SYLLABUS POINT : SANGYAHARAN / ANAESTHESIA: DEFINITION & TYPES.

ANAESTHESIA
DEFINITION

 Anaesthesia or anaesthesia is a state of temporary induced loss of sensation or awareness.

 A patient under the effects of anesthetic drugs is referred to as being Anesthetized.
 Anaesthesia enables the painless performance of medical procedures that would cause
severe or intolerable pain to an unanesthetized patient.

TYPES

1. General Anaesthesia
2. Local Anaesthesia
3. Regional Anaesthesia

PROPERTIES OF AN IDEAL ANAESTHETIC

1. For the patient
 It should be pleasant, nonirritating, should not cause nausea or vomiting. Induction
and recovery should be fast with no after effects.
2. For the surgeon
 It should provide adequate analgesia, immobility and muscle relaxation. It should be
noninflammable and nonexplosive so that cautery may be used.
3. For the anaesthetist
 Its administration should be easy, controllable and versatile.
4. Margin of safety should be wide—no fall in BP.
5. Heart, liver and other organs should not be affected.
6. It should be potent so that low concentrations are needed and oxygenation of the patient
does not suffer.
7. Rapid adjustments in depth of anaesthesia should be possible.
8. It should be cheap, stable and easily stored.
9. It should not react with rubber tubing or soda lime.

PREOPERATIVE ASSESSMENT
A patient posted for surgery is examined at least one day before of surgery.
If patient has any associated disease. which need to be control first as Diabetes melitis &
Hypertension

 HISTORY

1. Chronic Cough, Smoking, Alcohol, Drug Intake, Drug Allergy.

2. Any previous diseases like Hypertension, Diabetes Mellitus, Epilepsy, Bronchial Asthma,
Tuberculosis, Hepatitis, Cardiac Diseases.
3. Drug therapy: Steroids, Antihypertensives, Sedatives, Antibiotics, Antiepileptics.

 EXAMINATION

1. GENERAL
i. Posture v. Neck Movements ix. Oedema
ii. Teeth vi. Tremor x. Jaundice
iii. Mouth Openiing vii. Airway xi. Cyanosis.
iv. Dilated Veins viii. Anaemia

2. SYSTEMIC EXAMINATION

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 SYSTEM EXAMINATION
1. Respiratory System Asthma, Tuberculosis, Emphysema, COPD
2. Airway Mouth opening, Temporomandibular Joint Assessment
3. CVS HTN, IHD, Arrhythmias, Cardiac Failure, Valvular Diseases
4. Spine Curvature, Intervertebral Space, Skin over the area for any infn.
5. Other Systems Abdomen, Skeletal System

PREOPERATIVE INVESTIGATIONS

1. Haematocrit 5. Electrolytes 9. Renal Function Tests

2. Blood Sugar 6. Chest X-Ray 10. Liver Function Tests
3. Blood Urea 7. Blood-Gas Analysis 11. ECG
4. Serum Creatinine 8. Cardiac Assessment

PRE OPERATIVE PREPARATION

1. Establish a good conversation with patient.

2. Collect History of patient with examination.
3. Informed written consent should be taken.
4. If significant disease is present, then first it is brought under controlled.
5. Strictly NBM before 4 hrs of surgery.
6. Control of respiratory and cardiac diseases.
7. Improvement of Hb% status, if anaemia is present.
8. Preoperative antibiotics are given.
9. Blood should be kept ready for major cases.
10. Starvation for 4 hours for liquids and 6 hours for solids.
11. Bladder and bowel should be emptied to prevent soiling on the operation table.
12. Urinary catheter may be passed and enema may
13. Dentures, contact lenses, jewellery must be removed.
14. Surgical area should be cleaned and properly prepared.

