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ANESTHESIA
DOCTOR NASRULLAH KHAN
MBBS FCPS
CONSULTANT ANESTHETIST
INTRODUCTION
ANESTHESIA
General anesthesia is defined as the condition of
pharmacogenic loss of consciousness which is
purposeful and easily reversible. In this condition patient
is unresponsive to painful surgical stimuli .
During anesthesia the depth of unconsciousness,
status of cardiovascular system and respiratory system
are closely monitored.
AWARENESS
Awareness is defined as unintended perception of some
of stimuli in form of pain or hearing when a patient has not
had enough general anesthetic or analgesic to prevent
consciousness.
It can be a distressing or traumatic experience for the
patient and it occurs usually just prior to the anesthetic
completely taking effect or as the patient is emerging from
anesthesia. In very few instances, it may occur during the
surgery itself.
INCIDENCE
Awareness is a rare complication in general
anesthesia. The risk varies among countries,
depending on their anesthetic practices. In the
United States, the incidence of intraoperative
awareness is 0.1 per cent to 0.2 per cent of
patients undergoing general anesthesia. The
incidence of intra operative awareness depends
on the type of surgery. Trauma patients have the
highest incidence (11%-43%) followed by patients
undergoing cardiac surgery (1.14%) and patients
undergoing Cesarean section (0.9%).
CAUSES
The cause of awareness is usually
traceable to one of three factors:
Light anesthesia due to
Specific anesthetic techniques such as
the use of nitrous oxide, opioids, and
muscle relaxants
Difficult intubation
Premature discontinuation of anesthetic
Myocardial depression
Cesarean section
Machine malfunction or misuse of the
technique such as :
Failure to check equipment
Vaporizer and circuit leaks
Errors in intravenous infusion
Accidental administration of muscle
relaxants to patients who are awake
Increased anesthetic requirement for
the following reasons:
Individual variability in anesthetic
requirements
Chronic alcohol, opioid, or cocaine abuse
EXPERIENCES RECALLED BY
PATIENTS
1. Conversations of the surgical staff
2. Various images and pictures
3. Dream-like events
4. Pain
5. Paralysis
6. Anxiety
7. Helplessness
8. Posttraumatic stress disorder:
I. nightmares, irritating dreams, sleep
disorders
II. irritating thoughts
III. excitability
IV. avoidance of medical care
The recalling of these experiences can start immediately
after surgery, in the recovery room, or several days later.
MONITORING DEPTH OF
ANESTHESIA
A. Subjective methods
1. Autonomic response
2. Patient Response to Surgical Stimulus (PSRT)
Scoring system
3. Isolated forearm technique
B. Objective methods
1. Spontaneous surface electromyogram (SEMG)
2. Lower oesophageal contractility (LOC)
3. Heart rate variability (HRV)
4. Electroencephalogram and derived indices
Compressed spectral array/ Spectral edge
frequency/ Median frequency
Bispectral index
Entropy
Narcotrend index
Patient state index
Snap index
Cerebral state index
5. Evoked potentials
Somatosensory evoked potentials
Visual evoked potentials
Auditory evoked potentials
Auditory evoked potential index
A-Line autoregressive index
6 .Functional near infrared (fNIR) technology
1.Isolated forearm technique
Tunstall in 1977 was the first who tried to
estimate the anesthesia depth of his patients by
applying the isolated forearm technique. Before
the administration of the neuromuscular blocking
agents he was inflating a cuff at the patients hand
and was estimating the depth of anesthesia by the
movement of the hand after giving orders via
microphone and headphones24. The danger of
hand ischemia limited the time that this method
could be applied
2.Autonomic and harmonic response
(Two thousand and two hundred dollars are required in order to prevent one case of
awareness).
Bispectral Index Values
100 awake
65 - 85 sedation
45 - 65 general anesthesia
<40 burst suppression
0 no electrical activity
8. Infrared Gas Analyzers
Continuous measurement of concentration of volatile
agent by Infrared Gas Analyzers in anesthesia circuit
gives very good clue about the level of anesthesia
,because we know the MAC of each volatile agent.
MAC is that concentration which causes no response to
surgical stimulus in 50% of cases.
Minimum alveolar concentration of various volatile agents.