“nothing in life is to be feared. it is only to be understood.” marie curie (`868-1934)
TRANSCRIPT
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“Nothing in life is to be feared.It is only to be understood.”
Marie Curie (`868-1934)
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General anesthesia
Regional anesthesia
Monitored anesthesia care
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General anesthesia
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“Before him surgery was agony.”Epitaph on a monument honoring W. Morton
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General anesthesia
The goals of general anesthesia:
- Mandatory: -amnesia/sedation/hypnosis
-analgesia
-maintenance of homeostasis
- Optionally: -muscle relaxation
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General anesthesia indications
Indications based on the surgical procedure: -surgical procedures requiring analgesia and
muscle relaxation, that cannot be performed using regional anesthesia techniques: upper abdominal surgery, thoracic surgery, head and neck surgery, shoulder surgery etc.
-surgical procedures that significally interfere with vital functions: neurosurgery, thoracic surgery, cardiac surgery, surgery of the aorta etc.
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Indications based on the patient condition: -different pathologies or ongoing treatments that
make the regional anesthesia tachniques contraindicated: the patients with coagulation disorders, anticoagulant treatments, infections or other lesions in the area where a regional anesthesia procedure would be performed;
-systemic diseases with definite functional limitations: the patient with respiratory insufficency, shock, coma, major hydroelectrolytic or acido-basic imbalance.
General anesthesia indications
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Drugs used for general anesthesia
HypnosisAnalgesiaMuscle relaxationMaintenance of homeostasis
can all be achieved by administering one or more drugs
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Drugs used for general anesthesia• Inhalatory anesthetics:
-gaseous form nitrous oxide
-volatile liquids halothane, isoflurane, sevoflurane si
desflurane
The advantage of entering and leaving the body by ventilation with minimal metabolization.
They result in sedation, analgesia and light muscle relaxation.
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The potency of an inhalatory anestheticMAC (minimal alveolar concentration)
= the alveolar concentration of the anesthetic that abolishes the movements caused by the skin incision in 50% of the patients
Each inhalatory anesthetic has its own specific MAC.
Modern anesthesia - new types of MAC:• MAC intubation ( MAC that facilitates the intubation in 50% of the patients);• MAC bar (MAC that abolishes the hemodynamic response in 50% of the
patients);• MAC awake (MAC at which awakening occurs in 50% of the patients).
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Inhalant anesthetic
Class Concentration in balanced anesthesia
Advantages/disadvantages Side effects
Nitrous oxide
Gaseous 40-66% Light analgesiaAccumulation in airway spaces
Risk of hypoxemiaEuforia
Halothane Volatile 1,5-2% Bronchodilatation Slow dynamics
Cardio-vascular depression
Isoflurane Volatile 1,5-2% BronchodilatationMedium dynamics
Vasodilatation
Sevoflurane Volatile 2-3% BronchodilatationFast dynamicsCardio-vascular stability
Compound A
Desflurane Volatile 6-8% Airway irritantSpecial vapporiser
Sympathetic stimulation
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Intravenous anesthetics:
Short acting:
Barbiturates → metohexital
thiopental, tiamital
Imidazolic compounds → etomidate
Alkylphenols → propofol
Steroids → eltanolone
Long acting:
Ketamine
Benzodiazepines → diazepam, midazolam
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THIOPENTAL:
-very rapid induction; maximal effect in 40 s;
-superficial anesthetic sleep;
-NO an analgesic effect;
-weak muscle relaxation.
Administration: slow i.v.
Side effects: risk of respiratory and circulatory depression
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PROPOFOL
-very liposoluble fatty acid;
-hepatic metabolisation in great extent → short effect;
Pharmacodynamic action:
-pharmacologic effects similar with those of Thiopental;
-less residual effects.
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KETAMINEPharmacodynamic action: Dissociative anesthetic: - dissociation from the environment
- superficial sleep - strong analgesia
Advantages:-No respiratory depressant effect; -hemodynamic stability by the release of
catecholamines -bronchodilatatory effect
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Hypnotic Class Induction dose
Single dose duration of action
Side effects
Thiopental Short acting barbituric
2-4 mg/kg 5-10 min Arterial hypotension, respiratory depression, tachycardia, decreases the cardiac output
Propofol Alkylphenol 1-2 mg/kg 5-10 min Arterial hypotension, respiratory depression, tachycardia
Etomidat Imidazolic compound
0,3 mg/kg 5-10 min Adrenal glad inhibition
Diazepam Benzodiazepines 0,3 mg/kg 10-60 min Interindividual response variability
Midazolam Benzodiazepines 0,2-0,3 mg/kg
5-15 min Respiratory depression
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Analgetics: Opioids: -the class of analgesics with the broadest intra-
anesthetic utilisation; -profound dose-dependant analgesia; -in spite of their quasi-constant use during general
anesthesia, the opioids are not anesthetics because the loss of consciousness is not a regular effect
-they regularly result in respiratory dose-dependent depression. Cardiovascular depression is a variable effect.
