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Introduction To Anaesthesia
Introduction To Anaesthesia
An introduction to anaesthesia
Introduction divided into three stages: induction, main- n Central neuraxial block, e.g. spinal or
Anaesthetic experience in the undergradu- tenance and emergence. epidural (Figure 1 and Table 1).
ate timetable is often very limited so it can In regional anaesthesia, nerve transmis-
remain somewhat of a mysterious practice sion is blocked, and the patient may stay Components of a general
well into specialist training. This introduc- awake or be sedated or anaesthetized dur- anaesthetic
tion to the components of an anaesthetic ing a procedure. Techniques used include: A general anaesthetic always involves an
will help readers to get more from clinical n Local anaesthetic field block hypnotic agent, usually an analgesic and
attachments in surgery and anaesthetics or n Peripheral nerve block may also include muscle relaxation. The
serve as an introduction to the topic for n Nerve plexus block combination is referred to as the ‘triad of
novice or non-anaesthetists. anaesthesia’.
Figure 1. Schematic vertical longitudinal section The relative importance of each com-
Types and sites of anaesthesia of vertebral column and structures encountered ponent depends on surgical and patient
The term anaesthesia comes from the when performing central neuraxial blocks. * factors: the intervention planned, site,
Greek meaning loss of sensation. negative pressure space filled with fat and surgical access requirement and the
Anaesthetic practice has evolved from a venous plexi. † extends to S2, containing degree of pain or stimulation anticipated.
need for pain relief and altered conscious- arachnoid mater, CSF, pia mater, spinal cord The technique is tailored to the individu-
ness to allow surgery. Early anaesthetics above L1/2 and spinal nerves. al situation.
used plant derivatives with later introduc- Ligamentum Epidural space*
tion of ether, inhaled gases and chloro- flavum Induction
form. Modern anaesthesia has been devel- (tough) The induction of anaesthesia refers to the
oped and refined to enable surgery, inter- transition from an awake to an anaesthe-
Spinous Vertebral
ventions, pain relief and stabilization, and tized state. This end point can be ill defined
process body
organ support. and the process of induction is a time of
Various forms of anaesthesia are con- physiological disruption with multi-system
Dural Intervertebral
ducted throughout the hospital and sac† disc effects.
beyond. The operating theatres are the
most common venue but anaesthetics are Standard induction
delivered on the labour ward, day surgery, Intravenous
intensive care, the emergency room, The standard induction is with the intra-
interventional radiology, computed venous agent propofol. A calculated by
tomography and magnetic resonance Dura mater weight dose is delivered and the effects
imaging, and on the wards during emer- Supraspinous Interspinous reviewed before further titration of the
Posterior Anterior
gency care and transfer of acutely unwell ligament ligament drug. Delays in inducing anaesthesia may
longitudinal longitudinal
patients. Certain regional procedures ligament ligament represent slow arm–brain circulation time
may take place in pain clinics and out- (e.g. elderly, cardiovascular disease),
patient settings.
In general anaesthesia a reversible state Table 1. Characteristics of different central neuraxial blocks
of unconsciousness is achieved. It can be
Dr Ciara Donohue is Specialist Registrar Subarachnoid (spinal) Epidural
in Anaesthesia in the Centre for Anaesthesia,
University College London Hospitals,
London NW1 2BU, Mr Ben Hobson
is Medical Student at University College
London, London, and Dr Robert CM Injection through dura into CSF Catheterization of potential space outside dura
Stephens is Consultant Anaesthetist, Low volume (up to 3 ml) High volume (>10 ml)
University College London Hospitals and
High concentration local anaesthetic 0.5% bupivicaine Variable concentration local anaesthetic, analgesia
Honorary Senior Lecturer in the Centre for
0.1% bupivicaine, anaesthesia up to 2% lignocaine
Anaesthesia, University College London,
London Rapid onset dense sensorimotor block Gradual titration of block density, may be motor
sparing
Correspondence to: Dr C Donohue Profound vasodilation causing haemodynamic instability Gradual titration causing less haemodynamic
(ciaradonohue@doctors.org.uk) disturbance
preoperative visit, history, examination and effector site concentration can be dialled systemic effects of anaesthesia vary with the
review of investigations and previous up alongside basic patient demographics drugs used so different agents are favoured
anaesthetic charts contribute to the assess- (age, sex, weight) and the pump adjusts the in different clinical contexts. In general,
ment of the airway and perioperative plan- rate of infusion to achieve the specified intravenous (propofol and thiopentone)
ning (Cranshaw and Cook, 2011). drug concentration. This is known as a and volatile agents all reduce blood pres-
target controlled infusion. Effective secure sure as a result of vasodilation, and negative
Maintenance intravenous access is crucial. inotropy and chronotropy. Starting posi-
Maintenance of anaesthesia refers to keep- The choice of maintenance technique tive pressure ventilation (i.e. ventilating
ing a patient unconscious and can be may be determined by surgical and patient someone) can impede venous return to the
achieved using inhaled volatile agents or factors and the experience of the anaes- heart, reducing preload and cardiac output.
continuous infusion of intravenous agents. thetist. Total intravenous anaesthesia is The sympathetic stimulation from surgery
Volatile agents are most commonly used, often used in day surgery, neurosurgery or opposes these changes.
