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Introduction History Theories of mechanism of action of general anesthesia Pre operative evaluation & premedication of the patient Stages of anesthesia The anesthetic machine Anesthetic agents Other drugs administered during anesthesia
Introduction
Introduction
Anesthesia- ( Greek) - Insensible/without any feeling According to Bennet: Anesthesia means loss of all modalities of sensation, particularly pain, along with reversible loss of consciousness
According to Goodman and Gillman: The anesthetic state is defined as a collection of component changes in behavior or perception.
GENERAL ANAESTHESIA is a controlled state of unconsciousness, accompanied by partial or complete loss of protective reflexes, including the inability to maintain an airway independently and respond purposefully to stimulation or verbal command.
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Cooling with cold water, ice; Distraction by counter irritation with stinging nettles; Carotid compression and nerve clamping. Concussion anaesthesia relied on the hammer stroke. Acupuncture Hypnosis Cocaine
History
Nitrous oxide
Chloroform introduced
History
William Morton
Queen Victoria
(born 1819, reigned 1839 - 1901) Chloroform (CHCl3)
The delivery in 1853 of Victoria's eighth child and youngest son, Prince Leopold, was successful: chloroform was administered by Dr John Snow, the world's first anaesthetist.
History
In. 1887 Frederic Hewitt invented a gas & oxygen machine. In 1910 Mc Kesson introduced intermittent flow machine, which provided control of O2 and N2O on demand.
Lipid/water partition theory Surface tension theory Theory of inhibition of energy production/ utilization Clathrates formation theory Membrane expansion theory Membrane fluidization/ perturbation theory
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A direct parallelism exists between lipid water partition co efficient of drugs and their anesthetic potency. The minimum alveolar concentration (MAC) shows excellent correlation with oil/gas partition coefficient of inhalation anesthetics. However this only reflects the capacity of anesthetics to enter the CNS and attain a sufficient concentration in neuronal membrane but not the mechanism by which anesthesia is produced.
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General anesthetics reduce surface tension at all cell membrane and thus affect its permeability, electrical and /or enzymatic properties. This theory is generally not accepted.
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This theory states that general anesthetics decreases the production of action potential in the brain. Decrease in energy production In the brain is probably an effect rather than the cause of general anesthesia.
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Water has a crystal like molecular arrangement. General anesthetics are believed to fill up the spaces between micro crystals (clathrates) and make water structured. They plug the pores and impede ionic fluxes. However this behavior is also dependant on hydrophobicity. But there is no evidence of clathrate formation at body temperature.
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The general anesthetics occupy the space in the nerve membrane in the brain and expand it disproportionately (about 10 times their molecular volume). This causes increased surface pressure in the membrane, there by closing ionic channels. This theory in much widely accepted.
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The anesthetics by dissolving in the membrane lipids, increases the degree of disorder in their structures, favoring a gel-liquid transition. (Fluidization). Normally fluidization occurs at high temperatures. General anesthetics make it possible to occur at low temperatures. This affects the state of membrane bound proteins which regulates ionic fluxes.
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Purpose:
1.
2.
3.
4.
5.
To obtain pertinent information about the patients medical history and physical as well as mental condition. To determine the need for a medical consultation and the kind of investigations required. To educate the patient about anesthesia, per operative care, pain treatment, in the hope of reducing anxiety and thereby facilitating recovery. To choose the anesthesia plan to be followed, guided by the risk factors, uncovered by the medical history. To obtain an informed consent.
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Contd..
History
Current problems. Other known problems Treatment/ medications for the problem. Current drug use. H/O use of tobacco, alcohol etc H/O drug allergies. Prior anesthetic exposure. General health of the patient And Review of systems.
Physical examination:
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ASA Classification
Class 1 Class 2
Class 3 Class 4
Class 5
Class 6 Class E
Review of systems
Neurologic evaluation of the patient Cerebro vascular evaluation of the patient Cardiovascular evaluation Pulmonary evaluation. Gastro intestinal evaluation Endocrinal system evaluation.
