Anesthesia

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Anesthesia

• GHAZI ALDEHAYAT MD
• 
  

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Ancient and Mediaeval times
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Anesthesia

• Anesthesia
• Intensive care
• Chronic pain management

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Anesthesia

• Anesthesia
• CPR
• Acute Pain control
• Difficult Lines
• Evaluating critical patints

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Anesthesia

• Theatre
• Radiology
• Interventional radiology
• Cardiology
• ECT
• GI

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Types Of Anesthesia
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Types of Anesthesia

• General Anesthesia
• Regional Anesthesia
• Local Anesthesia
• Sedation

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General Anesthesia

• Preoperative evaluation
• Intraoperative management
• Postoperative management

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PREOPERATIVE visit?
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Purpose of preoperative visit

• Medical assessment of the patient.
• Decide the type of anesthesia.
• Establish rapport with the patient.
• Allay anxiety and decrease pain.
• Obtain informed consent.
• Ask for further investigation and managment.
• Decide risk versus benefit .
• Prescribe medications, e.g Thromboembolic
  prophylaxis.
• (Optimize the condition of the patient)

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Pre-Operative Assessment

• History
• Indication for surgery
• Surgical/anesthetic hx previous
  anesthetics/complications, previous intubations,
  
• Medications, drug allergies

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• Medical history
• CVS CAD, MI, CHF, HTN, valvular disease,
  dysrhmias, PVD, conditions requiring endocarditis
  prophylaxis, exercise tolerance, CCS class, NYHA
  class
• Resp smoking, asthma, COPD, recent URTI, sleep
  apnea
• GI GERD, liver disease
• Renal insufficiency, dialysis
• CNS seizures, CVA, raised ICP, spinal disease,
  arteriovenous malformations

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• Hematologic anemia, coagulopathies, blood
  dyscrasias
• MSK conditions associated with difficult
  intubations arthritis, RA, cervical tumours,
  cervical infections/abscess, trauma to C-spine,
  Down syndrome,
• scleroderma, obesity
• Endocrine diabetes, thyroid, adrenal disorders
• Other morbid obesity, pregnancy, ethanol/other
  drug use

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• FHx malignant hyperthermia, atypical
  cholinesterase (pseudocholinesterase), other
  abnormal drug reactions

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Physical Examination

• Physical exams of all systems.
• Airway assessment to determine the likelihood of
  difficult intubation

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• Bony landmarks and suitability of areas for
  regional anesthesia if relevant
• Focused physical exam on CNS, CVS and
  respiratory (includes airway) systems
• General, e.g. nutritional, hydration, and mental
  status
• Pre-existing motor and sensory deficits
• Sites for IV, central venous pressure (CVP) and
  pulmonary artery (PA) catheters,
• regional anesthesia

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• Investigations According to( ranged from none to
  most comlicated)
• Age
• Surgery
• Medical condition
• As clinically indicated
• Low risk no further evaluation needed
• Intermediate risk non-invasive stress
  testing
• High risk proper optimization /-
  delaying/canceling procedure

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• American Society of Anesthesiology (ASA)
  classification
• Common classification of physical status at time
  of surgery
• A gross predictor of overall outcome, NOT used
  as stratification for anesthetic risk (mortality
  rates)
• ASA 1 a healthy, fit patient (0.06-0.08)
• ASA 2 a patient with mild systemic disease,
  e.g. controlled Type 2 diabetes, controlled
  essential HTN, obesity (0.27-0.4), smoker

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• ASA 3 a patient with severe systemic disease
  that limits activity, e.g. angina, prior MI, COPD
  (1.8-4.3), DM, obesity
• ASA 4 a patient with incapacitating disease
  that is a constant threat to life, e.g. CHF,
  renal failure, acute respiratory failure
  (7.8-23)
• ASA 5 a moribund patient not expected to
  survive 24 hours with/without surgery, e.g.
  ruptured abdominal aortic aneurysm (AAA).
• ASA 6 Brain death patient
• For emergency operations, add the letter E after
  classification

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• Medications
• Pay particular attention to CVS and resp meds,
  narcotics and drugs with many side effects and
  interactions prophylaxis.
• Risk of GE reflux Na citrate 30 cc PO 30 mins
  hour pre-op.
• Risk of adrenal suppression steroid coverage
• Risk of DVT heparin SC,LMW Heparin, Mechanical
  methods.

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• Optimization of co-existing disease
  bronchodilators (COPD, asthma), nitroglycerine
  and beta-blockers (CAD risk factors)
• Pre-operative medications to stop
• Oral hypoglycemics stop on morning of
  surgery
• Antidepressants.
• Pre-operative medication to adjust
• Insulin, prednisone, coumadin, bronchodilator

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• Decide, whether to proceed with surgery ,to send
  patient for further management or to cancel the
  operation.
• Discus anesthetic options.
• Decide which is the most useful for the patient.
• Informed concent.
• Risk stratification .