PREOPERATIVE MEDICATIONS

CAUSE DRUGS USED DOSE

To reduce Sedation and Anxiety Pethidine 50 mg
Morphine & Diazepam 10 mg
To reduce Vomiting Promethazine 12.5 mg
To reduce Secretion Inj. Atropine 0.6 mg
Blood Loss Blood Transfusion If Needed

PHYSICAL EXAMINATION
1. Oral Hygiene 5. Pallor
2. Examination of loose & artificial 6. Clubbing & Cyanosis
teeth 7. BP
3. Nutritional & Hydration Status 8. Heart Sounds
4. Body Built 9. Peripheral Pulsation

EQUIPMENTS FOR ANAESTHESIA

1. Laryngeal scope 5. Ambubag

2. Endo Tracheal Tube (ETT) 6. Boyle’s apparatus
3. Oropharyngeal airway 7. Pulse oximeter
4. Nasopharyngeal airway 8. Cardiac monitor

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 9. B. P. Instrument 12. Emergency drug Tray
10. Stethoscope 13. Suction catheter
11. Spinal Needle 14. Source of 02

CLASSIFICATION
(ACC. TO AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) )

GRADE FEATURE
ASA I  No abnormality
ASA II  Mild systemic disorders
ASA III  Moderate systemic disease with normal activity
ASA IV  Severe systemic disease that is threatening to the life of the patient
ASA V  Moribunt- not expected to survive 24 hrs with or without operation.
 Patient is dead posted for organ donation.

I. LOCAL ANAESTHESIA – DRUGS, TECHNIQUES, INDICATIONS,

CONTRAINDICATIONS, COMPLICATIONS AND THEIR MANAGEMENT.

DEFINITION

 LA is defined as reversible depression of nerve impulse conduction leading to temporary

loss of sensation and relief of pain because of disturbed nerve conductivity.
 Local anaesthesia is any technique to induce the absence of sensation in a specific part of
the body, generally for the aim of inducing local analgesia, that is, local insensitivity
to pain, although other local senses may be affected as well.
 Local anaesthesia is anaesthesia of a small part of the body such as a tooth or an area of
skin.
 A local anaesthetic is a medication that causes reversible absence of pain sensation,
although other senses are often affected, as well.
 It blocks both conduction and generation of impulse.

CLASSIFICATION :

1. Injectable Anaesthetics
A. Low Potency, Short Duration
Procaine Chloroprocaine
B. Intermediate Potency And Duration
Lidocaine (Lignocaine) Prilocaine
C. High Potency, Long Duration
Tetracaine (Amethocaine) Ropivacaine
Bupivacaine Dibucaine (Cinchocaine )
2. Surface Anaesthetics
A. Soluble
Cocaine Tetracaine
Lidocaine Benoxinate
B. Insoluble
Benzocaine Butylaminobenzoate
Oxethazaine

TECHNIQUES & USES

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 1. SURFACE ANAESTHESIA / TOPICAL ANAESTHESIA

 Skin is anaesthetized by local anaesthetic agents used as spray, ointment, cream, jelly
and lotion.

2. INFILTRATION ANAESTHESIA

 Injection of local anesthetic drug into area which is to be incised in a circular manner.
 Infiltration is used for minor operations, e.g. incisions, excisions, hydrocele,
herniorrhaphy, etc. when the area to be anaesthetised is small.

3. FIELD BLOCK

It is produced by injecting the LA subcutaneously which blocks entire field of

excisionwhere disease is located.

4. NERVE BLOCK

It is produced by injecting the LA around the appropriate nerve trunks or plexuses.

Frequently performed nerve blocks are—lingual, intercostal, ulnar, sciatic,
femoral, brachial plexus, trigeminal, facial, phrenic, etc.—used for tooth
extraction, operations on eye, limbs, abdominal wall, fracture setting, trauma to
ribs, neuralgias, persistent hiccup, etc.
The primary purpose of nerve block anaesthesia is to abolish pain and other
sensations.

TECHNIQUE
Supraclavicular approach is commonly used

Needle is passed downwards, backwards and medially towards first rib, 1cm
above midpoint of clavicle

Once needle hits the first rib, 15-20 ml of 1.5% xylocaine is injected .