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BENZODIAZEPINES:
E.g.: Diazepam, Midazolam, Oxazapam, Lorazepam. Produces anxiolysis, sedation and amnesia
OPIOD ANALGESICS:
E.g.: Morphine, Fentanyl, Pethidine, Pentozocaine etc It produces sedation and analgesia. E.g.: Atropine, Glycopyrolate, Scopolamine Dosage
ANTICHOLINERGIC AGENTS:
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Contd..
ANTICHOLINERGIC AGENTS:
Increases the heart rate by blocking the action of acetylcholine on muscarinic receptors in SA node. Very useful in preventing intraoperative bradycardias resulting from stimulation of carotid sinus or vagal stimulation. Antisialagouge action
Glycopyrolate is more potent and long acting drying agent and is likely to increase the heart rate. Scopolamine is more effective Antisialagouge than atropine.
Glycopyrolate doesn't cross blood brain barrier and hence doesn't cause sedation/ amnesia. Scopolamine has good sedative and amnesic effect. Atropine cause delirium in elderly individuals, so glycopyrolate is better than atropine for elderly individuals
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ASPIRATION PROPHYLAXIS,
E.g.: Cimetidine, Ranitidine, and Famotidine. E.g.: Metoclopramide E.g.: Sodium citrate solution
Antacids
Antiemitic agents.
2 hours prior
2-3 hours prior 2-3 hours prior 2-3 hours prior
STAGE OF ANALGESIA.
Starts from the beginning of anesthetic inhalation and lasts up to loss of consciousness. Pain is progressively abolished at this stage
STAGE OF DELIRIUM
Starts from the loss of consciousness to beginning of irregular respiration. Apparent excitement is seen. Heart rate and BP may rise and pupils dilate due to sympathetic stimulation. 27
SURGICAL ANAESTHESIA.
Plane 1- Roving eye balls. This plane ends when eyes become fixed. Plane 2- Loss of corneal and laryngeal reflexes. Plane 3- Pupil starts dilating and light reflex is lost. Plane 4- Intercostal paralysis, shallow abdominal respiration, dilated Pupil
As
anesthesia passes to deeper planes progressively, the muscle tone decreases, BP falls, HR increases with weak pulse, and respiration decreases in depth and later in frequency also. 28
MEDULLARY PARALYSIS.
Cessation of breathing to failure of circulation and death. Pupil is widely dilated, Muscles are totally flabby, BP very low.
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Stages
Excitation
Tolerance
consciousness
diaphragm Resp. eye motion pupil size eye closing conjunctiva
reflexes
coughing
secretion
swallowing vomiting
abdomen smooth m.
Muscle tone
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Comprises of
A
means of supplying gasses either from attached cylinders or from piped medical supplies. Methods of measuring flow rate of gasses. Apparatus for vaporizing volatile anesthetic agents. Breathing system and ventilators for delivery of the gasses and vapors from the machine to the patient. Apparatus for scavenging anesthetic gasses in order to minimize environmental pollution.
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Pipeline supply
Primary
gas source for the anesthesia machine Supplies oxygen, nitrous oxide, and air "normal working pressure" 50 psi
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Cylinder supply
Reserve E cylinders Color-coded Pressure regulator
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Flow meter
Minimum O2 concentration at the common gas outlet is between 23% and 25%
Linked
flow meter
Oxygen flow meter and the N2O flow meter are connected mechanically which will cause reduction of the oxygen flow when N20 flow will be increased and vice versa.
