PRINCIPLES OF ANESTHESIA

Dr. VIRENDRA ATHAVALE

PROFESSOR
DEPARTMENT OF GENERAL SURGERY

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 CONTENTS
 Preoperative assessment
 Preoperative management
 Positioning
 Types of Anesthesia
 General Anesthesia
◦ Intraoperative complications
◦ Postoperative care
 Local Anesthesia
◦ Effects & Systemic toxicity
 Spinal Anesthesia
 Epidural Anesthesia
 Nerve blocks
 PREOPERATIVE ASSESSMENT
 History of presenting illness
 Previous medical history – DM, HTN, BA, TB, epilepsy, IHD
 Surgical history – CAG/ CABG
 Drug intake and allergy
 Addictions – chronic cough, smoking, alcohol
 General physical examination
Vital signs – Pulse, BP
Pallor, icterus, cyanosis, clubbing
Spine – curvature, intervertebral space, skin over the area
Veins, Neck movements, Posture, Dentition
 Systemic examination – respiratory and cardiac system.
 Preoperative investigations – Routine blood investigations, chest
x-ray, ECG, cardiac assessment.
 ASA CLASSIFICATION
 The American Society of Anesthesiologists have classified the
patient’s preoperative physical status into –

ASA 1 – Healthy patient, no medical problems

ASA 2 - Mild systemic disease
ASA 3- Severe systemic disease, not incapacitating
ASA 4 – Severe systemic disease which is a constant threat
to life
ASA 5 – Moribund patient who is not expected to survive
without the operation
ASA 6 – Brain dead patient whose organs are being removed
for donor purposes

 A suffix E is added if the surgery is an emergency.

 PREOPERATIVE MANAGEMENT
 Optimization of comorbid conditions.
 Withhold anti platelets 5 days before surgery.
 Improvement of Hb >10% and book blood products if needed.
 Written and informed consent.
 Surgical area is shaved, scrubbed and prepared.
 Solids up to 6 hours and clear liquids up to 4 hours prior to
surgery.
 Preoperative antibiotics.
 Premedication –
◦ Anxiety – Diazepam or Lorazepam
◦ Pain – Tramadol or Morphine
◦ Secretions – Glycopyrrolate
◦ Baroreceptor reflex – Propranolol or Clonidine
◦ Nausea & acidity – Metoclopromide/ Promethazine/
Pantoprazole
 POSITIONING
The patient is placed on the operating table in a position
appropriate for the proposed surgery.

• The lithotomy position may result in nerve damage.

• The lateral position may cause asymmetrical lung ventilation.

• The prone position may cause abdominal/ thoracic
compression.
• The trendelenburg position may cause pressure on
the diaphragm.
• The sitting position needs good support of the head.
• The supine position may cause supine hypotensive
syndrome during pregnancy.
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 TYPES OF ANESTHESIA

GENERAL REGIONAL
ANESTHESIA ANESTHESIA

Local anesthesia
Spinal anesthesia
Epidural anesthesia
Peripheral nerve block
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 GENERALANESTHESIA
• In general anesthesia, the patient is unconscious and there
is a generalized and reversible depression of the central
nervous system. It includes hypnosis/ sedation, amnesia,
analgesia and muscle relaxation.
• GA is appropriate for most surgical procedures.

• General anesthetics are of two main types –

• Inhalational (Halothane, Isoflurane, Enflurane,
Desflurane, Sevoflurane, Nitrous oxide)
• Intravenous (Thiopentone, Etomidate, Propofol,
Ketamine, high dose opioids or benzodiazepines)

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 COMPLICATIONS
 Intra-arterial injection of drug
 Myocardial depression and cardiac arrest
 Cardiac arrhythmias
 Laryngeal and bronchial spasm
 Hypoxia, ARDS, respiratory failure
 Pneumothorax
 Anaphylaxis
 Mendelson’s syndrome – due to regurgitation of acid from
stomach causes aspiration
 Malignant hyperthermia – marked increase in the metabolic
rate with rise of temperature causing metabolic acidosis and
hyperkalemia.
 POST OPERATIVE CARE
 Immediate post operative period is important and critical,
because the patient may not be fully conscious.
 The patient is kept in the recovery room until he/she recovers
from anesthesia.
 Pulse, temperature, BP, BSL monitoring
 Check level of consciousness
 Check tongue for hydration

 Adequate breathing is important otherwise hypoxia sets in

which gradually leads to cardiac arrest.
 Respiratory problems - laryngeal spasm, falling of tongue
backwards blocking the airway, aspiration, bronchospasm, ARDS
or respiratory failure. Oxygen supplement through the mask,
observation and proper positioning are the treatment.
 Cardiac monitoring is a must. Circulatory problems like
hypotension, arrhythmias, hypertension, cardiac arrest could occur.