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 5. INTRAVENOUS LOCAL ANAESTHESIA ( BIER’S BLOCK )

TECHNIQUE

 Limb is exsanguinated & occluded with tourniquet with pressure 30mmhg more than
systolic pressure of the patient.
 Needle is placed in the selected vein.
 Xylocaine – 40 ml of 0.5% for upper limb
80ml of 0.25% for lower limb
 Side effects: Hypotension, Convulsions, Death

6. SPINAL ANAESTHESIA

 Spinal anaesthesia is also known as saddle block/saddle anaesthesia .

 It is the injection of LA into the subarachnoid space between L2–3 or L3–4 i.e. below
the lower end of spinal cord, causing loss of sympathetic tone, sensation and motor
function.
 Spinal anaesthesia is used for operations on the lower limbs, pelvis, lower abdomen, e.g.
prostatectomy, fracture setting, obstetric procedures, caesarean section, etc
 When they are injected in sub arachnoid space it is called as Spinal Anaesthesia.
 Saddle Anaesthesia means after injecting anesthetic drug in subarachnoid space patient
gives sitting position on table for 10 min. Then it is known as Saddle Block or Saddle
Anaesthesia.

TYPES
TYPE INJ. LEVEL
1. Caudal Anaesthesia  Upto L5
2. Low Spinal Anaesthesia  Upto L1
3. Mid Spinal Anaesthesia  Upto T10
4. High Spinal Anaesthesia  Upto T6
5. Unilateral Spinal Anaesthesia

USEFUL DRUGS IN SPINAL ANAESTHESIA

ADVANTAGES

1. Profound relaxation.
2. Retention of consciousness.
3. No irritation of lungs
4. Operative hemorrhage less due to fall of Blood Pressure
5. Economical

DISADVANTAGES

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 1. Technical difficulties by unexpert.
2. CSF leak

INDICATIONS

1. Provide excellent muscle relaxation

2. Prostectomy
3. LSCS
4. Hysterectomy and Hemorrhoidectomy
5. Fistulectomy
6. Lower limb fractures,
7. Urological, gynaecological, lower limb, & below umbilical operations.
8. Respiratory diseases.
9. Suffering from liver & kidney diseases as well as diabetes.

CONTRAINDICATIONS

1. Without patient’s will

2. Shock
3. Hypoxia
4. Severe anemia
5. Dehydration
6. Active neurological disease
7. Infection
8. Hypotension and hypovolemia.
9. Uncooperative or mentally ill patients.
10. Infants and children—control of level is difficult.
11. Bleeding diathesis.
12. Raised intracranial pressure.
13. Vertebral abnormalities e.g. kyphosis, lordosis, etc.
14. Sepsis at injection site.

PROCEDURE OF SPINAL ANAESTHESIA

1. Spinal Anaesthesia may be administrated to patient in sitting position or in right & left
lateral position.
2. The patient lies either in left or right lateral position & back is kept parallel to edge of
table.
3. Leg should be flexed while in sitting position patient sits on table with back bent forward
& advised to rest his arm on his shoulde.
4. The back is cleaned with savlon, iodine & spirit, under strict aseptic precautions.
5. Vertebral spines are identified from highest point of iliac crest L3, L4. intervertebral
space L 4 & L5 space commonly used.
6. In uncooperative patients, wheel of local anesthetic drug is injected at the site of spinal
anaesthesia.
7. Lumbar puncture needle 25 to 27 G is inserted in midline. between intervertebral space
perpendiculars to skin.
8. Spinal needle passes following structures. .

i. Skin vi. Epidural space

ii. Subcutaneous tissue vii. Dura. matter
iii. Supra spinal ligament viii. Sub arachnoid space
iv. Inter spinal ligament
v. Ligamentum Flaveum
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 9. Correct position of tip of needle is identified by:-
a. Free resistant to hand
b. Continuous CSF free flow
10. After making confirmation tip of needle is in subarachnoid space. Drug is then injected
slowly as per requirement.