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An oxygen leak from the flow tube can produce a hypoxic mixture, regardless of the arrangement of the flow tubes
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Vaporizer
They results in the increase of the temperature The liquid form of the anesthetic agent vaporizes to its gaseous form. The vaporization can be with
Dry heat or With Ultraviolet light
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A circle system can be semiopen, semiclosed, or closed, depending on the amount of fresh gas inflow
Semiopen system has no rebreathing and requires a very high flow of fresh gas Semiclosed system is associated with rebreathing of gases Closed system is one in which the inflow gas exactly matches that being consumed by the patient
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of inspired gas concentrations, Conservation of respiratory moisture and heat, Prevention of operating room pollution
Disadvantage
Complex
design
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ABSORPTION
Lack of toxicity with common anesthetics, low resistance to airflow, low cost, ease of handling, and efficiency 3 formulations
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ABSORPTION
80% calcium hydroxide, 15% water, 4% sodium hydroxide, and 1% potassium hydroxide (an activator)
Baralyme
Carbon monoxide and the nephrotoxic substance known as compound A not produced
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ABSORPTION
Absorptive Capacity
Soda lime is 26 L of carbon dioxide per 100 g of absorbent Calcium hydroxide lime has been reported at 10.2 L per 100 g of absorbent
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SCAVENGING SYSTEM
The collection and the subsequent removal of vented gases from the operating room Attached to the exhaust valve Consists of tubings that collects gases and directs them outside the building or to a charcoal canister (1) the gas-collecting assembly (2) the transfer means (3) the scavenging interface (4) the gas-disposal assembly tubing (5) an active or passive gas-disposal assembly
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Components
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Gas supply
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Rebreathing circuit
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A. INHALATIONAL.
Gases:
-
Liquids.
-
Contd..
B. INTRA VENOUS.
1. Inducing agents:
-
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Contd..
C. For the anesthetist: Its administration should be easy, controllable and versatile.
Wide safety margin Heart, lever or other organs should not be affected Should be potent in low concentration Rapid adjustment of depth of anesthesia should be possible Cheap, stable and easily stored 50 Should not react with rubber tubing or soda lime.
The amount of drug used to produce lack of reflex response to skin incision in 50% of patients. Factors which decreases the MAC.
Sedative
drugs such as pre medication agents, analgesics N20. Increasing age Drug which affect the neurotransmitter release such as methyldopa, pancuronium, clonidine Higher atmospheric pressure. 51 Hypocapnia
Factors
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HALOTHANE [fluothane]
MAC 0.75% Colorless volatile liquid with sweet odour. Non irritant and non inflammable. This is 4 to 5 times more potent anesthetic agent than ether.
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Contd..
Actions:
BP falls in proportion to the concentration of the vapors inhaled. Hypotension Respiratory depression in proportion to the concentration of halothane inhaled. Breathing: shallow and depressed. Increases the CSF pressure. Causes moderate relaxation of skeletal muscles. Post op nausea and vomiting not severe as in ether. Shivering.
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ETHER
Highly volatile and colorless liquid. It is inflammable in air and explosive with oxygen,
About 85 to 90% of the drug will get excreted through the lungs. Stimulates the sympathetic system yielding to increase in heart rate and to depress the vagus nerve. BP falls in the deeper planes of anesthesia
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Contd..
Respiratory movements first increase due to stimulation of respiratory centre and later on it decreases as the anesthesia deepens. Stimulates salivation, so atropine pre medication is advised. Irritant to respiratory tract and produces cough and laryngeal spasm. On induction it induces analgesia followed by-excitement and then anesthesia. Increases CSF pressure and blood glucose levels. Produces post operative nausea and vomiting in 50 % of patients
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ENFLURANE
MAC 1.68% Non inflammable Non irritant Strong anesthetic agent with pungent odour
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Contd..
ACTIONS
Depresses the cardiovascular system. Heart rate remains relatively stable. Increases the BP As the depth of the anesthesia increases, respiratory system will be depressed. Induction and recovery slower compared to Halothane. Produces brief clonic seizures at deeper levels if respiration is not assisted. Contraindicated in Epileptics .
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ISOFLURANE
Rapid onset and reversal. Profound respiratory depression with decreased tidal volume Depresses the cardiovascular system. Decreases the BP as the dosage increases. Produces good muscle relaxation. Increases the intra cranial pressure secondary to increased cerebral blood flow (vasodilatation). 59
Contd..
