Anesthesia Analgesia nTrauma dept. UH Brno Obrázek nPain - most common cause of meeting with physician nLat. pati / patiens - to bear/ suffer n nPain – tissue damage – disease, injury, inflammation n n medical procedures: nDiagnostic nTherapeutic n C:\Users\Martin\Desktop\obr. orthobull\Detail-from-Operating-Tent-Camp-Letterman-Gettysburg-Pennsylvania-1863-The-Metropolitan-M useum-of-Art-New-York-DP254883.png Kolonoskopie – EndoGastro Terms nFrom Greece nAnesthesia - an aesthos - without perception nRemoval of all perceptions, even consciousness nAnalgesia – an algos – without pain nRemoval of just painful perception nAnalgosedation nPainless with persistent bur decreased state of consciousness nPreserved spontaneous ventilation, patient alertness after stronger stimulation n n Pain nPain is an subjective unpleasant sensory and emotional experience arranged by ascending nerve system and brain cortex. It is arising from actual or potential tissue damage or described in terms of such damage n nPain pathway – three neuron ascending pathway, associated with activation of sympathetic n n Nociception – origin and transmission of signal of pain nPain – the result of processing of signal from nociceptor in central nervous system Origin of pain nThe pain originates from direct painful stimulation of nociceptors when tissue is damaged or as affection of nociceptors when inflammatory / ischemic condition occurs in surrounding tissue. tuber.jpg Nociceptor - Wikipedia Nociceptors nFree nerve endings – usually no active (silent receptors) are activated by decrease of pH, increased level of extracellular K+, prostaglandins, leukotrienes, histamine n nPolymodal nociceptors – normally - cold, heat, mechanical stimulation, proprioception threshold stimulation – pain stimulation n nHigh-pressure nociceptors – usually sensation, pressure, vibration, pain when overstimulation n n Nerve fibers nFibers A δ – low myelinated, „fast fibers“ 5-30 m/s, first acute, fast, sharp pain immediately with injury , discrete receptive area, precise localization of pain n nNon-myelinated fibers C – „slow fibers“ 0,5-2m/s, terminal endings, second dull, itching, burning, throbbing pain, large receptive area, localize just general body parts . n nFibers Aα/Aβ – strong myelinated, lower stimulation threshold than A δ/C , mainly transfer harmless tactile sensation – vibration, tingling, 30–70 m/s, can diminish A δ/C perception n n Types of Pain nAcute – short lasting seconds - weeks, max up to 3M n - trauma, surgical incision, disease. n - acute stress - vegetative sympathetic activation - catecholamine's – HR, RR, sweating, catabolism, hyperglycemia, n muscle tension n n nChronic – longer > 3M , persist even after removing / healing up painful stimulus. Interferes with functioning and quality of life, chronic stress, no vegetative sympathetic signs – n nSuperficial somatic pain – sharp, well localized, precision of localization depends on areal density of receptors (face / back) n nDeep somatic and visceral pain – dull, aching, burning, long lasting, diffuse badly localized, can be figurative for other body parts (MI – left arm), sympathetic reaction, hyperesthesia nSomatic - A δ/C fiber, parietal surface abdom., thor. nVisceral only C fibers n nNerve root pain – (radicular pain) irritation of nerve roots (spur, herniated disc, infection) , pain burning or sharp, stemming from the back to periphery, tingling, numbness, muscle weakness, increased n nNeuropathic pain - painful perception due to damaged / malfunctioning nerves n - Diabetic neuropathy, trigeminal neuralgia, Phantom pains - changed threshold of perception, Pain assessment nThe pain is a subjective perception, these is no objective measurement. Each measurement of pain depends on individual patient feeling of pain. n nPain assessment on scale – from no pain up to the most unbearable pain. n nVisual analogue scale nNumeric scale 0-10 nFaces pain scale n n n C:\Users\Martin\Desktop\obr. orthobull\Visual-analogue-scale-VAS-for-assessment-of-childrens-pain-perception.jpg Medicine for pain relieve nNon-opiate analgesics n - antipyretics – Paracetamol /Acetaminophen , n increases pain threshold n - Nonsteroidal anti-inflammatory drugs (NSAID) n inhibition prostaglandins synthesis COX nOpiate, opioids n - bind specific receptors in brain and spinal cord n nLocal anesthetics (catheter techniques). nAdjuvant Co-analgesics (TCA, anti-convulsive ) n WHO pain management ladder nStep 1 – Nonopiod analgesics (Paracetamol, Metamizol, Brufen). nStep 2 – moderate opioids (Tramadol, Codeine) + Nonopiod analgesics. nStep 3 – Strong opioids (Morphine, Oxycodone) + Nonopioid analgesics + regional anesthesia n C:\Users\Martin\Desktop\obr. orthobull\New-adaptation-of-the-analgesic-ladder.png Post-operative pain management lParacetamol 1000mg i.v. q6-8h lDipidolor (piritramide) i.v./i.m.; tramadol; n lMorphine 10mg i.v. / s.c. (onset 5/15 min) q4h; increased 5-10mg; lSufenta continuous (5-10 ug/h i.v.) n CAVE – respiratory depression n nAnalgesics administration lIn a sufficient dosage lSufficiently long period lRespect dosage intervals according to biological T1/2 half-life. + regional anesthesia Non-pharmacological pain management nImmobilization nCryotherapy - Ice – reduce pain and selling, apply 15-20min /h, n decrease nerve conduction velocity n Heat – reduce pain and muscle spasm, apply 20- n 30min q2h, up to 2cm, improves blood flow nMassage techniques – relax tight muscles nTranscutaneous electrical nerve stimulation (TENS) unit – peripheral neuropathy - low level current over painful area cca 30 min, (PENS) - percutaneous n nPhysical therapy - correction of posture nAcupuncture – stimulation acupuncture points Gate control theory nPainful and mechanical, thermal stimulation go through same projection interneuron in dorsal horn n nLarge myelinated non-nociceptor fibers reduce stimulation from small nociceptor fibers – pain sensation is reduced by other forms of stimulation Gate Control Theory of Pain | HowStuffWorks Untitled Document The Physiology of Pain Mechanisms: From the Periphery to the Brain - ScienceDirect Anesthesiology n nAnesthesiology - is a branch of medicine that focuses on pain relieve during and after surgery / procedures. nResuscitation - is a term describing the process of correcting physiological disorders in an acutely unwell patient nIntensive care medicine or critical care medicine is a branch of medicine concerned with the diagnosis and management of life-threatening conditions requiring sophisticated organ support and invasive monitoring nChronic pain management – relieve from degenerative diseases pain, cancer pain n n n n n n n Brno_Bariérový-operační-sál-.jpg n sal.jpg nICU 439_2b9e5e4fbd.jpg General anesthesia nTtemporary medically induced coma and loss of protective reflexes and all perceptions resulting from the administration of one or more general anesthetic agents nReversible condition that is characterized by unconsciousness, amnesia, analgesia, muscle relaxation, maintenance of physiologic stability with low reaction to surgical stress nControl nRequires protection of airways and ventilation n 7-Surprising-Facts-about-Anesthesia-722x406.jpg History nPain management ….. n nAncient Egypt, Syria, Greek – decoction /infusion from opium, Mandrake root n n n n n n3000 B.C. - Egypt = nerve compression (axilla – hand) n n16th century - alcohol + opium n n n n 3833020071_3d878227dc_o.jpg 1502420864110970252.jpg Harry Potter: Magical Creatures Mandrake | Figurky a sošky | Fate Gate n1846 - Morton (USA) – Ether, 1st General Anesthesia – tumor of mandible n1847 - 1st ether General Anesthesia in Bohemia – Celestin Opitz, Prague n1884 – Local anesthesia n n n n n n n1847 – chloroform 1950's – halothan n1955 – 1st Anesthesiology dept. St. Anne´s UH n n n n n Obrázek - Erythroxylum coca (rudodřev koka) | BioLib.cz Ether, Alcohol, and Hypnosis: A Brief History of Anesthesia (Part 1) | Anesthesia Myths: Get the Facts, Lose the Fear | История болезни, Медицина, Медицинский Preoperative phase nPreoperative examination – GP, internal medicine, labs, ECG, chest X-ray nPreop. Anesthetic. evaluation - reduce intraoperative risks n nAssess risks nChoose most appropriate type of anesth. npremedication nAirway exam nInformed consent n Informed Consent | UW Department of Bioethics & Humanities nPremedication – anxiolysis, sedation - tranquilizers (benzodiazepine), elimination of unwanted vagal reflexes – reduces use of medication at induction of GA n nAssess the risks Airways management nJaw thrust – chin forward movement, oro/nasopharengeal airway, mask laryngeal mask - don´t protect airways against aspiration / leakage nEndotracheal tube with balloon – sealing under vocal cords * indication – full stomach (ileus, trauma), prone, lateral decubitus position, * Hemodynamically / respiratory unstable patient * Selective lung intubation * Essential - muscle relaxation (Sukcinylcholin) n head-tilt/chin-lift, jaw-thrust maneuvers n Tongue-blocking-airways.png 1.gif n Obrázek n Obrázek Laryngeální+maska+80.