ANESTHESIA

Brief History of Anesthesia

3 phases of anesthesia:
1. pre-operative
2. peri-operative
3.post-operative

Cocaine plant(extract)- used to abate the pain in ancient times

Anaesthesia
- 1751 Baileys English Dictionary
- a defect of sensation
- 1846 --> liver Wendell Holmes sleep like state that makes painless surgery possible

Joseph Priestley
- discovered nitrous oxide (1772) (for labor anesthesia)
- blue tank

Humphry Dacy (1779)

- first to describe the analgesic effects of nitrous oxide

Horace Wells (1844)

- fist to publicly promote nitrous oxide gas inhalation for pain relief during dental and surgical procedure

William TG Morton (1846)

- first to publicly use diethyl ester to produce surgical anesthesia

James Y. Simpson (1847)

- introduced chloroforms as an alternative to ether
- Labor anesthesia

John Snow
o consider as the 1st anesthetist
o regarded as the Father of Anesthesia
o famous patient was Queen Victoria for anesthesia in labor (choloform)

Carl Koler (1864)

- introduced topical anesthesia using cocaine

August Buer (1898)

- introduced the first true spinal anesthesia

John Lundy (1926)

- introduced the concept of balanced anesthesia

DR. Quintin Gomez

- Father of Anesthesia in the Philippines

AIRWAY MANAGMENT

Applied Anatomy of the Airway

Nose --> Nasopharynx
Mouth --> Oropharynx

Pharynx
- u-shaped muscular structure
- extend from base of skull to cricioid cartilage

3 Anterior Openings
a. Nasal Cavity nasopharynx
b. Mouth oropharynx
c. Larynx laryngopharynx

Epiglotis
- separates the oropharynx from the hypopharynx
- prevents aspiration during swallowing
- ???

Larynx
- 9 Cartilages
thyroid
cricoid
epiglottic

1
 arytenoid (paired)
corniculate (paired)
cuneiform (paired)

Rima glottidis (glottis)

- narrowest portion of airway above 8 years old

Cricoid ring
- narrowest portion of airway in young children

INNERVATION
Sensory
- CN V
- CN IX --> tongue posterior 3rd, pharynx, tonsils, soft palate
- CNVII
- CN X --> airway below the epiglottis

Sensory Nerve Supply of the Airway

CN V
- V1 --> ophthalmic division (anterior ethmoidal nerve)
- V2 --> maxillary division (sphenopalatine nerve)
- V3 mandibular division (lingual nerve)

CN IX
- Superior laryngeal nerve
- Internal laryngeal n.
- Recurrent laryngeal n.

Motor Nerve Supply

Vagus Nerve

Superior Laryngeal Branch

External Laryngeal (motor) Internal Laryngeal (sensory)

Effects of Laryngeal Nerve Injury

NERVE EFFECT OF NERVE INJURY
Superior Laryngeal Nerve
- Unilateral Minimal effects
- Bilateral Hoarseness, tiring of voice
Right Laryngeal Nerve
- Unilateral Hoarseness
- Bilateral
Acute Stridor, Respiratory distress
Chronic Aphonia
Vagus Nerve
- Unilateral Hoarseness
- Bilateral Aphonia

Trachea
- extends from the lower of the cricoid cartilage to the carina
- 4cm in neonate
- 10 -14 cm in adult

Causes of Difficult Airway

- Anatomic features
- Pathologic states
- Technical and mechanical factors

Physical Findings that suggest Difficult Airway Managemet

- Obesity
- Pregnancy
- Ascites
- Whiskers, flat nasal bridge, large face
- Small mouth
- Limited cervico-occipital extension
- Short neck
- Stridor, retractions
- Hoarseness
- underwater voice
- Nasogasric tube in situ
- Mallampatis sign
- Large goiter or neck mass

2
 - Tracheostomy scar

Airway Obstruction

Hypoventilation

Hypercapnia

Hypoxemia

Hyperventilation

Hypoxemia
Steps in Effective Denitrogenation
Pressure
o relief valve fully open to avoid excessive airway pressure
O2 flow at 8-10LPM
Leak-free mask fit to prevent room air entertainment
2-3 minutes of tidal breathing or 4 vital capacity breaths
Airway Management without Tracheal Intubation (Equipment)
- face mask
- laryngeal mask airway
- combitube
Relief of Airway Obstruction
- Hypoxemia is a threat
- (+) Pressure ventilation may fill the stomach
- Pulmonary edema 2 inhalation or gastric contents
Tracheal Intubation: INDICATIONS
A. During Anesthesia
ensure ventilation or oxygenation
airway patency
protection against pulmonary aspiration
provide separate ventilation to each lung

B.
Post Anesthesia or Critical Care
provide ventilation or other pressure therapy
maintain airway patency
protect airway from contamination
Laryngoscopy (Cormack and Lehane)
GRADE DESCRIPTION
I Entire glottis seen
Only posterior structures of glottis
II
seen
III Only the epiglottis seen
IV Even the epiglottis not seen

Monitoring the Anesthesized Patient

Essential Monitors
- Observation
- Stet
- BP
- Pulse oximeter
- ECG
- Capnograph
- Temperature
- Nerve Stimulator
- Anesthesia Record

Stet
- precordial
- esophageal
BP
- every 5 minutes --> patient is stable
- monitor continuously or every 2 minutes --> induction of anesthesia
Central Venous Pressure
- index of the preload and circulatory blood volume to the R ventricle
decreased CVP
o hypovolemia
o increased venous capacitance
increased CVP
o hypervolemia
o vasoconstriction
o increased intrathoracic pressure
o cardiac dysfunction (with hypotension)
o cardiac tamponade
o incompetent tricuspid valve
Pulse Oximetry

3
 - mandatory intraoperative monitor
- measures the O2 saturation of Hgb in arterial blood at 660-940nm --> indicate relative proportion of oxyhemoglobin and deoxyhemoglobin
ECG
- most sensitive and practical monitor fro detection of disorders of cardiac rhythm and conduction
- V5 --> the most sensitive lead for the detection of peri-operative myocardial ischemia
Temperature
Hypothermia
Deleterious Effects of Hypothermia
- cardiac dysrhythmias
- increased peripheral vascular resistance
- shift of Hb-O2 saturation curve to the left
- altered mental status
- decreased drug metabolism
- impaired renal function
Urinary Output
- reflection of kidney perfusion and function
- indicator of renal, cardiovascular and fluid volume status
- normal urine output --> o.5-1.0ml/kg/hour
Standard for Basic Anesthesia Monitoring (ASA 1998)

2008 International Standards for Safe Practice of Anesthesia

Monitoring during Anesthesia

- Oxygenation
- Airway and ventilation
- Circulation
- Tempearature
- Neuromuscular Function
- Depth of Anesthesia
- Audible signals and alarms