Actions:
Moderate increase in pain threshold Slight amnesia effect Euphoria is frequent Decreased sense of smell Improved hearing Slight myocardial depression Minimal effect on respiration Reduces MAC of other gaseous agents by 50%
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and
Maintenance Reversal
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concentrate
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THIOPENTONE SODIUM.
Dosage:
3-5mg/kg Ultra short acting barbiturate Highly soluble in water Produces unconsciousness in 15-20 seconds Produces CNS depression which persists for> 12 hours. Poor analgesic and weak muscle relaxant Respiratory depression with inducing doses of thiopentone is generally transient, but with large dose it will be severe. 66
Contd..
Bp falls immediately after injection but recovers rapidly. Cardiovascular collapse may occur if hypovolemia, shock or sepsis are present. Adverse effects:
Laryngospasm Shivering
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METHOHEXITAL SODIUM
Dosage:
1-1.5mg/kg.
3 times more potent than thiopentone. Quicker and brief actions. Unconsciousness is usually induced in 15-30 seconds. Consciousness will regain within 2-3 minutes. Actions:
Less hypotensive compared to thiopentone. Causes slight increase in heart rate. Moderate hypoventilation Short period of apnea may be seen after iv injection. This drug is contraindicated in epileptic patients.
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PROPOFOL
Phenol derivative. Oil in water emulsion pH between 7.0 and 8.5. Dosage:
G.A Induction: 2 to 2.5 mg/kg titrated over 20 to 3.0 seconds. Maintenance: 25% of the induction dose. Sedation: 3mg/kg/hr in an infusion pump.
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Contd..
Action
Rapid onset: 45 seconds. Average duration of anesthesia: 10 minutes. Antiemetic property is present. So post op nausea and vomiting less. Decreases arterial pressure by 30%. No heart rate change. Cardiac output decreases minimally. Incidence of phlebitis is 0.6%. Pain at the injection site.
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Dosage:
Mild decrease in BP by decreasing anxiety and causing muscle relaxation. Antiemetic property is present. Produces amnesia which increases as the dose increases . Produces emotional responses in adolescent females.
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MIDAZOLAM [1-5mg/ml]
Onset of action: 1 minute. Given slowly, 1 mg over 2 minutes. Soluble in water. Less chance of thrombophlebitis. Respiratory depression may occur at higher dose. Faster acting. Short clinical action than diazepam. Half life 2.5 hours. 72
Muscle tone increases. Heart rate, cardiac output and BP are elevated due to sympathetic stimulation
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Contd..
Dosage:
Onset of action: within 1 to 3 minutes Recovery starts after 10 - 15 minutes, but the patient remains amnesic for 1 to 2 hours. Delirium, hallucinations and involuntary movements occurs in 50% patients. Children tolerate the drug well.
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Contd..
Recommended for
Surgeries on the head and neck Asthmatic patients (relieves bronchospasm) Hypovolemic patients.
Contraindicated in:
Hypertensive patients Ischemic heart diseases. Unmarried females
As
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Contd..
Dosage:
Fentanyl 0.5 mg+ Droperidol 2.5mg/ml 4 to 6 ml is diluted in 5% dextrose sol and infused over 10 minutes . Supplemental doses of Fentanyl can be given at 30 minutes intervals.
Patient remains drowsy but conscious. Respiratory depression present. Slight fall in BP. Heart rate increases. Recovery is slow,
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Contd..
Abnormal
movements can be seen. Psychomotor function remains depressed for many hours. Can be converted to 'neuroleptanesthesia' by administering 65% N20 and 35% 02.
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Notes
Thiopentone
(barbiturate)
fast
Midazolam
(benzodiazepine)
slow
Ketamine
slow
Psychotomimetic effect
very fast Cardiovascul ar and respiratory depression
Propofol
fast
Advantages
- controllable reversibility
(duration of action can be controlled)
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Muscle relaxants
During maintenance of anesthesia muscle relaxation may be required to facilitate surgery and intermittent positive pressure ventilation
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Muscle relaxants
Muscle relaxants are either depolarising or non-depolarising agents
Depolarising agents
For example - suxamethonium Act rapidly within seconds and last for approximately 5 minutes Used during induction of anaesthesia Gets metabolized with pseudocholinestrase enzyme and its effect wears off. Has a short duration of action.
