Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Compiled By Touqeer
Categories Of Pain
Postoperative pain can be divided into acute pain & chronic pain Acute pain is experienced immediately after surgery (up to 7 days) Pain which lasts more than 3 months after the injury is considered to be chronic
Weak opioids
Strong opioids
Adjuvant
Ketamine Gabapentine , Pregabalin Clonidine, Dexmedetomidine
1. ECG 2. Pulse oximeter waveform 3. Capnograph waveform 4. Inspired/ expired gas and aneasthetic agent concentration
Types of Anesthesia
Types of anesthesia include local anesthesia, regional anesthesia, general anesthesia, and dissociative anesthesia. Local anesthesia inhibits sensory perception within a specific location on the body, such as a tooth or the urinary bladder. Regional anesthesia renders a larger area of the body insensate by blocking transmission of nerve impulses between a part of the body and the spinal cord.
Trigeminal nerve blocks (face) Ophthalmic nerve block (eyelids and scalp) Supraorbital nerve block (forehead) Maxillary nerve block (upper jaw) Sphenopalatine nerve block (nose and palate) Cervical epidural, thoracic epidural, and lumbar epidural block (neck and back) Cervical plexus block and cervical paravertebral block (shoulder and upper neck) Brachial plexus block, elbow block, and wrist block (shoulder/arm/hand, elbow, and wrist) Subarachnoid block and celiac plexus block (abdomen and pelvis)
Spinal anesthesia
Spinal anesthesia It is the injection of small amounts of local anaesthetics into the ( CSF ) at the level below ( L2 ) ,where the spinal cord ends , anesthesia of the lower body part below the umbilicus is achieved.
14
Advantages of SPA
Cost: The costs associated with SPA are minimal Patient satisfaction: the majority of patients are very happy with this technique. Respiratory disease: SPA produces few adverse effects on the respiratory system as long as unduly high blocks are avoided. Patent airway: As control of the airway is not compromised, there is a reduced risk of airway obstruction or the aspiration of gastric contents. Diabetic patients: There is little risk of unrecognised hypoglycaemia in an awake patient.
Advantages of SPA
Muscle relaxation: SPA provides excellent muscle relaxation for lower abdominal and lower limb surgery. Bleeding: Blood loss during operation is less than when the same operation is done under general anaesthesia. Splanchnic blood flow: Because of its effect on increasing blood flow to the gut, spinal anaesthesia reduces the incidence of anastomotic dehiscence. Visceral tone: The bowel is contracted by SPA and sphincters relaxed although peristalsis continues. Normal gut function rapidly returns following surgery. Coagulation: Post-operative deep vein thromboses and pulmonary emboli are less common following spinal anaesthesia.
Indications
Operations below the umbilicus : hernia repairs , gynaecological and urological operations Any operation on the perineum or genitalia All operations on the leg except for limb amputation which is possible but an unpleasant experience for an awake patient so here te patient is supplied with light general anesthetic.
Contra-indications
Patient refusal Uncooperative patients : like young children and psychiatric or mentally handicapped patients Clotting disorders : as bleeding from ruptured peridural vein is common , patients with low platlet count or those on anticoagulant drugs (heparin + warfarin ) are at high risk of hematoma formatiom Septicemia : leading to CSF infection and meningitis
Contra-indications
Hypovolemia : since SPA has marked hypotensive effect ,hypovolemic patients must be adequately rehydrated and resuscitated Anatomical deformities (relative contraindication) as it will probably only serve to make the dural puncture more difficult. Neurological disease. Any worsening of the disease postoperatively may be blamed erroneously on the spinal anaesthetic. Inadequate resuscitative drugs and equipment. No regional anaesthetic technique should be attempted if drugs and equipment for resuscitation are not immediately to hand.
Clean the patients back with antiseptic. Locate a suitable interspinous space. Raise an intradermal wheal of LA agent at proposed puncture site.
23
25
28
Epidural Anesthesia
Local anaesthetic solutions are deposited in the peridural space between the dura mater and the periosteum lining the vertebral canal. The peridural space contains adipose tissue, lymphatics and blood vessels. The injected local anaesthetic solution produces analgesia by blocking conduction at the intradural spinal nerve roots.
29
Epidural Anesthesia
Epidural Anesthesia
Technique: Loss of resistance technique to identify the epidural space. 0.5% Bupivacaine (mainly) or lidocaine (2.0%) is usually used to produce epidural anaesthesia.
31
Epidural Anesthesia
Indication and Contraindication: the same of spinal anaesthesia. Additional indication is the post operative Paine management using the epidural catheter technique. Complications: the same of spinal anaesthesia, except the post dural puncture headache.
32
Dosis: 2.5- 3.5 ml bupivacaine 0.5% heavy Doses: 15- 20 ml bupivacaine 0.5% Onset of action: rapid (2-5 min) Density of block: more dense Hypotension: rapid Headache: is a probably complication Onset of action: slow (15-20 min) Density of block: less dense Hypotension: slow Headache: is not a probable.
