Anesthesia

• Is an induced state of partial or total loss of

sensation, occurring with or without loss
of conscience.
• Anesthesia is defined as the absence of
normal sensation. This also includes loss
of protective reflexes!
• Anesthesia provides:
amnesia – analgesia – muscular relaxation
 History of Anesthesia

• Ether synthesized in 1540 by Cordus

• Ether used as anesthetic in 1842 by Dr.
Crawford W. Long
• Ether publicized as anesthetic in 1846 by Dr.
William Morton
• Chloroform used as anesthetic in 1853 by Dr.
John Snow
History of Anesthesia
 History of Anesthesia

• Endotracheal tube discovered in 1878

• Local anesthesia with cocaine in 1885
• Thiopental first used in 1934
• Curare first used in 1942 - opened the “Age of
Anesthesia”
 Purposes of Anesthesia

• To produce muscle relaxation

• To produce analgesia
• To produce artificial sleep or to cause loss of
consciousness
• To block transmission of nerve impulses
• To suppress reflexes
 Selection of anesthesia is influenced by
the following:
• Type and duration of the procedure
• Area of the body having surgery
• Safety issues to reduce injury, such as airway
management
• Whether the procedure is an emergency
• Options for management of pain after surgery
• How long it has been since the client ate, had any
liquids, or any drugs
• Client position needed for the surgical procedure
 General anesthesia
• Is a reversible loss of consciousness induced by
inhibiting neuronal impulses in several areas of
the central nervous system
• General anesthetics are agents that block the
pain stimulus at the cortex
Produces a state of the:
➢ Analgesia
➢ Amnesia
➢ Unconsciousness characterized by loss of
reflexes and muscle tone
 Stages of General anesthesia
Stage 1 (analgesia and sedation, relaxation):
1. Begins with induction and ends with loss of
consciousness
2. Client feels drowsy and dizzy, has a reduced
sensation to pain and is amnesic
3. Hearing is exaggerated
Nursing Intervention
1. Close operating room doors, dim the lights,
and control traffic in the operating room
2. Position client securely with safety belts
❑ Stage 2 (Excitement, delirium):
• Characterized by struggling, shouting,
laughing, singing or crying--- maybe prevented
if anesthetic is administered smoothly and
quickly
• Client may have irregular breathing, increased
muscle tone, and involuntary movement of
the extremities during this stage
• Laryngospasm or vomiting may occur
• Pupils dilate but contract if exposed to light
Nursing Intervention
1. Avoid auditory and physical stimuli
2. Protect the extremities
3. Assist the anesthesiologist or CRNA with
suctioning as needed
4. Stay with client.
Stage 3 ( Operative anesthesia, surgical
anesthesia)
1. Begins with generalized muscle relaxation
and ends with loss of reflexes and
depression of vital function
2. Pupils are small but contract when exposed
to light. Respirations are regular, the pulse
rate and volume are normal, and the skin is
pink or slightly flushed
3. The jaw is relaxed, and there is quite, regular
breathing.
4. The client cannot hear
5. Sensations are lost
Nursing Intervention
1. Assist the anesthesiologist with intubation
2. Place patient into operative position
3. Prepare the clients skin over the operative
site as directed.
Rationale
1. Providing assistance helps promote smooth
intubation and prevent injury

2. Performing procedures as soon as possible

promotes time management to minimize
total anesthesia time for the client.
Stage 4 (Danger)
1. Begins with depression of vital function and ends
with respiratory failure, cardiac arrest, and possible
death
2. Respiratory muscles are paralyzed; apnea occurs
3. Pupils are fixed and dilated.
Nursing Intervention
1. Prepare for and assist in treatment of cardiac and /or
pulmonary arrest
2. Document occurrence in the client’s chart.
Rationale
1. Teamwork and preparedness help decrease injuries
and complications, and promote the possibility of a
desired outcome for the client
Depth of anesthesia
CNS depression which is caused by accumulation of the anesthetic drug in
the brain (corex, subcortex, midbrain, spinal cord, medullary centers).

Stage I—Analgesia: Loss of pain sensation. The patient is conscious and

conversational.

Stage II—Excitement: The patient experiences violent combative

behavior. There is a rise and irregularity in blood pressure. The respiratory
rate may increase

Stage III—Surgical anesthesia:

Regular respiration and relaxation of the skeletal muscles.
Eye reflexes decreased progressively, until the eye movements cease and
the pupil fixed. Surgery may proceed during this stage.