+léta+–+Archie+Brain,+Londýn.jpg n 350px-Endotracheal_tube_colored.png Tracheal-tubes-used-in-the-study-A-Hi-Lo-TM-tracheal-tube-group-C-B-TaperGuard-TM.png intubation.jpeg n 1280px-Larynx_(top_view).jpg Larynx_normal2a.jpg K čemu jsou laryngoskopy? - Oceán zdraví n GlideScope-assisted fiberoptic bronchoscope intubation in a patient with severe rheumatoid arthritis - ScienceDirect PDF] Endotracheal intubation using a fiberoptic bronchoscope and laryngeal mask airway in ICU | Semantic Scholar Anesthesia machine nTechnically enables mechanical ventilation, monitorinf of vital signs nadminister O2/AIR/N2O, inhalation anesthetics n nHigh pressure system nLow pressure system – mixture of breathing gases with inhalation anesthetic nBreathing circuit – inhalation/exhalation circuit nVentilation systems (manual and mechanical) nScavenging system – used gases nINSULFLATION mixture of gases with anesthetics ninspirium (20-25 cm H20) nexpirium - passive, stop of insufflation Obrázek n Basic monitoring through GA nVital signs, respiration, ventilation, intensity of anesthesia n nECG nNIBP nSpO2 nTemperature nPressure in airways, inspiration/expiration volume nEtCO2 n Blood pressure cuff on a hospitalized female patient after surgery Stock Photo - Alamy Nellcor Compatible Sp02 Finger Probe n nMonitoring ventilator Advanced monitoring nInvasive BP (MAP) nCVP; (PAWP) nAnalysis of ventilation gases (O2, N2O, anesthetics) nspirometry nHourly urine output nrelaxometry n n C:\Users\Martin\Desktop\obr. orthobull\art.jfif C:\Users\Martin\Desktop\obr. orthobull\cvad6.jpg Neuromuscular block monitoring by smartphone application (i-TOF© system): an observational pilot study | npj Digital Medicine Induction of GA n3 drugs supplementary GA n nAnalgesics – opioids nAnesthetics nMuscle relaxants ninfusion n n n n nAuxiliary drugs n n Sedatives, hypnotics, Inhalation anesthetics muscle relaxants Analgesics -opioids -N2O Induction of GA n1 – 3 drugs i.v - the most effective application way nIn lethal doses n nLead to no self-control, unable call for help, suppression of vital autoregulation mechanisms n( through GA we count on perfect residual autoregulation functions) n n unmask of compensated disturbances (hypovolemia, relative respiratory insufficiency) n n30 - 60s from fully conscious to vitally dependent on anesthetist n n n n n n n nOpioids - i.v. nBolus / continual n nFentanyl, Alfentanil, Sufentanil, Remifentanil, Morphine n nMuscle relaxants- i.v. nEnables intubation, mechanical ventilation, enables surgical procedures n nNot necessary every time nPlace of action – neuromuscular junction n n n Anesthetics nI.V. - TIVA lPropofol lBarbiturate: Thiopental lEtomidate lKetamine n nInhalation - enters through pulmonary veins, acts in the brain, spreads through partial pressure gradient lHalotan, Isofluran, Sevofluran, N2O l ni.m., p.r. n nBenzodiazepiny: Diazepam, Midazolam C:\Users\Martin\Desktop\obr. orthobull\DqiCW0tXgAAACHS.jpg Depth of GA nDue to concentration of inhalation anesthetic n nI. stage: analgesics phase – administration, analgesia and subsequent amnesia up to loss of consciousness. Conversation possible nII. stage: excitement stage – unconsciousness, irregular respiratory and heart rate, breath holdings, uncontrolled movements, risk of vomiting, risk of cardiac nIII. stage: surgical anesthesia – muscle relaxation, respiratory, heart rate depression and stabilization, loss of reflexes. nIV. stage: too much anesthetic – overdose – brain stem/ medullary depression, vasomotor, and respiratory inhibition respiratory and cardias arrest. n JaypeeDigital | eBook Reader Intraoperative care nprocedure in the operating field noperation of technical systems nVital signs monitoring nMaintenance of 3rd phase of anesthesia – sufficient analgesia and anesthesia, circulation volume supplementation n lReaction to surgical stimuli (pain) ni.v.: - opioids -infusions -sympathomimetic n nChange concentration of inhalation anesthetics n Postoperative care nPut out of GA n nFinished surgical procedure nNo surgical bleeding nStable ABC´s nRegain of muscle strength nExhalation of the anesthetic (body, not lungs) n nRegain of conscious and alertness nobey simple calls , to cough, rises head above the pad n nUnstable ABC´s, unconsciousness - continue analgosedation + MV – go on ICU n n n n Postoperative care nobservation 2h – ICU/ HDU/ Postanesth. Care Unit – PACU – monitoring of vital signs nFollow-up monitoring - up to 4-6 h post op. – BP, HR, SpO2, consciousness, urine out put nNecessary sufficient postoperative analgesia, volume therapy n 591_2b9e5e4fbd.jpg Risks and complications