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Opioids Class Medium dose
Single dose duration of action
Side effects
Morphine μ Agonist 0,2 mg/kg 30-60 min Respiratory depression, sedation. hTA, bradycardia
Pethidine μ/Δ Agonist
1 mg/kg 20-30 min Sedation, nausea/vomiting, HTA, tachycardia
Fentanil μ Agonist 5-15 μg/kg 20 min Respiratory depression
Sufentanil μ Agonist 0,3-1 μg/kg
Respiratory depression
Alfentanil μ Agonist 5-50 μg/kg Respiratory depression
Remifentanil
μ Agonist 0,5-1 μg/kg
1-3 min Respiratory depression
Buprenorphine
Agonist/ antagonist
0,3 mg 3-4 ore Ceilling effect
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Muscle relaxants: -substances that act at the neuromuscular junction
level and prevent the transmission of the physiologic stimulus for the muscular contraction;
-NO action on the CNS, NO loss of consciousness, NO analgesia;
-utilized for the facilitation of the airway instrumentation, of mechanical ventilation and of the surgical intervention;
-results in alveolar hypoventilation or apnea by the action on the respiratory muscles;
-minimal cardio-vascular effects.
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Muscular relaxant
Class Intubation dose
Single dose duration of action
Particular instructions
Succinylcholine
D 1-1,5 mg/kg 10-15 min Full stomach
Pancuronium ND 0,1 mg/kg 30-40 min Bradycardia
Vecuronium ND 0,08 mg/kg 20-30 min Cardiac affections
Atracurium ND 0,5 mg/kg 20 min Kidney failure
Cisatracurium ND 0,2 mg/kg 20 min Kidney failure
Mivacurium ND 0,2 mg/kg 10-15 min Short interventions
Rocuronium ND 0,6-0,9 mg/kg 30-60 min Full stomach
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Anesthesia apparatus
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Anesthesia Apparatus
Components: -connection with the sources of medical fluids -flowmeters -vaporizers -anesthetic circuit -CO2 scavenger system -balloon ventilation system -overpressure valve -mechanical ventilation module -emergency oxygen delivery circuit
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-ventilation parameters setting module;
-ventilation parameters and inhalation anesthetics monitoring module;
-alarm module;
-vacuum system (sucction).
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Intraanesthesic monitoring
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Intraanesthesic monitoring Standard I: -the presence in the room of an anesthesiologist or
a qualified staff member throughout the duration of the anesthesia.
Standard II: -oxygenation: inspiratory oxygen concentration
(FiO2), pulsoxymetry (SpO2); -ventilation: clinical evaluation, auscultation,
capnography; -circulation: electrocardioscopy (continuous),
noninvasive arterial blood pressure and pulse measurement;
-body temperature.
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Monitoring
Respiratory Airway pressure, tidal volume, minute ventilation, respiratory rate, O2/CO2 inspiratory concentration, concentration of volatile anesthetic agent, pulsoxymetry
Cardiovascular Non-invasive arterial pressure, multiple leads ECG, computerized analysis of ST segment, central venous pressure, pulmonary artery pressure (systolic, medium, diastolic, wedge) cardiac output, extra-vascular pulmonary water, peripheral vascular resistance, ScvO2, SvO2.
Hypnosis BIS (bispectral index)
Muscle relaxation Peripheral nerve stimulator
Renal Diuresis
Temperature Central, peripheral
Acid - base equilibrium
Blood gas analysis
Electrolytes Na, K, Cl, Ca
Haematological analysis, coagulation studies
Platelets, aPTT, INR
Oxygen transportation
Hb, Ht, cardiac output, SaO2, PaO2
Metabolic Glucose
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Preanesthetic visit
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Preanesthetic exam:
-psychological preparation of the patient;
-clinical and laboratory evaluation of the patient;
-asignement to an anesthetic risk group (ASA scale)
-choosing the anesthetic technique and obtaining the informed consent;
-set up of an anesthetic plan.