COMPLICATIONS OF SPINAL ANAESTHESIA

1. Hypotension due to vasodilation 6. Infection.

2. Septic meningitis 7. Retention of urine
3. Paraplegia 8. Intravertebral disc injury
4. Backachce 9. Headache
5. Cauda equina syndrome 10. Respiratory depression

CAUDAL ANAESTHESIA

 It is the sacral component of spidural space and access is through the sacral hiatus.

PROCEDURE

1. It is given in lateral position.

2. Needle is inserted through the sacral hiatus to enter the caudal epidural space.
3. Drug is then injected into the space.

INDICATIONS

1. Haemorrhoidal surgery
2. Circumcision
3. Small procedures in perineum like cystoscopy.

COMPLICATIONS

1. Trauma to the anal canal

2. Intravascular injection

7. EPIDURAL ANAESTHESIA

 Epidural anaesthesia is a type of local anaesthesia.

 It isa direct block of spinal nerve roots in epidural space leading to centrifugal spread
which affects the nerve in block known as epidural anaesthesia.

TECHNIQUE

1. It can be done with the patient in the lateral decubitus position.

2. Epidural needle does not have sharp tip, so chance of puncture in dura matter is very
rare.
3. In epidural anaesthesia 16 to 17 touhy needle is used. Needle is passed through the
midline or para medium. Needle passes structure as similar to spinal anaesthesia except
penetration into sub-arachnoid space.

ADVANTAGES OF EPIDURAL ANAESTHESIA

1. It can be used for continuous repeated prolonged anaesthesia.

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 2. It can be used for postoperative analgesia.
3. It can be kept for several days.

ADVANTAGES OF LOCAL ANAESTHESIA

1. Technically simpler.
2. GA is avoided.
3. Consciousness is retained.
4. Pt. can have food earlier after surgery.

COMPLICATIONS OF LOCAL ANAESTHESIA

1. CNS effects are -

i. Light-Headedness vi. Shivering
ii. Dizziness vii. Twitching
iii. Auditory And Visual viii. Involuntary Movements
Disturbances ix. Finally Convulsions
iv. Mental Confusion x. Respiratory Arrest.
v. Disorientation
These can be prevented and treated by diazepam.
2. Cardiovascular toxicity of LAs –
i. Bradycardia iii. Cardiac Arrhythmias
ii. Hypotension iv. Vascular Collapse
3. Injection of LAs may be painful.
4. Delayed wound healing .
5. Hypersensitivity reactions-
i. Rashes iv. Contact Sensitization
ii. Angioedema v. Asthma
iii. Dermatitis vi. Rarely Anaphylaxis Occur.

CONTRAINDICATION TO LOCAL ANAESTHESIA

Absolute Contraindications

1. History of Allergy to Local Anesthetic Agents

2. Local anesthetic agents belonging to the same chemical group should not be used.
3. Documented Allergy to Other Constituents of the solution.
4. History of allergy to any of the constituents of the local anesthetic solution.

Relative Contraindications

1. Fear and apprehension

2. Presence of acute inflammation or Suppurative infection at the site of insertion of the
needle.
3. Infants or small children
4. Mentally retarded patients
5. Restricted mouth opening
6. Patients with Medical disease-
i. Cardiovascular Disease
ii. Hepatic Dysfunction
iii. Renal Dysfunction
iv. Clinical Hyperthyroidism

DIFFERENCE BETWEEN SPINAL AND EPIDURAL ANAESTHESIA

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 SPINAL ANAESTHESIA EPIDURAL ANAESTHESIA
1. Onset of blockage is fast ( 1 min.). 1. Onset of blockage is slow ( 2 min.).
2. Only lumbar puncture. 2. Lumbar, sacral, thoracic, cervical puncture.
3. Duration limited. 3. Duration prolonged.
4. Needle used : 23-25 no. 4. Needle used : 16-17 no.
5. Less chance of CSF contamination. 5. More chance of CSF contamination.
6. Small dose inj. 6. Large dose inj.
7. Headache absent. 7. Headache present.
8. Backache more persistant. 8. Backache present.
9. Less severe hypotension. 9. More severe hypotension.
10. Faulty anaesthesia. 10. Excellent anaesthesia.

