Surgical anaesthesia

Dr. Jnos Lantos

Department of Surgical Research and Techniques

The revelation
On 16 October 1846 William T.G. Morton performed the first successful demonstration of ether anaesthesia in the Massachusetts General Hospital, Boston, USA.

Early painkilling techniques

The single or combined use of stupefying agents such as ethyl alcohol, mandragora, cannabis and opium to deaden the sensibilities prior to surgery had been practiced in classical antiquity.

Early painkilling techniques

Non-pharmacological methods: Blood-letting
(undoubtedly relieved pain, though it was carried out to dangerous and often fatal excess.)

Cooling with cold water, ice; Distraction by counterirritation with stinging nettles; Carotid compression and nerve clamping. Concussion anaesthesia relied on the hammer stroke. Acupuncture Hypnosis Cocaine

 (N2O)
1772 .

Joseph Priestley (1733-1804)

, (1800). "

Humphry Davy (1778-1829)

Pioneers in surgical anesthesia

Charles Jackson (1805 - 1880) Horace Wells (1815 - 1848) William Thomas Green Morton (1819-1868)

16 October 1846 Ether Day in Boston

"Gentlemen, this is not a humbug"

Ether Dome

Painting of Robert Hinckley

Ether dome c. 1930

M. H. Hart: The 100

A Citadel Press Book, 1978.

The ranking of the most influential persons in history

1. Mohammed 2. Newton 3. Jesus Christ 4. Buddha 5. Confucius 6. Saint Paul 7. Caj Lun 8. Gutenberg 9. Columbus 10. Einstein . 37. Morton . 55. Harvey . 60. Lister

"Gentlemen, this is no humbug"

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. "Dr Snow gave that blessed chloroform and the effect was soothing, quieting and delightful beyond measure", Her Majesty reported.

Anaesthesia
Anaesthesia can be produced:
- either by administration of drugs which produce a loss of consciousness (general anaesthesia),

- or localised areas of the body can be made insensitive using local anaesthetics (local anaesthesia).

Local anaesthesia (analgesia)

Local anaesthetics affect only part of the body:
the loss of sensation in a limited body area, and the patient remain conscious.

Method:
Direct injection of local analgesic drugs close to peripheral nerves, major nerve trunks or nerve roots to produce analgesia by blocking conduction of afferent impulses.

Local anaesthesia (analgesia)

Degrees of local anaesthesia (analgesia)
Surface anaesthesia:
gel, spray

Local infiltration:
for minor surgical procedures on skin

Local nerve block:

tooth, etc.

Regional anaesthesia:
Spinal anaesthesia
local anaesthetic into CSF below termination of cord at L1

Epidural anaesthesia
local anaesthetic agent into the epidural space

General anaesthesia
General surgical anesthesia is defined as a reversible level of unconsciousness in which the cardiac and pulmonary function remain intact, the patient does not respond to pain, and muscular relaxation is adequate for the required operation.

General anaesthesia
General anaesthesia = Hypnosis + Analgesia + Relaxation
Hypnosis = suppression of consciousness Analgesia = suppression of physiological responses to stimuli Relaxation = suppression of muscle tone and relaxation

A controlled reversible state of:

Amnesia (with loss of consciousness) Analgesia Akinesia (skeletal muscle relaxation) Autonomic and sensory reflex blockade Called the 4 As of General Anaesthesia.
In practice these effects are produced with a combination of drugs rather than with a single anaesthetic agent.

General anaesthesia
General anaesthesia can be produced: - either by anaesthetics directly injected into the blood via the intravenous route (intravenous anaesthesia) - or by anaesthetics absorbed into the blood alveoli following inhalation (inhalation anaesthesia). General anaesthetics are given systematically and exert their effect on the central nervous system.

General anaesthesia
Basis:
The various susceptibility of different regions of the central nervous system to anaesthetic agents.
cerebral cortex subcortical motor centers midbrain cerebellum medulla oblongata This selective susceptibility allows the induction of narcosis without the serious risk of circulatory and pulmonary failure.

The signs of depth of anaesthesia

Circulation:
blood pressure, heart rate

Respiration:
frequency, volume, character (thorax, diaphragm)

Eye:
motion, pupil size
reflexes: light, eye closing, conjunctiva, cornea

Other reflexes:
coughing, swallowing, vomiting

Muscle tone:
limb, abdomen, smooth muscle

Stages of anaesthesia
Arthur E. Guedel 1883-1956

Stages of Anesthesia
Stage of Analgesia:
Analgesia without amnesia, impaired judgment, vertigo/ataxia, increased respiration, blood pressure, heart rate

Stage of Excitement:
Delirious, excited, amnesic. Irregular respiration, struggling, retching and vomiting

Stage of Surgical Anesthesia

Recurrence of regular respiration --> cessation, Loss of corneal, swallowing, eyelid reflexes Skeletal muscle relaxation Decreased blood pressure

Stage of Medullary Depression

Begins at cessation of spontaneous respiration --> severe depression of vasomotor and respiratory centers -->without support = Death

Stages

Analgesia

Tolerance

Excitation

Asfixia Planes thorax cornea light limb

consciousness
diaphragm Resp. eye motion pupil size eye closing conjunctiva reflexes coughing

secretion

swallowing vomiting

abdomen smooth m.