Non-depolarising agents
For example Vecuronium, Pancuronium, Atracurium, Rocuronium Act over 2-3 minutes and effects last for 30 minutes to one hour Competitive antagonism of acetylcholine receptor Used for muscle relaxation
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In boluses at induction and before incision, then maintenance as needed. Additional doses based upon sympathetic response to pain, like increased HR, BP. Fentanyl, a synthetic narcotic,
Contd..
Morphine- 5min onset, peak at 20min. Metabolites cleared by kidney Histamine release with hypotension possible. Ketamine-Intense analgesia, amnesia, dissociative anesthesia.
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Contd..
Ketamine increases HR, BP, bronchodilator, Increased Cerebral Blood Flow. Illusions, dysphoria. Not a respiratory depressant, Can be sole anesthetic agent. One of several induction agents, good for children, contraindicated in head injury.
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REVERSAL OF ANESTHESIA.
The timing of the last dose of muscle relaxant is important, and if it is too near to the conclusion of surgery, adequate time must be allowed before reversal is attempted. Non depolarizing muscle relaxants are reversed by anticholinestrase drugs.
E.g.: Neostigmine Sulphate [0.05 to 0.07 mg/kg] Atropine Sulphate (Anticholinergic) is administered along with this to prevent muscarinic effects of neostigmine like bradycardia, profuse salivation and bronchospasam 86
Flumazenil
Neostigmine
Tracheal intubation
Airway patency
Protects
Control of ventilation
ventilation
over a long period of time without intubation can lead to gastric distention and regurgitation
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Topical lidocaine or phenylephrine should be applied to the nasal passages 0.5-1.0% phenylephrine and 4% Lidocaine, mixed 1:1 should also give satisfactory results Generously lubricate the nares and endotracheal tube ET tube should be advanced through the nose directly backward toward the nasopharynx
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Insert from right to left Ensure the lower lip is not being pinched by the lower incisors and laryngoscope blade Visualize anatomy Blade in vallecula Lift up and away Lift epiglottis indirectly
Insert from right to left Ensure the lower lip is not being pinched by the lower incisors and laryngoscope blade Visualize anatomy Blade past vallecula and over epiglottis Lift up and away Lift epiglottis directly
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Condensation (fogging) of water vapor in the tube on exhalation Refilling of reservoir bag during exhalation Maintenance of arterial oxygenation Chest X-ray: the tip of the ET tube should be between the carina and thoracic arc or approximately at the level of the aortic arch
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Extubation
Ensure that the patient is recovering is breathing spontaneously with adequate volumes Evaluate the patient's ability to protect his airway by observing whether the patient responds appropriately to verbal commands
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Extubation steps:
Oxygenate patient with 100 percent high flow O2 for 2 to 3 minutes If secretions are suspected in the tracheobronchial tree, remove them with a suction catheter through the lumen of the endotracheal tube Ensure that the patient is not in a semiconscious state
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Extubation steps:
Turn the patient onto his side if he is still unconscious Unsecure the endotracheal tube from the patient's face Deflate the cuff and remove the endotracheal tube quickly and smoothly during inspiration Continue to give the patient O2 as required
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Direct trauma to teeth, luxation of teeth Fracture and or subluxation of cervical spine Nasal hemorrhage Surgical emphysema of the neck and mediastinum Aspiration of gastric contents. Accidental intubation of esophagus. Obstruction of the airway Rupture of the trachea and bronchus. Difficult extubation Tracheal collapse. Airway obstruction. Aspiration of stomach contents.