I. REGIONAL AND GENERAL ANAESTHESIA – DRUGS, TECHNIQUES,

INDICATIONS, CONTRAINDICATIONS, COMPLICATIONS AND THEIR
MANAGEMENT.

REGIONAL ANAESTHESIA
DEFINITION

 Regional anaesthesia is the use of local anesthetics to block sensations of pain from a large
area of the body, such as an arm or leg or the abdomen by using local anaesthetic agent.
 Regional anaesthesia allows a procedure to be done on a region of the body without your
being unconscious.
 For regional anaesthesia, the anesthetic is injected close to a nerve, a bundle of nerves, or the
spinal cord.

DRUGS

USES
Regional anaesthesia is most often used when the procedure:
Is confined to a specific region of the body.

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 Involves a large area of the body where injection of large amounts of an anesthetic might
cause side effects that affect the entire body.
Does not require general anaesthesia.

RISKS AND COMPLICATIONS FROM REGIONAL ANAESTHESIA

1. For regional anaesthesia, an anesthetic is injected close to a nerve, a bundle of nerves, or the
spinal cord. In rare cases, nerve damage can cause persistent numbness, weakness, or pain.
2. Regional anaesthesia also carries the risk of systemic toxicity if the anesthetic is absorbed
through the bloodstream into the body.
3. Other complications include heart or lung problems, and infection, swelling, or bruising
(hematoma) at the injection site.

CONTRAINDICATIONS

DIFFERENCE BETWEEN LOCAL ANAESTHESIA & REGIONAL ANAESTHESIA

LOCAL ANAESTHESIA REGIONAL ANAESTHESIA

1. A local anaesthesia only blocks the 1. Regional anaesthesia blocks pain to a

injected direct area. large portion of the body at one time.

2. Agents such as lidocaine or 2. This includes epidural, spinal, and

marcaine are local anesthetics that peripheral nerve blocks. The nerve
can be injected directly into the block is delivered approximate to the
area to be operated upon with a 1-4 nerve bundle or group for peripheral
hour blockade. nerve blockade.

3. Local anaesthesia numbs just a 3. Regional anaesthesia numbs a larger

small area of tissue where a minor (but still limited) part of the body and
procedure is to be done. does not make the person unconscious.

4. Local anaesthesia is where a drug 4. Regional anaesthesia is where a drug

is injected near nerves in is injected into the veins of an arm or
or through the skin providing loss leg while using a tourniquet to create
of sensation to the area of the temporary loss of feeling and/or
surgical operation. movement of a limb.

5. Risks include infection, 5. Risks include infection, convulsions,

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 convulsions, weakness, persistent persistent numbness, residual pain and
numbness, residual pain and injury injury to the blood vessels.
to the blood vessels.

6. For local anaesthesia the patient is 6. For regionals, the patient can either be
conscious. under conscious sedation or awake.

GENERAL ANAESTHESIA

DEFINITION
 General anaesthetics (GAs) are drugs which bring about loss of modalities of sensation
particularly pain along with all reversible loss of all sensation.
 The cardinal features of general anaesthesia are:
1. Loss of all sensation, especially pain
2. Sleep (unconsciousness) and amnesia
3. Immobility and muscle relaxation
4. Abolition of somatic and autonomic reflexes.

CLASSIFICATION

MECHANISM OF ACTION
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  Depresses all functional unit of CNS.
 Particularly inhibit ascending reticular artibating system ( ARAS) which maintain state
of wakefulness.
STAGES OF ANAESTHESIA

1. STAGE OF ANALGESIA

 Starts from beginning of anaesthetic inhalation and lasts upto the loss of consciousness.
 Pain is progressively abolished.
 Patient remains conscious, can hear and see, and feels a dream like state; amnesia
develops by the end of this stage.
 Reflexes and respiration remain normal.
 Though some minor operations can be carried out during this stage, it is rather difficult to
maintain—use is limited to short procedures.

2. STAGE OF DELIRIUM

 From loss of consciousness to beginning of regular respiration.