33
REGIONAL ANESTHESIA
Pain - 25% of patients still experience pain despite spinal anaesthesia Post-dural headache from CSF leak Hypotension and bradycardia through blockade of the sympathetic nervous system Limb damage from sensory and motor block Epidural or intrathecal bleed Respiratory failure if block is 'too high' Direct nerve damage Hypothermia Damage to the spinal cord - may be transient or permanent Spinal infection Aseptic meningitis Haematoma of the spinal cord - enhanced by use of LMWH preoperatively Anaphylaxis Urinary retention Spinal cord infarction
Topical Anesthesia
Topical Anesthesia
A topical anesthetic is a local anesthetic that is used to numb the surface of a body part. They can be used to numb any area of theskin as well as the front of the eyeball, the inside of the nose, ear or throat, the anus and the genital area. Topical anesthetics are available in creams, ointments, aerosols, sprays, lotions, and jellies. Examples include benzocaine, butamben, dibucaine, lido caine,oxybuprocaine, pramoxine, proparacaine, proxymetacaine, and tetracaine (also named amethocaine)
Topical Anesthesia
Topical anesthetics are used to relieve pain and itching caused by conditions such as sunburn or other minor burns, insect bites or stings, poison ivy, poison oak, poison sumac, and minor cuts and scratches.[2] Topical anesthetics are used in ophthalmology and optometry to numb the surface of the eye (the outermost layers of the cornea andconjunctiva)
Topical Anesthesia
Lidocaine Dibucaine Tetracaine Benzocaine EMLA
Complications of GA
Pain Nausea and vomiting - up to 30% of patients Damage to teeth - 1 in 4,500 cases Sore throat and laryngeal damage Anaphylaxis to anaesthetic agents - figures such as 0.2% have been quoted Cardiovascular collapse Respiratory depression Aspiration pneumonitis - up to 4.5% frequency has been reported; higher in children Hypothermia Hypoxic brain damage
Nerve injury - 0.4% in general anaesthesia and 0.1% in regional anaesthesia Awareness during anaesthesia - up to 0.2% of patients; higher in obstetrics and cardiac patients Embolism - air, thrombus, venous or arterial Backache Headache Idiosyncratic reactions related to specific agents, eg malignant hyperpyrexia with suxamethonium, succinylcholine-related apnoea Iatrogenic, eg pneumothorax related to central line insertion Death
Complications of GA
General Anesthesia
Sleep induction Loss of pain responses Amnesia Skeletal muscle relaxation Loss of reflexes
General Anesthesia
Stages of Anesthesia
Stage I
Analgesia
Stage II
Disinhibition
Surgical anesthesia
Stage III
Stage IV
Medullary depression
Inhalation Anesthetics
Ether (diethyl ether) Nitrous Oxide Halothane (Fluothane) Enflurane (Ethrane) Isoflurane (Forane)
Intravenous anesthetics
Ketamine Etomidate Propofol Thiopental
Local anesthetics
Esters Cocaine Chloroprocaine Procaine Tetracaine Amides Bupivacaine Lidocaine Ropivacaine Etidocaine Mepivacaine
Local anesthetics
Techniques of administration
Topical: benzocaine, lidocaine, tetracaine Infiltration: lidocaine, procaine, bupivacaine Nerve block: lidocaine, mepivacaine Spinal:
bupivacaine, tetracaine bupivacaine
Epidural:
Local anesthetics
1.Vasoconstrictors ,Epinephrine is added to local anesthetics in extremely dilute concentrations 2.Epinephrine will prolong duration of action of all local anesthetics 3.Vasoconstrictors should not be used in Fingers,Toes, Nose, Ear lobes & Penis
Local/Field Anesthesia
Application of local subcutaneously to anesthetize distal nerve endings Uses:
Suturing, minor superficial surgery, line placement, more extensive surgery with sedation
Advantages:
minimal equipment, technically easy, rapid onset
Disadvantages:
potential for toxicity if large field
Disadvantages:
duration limited by tolerance of tourniquet pain, toxicity
Advantages:
relatively small dose of local anesthetic to cover large area; rapid onset
Disadvantages:
technical complexity, neuropathy
Plexus Blockade
Injection of local anesthetic adjacent to a plexus, e.g cervical, brachial or lumbar plexus Uses :
surgical anesthesia or post-operative analgesia in the distribution of the plexus
Advantages:
large area of anesthesia with relatively large dose of agent
Disadvantages:
technically complex, potential for toxicity and neuropathy.
Advantages:
technically easy (LP technique), high success rate, rapid onset
Disadvantages:
high spinal, hypotension due to sympathetic block, post dural puncture headache.
Disadvantages:
Technically complex, toxicity, spinal headache
Preoperative Fasting
The standard order of NPO past midnight for preoperative patients is based on the theory of reduction of volume and acidity of the stomach contents during surgery. Recently, guidelines have recommended a shift to allow a period of restricted fluid intake up to a few hours before surgery The ASA recommends that adults stop intake of solids for at least 6 hours and clear fluids for 2 hours. When the literature was recently reviewed by the Cochrane group, they found 22 trials in healthy adults that provided 38 controlled comparisons.
I- History:1- Current problem 2- Other known problems 3- Medication history 4- Previous anesthetics ; surgery & obstetric deliveries. 5- Family history. 6 Last oral intake.
Review of organ systems: General ( including activity level ). Respiratory. Cardiovascular. Renal. GIT. Hematological. Neurological. Psychiatric. Endocrinal
Definition
A normal healthy patient.
2
3 4
A patient with mild systemic disease & no functional limitation. Moderate to severe systemic disease that result in some functional limitation. severe systemic disease that is a constant threat to life and functionally incapacitating.
( continued )
6
E