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Intraoperative management
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GENERAL ANESTHESIA

• Airway management
• Endotracheal intubation( Body cavities, Full
  stomach, prone position, compromised, Very long
  operations, Airway involvment )
• Laryngeal mask Airway( peripheral, No indication
  for ETT)
• Mask( very short, no indication for ETT)
• Ventilation
• Spontaneous ( No muscle relaxant)
• Controlled ( With muscle relaxant)

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GENERAL ANESTHESIA

• PREPARATION
• monitoring
• position
• Intravenous fluid
• Drugs, anesthetic and non Anesthetic
• Warming
• CONDUCT OF ANESTHESIA
• PERIOPERATIVE MEDICINE

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• Monitoring according to paitent medical
  condition and surgery proposed
• Basic ECG, NIBP,SpO2, EtCO2, Temp,FiO2,
  Anesthetic gases, Airway pressure, The presence
  of anesthetist all through
• procedure.
• Others Nerve stimulator, Invasive Bp, CVP,
  CO, BIS, PA Catheter, TEE, UO Lab tests, ABGs,
  CBC, LFT , Coagulation, TEG

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Basic Principles of Anesthesia

• Anesthesia defined as the abolition of sensation
• Analgesia defined as the abolition of pain
• Triad of General Anesthesia
• need for unconsciousness
• need for analgesia
• need for muscle relaxation

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Recovery Maintinance Induction
Discontinue Inhalational Intravenous Intravenous(egThiopentone,Propofol) Inhalational( sevoflurane,Halothane) Hypnosis (unconsciousness)
Multimodal))Good Analgesi Opioids,Regional, Local NSAIDS Parasetamol Systemic (opiods,NSAIDS) Regional( Epidural,Spinal) LA N2O Systemic( opiods, Fentanyl,Remifentanil,Alfentanil) Analgesia
Reversal by Anticholinstrases( Neostigmine,) Atropine Non Depolarizing Depolarizing (suxamethoniom) Non Depolarizing (steroids, vecuronium) Benzylisoquinolonium Cis atracurium) Muscle Relaxation
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Intravenous Anesthetic Agents

• Thiopental
• Thiobarbiturates
• Uses for iduction, decrease ICP, Status
  epilepticus
• CNS Hypnosis within 30 seconds ,decreased
  intracrainial pressure.
• CVS depression, hypotension, tachycardia
• Respiratory depression, spasm
• CI porphyria
• Arterial injection

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Intravenous Anesthetic Agents

• PROPOFOL ( Deprivan)
• USES induction, maintenance, sedation in the
  ICU, sedation
• Contra indicated in children.
• CNS Hypnosis within 30 seconds ,decreased
  intracrainial pressure.
• CVS depression more than Thiopental
• Respiratory Depression, no spasm
• Caloric load in the ICU, propfol infusion
  syndrome

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Intravenous Anesthetic Agents

• Ketamine
• Phencyclidine
• Uses, shock, burn, field.
• CNS, dissociation, hallucination, analgesia,
• Increased intracrainial pressure.
• CVS Stimulation, hypertension, tachycardia
• Respiratory, less depression.

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Intravenous Anesthetic Agents

• Etomidate
• Stable cardiovascular
• Steroid depression

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Inhalational Anaesthesia

• Halothane
• Enflurane
• Isoflurane
• Sevoflurane
• Desflurane
• N2o
• Xenon
• 
  
• 
  

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Inhalational

• Anesthesia induced by inhalational effec
• Tdifferent in their potency, indicated by MAC.
• Different in rapidity of induction and recovery.
• Common pharmacological properties,
• CVS depression with tachy or bradycardia
• REP Depression.
• CNS increased intracranial pressure

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Opioid

• Fentanyl
• Morphine
• Alfentanl
• Remifentanil

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• All have almost the same pharmacodynamics of ,
• Morphine, Analgesia, Sedation ,
  Respiratory depression, Nausea and vomiting,
  meiosis, constipation.
• Different in their pharmakokinitcs.

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Muscle relaxant

• Depolarizing
• Suxamethonium
• Short acting, rapid onset,
• Many Side effects, hyperkalemia, arrythmias,
• Muscle pain ,Scoline apnea.

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• Non Depolarizing
• Aminosteroid organ metabolism
• Benzylisoquinolonium Histamine release,
• Long acting

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Local anaesthetics

• Lidocaine, lignocaine,xylocaine
• Bupivacaine ( marcaine)
• Cocaine
• Procaine

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• Regional ( spinal , epidural)
• Local
• Different side effects
• Marcaine CI by intravenous
• LA toxicity. Maximum doses,
• Perioral numbness, tinnitus, conulsions, resp
  depression, Cardiac arrest
• Treatment, ABC, symptomatic, intralipid(
  propofol)

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Reversal

• Neostigmine
• Atropine

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Monitoring

• Basic ( ECG, BP, SPO2, EtCO2) Observation
• Advanced ( IBP , CVP, CO .ETc

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Awareness

• Awarness
• Definition
• Types
• Effect
• Causes
• Manegment

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• Thank you