 Apparent excitement is seen—patient may shout, struggle and hold his breath; muscle
tone increases, jaws are tightly closed, breathing is jerky; vomiting, involuntary
micturition or defecation may occur.
 Heart rate and BP may rise and pupils dilate due to sympathetic stimulation.
 No stimulus should be applied or operative procedure carried out during this stage. This
stage is inconspicuous in modern anaesthesia.

3. SURGICAL ANAESTHESIA

 Extends from onset of regular respiration to cessation of spontaneous breathing. This

has been divided into 4 planes which may be distinguished as:
i. PLANE 1 - Roving eyeballs. This plane ends when eyes become fixed.
ii. PLANE 2 - Loss of corneal and laryngeal reflexes.
iii. PLANE 3 - Pupil starts dilating and light reflex is lost.
iv. PLANE 4 - Intercostal paralysis, shallow abdominal respiration, dilated pupil.
 As anaesthesia passes to deeper planes, progressively— muscle tone decreases, BP
falls, HR increases with weak pulse, respiration decreases in depth and later in
frequency also.

4. MEDULLARY PARALYSIS

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  Cessation of breathing to failure of circulation and death.
 Pupil is widely dilated, muscles are totally flabby, pulse is thready or imperceptible and
BP is very low.

INHALATIONAL ANAESTHETICS

TECHNIQUES OF INHALATION OF ANAESTHETICS

1. Open Drop Method

 Liquid anaesthetic is poured over a mask with gauze and its vapour is inhaled with
air.
 Eg. Ether.

2. Through Anaesthetic Machines

 The gases are delivered to the patient through a tightly fitting face mask or
Endotracheal Tube or Boyle’s Apparatus.
 Eg. Nitrous oxide, Ethylene.

INHALATIONAL ANAESTHETICS

DRUGS DEFINITION ADVANTAGES DISADVANTAGES

 Non-Irritating  Safest Anesthetic Drug  Muscle relaxation is
 Better Smelling  Non- Inflammable unsatisfactory
 Colorless  Non-irritant to patient  Teratogenic effect
1. Nitrous oxide  Inorganic Gas  Pleasant to inhale  Blood pressure is
 Post - operative increased
complication is less
 Colorless,  Used for all types of  Highly irritative to
Volatile Liquid surgery upper respiratory
 Safe tract
2. Ether  Simple to administrate  Vapor inhalation is
 Little toxic axn. on unpleasant for
heart patient
 Increases secretions
of all the glands
 Colorless Liquid  Volatile anesthetic drug  Respiratory
 Volatile & most expensive. Depression
3. Halothane Anesthetic  Non - inflammable  No Analgesic
(Fluothane)  Non-irritant to Properties
respiratory tract.  Hepatotoxic Effect
 Rapid,smooth & with
fast recovery

INTRAVENOUS ANAESTHETICS

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 DRUGS DEFINITION ADVANTAGES DISADVANTAGES
 Ultra short acting  Non-irritant to lungs  Fall in blood pressure.
barbiturate. & non-explosrve.  Poor analgesic &
 Used mainly for  Less nausea & relatively large quantity
1. Thiopentone minor surgeries. vomiting. is needed to produce
Sodium  Muscle relaxation is true anaesthesia.
rapid.  Recovery period is
long & drowsiness
persists after one hour.
 Also known, as  Respiration is not  Dangerous for IHD
“Dissociative depressed. patients.
(sudden temporary  Muscle tone  Delirium,
2. Ketamine alteration) increases. Hallucinations &
anaesthesia.  Useful for burn Involuntary
dressing & I & D. movements.
 Good for repeated  Heart rate, cardiac
use. output & blood
pressure are elevated.

COMPLICATIONS OF GENERAL ANAESTHESIA

1. Hypotension 6. Vomiting 12. Cardiac Arrest

2. Respiratory 7. Organ Toxicity 13. Renal Failure
Depression 8. Airway Obstruction 14. Hepatic Failure
3. Laryngeal Spasm 9. Bronchospasm
4. Delirium 10. Respiratory Failure
5. Nausea 11. Arrythmias

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