COMPLICATIONS AT EXTUBATION
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Monitoring
Placement of electrodes which monitor heart rate and rhythm. Help the anaesthetist to identify early signs of dysrhythmias, myocardial ischemia, electrolyte abnormalities. Detect 95% of intraoperative ischemia, allowing for early intervention The placement of this device (usually on one of the fingers) allows for early detection of a fall in a patient's 99 haemoglobin saturation with oxygen (hypoxemia).
Monitoring
Placing a blood pressure cuff around the patient's arm, forearm or leg. A blood pressure machine takes blood pressure readings at regular, preset intervals throughout the surgery.
Invasive
For patients with significant heart or lung disease, the critically ill, major surgery such as cardiac or transplant surgery, or when large blood losses are expected. Technique involves placing a special type of plastic cannula in the patient's artery usually the femoral and radial sites
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Monitoring
4.Urine outputA
measure of end-organ perfusion; Foley for all cases over 2 hrs, Decompress bladder.
used
warns if the fraction of inspired oxygen drops lower than room air (21%).
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Monitoring
the amount of carbon dioxide expired by the patient's lungs. Allows the anaesthetist to assess the adequacy of ventilation. Unexpected rise in CO2:
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Monitoring
9. Temperature measurement
To
diagnose hypothermia and fever, and to aid early detection of malignant hyperthermia.
verify depth of anaesthesia may also be used. Reduces the likelihood that a patient will be mentally awake, although unable to move because of the paralytic agents. Also reduces the likelihood of a patient receiving significantly more amnesic drugs than actually necessary to do the job. 103
DURING ANESTHESIA
Respiratory depression and hypercarbia. Increased salivation, respiratory secretions. Cardiac arrhythmias, asystole Fall in BP. Aspiration of gastric contents, acid pneumonitis. Laryngospasm, asphyxia Delirium, convulsions.
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Contd..
AFTER ANESTHESIA.
Nausea, vomiting Persisting sedation; impaired psychomotor function Pneumonia Liver / kidney damage Nerve palsies- due to the faulty positioning Delirium Malignant hyperthermia
105 Stop surgery! 100% oxygen; Dantrolene Sodium and ice to cool
Causes
Is per- operative hypothermia secondary to anaesthetic induced inhibition of thermoregulation. Causes both cutaneous vasodilation and reduction in the thresholds for activation of vasoconstriction and shivering. In turn this results in redistribution of body heat from core to periphery with subsequent rapid hypothermia during anaesthesia.
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Contd..
Prevention
Increasing the ambient temperature in theatre, Using conventional or forced warm air blankets Using warmed intravenous fluids.
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Contd..
Drug treatment:Drug Pethidine Clonidine Tramadol Ondansetron Suggested Dose And Route 0.35 mg/kg may repeat 4 at 5 min. intervals iv 0.15 mg iv 1mg/kg iv 8mg iv Role Treatment Treatment Treatment or Prophylaxis Prophylaxis
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Conclusion
Individual variation of patients response to general anaesthetics are so great that reliable dose/response relationship do not exist. General anaesthetics can not be administered in a predetermined dosage based on mg/kg body weight without running the risk of serious over dosage in some patients and inadequate depth of anaesthesia in others.
Evaluation of depth of anaesthesia is neither easy nor precise but instead highly subjective, clinical signs varying not only with each general anaesthetic but also with each patient.
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Bibliography
ORAL AND MAXILLOFACIAL SURGERY Vol 1- Daniel Laskin ORAL AND MAXILLOFACIAL SURGERY Vol 1 - ANESTHESIA. Fonseca MANUAL OF ORAL AND MAXILLOFACIAL SURGERY- Paul Laskin PHARMACOLOGY AND THERAPEUTICS FOR DENTISTRY- Enid A Neid 3rd edition A TEXT BOOK OF ANESTHESIA- Ailkenhead 4th edition CLINICAL PHARMACOLOGY- K. D. Tripati A PRACTICE OF ANESTHESIA . Thomas EJ Healy& Paul R Knight 3rd edition CLINICAL PHARMACOLOGY. P. N. Bennette
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Thank you!