delivered via vaporisers found on the ‘back if patients get severe postoperative nausea Intravenous (propofol, thiopentone and
bar’ of the anaesthetic machine which feed and vomiting as it avoids emetogenic etomidate) and volatile agents are all respi-
into the breathing circuit. The concentra- volatiles and enables rapid recovery with ratory depressants and depress airway
tions of the inhaled agents are measured minimal hangover effect (Yuill and reflexes to differing degrees. Propofol is
and displayed. Expired end tidal concen- Simpson, 2002). particularly effective at inducing transient
tration is equivalent to the alveolar concen- apnoea and depressing airway reflexes
tration which in turn represents the con- Systemic effects of general facilitating placement of supraglottic
centration at the site of action (CNS). This anaesthesia devices post induction. Of the volatile
gives the anaesthetist an idea of the amount General anaesthesia leads to multi-system agents, sevoflurane is the least irritant to
of anaesthetic agent reaching the patient physiological changes (Tables 3 and 4). The airways making it particularly suitable for
and the likely depth of anaesthesia. The
minimal alveolar concentration is the alve- Table 3. Systemic effects of general anaesthesia
olar concentration of a volatile agent which
when given alone prevents movement in System Common anaesthetic agents Ketamine
50% of healthy volunteers to a standard Cardiovascular Hypotension: mean arterial pressure = (heart rate Normotension or hypertension
surgical stimulus (e.g. skin incision). The x stroke volume) x systemic vascular resistance
minimal alveolar concentration varies
Vasodilation (↓systemic vascular resistance) Tachycardia
between different volatile agents inversely
related to their potency (as their structures Negative chronotropy (↓heart rate)
vary) and is also affected by other pharma- Negative inotropy (↓stroke volume)
cological and physiological variables (Yentis Respiratory Loss of airway reflexes and tone Airway reflexes and tone maintained
et al, 2009).
Intravenous maintenance of anaesthesia Bronchodilation
can be achieved with infusions of propofol GastrointestinalI Propofol = antiemetic Salivation
with or without an opioid delivered via a Volatiles = emetogenic Emetogenic
pump. Several pharmacokinetic models
CNS Hypnosis Dissociative anaesthesia, analgesia,
have been developed which map the theo- hallucinations
retical body compartments among which a
From Sasada and Smith (2008)
drug distributes. The desired plasma or
Conclusions P, Kenny G, eds. Basic Physics and Measurement in Care. 3rd edn. Cambridge University Press,
Anaesthesia. 5th edn. Butterworth-Heinemann, Cambridge: 99–102
Anaesthesia is an enormous subject and London: 171 Sasada M, Smith S (2008) Drugs in Anaesthesia and
this article is merely a tip of the iceberg Doherty M, Buggy D (2012) Intraoperative fluids: Intensive Care. 3rd edn. Oxford University Press,
introduction to some types of regional and how much is too much? Br J Anaesth 109(1): Oxford
69–79 Sinclair RCF, Luxton MC (2005) Rapid sequence
general anaesthesia. Harper CM, Andrzejowski JC, Alexander R (2008) induction. Contin Educ Anaesth Crit Care Pain
Anaesthetists, while developing special- NICE and warm. Br J Anaesth 101(3): 293–5 5(2): 45–8
ized airway skills and a deep understanding King JM, Hunter J (2002) Physiology of the Walker A, Reshamwalla S, Wilson I (2012) Surgical
neuromuscular junction. Br J Anaesth CEPD safety checklists: do they improve outcomes? Br J
of physiology and pharmacology, need an Reviews 2(5): 129–33 Anaesth 109(1): 47–54
holistic approach and broad knowledge Knight DJW, Mahajan RP (2004) Patient Yentis S, Hirsch N, Smith G (2009) Anaesthesia and
base because of the varied nature of their positioning in anaesthesia. Contin Educ Anaesth Intensive Care A-Z. 4th edn. Churchill
Crit Care Pain 4(5): 160–3 Livingstone, London: 354
role. Anaesthetists will come into contact Peck TE, Hill S, Williams M (2008) Core drugs in Yuill G, Simpson M (2002) An introduction to total
with approximately two thirds of hospital anaesthetic practice. In: Peck TE, Hill S, Williams intravenous anaesthesia. Br J Anaesth CEPD
patients in a diverse range of clinical con- M, eds. Pharmacology for Anaesthesia and Intensive Reviews 2(1): 24–6
texts and environments. Hopefully this
article has whetted your appetite to know
more or given you a fresh insight into a
KEY POINTS
specialty which is taking place in all cor- n Anaesthesia means loss of sensation and can be divided into regional anaesthesia (blockade of nerve
ners of your hospital. BJHM transmission) or general anaesthesia (a reversible state of unconsciousness).
Conflict of interest: none. n General anaesthesia often comprises a triad of hypnosis, analgesia and muscle relaxation.
n General anaesthesia can be divided into three stages: induction, maintenance and emergence.
Al-Shaikh B, Stacey S (2007) Non invasive
monitoring. In: Al-Shaikh B, Stacey S, eds. n Under general anaesthesia airway tone and reflexes are lost and the airway must be maintained
Essentials of Anaesthetic Equipment. 3rd edn.
Churchill Livingstone, London: 151–3 with manual manoeuvres, adjuncts (Guedel, laryngeal mask airways) or definitive devices which also
Appiah-Ankam J, Hunter J (2004) Pharmacology of protect the airway from regurgitation and aspiration (e.g. endotracheal tubes).
neuromuscular blocking drugs. Contin Educ
Anaesth Crit Care Pain 4(1): 2–7 n General anaesthesia leads to multi-system physiological changes particularly at induction and
Cranshaw J, Cook T (2011) Airway assessment and emergence.
management. In: Allman K, Wilson I, eds. Oxford
Handbook of Anaesthesia. 3rd edn. Oxford n Other aspects of perioperative care central to anaesthetic practice include thermal homeostasis, fluid
University Press, Oxford: 970–6
Davis P, Kenny G (2007) Biological Electrical
balance, positioning, avoidance of awareness, analgesia and patient safety.
Potentials: Their display and recording. In: Davis
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