 GIT problems like vomiting, regurgitation

Renal problems – Oliguria (urine output is less than 30ml/hour)

 It may be due to hypovolemia, hypotension, acidosis, sepsis,
transfusion reaction or toxins.
 Blood urea and serum creatinine should be repeated at regular
intervals. Fluid and electrolyte imbalance should be corrected if any.
 100ml 20% mannitol/ 40-80mg Furosemide are often required.

 Blood gas analysis if on ventilator

 Serum electrolytes
 Encouraging limb movements
 Watch for restlessness, shivering and pain
 LOCAL ANAESTHETICS
They are drugs when injected around the nerves, block impulse
conduction distal to the site of injection and produce analgesia
and anesthesia in that area.

Classified into two groups

◦ Aminoesters – Procaine, Chlorprocaine,Tetracaine.

◦ Aminoamides – Lignocaine, Bupivacaine, Ropivacaine.

 LIGNOCAINE
It is the most commonly used local anesthetic agent.

 Skin infiltration – 0.5 to 1%

 Nerve block – 1%
 Epidural 1.5 to 2%
 Spinal – 5%
 Topical – 2% (lignocaine jelly)
-10% (lignocaine spray)

It is often combined with adrenaline which increases it’s

duration of action and creates a relatively bloodless field by
causing vasoconstriction. It should not be used in places of end
arteries like glans penis, ear lobule, tip of the nose, fingers and
toes.
 EFFECTS OF LOCAL ANESTHESIA
LOCAL EFFECTS –

They block the sodium channel in the neuronal membrane

and thus the propagation of the impulses across it.

SYSTEMIC EFFECTS –

When high plasma concentrations are reached, they produce

systemic effects.
Lignocaine can be used as an anti-arrhythmic agent.
SYSTEMIC TOXICITY –

If significant amount of anesthetic reaches the tissues of heart

and brain, they exert a membrane stabilizing effect as on
peripheral nerve, resulting in progressive depression of
function.
 SYSTEMIC TOXICITY
As the plasma concentration rises, CNS toxicity manifests as
◦ Tingling, numbness, tinnitus, light headedness
◦ Loss of consciousness
◦ Convulsions
◦ Coma
◦ Respiratory arrest

 CVS toxicity presents as myocardial depression, cardiac arrhythmias

and ventricular arrest.

 The likelihood of toxicity depends on factors like the amount of

drug injected, the site of injection (certain sites are very vascular
compared to others), addition of vasoconstrictors, rapidity of
injection, nature of drug given (Bupivacaine is cardio toxic) and
presence of associated conditions like low cardiac output or renal
failure.
HOW CAN WE PREVENT TOXICITY?

 Do not exceed recommended doses.

 Aspirate to rule out presence of the needle tip in a vessel
before injecting the drug
 Avoid injecting a large bolus at once. Small boluses given
slowly to achieve the desired effect are safer.

HOW DO WE TREAT TOXICITY?

 Patency of airway must be maintained.

 Oxygen by face mask.
 Ventilation if apnea occurs.
 Convulsions are treated with IV Diazepam/ Thiopentone
 Cardiovascular collapse is treated with Ephedrine,
ionotropes, vasoconstrictors or CPR if needed
 Arrhythmias treated appropriately.
 SPINAL ANESTHESIA
 When the local anesthetic is administered as a single injection
into the subarachnoid space, in the CSF (cerebrospinal fluid)
around the spinal cord, it is called spinal anesthesia.
 It causes loss of sympathetic tone, sensation and motor function.

Indication – surgery below the umbilicus

Types
◦ Caudal – upto L5
◦ Low spinal – upto L1
◦ Mid spinal – upto T10
◦ High spinal – upto T6
◦ Unilateral spinal
 EFFECTS OF SPINAL ANESTHESIA
1. CARDIOVASCULAR SYSTEM

 Hypotension – Due to the blockade of sympathetic

nerve below the level of spinal block, there is profound
vasodilatation in the affected areas. A relative hypovolemia
occurs and hypotension is seen.

 The vessels in the upper limb constrict to compensate for

the vasodilatation in the lower limbs. This is the pink
trousers, blue jacket phenomenon.

 Bradycardia – Heart rate is maintained in low blocks but

in higher blocks, sympathetic blockade can cause
unopposed action of the parasympathetic system and
bradycardia.