Stage IV—Medullary paralysis: Severe depression of the respiratory and

vasomotor centers occur during this stage. Death can rapidly ensue unless
measures are taken to maintain circulation and respiration.
 General Anesthetics
Signs and Stages of Anesthesia
(Somewhat related to the response from Diethyl Ether):

1. Analgesia. Mild CNS depression. Suitable for surgical procedures not

requiring muscle relaxation. All anesthetics do not produce analgesia.

2. Delirium: An excited state resulting from cortical motor depression.

This can be avoided with rapidly acting, potent anesthetics. This stage
extends from the lack of consciousness in stage 1 to surgical anesthesia
in stage 3.

3. Surgical Anesthesia: Further subdivided into stages representative of

increasing muscle relaxation, the final stage is disappearance of muscle
tone.

4. Respiratory paralysis: Generally not desirable.

19
 Administration of General Anesthesia
Inhalation-
a. Gaseous Agent – nitrous oxide is
the most common used agent and
is usually given with oxygen. It is
colorless, odorless gas that provides
analgesia
b. Volatile agents – liquid agents
vaporized for inhalation. O2 is the
carrier, flowing over or bubbling
through the liquid in the vaporizer
system on the anesthesia machine.
 Intravenous injection- administered through a
vein. The patient feels a simple, pleasant and rapid
induction. Unconsciousness generally occurs about
30 seconds to 1 minute after the initial IV
administration.

1. Barbiturates – it acts rapidly, causing unconsciousness

within 30 seconds. Ex: Thiopental Na ( Penthotal Na)
2. Ketamine (Ketalar) – ketamine is a dissociative
anesthetic agent. Rapid onset of a trancelike, analgesic
state occur. Often used for diagnostic and short surgical
procedures.
3. Propofol (Diporivan) – is a short acting anesthetic agent.
Hypnosis occurs in less than 1 minute from the time of
injection. The drug is eliminated rapidly and the client
becomes responsive within 8 minutes after the infusion
ends.
Adjuncts to General anesthetic Agents
• Sedatives – common drugs in the class include
midazolam (Dormicum) and diazepam (Valium). All have
hypnotic, sedative, muscle relaxant, and amnesic effects

• Opioid analgesics (narcotics)– common opioid analgesic

enhance anesthesia include morphine sulfate,
meperidine, fentanyl and sufentanil

• Neuromuscular Blocking Agents – are used to relax the

jaw and vocal cords immediately after induction so that
the endotracheal tube can be placed. This is used to
provide continued muscle relaxation. Ex: Succinylcholine
 Potential Complications of
General Anesthesia
• Overdose
• Unrecognized hypoventilation
• Complications of intubation
• Anaphylaxis
• Hypothermia
• Injury r/t positioning, burns
• Malignant hyperthermia
 Malignant Hyperthermia
• Rare but extreme emergency
• Occurs most often with inhalants
• Genetic predisposition
• Uncontrolled acceleration of muscle
metabolism and increased BMR
• Life threatening elevated temperature,
hyperkalemia, acidosis
 Emergency Treatment of
Malignant Hyperthermia

• Stop surgical procedure/anesthesia if possible

• Hyperventilate with 100% oxygen
• Administer DANTROLENE intravenously
• Undertake body cooling measures:
Iced NS intravenously
Cooling blanket
 Local anesthesia
• Injection of a solution containing anesthetic into the
tissues at the planned incision site.
• Briefly disrupts sensory nerve impulse transmission
form a specific body area or region.

Advantages:
• Simple, economical, and non-explosive
• Equipment needed is minimal
• Post operative recovery is brief
• Undesirable effects of GA are avoided
• Ideal for short and superficial surgical procedures
 Local Anesthesia
Advantages Disadvantages

• Client remains • Client remains

conscious conscious
• Cost effective • Potential for local tissue
• Minimal recovery time irritation
• Vasoconstrictive agents • Potential for sudden
decrease bleeding systemic reaction such
as hypotension
Types of Local anesthesia
1. Topical anesthesia – topical agents are
applied directly to the area of skin or
mucous membrane surfaced to be
anesthetized