Muscle tone

Risk of overdosage
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 overdosage 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.

Monitoring during anaesthesia

General anaesthesia removes ability of patient to protect himself. Safety and physiological control becomes the responsibility of the anaesthetist, therefore the continuous presence of an adequately trained anaesthetist is essential, and accurate monitoring of vital signs is obligatory.
Anaesthetist needs to:
maintain airway and oxygenation, preserve circulation, prevent hypothermia, prevent injury, monitor during anaesthesia

Monitoring of the following is essential for all patients:

temperature, heart rate, blood pressure, ECG, oxygen content of inspiratory gas mix, end-tidal carbon dioxide, pulse oximetry Facilities for cardiopulmonary resuscitation should be immediately available.

Inhalation anaesthetics
Anaesthesia is normally maintained with inhaled volatile anaesthetic agents.
- Drugs administered via face mask or endotracheal tube. - Volatile liquids vaporized in a carrier gas. - Nitrous Oxide (N2O), a gas at ambient temperature /pressure, is a low potency adjunct. Potency of inhalation anaesthetics can be characterised by

MAC = Minimum alveolar concentration

It is the alveolar concentration required to keep 50% of population unresponsive to a painful stimuli.

Characteristics of inhalation anaesthetics

They are lipid soluble hydrocarbons. They have high saturated vapour pressures. Modern agents are potent, non-inflammable and non-explosive.

Halothane

Isoflurane

Sevoflurane

Enflurane

Desflurane

Properties of inhalation anaesthetics

Nitrous oxide Induction Recovery Analgesic effect Respiratory track irritation Blood pressure Metabolism MAC Induction dose Maintaining dose fast fast + 0% 104 % Halothan Enfluran Isofluran Sevofluran Desfluran

medium medium decreases 20 % 0,75 % 3% 2,05 %

medium medium decrease s 2,4 % 1,6 % 1-10 % 0,6-3 %

medium medium decreases 0,2 % 1,2 % 1-4 % 0,5-3 %

fast fast decreases 3% 2,05 % 5-8 % 0,5-3 %

fast fast + decreases 0,02 % 6% 4-11 % 2-6 %

The advantages and disadvantages

Inhalation anaesthesia Intravenous anaesthesia
- fast induction

Advantages

- controllable reversibility
(duration of action can be controlled)

Disadvantages - relatively slow induction

- irritation of airways - claustrophobic feeling

- duration of action can not be controlled

(termination of action require biotransformation or excretion processes over which the anesthetist has no control)

Properties of intravenous anaesthetics

Drug Induction Recovery Main unwanted effects
Cardiovascular and respiratory depression

Notes

Thiopentone
(barbiturate)

fast

accumulation occurs giving slow recovery slower than others

Widely used agent for routine purposes

Midazolam
(benzodiazepine)

slow

Little cardiovascular and respiratory depression Psychotomimetic effect Produces good analgesia and amnesia Rapidly metabolized. Possible to use as continuous infusion

Ketamine

slow

Propofol

fast

very fast

Cardiovascular and respiratory deprivation

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

Non-depolarising agents
For example - vecuronium Act over 2-3 minutes and effects last for 30 minutes to one hour Competitive antagonism of acetylcholine receptor Used for muscle relaxation

Premedication
Is the administration of drugs prior to an anaesthetic.

Has three potentially useful effects: Anxiolysis

Can be achieved with benzodiazepines.

Reduce parasympathetic reflexes

parasympatholytic drugs (Atropine)

Analgesia
Best achieved with strong opiates (Fentanyl).
Opiate analgesics also have useful sedative properties.

Advantage:
decreased requirement for general anaesthetic agents

Systems in inhalation anaesthesia

1. Open system: no reservoir, no rebreathing, no provision
for assisting ventilation: simple, cheap, but difficult to maintain a stable anaesthetic state. Pollutes the environment.

2. Semi open system: with a gas reservoir and no

rebreathing: commonly used in paediatric anaesthesia. Stable system and allows assisted and controlled ventilation.

3. Semi closed system (most commonly used):

incorporates a gas reservoir and rebreating circuit that allows partial rebreathing: - soda lime container; - provides an inherent stability.

4. Closed system: has a gas reservoir but no gas escapes

from the system: - difficult to control; - economical, minimally pollutes the environment.


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Scheme of anaesthetic circuit

Gas supply

Rebreathing circuit

Pop-off valve

Sources
www.virtual-anaesthesia-textbook.com/ www.general-anaesthesia.com/ www.johnpowell.net/ N. M. Green: Anesthesia J. J. Savarese, E. Lowenstein: Anesthesia