection at injection site
- local anesthetic depression of the cervical spinal cord and brainstem 2. severe hypovolemia
- total sympathetic block 3. bacteremia
- SSx: dysphonia, dyspnea, upper extremity numbness, loss of 4. infection at the site of procedure
consciousness, papillary dilation, hypotension, bradycardia, cardiac 5. intracranial hypertension
arrest 6. severe valvular stenotic lesion
- management: B. Relative contraindications
a. ventilation 1. low back pain
b. support circulation (increase BP, increase HR) with vasopressor 2. sepsis
drugs or atropine sulfate 3. progressive degenerative/demyelinating neurologic diseases
c. volume infusion
Factors that determine effect:
A. Spinal Anesthesia 1. resorption of anesthetic agent from CSF into the systemic circulation
- subarachnoid block 2. patient characteristics
- deposition of local anesthetic in the SAS a. height
- landmark: CSF b. position
- lumbar subarachnoid puncture c. intraabdominal pressure increased intraabdominal pressure spreads
- below L1 in adults; below L3 in children local anesthetic to a higher extent
- principal site of effect: spinal nerve roots and spinal cord d. anatomic position of spinal cord or configuration of the spinal cord
- Tuffiers Line: point between the 2 iliac crests corresponding to L2 and L3 e. pregnancy
- subarachnoid space ends at S2 f. CSF volume
3. direction of the needle
*Lateral approach - L1-L5
- ideal for elderly patients - betweenL1 and L2: higher spread of local anesthetic
- bypass the ligaments and arthritic structures - direction of bevel upward/downward
- structures pierced: - total injected dose
1. skin 4. baricity
2. subcutaneous tissue - ratio of density of CSF to density of the local anesthetic
3. ligamentum flavum - >1: hyperbaric gravitates to dependent areas
4. dura mater - 1: isobaric
5. arachnoid mater - <1: hypobaric solution will float
C. Caudal Anesthesia
- a form of epidural anesthesia
- sacral hiatus (S5)
- dense, lower levels of block
- ideal for herniorrhaphy in children
- limitation: highly variable onset in adults
- risk of injection into the venous plexus
- difficulty of maintaining stability
Advantages:
1. avoidance of airway manipulation useful in asthmatics, difficult
intubation, full stomach
2. decreased stress response HPN and tachycardia is less
3. decreased thrombogenesis and subsequent thromboembolism in
orthopaedic hip surgery
4. improved bowel motility with less distention
5. less post-op nausea and sedation
6. better post-op pain control abdominal surgery
7. less pulmonary dysfunction