2. Local infiltration – is the injection of an

anesthetic agent directly into the tissue
around an incision, wound, or lesion.
 Spinal Anesthesia
• Indications
-surgical procedures below the diaphragm
-patients with cardiac or respiratory
disease
• Advantages
-mental status monitoring
-shorter recovery
• Disadvantages
-necessary extra expertise
-possible patient pain
• Contraindications
-coagulopathy
-uncorrected hypovolemia
 Spinal Anesthesia
• Involved medications
-lidocaine
-bupivacaine
-tetracaine
• Patient assessment
-continuous heart rate, rhythm, and pulse
oximetry monitoring
-level of anesthesia
-motor function and sensation return
monitoring
 Spinal Anesthesia
• Complications
-hypotension
-bradycardia
-urine retention
-postural puncture headache
-back pain
 Spinal analgesia

• Indications
-postoperative pain from major surgery
• Involved medications
-lipid-soluble drugs
-preservative-free morphine
• Monitoring recovery
-respiratory depression
-urine depression
-pruritus
-nausea and vomiting
 Regional Anesthesia
A form of local anesthesia in which an
anesthetic agent in injected around the nerves
so that the area supplied by the nerves is
anesthetized.

The patient receiving RA is awake and aware of

his surroundings unless medications are given
to produce mild sedation or to relieve anxiety.
 Regional Anesthesia Types
• Field Block
Injected around the operative field
• Nerve Block
Into or around a nerve or nerve group
• Spinal
Into subarachnoid space
• Epidural
Into epidural space
Administration of Regional Anesthesia
• Spinal Anesthesia-
produces a nerve block in
the subarachnoid space
by introducing a local
anesthetic at the lumbar
level, usually between L4
and L5.

• Autonomic nerve fibers

are the first affected and
the last to recover
 Peripheral nerve blocks
⦿ Blockade of brachial plexus, lumbar plexus, and
specific peripheral nerves via injection of local
anesthetic solutions into tissues surrounding
individual peripheral nerves or nerve plexuses
• Local anesthetics deposited near the vicinity of the
nerve diffuses from the outer surface (mantle) to
the center (core) of the nerve along a
concentration gradient
– Proximal structure: mantle
– Distal structures: core
 Peripheral Nerve Block
• Advantages:
– reduced physical stress (compared to central neuraxis anesthesia)
– Avoids airway manipulation and complications associated with endotracheal
intubation
– Indwelling catheters may be placed for prolonged block and analgesia
– Provides surgical anesthesia and postoperative analgesia
• Requirements:
– Cooperative patient
– Skilled anesthesiologist
– Surgeon accustomed to operating on awake patients
 Head and nECK
• Intracranial Blocks
– Neurosurgery and Scalp Surgeries
• Eye Blocks
• Face Blocks
• Ophthalmic Nerve Block
• Maxillary Nerve Block
• Mandibular Nerve Blocks
• Cervical Plexus Blocks
Handbook of Regional Anesthesia (ESRA) 2007
 Upper limb BLOCKS
• Interscalene block
• Supraclavicular
blocks
• Infraclavicular
blocks
• Axillary block

Handbook of Regional Anesthesia (ESRA) 2007

 Lower limb
BLOCKS
• Lumbar plexus block
• Iliofascial block
• Obturator block
• Sciatic blocks
• Ankle blocks

Handbook of Regional Anesthesia (ESRA) 2007

 Advantages
• Eliminates the need for expensive equipments
and drugs
• Relatively safe method of anesthesia
• Provides excellent method of anesthesia
• Does not cloud the patient’s consciousness or
alertness
• Useful for patients with respiratory or cardiac
problems
 Regional Anesthesia
Advantages Disadvantages

• Patient remains • Patient remains

conscious conscious
• No respiratory • Circulatory
depression or irritation depression/stasis
• Enhanced pain • Potential
management post- trauma/infection @ site
operatively of injection
• Edema - potential for
spinal headache
 Complications
• Hypotension
• Headache
• Post op paralysis
• Nausea and vomiting
• Urine retention
 Epidural Anesthesia
• A commonly used conduction block by
injecting a local anesthetic into the epidural
space that surrounds the dura matter of the
spinal cord
• Blocks sensory, motor, and autonomic
functions
• Have much higher doses
• All the complications in the SA can be observed
except headache
 Epidural ANESTHESIA
• Injection of a certain amount of local anesthetic
(with or without opiates) into the lumbar or
thoracic epidural space
• A catheter is inserted after the epidural space
has been located with a needle
– Controlled local anesthetic delivery
– “Redosing” of anesthesia for long procedures
– Post-operative analgesia with local anesthetics
and opiates
• Indications: abdominal, thoracic, and lower
extremity procedures