Risk I Patient without systemic diseases
Risk II Patient with systemic diseases without functional limitation
Risk III Patient with systemic diseases with functional limitation
Risk IV Patient with uncompensated systemic disease
Risk V Dying patient
Risk VI Brain dead patient, organ donor
E Emergency procedure
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Optimizing the patient status:
-the correction of dysfunctions and diseases in the preoperative period.
Premedication :
-reduced anxiety and reduced need for intra-operative anesthetics;
-decreasing certain risks (parasympathetic reflexes, the risk of aspiration);
-the facilitation of postoperative analgesia.
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Phases of general anesthesia Induction phase: -the period of transition from the state of conscious to the
state of general anesthesia; -CNS depression, ventilatory, cardiovascular depression,
muscle relaxation; -securing the airway. Maintenace phase: -providing the adequate depth of anesthesia by
administering anesthetics, analgesics and muscle relaxant agents.
Emergency phase: -the interruption of the administration of all volatile or
intravenous anesthetic agents; -the antagonisation of the muscle relaxant drug.
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General anesthesia techniques
Balanced anesthesia; Intravenous anesthesia; Volatile anesthesia; Combined techniques of general and regional
anesthesia:
-general anesthesia + epidural anesthesia.
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General anesthesia complications
Respiratory Hypoxemia, hypercapnia laryngeal spasm, bronchospasm, aspiration, ARDS, atelectasis
Cardio-vascular High/low blood pressure, tachy/bradycardia, myocardial ischemia, arrhythmia , hypovolemia, low cardiac output
CNS Convulsions, shivers, post anoxic encephalopathy, paresis by compression or elongation of peripheral nerves
Digestive Vomiting or regurgitation, hiccup
Renal Oligo/anuria, urinary retention, pre - renal failure
Metabolice Hyper/hypoglycemia, malignant hyperthermia
Hidro-electrolitics Extracellular space expansion (interstitial oedema), hypo/hyperkalemia, hypocalcemia
Acid-base Hypercloremic metabolic acidosis, lactacidemic
Coagulation Thrombocytopenia, dilutional coagulopathy, deep venous thrombosis
Allergical Cutaneous eruptions, Quincke oedema, bronchospasm, anaphylactic shock
Cutaneous Decubitus injury, accidental burns
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Regional anesthesia Subarachnoid (spinal) Epidural Sequential Caudal
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Regional anesthesia Indications: -the area can be anesthetised using regional blocks; -the surgical procedure does not affect the vital
functions; -patient's informed consent; Contraindications: -patient's refusal; -active coagulation disorders or anticoagulant
treatment; -infections or haematoma at injection site; -neurological deficit and lack of cooperation.
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Spinal Anethesia:
analgesia
muscle relaxation
sympathetic blockade -sympathetic blockade: hypotension, bradycardia,
urinary retention;
-hypovolemia is an absolute contraindication of spinal anesthesia;
-epidural analgesia is the standard procedure for peripartum analgesia;
-complications: systemic (high spred of anesthetic- total spinal anesthesia or systemic toxicity), headache.
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Local anestheticsAmides Esters
Lidocain Prilocain Procain
Mepivacain Etidocain Tetracain
Bupivacain Ropivacain Benzocain
Clinical use of local anesthetics
Central regional anesthesia/analgesia
Regional intravenous anesthesia
Peripheral nerve block or plexus
Infiltration anesthesia
Local anesthesia
Blocking of thehemodynamic response during tracheal intubation
in regional anesthesia we frequently use the combination between a local anesthetic and adrenaline, an opioid or clonidine, increasing the duration and quality of the block
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During regional anesthesia – mandatory equipments:Anesthesia delivery systemEquipments and materials for airway managementOxygen sourceMonitoring: ventilation, oxygenation, circulation, blood
pressure, EKG.
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Spinal anesthesia (sub-arachnoid block)
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Epidural anesthesia
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Sequential (combined) anesthesia
spinal / epidural
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Caudal anesthesia
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Plexus anesthesia or peripheral nerves blockadeSingle-shotCatheter
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Local anesthesiacontacttopical - skin, mucous membrane application tissue infiltration
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Monitored anesthesia care
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Monitored anesthesia care - intravenous administration of anxiolytic, sedative,
analgesic and amnesic drugs either isolated or supplementing a regional anesthesia procedure;
- indicated in: painful diagnostic or therapeutic procedures or supplementing a inappropiate regional block;
- the CPR equipments must be close-by at all times; - complications: respiratory depression with
hypoventilation and loss of airway protection.
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