Local and general anesthaesia 1st Dpt. of Surgery University hospital of Saint Anne Medical Faculty of Masaryk University, Brno Goals •Understand the: – definition – difference – indications – advantages –disadvantages History •Acient Egypt and Mezopothamy, Greece and Rome, Mid-Age (opium, mandrake, alcohol…) •1846 - Aether inhalatory anesthesia William Morton (removal of mandibular tumour) •30th of 20.century - artificial ventilation •BOOOM!!!.... General anesthesia •Definition : •targeted loss of perception of all sensations (touch, pain, heat, cold) - farmacologicaly induced coma (unconsciousness) – targeted intoxication • •Goal: •Assure non-paifull surgery for patient and secure desired conditions for surgery - neurovegetative stability of patient during operation (trauma, stress reaction) • •Parts: •Loss of consciousness (hypnotic phase) •Analgesia - opioids, NSAIDs, local anesthaesia •Muscle relaxation - central (BZD, inhalatory anestetics) v.s. peripheral •Vegetative stability - decreases stress reaction of organism • Types of anesthesia •Balanced- iv, inhalatory drugs, analgetics, transquillizers, myorelaxans •Combined – general + local •Sedation - shallow loss of consciousness •Analgosedation – analgesia + shallow loss of consciosness •Neuroleptanalgesia – sedation, analgesia, vegetative stabilisation •Local anesthesia – loss of pain perception Types of general anesthesia •Inhalatory • •Intravenous (TIVA) (TIVA – Total intravenous anesthesia) • •Combination (start iv. + ihhalatory) – mostly used • Depth of GA - stages (Guedel) •Used only for clear inhalatory anesthesia •I. – falling asleep •II. – excitation - motoric response, instability of circulation , high risk of vomiting • •III. – tolerance •IV. intoxication Monitoring of pacient -Saturation – oxygenation of pacient -ECG – beats per minut (tachycardia, bradykardia), arrhytmias (atrial / ventricular fibrilation, extrasystoly, asystoly), ST denivelation -Blood pressure – non – invasive or invasive -Conciousness -Deep of relaxation -Temperatur -Inhale and exhale gas concentration – O2, CO2, N2O, inhalatory anesthetics What do you need before you start anesthesia •Intravenous approach •Anesthetics machine – control before every use •Devices for secure airways - laryngoskope •Drugs •Nurse Step by step •i.v. approach •Preoxygenation with facemask - 100% O2 for 5 minut •Anesthetic drugs – anesthetics + analgetics + myorelaxans •Manual ventilation with face mask •Intubation •Arteficial ventilation – inhalatory anesthetics •Start of surgery • Výsledek obrázku pro glotis Airway secure •Face mask • •Supraglottic devices • •Infraglottic devices • •Cricothyrotomy • •Tracheotomy Supraglottic devices •Combitube – obsolent, two orifices – between balons and in the end Výsledek obrázku pro kombirourka Laryngeal mask •+ easy to use •- Not 100% safety for airway SouvisejÃcà obrázek Face mask ventilation • airway If it doesn‘t work? •Optimize head position – sniffing position • Výsledek obrázku pro sniffing position Výsledek obrázku pro vzduchovod Výsledek obrázku pro vzduchovod Still it doesn‘t work? •Use Guedel‘s oral or Wendel‘s nasal airduct (size from mouth/nose to ear) Výsledek obrázku pro vzduchovod Výsledek obrázku pro vzduchovod Then intubate What should you see What else can you see Grade III a IV predict difficult airway management SouvisejÃcà obrázek Devices that can you help •Videolaryngoscope Výsledek obrázku pro videolaryngoskop If you can‘t intubate •Cricothyrotomy - rescue procedure Výsledek obrázku pro koniotomie Výsledek obrázku pro minitrach Or tracheotomy – you need more time •A: cricothyrotomy •B: tracheotomy • Výsledek obrázku pro tracheotomie Výsledek obrázku pro tracheotomie RISKS and COMPLICATIONS •Airways: obstruction, dislocation of cannula, bronchospasm, aspiration… •Failling to secure airways •Shallow anesthesia •Hypotension, hypertension, arytmia •HYPOTHERMIA!!! - lethal triade! •Malignant hypertermia •Alergic reaction Postoperative care - next time Local Anesthaesia •Inhibition of nerve stimulus conduction by sensitive neurons •Physiology - interaction with Na+canals on cellular level •Loss of pain perception •Motoric function remains intact HISTORY •Congelation - Ice •1860 – Cocaine •1884 – 1st medical use •(psychiatry - S. Freud) •1905- 1st synthetic local anesthetic - procain •70th 20th century – next generations of synthetic LA • Types •Superficial (surfaces - skin, mucous membrane) •Infiltration •Field blocking •Epidural •Spinal (subarachnoideal) •Intravenous regional •(obsolent, risk of system efects – cardiotoxicity, neurotoxicity…) Infiltration vs. Field/nerve block Infiltration vs. Field/nerve block • •INFILTRATON –Just near of injection/application –It affects free nerve endings • •FIELD/NERVE BLOCK •Application near nerve bundle – effect on nerve endings – area wich is inervated by this nerve Examples of Blocks Efect of LA depends on: •Amount of LA used •Type of LA /Mesocain v.s. Marcain…/ •Blood supply of tissues •pH of tissues •Additive drug - adrenalin /max. dose 1mg/ Epidural anesthesia •Cervical, thoracical, lumbar •No effect on motoric •Loss of pain and sense •Block of vegetative nerv system Výsledek obrázku pro epidurálnà anestezie Dermatoms determine the height of the injection Výsledek obrázku pro dermatomy Výsledek obrázku pro epidurálnà jehla SouvisejÃcà obrázek Subarachnoideal anesthesia •Loss of motoric too •Only for lower limbs and pelvis •Risk of total spinal anesthesia (loss of function of breathing muscles) •Risk of injury of the spinal root Výsledek obrázku pro spinálnà anestezie Výsledek obrázku pro spinálnà anestezie Contraindications • •Infection in site of aplication •Alergic reaction in anamnesis •Hypokoagulation (Epidural, Subarachnoideal) •Non-compliance of patient •Non-agreement of patient Risk factors and complications •CNS toxicity: • Paradoxal stimulation, confusion, tremor, cramps, inhibition of breathing center •Cardiovascular toxicity: • Dysrythmia, arytmia, vasodilatation + hypotension •Hypersensitivity/alergic reaction •Bleeding, infection, needle breakage… • TAKE HOME MESSAGE •General anesthesia is not deep slumber •targeted loss of perception of all sensations (touch, pain, heat, cold) - farmacologicaly induced coma (unconsciousness) •I.V., gas, combined •Depth of anesthesia •Mantaining vital signs •Local anesthesia – types, indications •Combinations •Safety rules! • •