ANESTHESIA

An induced state of partial or total loss of sensation, occurring with or without loss of consciousness

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 are influenced by:

Client health problems Type and duration of 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

Anesthesia can be induced by:

General or balanced anesthesia Local or regional anesthesia Hypnosis or hypnoanesthesia Cryothermia Acupuncture

GENERAL ANESTHESIA
Reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the CNS patients are not arousable , not even in painful stimuli

Stages of General Anesthesia

Stage 1 (analgesia and sedation, relaxation)
Begins with induction and ends with loss of consciousness Client feels drowsy and dizzy, has a reduced sensation to pain and is amnesic Hearing is exaggerated

 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

 Stage 3 ( Operative anesthesia, surgical anesthesia)

Begins with generalized muscle relaxation and ends with loss of reflexes and depression of vital function 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

 LARYNGOSCOPE

 Stage 4 (Danger)
Begins with depression of vital function and ends with respiratory failure, cardiac arrrest, and possible death Respiratory muscles are paralyzed; apnea occurs

Administration of General Anesthesia

Inhalation
an easy controlled method of giving general anesthesa because intake and excretion of the agent occur mainly of the lungs Assisted respiratory Controlled respirations

 Gaseous Agent nitrous oxide is the most common used agent and is usually given with oxygen. It is colorless, odorless gas that provides analgesia 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.

Types of IV Injection
Barbiturates it acts rapidly, causing unconsciouness within 30 seconds. Ketamine (Ketalar) ketamine is a dissociative anesthetic agent Propofol (Diporivan) is a short acting anesthetic agent. Hypnosis occurs in less than 1 minute from the time of injection.

Adjuncts to General anesthetic Agents

Sedatives common drugs in the class Opioid analgesics (narcotics) common opioid analgesic enhance anesthesia Neuromuscular Blocking Agents are used to relax the jaw and vocal cords immediately after induction so that the endotracheal tube can be placed

 Nondepolarizing Blocking Agents

Block acetylcholine at the neuromuscular junction

Depolarizing Blocking Agents

Overstimulate the motor end plate at the neuromuscular junction.

 Balanced Anesthesia
A combination of IV drugs and inhalation agents used to obtain specific effects A combination is used to provide hypnosis, analgesia, amnesia, muscle relaxation and reduce reflexes with minimal disturbance of physiologic function

REGIONAL ANESTHESIA
Briefly disrupts sensory nerve impulse transmission from a specific body area or region

Systems affected
Motor fibers Sympathetic fibers Sensory fibers

Local Anesthesia
Delivered topically and by local infiltration

Topical Anesthesia
Applied directly to the area of skin or mucous membrane surface to be anesthetized This method often used for respiratory intubation and for diagnostic procedures such as bronchoscopy or cystoscopy

Regional Anesthesia
may be used when
General anesthesia cannot be used because of medical problems The client has had adverse reactions to general anesthesia The client has a preference and a choice is possible Pain management after surgery is enhanced by regional anesthesia

Types of Regional Anesthesia

Field block Nerve block Spinal Epidural

 Field block
Occurs with a serried of injections around the operative field. Injecting around a specific nerve or group of nerves depresses sensation at a local area

 Nerve block
Occurs with injection of the local anesthetic agent into or around a nerve or group of nerves in the involved area. Lidocaine and Bupivacaine

If injected into the bloodstream accidentally, can cause:

Seizures, cardiac depression, dysrhythmias, and respiratory depression

 Spinal anesthesia
Occurs by injecting an anesthetic agent into the cerebrospinal fluid in the subarachnoid space at the lumbar level Position: Knee-chest Can cause temporary partial or complete respiratory paralysis

Spinal anesthesia
Usually causes headache as an after effect due to:
Spinal needle used Leakage of CS fluid from the subarachnoid space through the puncture site Hydration status of patient

 Epidural anesthesia
The anesthetic agent is injected into the epidural space and the spinal cord areas are never entered. Doses are much higher compared to spinal anesthesia since the agent does not make direct contact with the spinal cord and nerve roots Used for:
Anorectal, vaginal, perineal, hip, and lower extremity surgeries.

 Advantages:
Decreased cardiac and pulmonary complications No headaches compared to SA Use of the epidural catheter for pain control after surgery

Disadvantage:
Greater technical challenge of introducing the agent into the epidural rather than the subarachnoid space.

 Moderate Sedation
Previously referred to as conscious sedation

POTENTIAL INTRAOPERATIVE COMPLICATIONS

Nausea and Vomiting Anaphylaxis Hypoxia and other respiratory complications Hypothermia Malignant hyperthermia (MH)

Malignant hyperthermia (MH)

Rare inherited muscle disorder that is chemically induced by anesthetic agents

 Onset: immediately after induction of anesthesia, several hours into the procedure or even after anesthetic has been terminated

Signs and Symptoms of MH

tachycardia of greater than 150 bpm earliest sign dysrhythmias muscle rigidity hypotension tachypnea skin mottling cyanosis myoglobinuria

Signs and Symptoms of MH

unexpected rise in the end-tidal carbon dioxide level with a decrease n oxygen saturation the most sensitive indication sinus tachycardia early indication extremely elevated temperature as high as 44 C or 111.2 F late sign of MH

Management of MH
Stop all anesthetic agents and succinylcholine Intubate Ventilate client with 100% oxygen using highest possible flow rate Administer dantrolene sodium (dantrium) IV at a dose of 2 3 mg/kg If possible, terminate surgery.

Management of MH
Assess: ABG and serum chemistries for metabolic acidosis and hyperkalemia Use active cooling techniques:
Administer iced saline (0.9% NaCl) IV at a rate of 15 mL/kg every 15 minutes for 3 doses Apply cooling blanket over torso Wrap of rub extremities with cold, wet towels or ice wrapped towels Lavage the stomach, bladder, rectum and open body cavities (if appropriate) with sterile iced normal saline

Management of MH
Monitor core body temperature Monitor cardiac rhythm Insert foley catheter Administer IV fluids at a rate and volume sufficient to maintain urine output above 2mL/kg/hr Monitor urine for presence of blood or myoglobin

Advantages and Disadvantages of Various Types of Anesthesia

Type

Advantages
Most controllable method Induction and reversal accomplished with pulmonary ventilation Few side effects

Disadvantages
Must be used in combination with other agents for painful or prolonged procedures Limited muscle relaxant effects Postoperative nausea and shivering common Explosive Must be metabolized and excreted from the body for complete reversal Contraindicated in presence of hepatic or renal disease Increased cardiac and respiratory depression Retained fat cells Drug interactions can occur Pharmacologic effects on the body may be unpredictable

General Inhalation

Intravenous

Rapid and pleasant induction Low incidence of post operative nausea and vomiting Requires little equipment

Balanced

Minimal disturbance to physiologic function Minimal side effects Can be used with older and high-risk clients

Type
Regional or Local

Advantages
Gag and cough reflexes stay intact Allows participation and cooperation by the client Less disruption of physical and emotional body functions Decreased chance of sensitivity to the agent Decreased intraoperative stress

Disadvantages
Difficult to administer to an uncooperative or upset client No way to control after administration Absorbs rapidly into the blood and causes cardiac depression or overdose Increased nervous sytem stimulation Not practical for extensive procedures because of the amount of drug that would be required to maintain anesthesia