www.webmm.ahrq.gov
 Advantages of EPIDURAL
ANESTHESIA
• Hip Surgery: Decrease blood loss and incidence of
deep venous thrombosis
• Thoracic Surgery: superior pain control, less
sedation, better pulmonary function
• Rapid recovery of gastrointestinal function
• Early ambulation
• Others:
– Labor analgesia
– Interventional pain modalities

www.3m.com
 COMPLICATIONS of EPIDURAL
ANESTHESIA
• [Similar to that of Spinal Anesthesia]
• Total Spinal Anesthesia
• Local Anesthetic Toxicity
• Spinal / Epidural hematoma
– concerns regarding catheter placement
and removal in patients on
anticoagulation
• Epidural Abscess

www.scielo.br
 TECHNIQUE - EA
• Patient positioned
• Landmarks identified
• Aseptic Preparation
• Local infiltration of LA at injection site
• Epidural puncture with Tuohy needle
– Epidural space identified: LORT, hanging drop
technique
– Note +/- of CSF, blood, paresthesia
• Epidural catheter threaded into space
• Test for inadvertent intravascular and
intrathecal placement of catheter
• Epidural injection of LA
 Level of Anesthesia Required for
Procedures
Dermatome Procedures
T4-T5 Nipple area (T4) Upper abdominal surgeries
T6-8 Xiphoid (T6) Intestinal surgery (including
appendectomy), gynecologic pelvic
surgery, and ureter
T10 Umbilicus Transurethral resection, vaginal delivery,
hip surgery
L1 Inguinal ligament Transurethral resection without bladder
distension; thigh surgery; lower limb
amputations
L2 to L3 (knee and below) Foot surgery
S2 to S5 (perineum) Perineal surgery, hemorrhoidectomy, anal
dilation
 DERMATOMES
www.aaofl.com
 Local conduction blocks
• Brachial plexus block- produces anesthesia of
the arm
• Para vertebral anesthesia- produces
anesthesia of the nerves supplying the chest,
abdominal wall and extremities
• Transsacral (caudal) block – produces
anesthesia of the perineum and occasionally
the lower abdomen
Common medications used in
local/regional anesthesia
Care of Patients
 Admitting the patient to the Post-anesthesia Care Unit (PACU)

• Transferring of the patient from

the OR to the PACU is the
responsibility of the
anesthesiologist.
• During transport the
anesthesiologist remains at the
head part of the patient and a
surgical team member remains at
the opposite side.
• Transporting the patient involves
the special consideration of the
incision site, potential vascular
changes and exposure.
 Nursing assessment in the PACU
• Vital signs- presence of artificial airway, o2 saturation,
BP, pulse, temperature.
• LOC- ability to follow command, pupillary response
• Urinary output
• Skin integrity
• Pain
• Condition of surgical wound
• Presence of IV lines
• Position of patient
 Post-Anesthesia Care Unit (PACU)
• Also called the recovery room or
postanesthesia recovery room
• Kept clean, quiet, free of unnecessary
equipment, with indirect lighting, and well
ventilated to help patients decrease anxiety
and promote comfort
• Should be equipped with necessary facilities
 Phases of Post-anesthesia Care
• Phase I PACU- used during the immediate
recovery phase, intensive nursing care is
provided.
• Phase II PACU- the patient is prepared for self
care or care in the hospital or an extended
care setting.
• Phase III PACU- patient is prepared for
discharge
Measures used to determine readiness for
discharge in the PACU
• Stable V/S
• Orientation to person, place, events and time
• Uncompromised pulmonary fxn
• Adequate O2 saturation
• UO at least 30ml/hr
• N and V absent or under control
• Minimal pain
 Evaluation:
Expected outcomes:
1. Indicates that pain is decreased intensely
2. Maintains optimal respiratory function
3. Does not develop DVT
4. Exercises and ambulates as prescribed
a. alternates periods of rest and activity
b. progressively increases ambulation
c. resumes normal activities with prescribed
time frame
d. performs activities r/t self care
5. Wounds heal without complications
6. Resumes oral intake and normal bowel function
a. reports absence of N and V
b. takes at least 75% of usual diet
c. is free of abdominal distress and gas pains
d. exhibits normal bowel elimination pattern
7. Acquires knowledge and skills necessary to manage
therapeutic regimen
8. Experiences no complications and has normal Vitals