of GA nThe most risky part – induction and termination of GA (stages I-III / III-I) nrisk – the more co-morbidities/ emergency procedure nAspiration (low pH, full/ atonic stomach) - pneumonia nAnaphylactic shock, embolism, IM, malignant hyperthermia, dysrhythmia nHypoventilation - asphyxia (the end of GA, extubation) n n nHidden hypovolemic shock with temporary centralization nSurgical complication – bleeding n Local /Regional anesthesia nBlocking of pain pathways nacts on the peripheral nerves (no CNS), - from the output of radicular nerves to the terminal end nWide range of procedures – bronchoscopy up to TJR, consciousness preserved npositives : postoperative analgesic effect, improves perfusion, does not restrict breathing, allows contact with patients nerve_block.jpg axillary block.png Sorts of local anesthesia nTopical (skin, mucosal) - application to the surface anesthetics, n vocal cords, trachea, urethra nInfiltration - infiltration on-site surgery nField block - interrupts conduction of nerve fibers in small distance from the surgical site nPeripheral nerve block nPlexus anesthesia nEpidural anesthesia nSpinal anesthesia n Local anesthetics nAmid nEster n n http://www.openanesthesia.org/wp-content/uploads/2015/03/Local-anesthetics-systemic-toxicity-tables .png nCave - allergies nEster type allergies more common n n angioedema n n n n C:\Users\Kubenstein\Desktop\main-qimg-8aabe5b3f1c30bafd93ca330985a61b8.jpg nTopical anesthesia n nlidocain, benzocain, tetracain ndentistry, ORL, ophtalmology, urology, Ob/Gyn, pediatric....(tattoo) nSpray, jelly, cream n n C:\Users\Kubenstein\Desktop\erzestelenitok-verzescsillapitok.jpg Emla Cream - Okanagan Pharmacy Emla Cream | How to Apply Emla Cream | Lidocaine Cream nInfiltration anesthesia n ninfiltration on-site of surgery nTrimekain (Mesocain), Artikain (Supracain), Chirokain ( Levobupivakain), Marcain (Bupivakain) nvasoconstriction + anesthetics C:\Users\Kubenstein\Desktop\209926_1_En_88_Fig2_HTML.gif How to administer lidocaine in wounds nField anesthesia n ninterrupts conduction of nerve fibers in small distance from the surgical site C:\Users\Kubenstein\Desktop\image00889.jpeg C:\Users\Kubenstein\Desktop\afp20140615p956-f4.jpg nPeripheral nerve block and Plexus anesthesia n nInstillation of anesthetics near to the main nerve branches n nBrachial plexus block naxillary block nSciatic nerve block nFemoral nerve block nFICB n n Lower Extremity Peripheral Nerve Blocks: Sciatic Nerve Block Nerve block - Wikipedia Central nerve blocks – neuraxial anesthesia n Obrázek Epidural anesthesia nEpidural anesthesia involves the use of local anesthetics injected into the epidural space nproduce a reversible loss of sensation and motor function nLA deposited in epidural space. Block spinal nerve roots that traverse peridural space. Blocks sympathetic nerves traveling with the anterior roots. Applications range from sensory analgesia, minimal motor block, or dense anesthesia and full motor block – controlled by drug choice, concentration, dosage nLoss of resistance technique / hanging drop – negative pressure * improves perfusion * Single-use needle / catheter for long period , slow onset * Vasodilatation – due to sympathetic effect – hypotension * According to the level of puncture: A. Lumbar puncture ( L3–L4) B.Thoracic C.Cervical n n Anesteziya-spinalnaya-i-epiduralnaya.jpg Obrázek P61 - Trenažér pro epidurální a spinální injekci - HELAGO-CZ, s.r.o. - Vybavení laboratoří a lékáren, dodávka výukových pomůcek, zdravotních simulátorů, projekce a výroba nábytku Epidural Anesthesia and Analgesia - NYSORA Spinal / subarachnoid anesthesia nLA deposited at subachnoid space, through dura mater, into CSF nActs on spinal nerves and dorsal ganglia, nProduces sympathetic block, sensory analgesia and motoric block nProcedures below diaphragm (upper abdomen up to toes), CS nVasodilation – hypotension nSingle shot , rapid onset nspreading density and body position ninstillation L4 n n n n anest5.jpg C:\Users\Martin\Desktop\obr. orthobull\09f01.jpg Complications of SA nbleeding nSSI nfailure effect nwrap catheter in the epidural space nhypotension during anesthesia –volume therapy, ephedrine nthe upward spread of the anesthetic in the subarachnoid anesthesia (cough, hypobaric solution, incorrect posture) => motor paralysis, hypotension, respiratory insufficiency nurinary retention nNerve injury nPost-puncture syndrome - headache n n n n n n kapka-moku-n.jpg qw-454x262.jpg epidural-anesthesia-46-638.jpg 2010--L10-04-Med-0220-01.jpg n urolog-kirurg-anesteziolog.jpg n