 Reduced cardiac output.

2. NERVOUS SYSTEM
 The anesthetic spreads by mixing with the CSF. A lower
concentration of drug is sufficient to block small sensory fibres
whereas the thick motor fibres require a larger concentration.
 A differential blockade is seen
Motor block till a level depends on the dose of the drug
Sensory block is 2 segments higher than the motor block
Sympathetic block is 2 segments higher than the the sensory.

3. GASTROINTESTINAL SYSTEM
 Unopposed parasympathetic activity leads to constriction of gut
with increased peristaltic activity.
 Nausea, retching and vomiting may be the symptom of impending
hypotension. It may need the administration of an anticholinergic
or an antiemetic agent.
 But because the bowel is contracted and the skeletal muscle
relaxation produced is greater, surgeons find it easier to operate.
4. PDPH (POSTDURAL PUNCTURE HEADACHE)

 When the needle is large and there is a leak of

cerebrospinal fluid from the dura puncture site, it causes
low CSF pressure.
 Whenever the patient sits up or becomes ambulatory, a
drag occurs on the brain and the meninges due to gravity
and loss of CSF which results in a postural headache
referred to the occipital region. It disappears when he
lies down supine.
 This is more common in the obstetric patients.
 It may occur up to 2 to 7 days post the puncture and
may persist for up to 6 weeks.
 Treatment
◦ Plenty of oral fluids may increase CSF production
◦ Rest, coffee, NSAIDs
◦ Epidural blood patch – 10 to 15 ml of patient’s own blood is drawn
under aseptic precautions. Epidural puncture is made at the same
space as before and the blood in injected into the epidural space
which clots and seals the puncture hole.
5. RESPIRATORY SYSTEM
 No changes are seen in spinal below T10.
 If the level ascends, intercostal nerves are gradually blocked,
intercostal muscles are paralyzed and respiratory depression
may occur. (Respiratory depression could also be due to
hypoperfusion of the respiratory center due to hypotension and
is treated with respiratory support and stabilization of the blood
pressure.
 Diaphragm, is supplied by the thick phrenic nerve which doesn’t
easily get blocked.

6.Total spinal block

When a large dose in injected, all spinal nerves are blocked causing
profound hypotension, bradycardia and collapse. It needs to be
treated promptly by volume infusion and vasopressors. Endotracheal
intubation and ventilation is done if necessary.

7. Retention of urine
OTHER EFFECTS -
 Backache could be due to positioning during surgery.
 Infection – Arachnoiditis, meningitis.
 Nerve injury – cauda equina syndrome.

CONTRAINDICATIONS OF SPINAL ANESTHESIA

◦ Allergy
◦ Infection at the site of injection
◦ Bleeding tendencies
◦ Hypovolemia
◦ Cardiac patients with valvular heart disease
◦ Increased intracranial pressure
◦ Spinal tumor
 EPIDURAL ANESTHESIA
In this type, local anesthetic is injected in the space around
the dura (epidural space). The local anesthetic blocks the
nerves as they emerge through the intervertebral foramen.

USES

• An epidural catheter helps

with continuous repeated
prolonged anesthesia.
• It can be used for post-
operative analgesia.
• It can be kept for several
days.
 Saddle block is low level spinal anesthesia given in sitting
position.

 It is used for anorectal and perianal surgeries like

haemorrhoidectomy.

 Caudal block is the administration of anesthesia in the

epidural space through the sacral hiatus.

 It is also used for post operative pain relief for perianal

surgeries or to supplement general anesthesia.
 BRACHIAL PLEXUS BLOCK (WINNIE’S BLOCK)

Injection of local anesthetics around the brachial plexus

produces analgesia and anesthesia in the upper limb.
It can be blocked by four different approaches –
1. Interscalene
2. Supraclavicular
3. Infraclavicular
4. Axillary

COMPLICATIONS —

◦ Haematoma
◦ Intravascular injection
◦ Pneumothorax
◦ Infection
 OTHER NERVE BLOCKS
1. Intercostal block
2. Median and ulnar nerve block
3. Cervical plexus block
4. Sciatic nerve block
5. Femoral nerve block
6. Finger block of digital nerves
7. Inferior dental and lingual nerve block – dental extraction
8. Ankle block for procedures of the foot involves blocking
of –
◦ Posterior tibial nerve
◦ Sural nerve
◦ Deep peroneal nerve
◦ Superficial peroneal nerve
◦ Saphenous nerve
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